Form CMS-1728-94 Home Health Agency Cost Report Certification and Settlem

05-13

FORM CM S-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 CCN:

CERTIFICATION AND SETTLEMENT SUMMARY

PERIOD:
From: ___________

_______________

WORKSHEET S

To: ___________

Intermediary Use Only:
[ ] Audited

Date Received

____________ [ ]

Initial

[ ] Desk Reviewed

Contractor No.

____________ [ ]

Final

[ ] Re-opened

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 certification statement and that I have examined the accompanying electronically
filed or manually submitted 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, this report and statement are true, correct, complete and 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-(5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECS. 3203-3203.2)

Rev. 16

32-303

3290 (Cont.)

FORM CM S-1728-94

HOME HEALTH AGENCY COMPLEX
IDENTIFICATION DATA

PROVIDER CCN:
________________

Home Health Agency Complex Address:
1
Street:
1.01
City:
Home Health Agency Component Identification
Contractor No.
Component
0
2
Home Health Agency
3
HHA-based CORF
3.50
HHA-based Hospice
4
HHA-based CMHC
5
HHA- based RHC
6
HHA-based FQHC
7 Cost Reporting Period (mm/dd/yyyy)

State:

Component Name
1

05-13

PERIOD:
From: ___________
To: ___________

WORKSHEET S-2

P.O. Box:
Zip Code:

1
1.01

Provider No.
2

Date Certified
3
2
3
3.50
4
5
6

From: ______________

To: ______________

7

8 Type of control (see instructions)

8

9 If this a low or no Medicare utilization cost report, enter "L" for Low or "N" for No Medicare Utilization.

9

Depreciation: Enter the amount of depreciation reported in this HHA for the methods indicated.
10 Straight Line
11 Declining Balance
12 Sum of the Years' Digits
13 Sum of lines 10, 11 and 12

10
11
12
13

14 Were there any disposals of capital assets during this cost reporting period?
15 Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period?
16 Was accelerated depreciation claimed on assets acquired on or after August l, l970 (See PRM 15-1,
Chapter l)?
17 If depreciation is funded, enter the balance at end of period.
18 Did the provider cease to participate in the Medicare program at the end of
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
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))?
21 Does the HHA qualify as a nominal charge provider (defined in 42 CFR 409.3)?
22 Does the HHA contract with outside suppliers for physical therapy services?
22.01 Does the HHA contract with outside suppliers for occupational therapy services?
22.02 Does the HHA contract with outside suppliers for speech therapy services?

14
15
16
17
18
19
20
21
22
22.01
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
1
23
24
25
26

27
27.01
27.02
27.03
28
29
FORM
29.01
29.02
29.03

Part B
2

HHA
CORF
CMHC
If the HHA componentized (or fragmented) its administrative and general service
costs, indicate whether option one or option two is being utilized. (See Section 3214)
(Enter "1" for option one and "2" for option two)
List amounts of malpractice premiums and paid losses:
Premiums
Paid Losses
Self Insurance
Are malpractice premiums and/or paid losses reported in other than the Administrative and General
cost center? If yes, submit a supporting schedule listing cost centers and amounts contained therein.
If you are part of a chain organization, enter "Y" for yes and enter the name and address of the home
office, otherwise, enter "N" for no.
Home Office No. :
Contractor No. :
Home Office Name:
Contractor Name:
Street:
P.O. Box:
City:
State:
Zip Code:

23
24
25
26

27
27.01
27.02
27.03
28
29
29.01
29.02
29.03

FORM CMS 1728-94-S-2 (05-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3204)

32-304

Rev. 16

05-07

FORM CM S-1728-94

HOME HEALTH AGENCY
STATISTICAL DATA

PROVIDER NO.:
______________

PART I - STATISTICAL DATA

DESCRIPTION

COUNTY
Title XVIII
Visits
Patients
1
2

3290 (Cont.)
PERIOD:
From: ___________
To: ___________
Cook
Other

Visits
3

WORKSHEET S-3
PARTS I - III

Total
Patients
4

Visits
5

Patients
6

1
2
3
4
5
6
7
8
9
10

Skilled Nursing
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Service
Home Health Aide
All Other Services
Total Visits
Home Health Aide Hours
Unduplicated Census Count Full Cost Reporting Period
10.01 Unduplicated Census Count Pre 10/1/2000
10.02 Unduplicated Census Count Post 9/30/2000

1
2
3
4
5
6
7
8
9
10
10.01
10.02

PART II - EMPLOYMENT DATA
(FULL TIME EQUIVALENT)
Number of hours in
your normal work week __________
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

Staff
1

Contract
2

Total
3

Administrator and Assistant Administrator(s)
Director and Assistant Director(s)
Other Administrative Personnel
Direct Nursing Service
Nursing Supervisor
Physical Therapy Service
Physical Therapy Supervisor
Occupational Therapy Service
Occupational Therapy Supervisor
Speech Pathology Service
Speech Pathology Supervisor
Medical Social Service
Medical Social Supervisor
Home Health Aide
Home Health Aide Supervisor

11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
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.
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):

28
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. 15-2, SEC. 3205)

Rev. 13

32-305

3290 (Cont.)

FORM CM S-1728-94

HOME HEALTH AGENCY
STATISTICAL DATA

05-07

PROVIDER NO.:

PERIOD:
From: ______________
To: ______________

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

DESCRIPTION
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47

Full Episodes
without Outliers
1

Full Episodes
with Outliers
2

WORKSHEET S-3
PART IV

Cook
LUPA Episodes
3

PEP Only
Episodes
4

Skilled Nursing Visits
Skilled Nursing Visit Charges
Physical Therapy Visits
Physical Therapy Visit Charges
Occupational Therapy Visits
Occupational Therapy Visit Charges
Speech Pathology Visits
Speech Pathology Visit Charges
Medical Social Service Visits
Medical Social Service Visit Charges
Home Health Aide Visits
Home Health Aide Visit Charges
Total Visits (Sum of lines 30,32,34,36,38,40)
Other Charges
Total Charges (Sum of lines 31,33,35,37,39,41,43)
Total Number of Episodes
Total Number of Outlier Episodes
Total Non-Routine Medical Supply Charges

SCIC within a
PEP
5

SCIC Only
Episodes
6

Totals
7
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47

FORM CMS-1728-94 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3205)

32-305.1

Rev. 13

05-13
HHA-BASED RURAL HEALTH CLINIC/
FEDERALLY QUALIFIED HEALTH CENTER
PROVIDER STATISTICAL DATA
Check
Applicable Box

FORM CM S-1728-94
PROVIDER CCN:
_____________
COMPONENT CCN:
_____________

3290 (Cont.)
WORKSHEET S-4

[ ] RHC
[ ] FQHC

Clinic Address and Identification:
1 Street:
1.01 City:
State:
2 Designation (for FQHCs only) - Enter "R" for rural or "U" for urban
Source of Federal Funds:
3
4
5
6
7
8

PERIOD:
FROM: __________
TO: ___________

Zip Code:

1
1.01
2

County:

Grant Award
1

Date
2

Community Health Center (Section 330(d), PHS Act)
Migrant Health Center (Section 329(d), PHS Act)
Health Services for the Homeless (Section 340(d), PHS Act)
Appalachian Regional Commission
Look-Alikes
Other (specify)

Physician Information:

3
4
5
6
7
8
Physician
Name

Billing
Number

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

9
Physician
Name

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

11

12
12.01
12.02
12.03

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
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
Clinic
Specify:
Specify:
Specify:

Saturday
from
to
13
14
12
12.01
12.02
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?
14 Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)? If yes, enter in column 2 the
number of providers included in this report. List all provider names and numbers below.
15 Provider name: ______________________________
Provider number: _______________
15.01 Provider name: ______________________________
Provider number: _______________
15.02 Provider name: ______________________________
Provider number: _______________
15.03 Provider name: ______________________________
Provider number: _______________
16 Are you claiming allowable GME costs as a result of "substantial payment" for interns
and residents? If yes, enter the number of Medicare visits in column 2 and total visits in column 3
performed by interns and residents and complete Worksheet RF-1, lines 20 and 27 as applicable.

13
14

Y/N
1

15
15.01
15.02
15.03
XVIII TOTAL 16
2
3

FORM CMS-1728-94-S4 (5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3233)

Rev. 16

32-305.2

3290 (Cont.)
HOSPICE IDENTIFICATION DATA

FORM CMS-1728-94
PROVIDER CCN:
_____________
HOSPICE CCN:
_____________

05-13
PERIOD:
FROM: _____________
TO: ________________

WORKSHEET S-5

PART I

Enrollment Days
1
2
3
4
5

Title XVIII
Unduplicated
Skilled
Unduplicated
Nursing
Days
Facility Days
1
2

Other
Unduplicated
Days
3

Total
Unduplicated
Days
(sum of
cols. 1 & 3)
4

Continuous Home Care
Routine Home Care
Inpatient Respite Care
General Inpatient Care
Total Hospice Days

1
2
3
4
5

PART I I

Census Data

Title XVIII
1

Title XVIII
Skilled
Nursing
Facility
2

6 Number of Patients Receiving
Hospice Care
7 Total Number of Unduplicated
Continuous Care Hours
Billable to Medicare
8 Average Length of Stay (line 5 divided by line 6)
9 Unduplicated Census Count

Other
3

Total
(sum of
cols. 1 & 3)
4
6
7

8
9

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

FORM CMS-1728-94-S-5 (5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,
SECTIONS 3239 - 3239.2)
32-306

Rev. 16

05-07

FORM CM S-1728-94

HHA-BASED CORF STATISTICAL DATA

PROVIDER NO.: _______________
CORF NO.: _______________

CORF TREATMENTS

1
2
3
4
5
6
7
8
9

10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychological Services
All Other Service
Total Treatments (Sum of lines 1-8)
CORF - NUMBER OF EMPLOYEES ( FULL TIME EQUIVALENT )
Enter the number of hours
in your normal workweek __________

PERIOD:
From: ___________
To: ___________
Title XVIII
Treatments
Patients
1
2

3290 (Cont.)
SUPPLEMENTAL
WORKSHEET S-6
Other
Treatments
3

Total
Patients
4

Treatments
5

Patients
6
1
2
3
4
5
6
7
8
9

Staff
1

Administrators and Assistant Administrators
Directors and Assistant Directors
Other Administrative Personnel
Direct Nursing Service
Nursing Supervisor
Physical Therapy Service
Physical Therapy Supervisor
Occupational Therapy Service
Occupational Therapy Supervisor
Speech Pathology Service
Speech Pathology Supervisor
Medical Social Service
Medical Social Supervisor
Respiratory Therapy Service
Respiratory Therapy Supervisor
Psychological Service
Psychological Service Supervisor

Contract
2

Total
3
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

FORM CMS 1728-94-S-6 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3220)

Rev. 13

32-307

3290 (Cont.)

FORM CM S-1728-94

05-07
PROVIDER NO.:

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

PERIOD:

_______________

From: ___________

WORKSHEET A

To: ___________
CONTRACTED

RECLASSI-

EMPLOYEE

TRANSPOR-

PURCHASED

SALARIES

BENEFITS

TATION (See

SERVICES

OTHER

(Fr Wks A-1)

(Fr Wks A-2)

Instructions)

(Fr Wks A-3)

COSTS

1

2

3

4

5

EXPENSES

RECLASSI-

FIED TRIAL

FICATION

BALANCE

ADJUST-

ALLOCATION

FOR COST

TOTAL

(Fr Wks A-4)

(Cols 6 + 7)

MENTS

(Col 8 + 9)

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

15

1500

Home Dialysis Aide Services

15

16

1600

Respiratory Therapy

16

HHA NONREIMBURSABLE SERVICES

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

Other

23

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

Total

29

29

FORM CMS-1728-94 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3206)

32-308

Rev. 13

08-99

FORM CM S-1728-94

3290 (Cont.)

COMPENSATION ANALYSIS

PROVIDER NO.:

PERIOD:

SALARIES AND WAGES

_______________

From: ___________

WORKSHEET A-1

To: ___________
ADMINISTRATORS

DIRECTORS

1

2

CONSULTANTS SUPERVISORS
3

ALL

TOTAL

NURSES

THERAPISTS

AIDES

OTHER

(1)

5

6

7

8

9

4

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. 15-2, SEC. 3207)

Rev. 7

32-309

3290 (Cont.)

FORM CM S-1728-94

08-99

COMPENSATION ANALYSIS

PROVIDER NO.:

PERIOD:

EMPLOYEE BENEFITS (PAYROLL RELATED)

_______________

From: ___________

WORKSHEET A-2

To: ___________
ALL

TOTAL

TRATORS

ADMINISDIRECTORS

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

2

Capital Related - Movable Equipment

1
2

3

Plant Operation & Maintenance

3

4

Transportation (See Instructions)

4

5

Administrative and General

5

6

Skilled Nursing Care

6

7

Physical Therapy

7

HHA REIMBURSABLE SERVICES

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

16

Respiratory Therapy

15
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

24

CORF

24

25

Hospice

25

SPECIAL PURPOSE COST CENTERS

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. 15-2, SEC. 3208)

32-310

Rev. 7

08-99

FORM CM S-1728-94

3290 (Cont.)

COMPENSATION ANALYSIS

PROVIDER NO.:

PERIOD:

CONTRACTED SERVICES/PURCHASED SERVICES

_______________

From: ___________

WORKSHEET A-3

To: ___________
ADMINISTRATORS

DIRECTORS

1

2

CONSULTANTS SUPERVISORS
3

4

ALL

TOTAL

NURSES

THERAPISTS

AIDES

OTHER

(1)

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. 15-2, SEC. 3209)

Rev. 7

32-311

3290 (Cont.)

FORM CM S-1728-94

08-99
PROVIDER NO.

RECLASSIFICATIONS

_______________

PERIOD:

WORKSHEET A-4

From: ___________
To: ___________

CODE
EXPLANATION OF RECLASSIFICATION ENTRY

(1)
1

INCREASE
COST CENTER
2

DECREASE
LINE NO.
3

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30 TOTAL RECLASSIFICATIONS (Sum of col. 4 must equal sum of col. 7)
(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. 15-2, SEC. 3210)

32-312

AMOUNT(2)
4

COST CENTER
5

LINE NO.
6

AMOUNT(2)
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Rev. 7

08-99

FORM CM S-1728-94

ADJUSTMENTS TO EXPENSES

Description (1)
1 Excess funds generated from operations,
other than net income
2 Trade, quantity, time and other discounts
on purchases (Chap. 8)
3 Rebates and refunds of expenses (Chap. 8)
4 Home office costs (Chap. 21)
5 Adjustments resulting from transaction
with related organization (Chap. 10)
6 Sale of medical records and abstracts
7 Income from imposition of interest,
finance or penalty charges (Chap. 21)
8 Sale of medical and surgical supplies to
other than patients
9 Sale of Drugs to other than patients
10 Physical therapy adjustment (Chap. 14)
10.1 Occupational therapy adjustment (Chap. 14)
10.2 Speech pathology adjustment (Chap. 14)
11 Interest expense on Medicare overpayments and
borrowings to repay Medicare overpayments
12 Lobbying Activities

PROVIDER NO.:
_______________

(2)
BASIS/CODE
1
B

3290 (Cont.)

PERIOD:
From: __________
WORKSHEET A-5
To: __________
Expense Classification on Worksheet A
To/From Which The Amount is to be Adjusted

Amount
Cost Center
2
3
(3,985) A& G Shared Costs

Line No.
4
5.01

B
B
A
From Wks
A-6
B
B

1
2

15,250 A& G Reimb. Costs
#REF!

5.02

3
4
5
6
7

A

8

A
From Supp
Wks A-8-3
From Supp
Wks A-8-3
From Supp
Wks A-8-3
A

9
10

A

Physical Therapy

7

Occupational Therapy

8

Speech Pathology

9

(2,050) A& G Nonreimb. Costs

5.03

10.1
10.2
11
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. 15-2, SEC. 3211)

Rev. 7

32-313

3290 (Cont.)

FORM CM S-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:
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
LINE NO.
1

COST CENTER
2

EXPENSE ITEMS
3

AMOUNT
4

WORKSHEET A-6

AMOUNT
ALLOWABLE
IN COST
5

NET
ADJUSTMENT
(col 4 -5)
6

1
2
3
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.

SYMBOL
(1)
1
1
2
3
4
5

Name
2

Address
3

Percent
Owned
by
Provider
4

Percent
Ownership
of
Provider
5

Type of
Business
6

(1) Use the following symbols to indicate the interrelationship of the provider to related organizations:
A.
B.
C.
D.

Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider.
Corporation, partnership or other organization has financial interest in provider.
Provider has financial interest in corporation, partnership or other organization.
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. 15-2, SEC. 3212)

32-314

Rev. 7

08-99

FORM CMS-1728-94
PROVIDER NO.:

ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCE
_______________
Description

1
2
3
4
5
6
7

Beginning
Balances
1

Purchases
2

3290 (Cont.)
PERIOD:
From: ___________
To: ___________
Acquisitions
Donations
3

WORKSHEET A-7

Total
4

Land
Land Improvements
Buildings and Fixtures
Building Improvements
Fixed Equipment
Movable Equipment
TOTAL

Disposals
and
Retirements
5

Ending
Balance
6
1
2
3
4
5
6
7

FORM CMS-1728-94-A-7 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3213)
Rev. 7

32-315

3290 (Cont.)

FORM CM S-1728-94

REASONABLE COST DETERMINATION FOR THERAPY
SERVICES FURNISHED BY OUTSIDE SUPPLIERS
Check applicable box:

08-99

PROVIDER NO.:

PERIOD:
From: ___________
To: ___________

________________
[ ] 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 I NFORM ATI ON
Total number of weeks worked (During which outside suppliers (excluding aides) worked)
Line 1 multiplied by 15 hours per week
Number of unduplicated HHA visits - supervisors or therapists (See Instructions)
Number of unduplicated HHA visits - therapy assistants (Include only visits made by therapy assistants and on which
supervisor and/or therapist was not present during the visit) (See Instructions)
5 Standard travel expense rate
6 Optional travel expense rate per mile

WORKSHEET A-8-3
PARTS I - III

1
2
3
4

7
8
9
10
11

Total hours worked
AHSEA (See Instructions)
Standard Travel Allowance (Cols 1 and 2, one-half of col 2, line 8; col 3, one-half of col 3, line 8)
Number of travel hours (HHA only)
Number of miles driven (HHA only)

PART I I - SAL ARY EQUI VAL ENCY COM PUTATI ONS
12 Supervisors (Col 1, line 7 times col 1, line 8)
13 Therapists (Col 2, line 7 times col 2, line 8)
14 Assistants (Col 3, line 7 times col 3, line 8)
15 Subtotal Allowance Amount (Sum of lines 12-14)
16 Aides (Col 4, line 7 times col 4, line 8)
17 Total Allowance Amount (Sum of lines 15 and 16)
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)
19 Weighted allowance excluding aides (Line 2 times line 18)
20 Total Salary Equivalency (Line 17 or sum of lines 16 plus 19)

21
22
23
24
25
26
27
28
29
30
31

PART I I I - TRAVEL AL L OWANCE AND TRAVEL EXPENSE COM PUTATI ON - HHA SERVI CES
Standar d Tr avel Allowance and Standar d Tr avel Expense
Therapists (Line 3 times col 2, line 9)
Assistants (Line 4 times col 3, line 9)
Subtotal (Sum of lines 21 and 22)
Standard Travel Expense (Line 5 times sum of lines 3 and 4)
Optional Tr avel Allowance and Optional Tr avel Expense
Therapists (Sum of cols 1 and 2, line 10 times col 2, line 8)
Assistants (Col 3, line 10 times col 3, line 8)
Subtotal (Sum of lines 25 and 26)
Optional Travel Expense (Line 6 times sum of cols 1-3, line 11)
Total Tr avel Allowance and Tr avel Expenses - HHA Ser vices; Complete one of the following
thr ee lines 29, 30 or 31, as appr opr iate
Standard Travel Allowance and Standard Travel Expenses (Sum of lines 23 and 24 - See Instructions)
Optional Travel Allowance and Standard Travel Expenses (Sum of lines 27 and 24 - See Instructions)
Optional Travel Allowance and Optional Travel Expenses (Sum of lines 27 and 28 - See Instructions)

1
2
3
4

Supervisors
1

Therapists
2

Assistants
3

Aides
4

5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

21
22
23
24
25
26
27
28
29
30
31

FORM CMS-1728-94-A-8-3 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC 3219-3219.3)

32-316

Rev. 7

05-07

FORM CM S-1728-94

REASONABLE COST DETERMINATION FOR THERAPY
SERVICES FURNISHED BY OUTSIDE SUPPLIERS
Check applicable box:

3290 (Cont.)
PROVIDER NO.:

________________
[ ] Physical Therapy services rendered before 4/10/98 [ ] Occupational Therapy [ ] Speech Pathology
[ ] Physical Therapy services rendered on or after 4/10/98

PART I V - OVERTI M E COM PUTATI ON

37
38
39
40
41

Descr iption
Overtime hours worked during cost reporting period (If col 4, line 32, is zero or equal to or greater
than 2,080, do not complete lines 33-40 and enter zero in each column of line 41)
Overtime rate (Multiply the amounts in cols 2-4, line 8 (AHSEA) times 1.5)
Total overtime (Including base and overtime allowance) (Multiply line 32 times line 33)
CAL CUL ATI ON OF L I M I T
Percentage of overtime hours by category (Divide the hours in each column on line 32 by the total
overtime worked - col. 4, line 32)
Allocation of provider's standard workyear for one full-time employee times the percentage on line 35)
(See Instructions)
DETERM I NATI ON OF OVERTI M E AL L OWANCE
Adjusted hourly salary equivalency amount (AHSEA) (From Part I, cols 2-4, line 8)
Overtime cost limitation (Line 36 times line 37)
Maximum overtime cost (Enter the lesser of line 34 or line 38)
Portion of overtime already included in hourly computation at the AHSEA (Multiply line 32 times line 37)
Overtime allowance (Line 39 minus line 40 - if negative enter zero) (Col 4, sum of cols 1-3)

42
43
44
45
46
47
48
49

PART V - COM PUTATI ON OF THERAPY L I M I TATI ON AND EXCESS COST ADJUSTM ENT
Salary equivalency amount (from Part II, line 20)
Travel allowance and expense - HHA services (from Part III, lines 29, 30 or 31)
Overtime allowance (from Part IV, col. 4, line 41)
Equipment cost (See Instructions)
Supplies (See Instructions)
Total allowance (Sum of lines 42-46)
Total cost of outside supplier services (from provider records)
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)

32
33
34
35
36

PERIOD:
From: ___________
To: ___________

Therapists
1

Assistants
2

WORKSHEET A-8-3
PART IV & V

Aides
3

TOTAL
4

32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49

FORM CMS-1728-94-A-8-3 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECS 3219.4 AND 3219.5)

Rev. 13

32-317

3290 (Cont.)

FORM CM S-1728-94

05-07
PROVIDER NO.:

PERIOD:

COST ALLOCATION - GENERAL SERVICE COST

From: ___________
_____________
NET EXPENSES

CAPITAL

FOR COST

RELATED COSTS

WORKSHEET B

To: ___________

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

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

FORM CMS-1728-94-B (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC 3214)
32-318

Rev. 13

05-07

FORM CM S-1728-94

3290 (Cont.)
PROVIDER NO.:

PERIOD:

COST ALLOCATION - STATISTICAL BASIS

From: ___________
_____________

WORKSHEET B-1

To: ___________

CAPITAL
RELATED COSTS

COST CENTER

PLANT

ADMINISTRA-

BLDGS &

MOVABLE

OPERATION

& FIXTURES

EQUIPMENT

MAINTENANCE

TRANS-

TIVE

(SQUARE

(DOLLAR

(SQUARE

PORTATION

RECONCIL-

(ACCUMU-

FEET)

VALUE)

FEET)

(MILEAGE)

IATION

LATED COST)

TOTAL

1

2

3

4

5A

5

6

& GENERAL

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. 15-2, SEC 3214)
Rev. 13

32-319

3290 (Cont.)

APPORTIONMENT OF PATIENT SERVICE COSTS

FORM CM S-1728-94

PROVIDER CCN:
______________

PART I - AGGREGATE AGENCY COST PER VISIT COMPUTATION
Cost Per Visit Computation

From Wkst
B, Col. 6,
Line:
1
6
7
8
9
10
11

Patient Services
1
2
3
4
5
6
7

Skilled Nursing
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide Services
Total (Sum of lines 1-6)

PART II - COMPUTATION OF THE AGGREGATE MEDICARE COST AND THE AGGREGATE OF THE MEDICARE LIMITATION (2)
Medicare Program Visits
MSA/CBSA CODE:
Part B
From Wkst. C,
Average
Not Subject
Subject
Part I, Col. 4,
Cost
to Deductibles
to Deductibles
Total Medicare Patient Service Cost Computation
Line:
Per Visit
Part A
& Coinsurance & Coinsurance
4
5
6
7
1
Skilled Nursing
1
2
Physical Therapy
2
3
Occupational Therapy
3
4
Speech Pathology
4
5
Medical Social Services
5
6
Home Health Aide Services
6
7
Total (Sum of lines 1-6)

Total Medicare Patient Service Cost Limitation Computation
8
9
10
11
12
13
14

Program
Cost
Limits
4

Part A
5

Medicare Program Visits
Part B
Not Subject
Subject
to Deductibles
to Deductibles
& Coinsurance & Coinsurance
6
7

Skilled Nursing
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide Services
Total (Sum of lines 8-13 plus the subscripts of lines 1-6, respectively)
(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.

05-07

PERIOD:
From: ______________
To: ______________

Cost
2

WORKSHEET C
PARTS I & II

Total

Visits
3

Average
Cost
Per Visit
(Cols 2 ÷ 3) (1)
4

Cost of Medicare Services
Part B
Not Subject
Subject
to Deductibles to Deductibles
Part A
& Coinsurance & Coinsurance
8
9
10

Total
(Sum of
Cols 8 & 9)
11

Cost of Medicare Services
Part B
Not Subject
Subject
to Deductibles to Deductibles
Part A
& Coinsurance & Coinsurance
8
9
10

Total
(Sum of
Cols 8 & 9
11

1
2
3
4
5
6
7

1
2
3
4
5
6
7

8
9
10
11
12
13
14

FORM CMS-1728-94-C (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3215 - 3215.5)

32-320

Rev. 13

05-13

FORM CM S-1728-94

APPORTIONMENT OF PATIENT SERVICE COSTS

PROVIDER CCN:
______________

PART III - SUPPLIES AND DRUGS COST COMPUTATION

Other Patient Services
15
Cost of Medical Supplies
16
Cost of Drugs
16.20 Cost of Drugs

From Wkst
B, Col. 6,
Line:
1
12
13
13.20

Total
Cost
2

Total
Charges
from HHA
Record)
3

Ratio
(Col 2 ÷ 3)
4

3290 (Cont.)

PERIOD:
From: ______________
To: ______________

Medicare Covered Charges
Part B
Not Subject
Subject
to Deductibles
to Deductibles
Part A
& Coinsurance & Coinsurance
5
6
7

WORKSHEET C
PARTS III, IV & V

Part A
8

Cost of Services
Part B
Not Subject
Subject
to Deductibles to Deductibles
& Coinsurance & Coinsurance
9
10

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
Census Count
Limitation Per
Cost of Medicare Services
For Each
MSA/Non-MSA
Part B
MSA /CBSA
CBSA/Non-CBSA
Not Subject
Subject
Total
Pre 10/1/2000
(From Your
to Deductibles to Deductibles
(Sum of
Contractor
)
(4)
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
1-6 (exculsive of subscripts))
18
Cost of Medical Supplies (from Part III, columns 8 and 9, line 15 (exclusive of line 15.01))
19
Total (Sum of lines 17 and 18)
20
21
22

23
23.01
23.02
23.03
23.04
23.05
23.06
23.07
23.08
23.09
24

17
18
19

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)
Cost of Medical Supplies (from Part III, columns 8 and 9, line 15 (exclusive of line 15.01))
Total (Sum of lines 20 and 21)
MSA /CBSA
Code (3)
0

Per Beneficiary Cost Limitation for MSA/CBSA:
Per Beneficiary Cost Limitation for MSA/CBSA:
Per Beneficiary Cost Limitation for MSA/CBSA:
Per Beneficiary Cost Limitation for MSA/CBSA:
Per Beneficiary Cost Limitation for MSA/CBSA:
Per Beneficiary Cost Limitation for MSA/CBSA:
Per Beneficiary Cost Limitation for MSA/CBSA:
Per Beneficiary Cost Limitation for MSA/CBSA:
Per Beneficiary Cost Limitation for MSA/CBSA:
Per Beneficiary Cost Limitation for MSA/CBSA:
Aggregate Per Beneficiary Cost Limitation (Sum of lines 23 and subscripts thereof)

PART V - OUTPATIENT THERAPY REDUCTION COMPUTATION

Patient Services
25
26
27
28

From Wkst. C,
Part I, Col. 4,
Line:
1
2
3
4

Average
Cost
Per Visit
2

Rev. 16

20
21
22

1

Part B
Subject to Deductibles and Coinsurance
Medicare
Medicare
Medicare
Program Visits Program Costs Program Visits
for Services
for Services
for Services
Before 1/1/98
Before 1/1/98 1/1/98-12/31/98
3
4
5

Physical Therapy
Occupational Therapy
Speech Pathology
Total (Sum of lines 25-27)
(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 (5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3215 - 3215.5)

15
16
16.20

2

Medicare
Program Visits
for Services
1/1/99-9/30/00
5.01

3

4

5

Medicare
Medicare
Program Visits Program Costs Application of
for Services on
for Services the Reasonable
or after 10/1/00 1/1/98-12/31/98 Cost Reduction
5.02
6
7

(Col 1 x 2)
6

23
23.01
23.02
23.03
23.04
23.05
23.06
23.07
23.08
23.09
24

Reasonable
Costs Net of
Adjustments
8

25
26
27
28

32-321

3290 (Cont.)

FORM CM S-1728-94

CALCULATION OF REIMBURSEMENT SETTLEMENT PART A AND PART B SERVICES

05-13
PROVIDER CCN:

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

Description
Reasonable Cost of Title XVIII - Part A & Part B Services
1
Reasonable Cost of Services (See Instructions)
2
Cost of Services, RHC & FQHC
3
Sum of Lines 1 and 2
4
Total charges for title XVIII - Part A and Part B Services - Pre 10/1/2000
4.01 Total charges for title XVIII - Part A and Part B Services - Post 9/30/2000
Customary Charges
5
Amount actually collected from patients liable for payment for services on a
charge basis (From your records)
6
Amount that would have been realized from patients liable for payment for services on
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)
8
Total customary charges - title XVIII (Multiply line 7 by line 4 for column 1) (Multiply line 7
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
line 8 exceeds line 3)
10 Excess of reasonable cost over customary charges (Complete only if line 3 exceeds line 8)
11 Primary Payer Amounts

PART A
1

PERIOD:
From: ___________ WORKSHEET D
To: ___________
PART B
Not Subject
Subject
to Deductibles
to Deductibles
& Coinsurance
& Coinsurance
2
3
1
2
3
4
4.01
5
6
7
8
9
10
11

PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT
PART A
Services
1

Description
Total reasonable cost (See Instructions)
Total PPS Payment - Full Episodes without Outliers
Total PPS Payment - Full Episodes with Outliers
Total PPS Payment - LUPA Episodes
Total PPS Payment - PEP Only Episodes
Total PPS Payment - SCIC within a PEP Episodes
Total PPS Payment - SCIC Only Episodes
Total PPS Outlier Payment - Full Episodes with Outliers
Total PPS Outlier Payment - PEP Only Episodes
Total PPS Outlier Payment - SCIC within a PEP Episodes
Total PPS Outlier Payment - SCIC Only Episodes
Total Other Payments
DME Payment
Oxygen Payment
Prosthetics and Orthotics Payment
Part B deductibles billed to Medicare patients (exclude coinsurance)
Subtotal (Sum of lines 12-12.14 minus line 13)
Excess reasonable cost (from line 10)
Subtotal (Line 14 minus line 15)
Coinsurance billed to Medicare patients (From your records)
Net cost (Line 16 minus line 17)
Reimbursable bad debts (From your records)
Pneumococcal Vaccine
Total Costs - Current cost reporting period (See Instructions)
Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets
Recovery of excess depreciation resulting from agencies' termination or decrease in Medicare utilization
Unrefunded charges to beneficiaries for excess costs erroneously collected based on correction of cost limit
Total cost before sequestration and other adjustments- (line 21
plus/minus line 22 minus sum of lines 23 and 24)
25.50 Other Adjustments (see instructions) (specify)
26
Sequestration Adjustment (See Instructions)
27
Amount reimbursable after sequestration and other adjustments (Line 25 plus line 25.5 minus line 26)
28
Total interim payments (From Worksheet D-1, line 4)
28.5 Tentative settlement (For intermediary use only)
29
Balance due HHA/Medicare program (Line 27 minus line 28) (Indicate overpayments in brackets)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2 , section 115.2
30
31
Balance due HHA/Medicare program (Line 29 minus line 30) (Indicate overpayments in brackets)
FORM CMS-1728-94-D (5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3216 - 3216.2)
12
12.01
12.02
12.03
12.04
12.05
12.06
12.07
12.08
12.09
12.10
12.11
12.12
12.13
12.14
13
14
15
16
17
18
19
20
21
22
23
24
25

32-322

PART B
Services
2
12
12.01
12.02
12.03
12.04
12.05
12.06
12.07
12.08
12.09
12.10
12.11
12.12
12.13
12.14
13
14
15
16
17
18
19
20
21
22
23
24
25
25.50
26
27
28
28.5
29
30
31

Rev. 16

08-99

PROVIDER NO.:
_______________

Description

1
2

3

PERIOD:
From: ___________
To: ___________

PART A
mm/dd/yyyy
Amount
1
2

Total interim payments paid to provider
Interim pymts payable on individual bills either submitted or to
be submitted to the intermediary, for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
List separately each retroactive lump sum
adjustment amount based on subsequent revision
of the interim rate for the cost reporting period.
Program
Also show date of each payment. If none write
to
"NONE" or enter a zero.(1)
Provider

Provider
to
Program

4

3290 (Cont.)

FORM CM S-1728-94

ANALYSIS OF PAYMENTS TO HHAs
FOR SERVICES RENDERED TO
PROGRAM BENEFICIARIES

SUBTOTAL (Sum of lines 3.01-3.49, minus sum
of lines 3.50-3.98)
TOTAL INTERIM PAYMENTS (Sum of lines 1, 2
and 3.99)(Transfer to Wkst D, Part II,
column as appropriate, line 28)

PART B
mm/dd/yyyy
3

WORKSHEET D-1

Amount
4
1
2

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4

TO BE COMPLETED BY INTERMEDIARY
5

6

7

List separately each tentative settlement payment
after desk review. Also show date of each
payment. If none, write "NONE" or enter
a zero. (1)
"NONE" or enter a zero. (1)
SUBTOTAL (Sum of lines 5.01-5.49 minus sum
of lines 5.50-5.98)
Determine net settlement
amount (balance due) based
on the cost report (See
Instructions)

Program
to
Provider
Provider
to
Program

.01
.02
.03
.50
.51
.52
.99

5.01
5.02
5.03
5.50
5.51
5.52
5.99

Program
to
Provider
Provider
to
Program

.01
6.01
.02
6.02
7

TOTAL MEDICARE PROGRAM LIABILITY
(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. 15-2, SEC. 3217)

Rev. 7

32-323

3290 (Cont.)

PROVIDER NO.:
___________

ASSETS
(Omit Cents)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

08-99

FORM CM S-1728-94

BALANCE SHEET
(To be completed by all providers maintaining fund type
accounting records. Nonproprietary providers not
maintaining fund type accounting records, should
complete the "General Fund" column only.)

CURRENT ASSETS
Cash on hand and in banks
Temporary investments
Notes receivable
Accounts Receivable
Other Receivables
Less: Allowance for uncollectible notes
and accounts receivable
Inventory
Prepaid Expenses
Other current assets
Due from other funds
TOTAL CURRENT ASSETS (Sum of lines 1-10)
FIXED ASSETS
Land
Land Improvements
Less: Accumulated Depreciation
Buildings
Less: Accumulated Depreciation
Leasehold improvements
Less: Accumulated Depreciation
Fixed equipment
Less: Accumulated Depreciation
Automobiles and trucks
Less: Accumulated Depreciation
Major movable equipment
Less: Accumulated Depreciation
Minor equipment nondepreciable
Other fixed assets
TOTAL FIXED ASSETS (Sum of lines 12-26)
OTHER ASSETS
Investments
Deposits on leases
Due from owners/officers

PERIOD:
From: ___________
To: ___________
SPECIFIC
PURPOSE
FUND
2

GENERAL
FUND
1

ENDOWMENT
FUND
3

WORKSHEET F

PLANT
FUND
4
1
2
3
4
5
6

(

)
7
8
9
10
11

(

)

(

)

(

)

(

)

(

)

(

)

28
29
30
31
32 TOTAL OTHER ASSETS (Sum of lines 28-31)
33 TOTAL ASSETS (Sum of lines 11, 27 and 32)
LIABILITIES AND FUND BALANCE
(Omit Cents)
CURRENT LIABILITIES
34 Accounts payable
35 Salaries, wages & fees payable
36 Payroll taxes payable
37 Notes & loans payable (short term)
38 Deferred income
39 Accelerated payments
40 Due to other funds
41 Other (Specify)
42 TOTAL CURRENT LIABILITIES (Sum of lines 34-41)
LONG TERM LIABILITIES
43 Mortgage payable
44 Notes payable
45 Unsecured Loans
46 Loans from owners - prior to 7/1/66
47 Loans from owners - on or after 7/1/66
48 Other (Specify)
49 TOTAL LONG TERM LIABILITIES
(Sum of lines 43-48)
50 TOTAL LIABILITIES (Sum of lines 42 and 49)
CAPITAL ACCOUNTS
51 General fund balance
52 Specific purpose fund balance
53 Donor created--Endowment fund balance--restricted
54 Donor created--Endowment fund balance--unrestricted
55 Governing body created--Endowment fund balance
56 Plant fund balance--Invested in plant
57 Plant fund balance-- Reserve for plant improvement,
replacement and expansion
58 TOTAL FUND BALANCES (Sum of lines 51 thru 57)
59 TOTAL LIABILITIES AND FUND BALANCE (Sum
of lines 50 and 58)

12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59

(
) = contra amount
FORM CMS-1728-94-F (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3218)

32-324

Rev. 7

08-99

FORM CM S-1728-94

STATEMENT OF
REVENUE AND EXPENSES

PROVIDER NO.:
___________

3290 (Cont.)
PERIOD
From: ___________
To: ___________

WORKSHEET F-1

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. 15-2, SEC. 3218)

Rev. 7

32-325

3290 (Cont.)

FORM CM S-1728-94
PROVIDER NO.:

STATEMENT OF CHANGES IN FUND BALANCES
GENERAL FUND
1

2

___________
SPECIFIC PURPOSE FUND
3
4

08-99
PERIOD:
From: ___________
To: ___________
ENDOWMENT FUND
5
6

WORKSHEET F-2
PLANT FUND
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
17

Total Deductions (Sum of lines 11-15)
Fund balance at end of period per balance sheet
(line 10 minus line 16)

16
17

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

32-326

Rev. 7

08-99

FORM CMS-1728-94

ALLOCATION OF GENERAL SERVICE
COSTS TO CORF REIMBURSABLE COST CENTERS
PART I - ALLOCATION OF GENERAL SERVICE COSTS TO CORF REIMBURSABLE COST CENTERS
NET
CAPITAL
EXPENSES
RELATED COSTS
CORF COST CENTER
FOR COST
BLDGS &
MOVABLE
(OMIT CENTS)
FIXTURES
EQUIPMENT
ALLOCATION (1)
0
1
2
1 Administrative and General
2 Skilled Nursing Care
3 Physical Therapy
4 Occupational Therapy
5 Speech Pathology
6 Medical Social Services
7 Respiratory Therapy
8 Psychological Services
9 Prosthetic and Orthotic Devices
10 Drugs and Biologicals
11 Medical Supplies
12 Durable Medical Equipment-Rented
13 Durable Medical Equipment-Sold
14 Other Part B Services
15 TOTALS (Sum of lines 1-14) (2)
(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

3290 (Cont.)

PROVIDER NO.:
___________________
CORF NO.:
___________________
PLANT
OPERATION
& MAINTENANCE
3

TRANSPORTATION
4

PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF CORF ADMINISTRATIVE AND GENERAL COSTS
1 Amount from Part I, column 6, line 15
2 Amount from Part I, column 6, line 1
3 Line 1 minus line 2
4 Unit cost multiplier for CORF A& G costs (Line 2 divided by line 3)(multiply each amount in column 6,
lines 2 through 14, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)

PERIOD:
FROM: _______________
TO: _________________

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE
& GENERAL
5

SUBTOTAL
6

WORKSHEET J-1
PARTS I & II

ALLOCATED
CORF
A& G (SEE
PART II)
7

TOTAL
(SUM OF
COLS 6 & 7)
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

1
2
3
4

FORM CMS 1728-94-J-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SECS. 3221-3221.2)

Rev. 7

32-327

05-00

FORM CM S-1728-94

3290 (Cont.)

PROVIDER NO.:
___________________
CORF NO.:
___________________

COMPUTATION OF CORF COSTS

PERIOD:
FROM: _______________
TO: __________________

WORKSHEET J-2

PART I - APPORTIONMENT OF CORF COST CENTERS NET OF THE APPLICABLE REASONABLE COST REDUCTION
TOTAL COSTS
(FROM SUPP.
WKST. J-1, PT.
I, COL. 8) (1)
1

CORF COST CENTER
(OMIT CENTS)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

TOTAL
CORF
CHARGES (2)
2

RATIO OF
COSTS TO
CHARGES
(COL. 1 / COL. 2)
3

TITLE XVIII
CORF
CHARGES *
4

TITLE XVIII
CORF COSTS
(COL. 3 X
COL. 4)
5

TITLE XVIII
CORF
CHARGES ON
OR AFTER
1/1/98 *
6

COSTS ON OR
AFTER 1/1/98

REASONABLE
COST
REDUCTION
AMOUNT

TITLE XVIII
COST NET OF
REASONABLE
COST
REDUCTION

7

8

9

TITLE XVIII
CORF

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychological Services
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Part B Services
TOTALS (Sum of lines 2-14)

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Fr. Wkst. B,
Col 6, Line:
16
7
8
9
12
13

16
17
18
19
20
21

Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Supplies
Drugs Charged to Patients

23

Total (Sum of lines 16 through 21)
(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
24 Total CORF costs - Add the amount from Part I, column 9, line 15 and the amount from Part II, column 9, line 23.
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.

16
17
18
19
20
21
23

4

5

6

7

8

9

24

* 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.15-2, SECS. 3222-3222.3)

Rev. 9

32-329

3290 (Cont.)

FORM CM S-1728-94

ALLOCATION OF GENERAL SERVICE
COSTS TO CORF COST CENTERS

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

CORF COST CENTER
(OMIT CENTS)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

08-99
PROVIDER NO.:
___________________
CORF NO.:
___________________

BLDGS &
FIXTURES
(SQUARE
FEET)
1

MOVABLE
EQUIPMENT
(SQUARE
FEET)
2

PLANT
OPERATION
& MAINTENANCE
(SQUARE
FEET)
3

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychological Services
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Part B Services
TOTALS (Sum of lines 1-14)
Total Cost to be Allocated
Unit Cost Multiplier

TRANSPORTATION
(MILEAGE)
4

PERIOD:
FROM: _____________
TO: ________________

RECONCILIATION
5A

WORKSHEET J-1
PART III

ADMINISTRATIVE
& GENERAL
(ACCUMULATED
COST)
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

FORM CMS 1728-94-J-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SEC. 3221.3)

32-328

Rev. 7

3290 (Cont.)

CALCULATION OF REIMBURSEMENT

FORM CM S-1728-94
CORF NO.:

FROM: _______________

___________________

TO: _________________

05-00
WORKSHEET J-3

SETTLEMENT - CORF SERVICES

PART I-COMPUTATION OF CUSTOMARY CHARGES FOR CORF SERVICES

1
1.1
1.2

Total reasonable cost of CORF services (See instructions)

1

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

1.1

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

Total CORF charges

4

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
10
11
11.1
11.2

Cost of CORF services (From line 3 )

9

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

10

Net Cost (Line 9 minus line 10)

11

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

11.1

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
23.5

Interim payments
Tentative settlement (For intermediary use only)

23
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. 15-2, SEC. 3223-3223.2

32-330

Rev. 9

05-07

FORM CM S-1728-94

ANALYSIS OF PAYMENTS TO
PROVIDER-BASED CORF FOR
SERVICES RENDERED TO PROGRAM
BENEFICIARIES

CORF NO.:
___________________

3290 (Cont.)
FROM: _______________
TO: _________________

DESCRIPTION
1
2
3

Total interim payments paid to CORF
Interim payments payable on individual bills either, submitted or to
be submitted to the intermediary, for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
List separately each retroactive lump sum
adjustment amount based on subsequent revision
of the interim rate for the cost reporting period.
Also show date of each payment. If none write
"NONE" or enter a zero. (1)

PART B
1
2
mm/dd/yyyy
Amount
1
2

Program
to
Provider
Provider
to
Program

4

WORKSHEET J-4

SUBTOTAL (Sum of lines 3.01-3.49, minus sum
of lines 3.50-3.98)
TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)
'(Transfer to Supp. Wkst J-3, Part II, line 23)

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54

.99

3.99
4

TO BE COMPLETED BY INTERMEDIARY
5

6

7

List separately each tentative settlement payment
after desk review. Also show date of each
payment. If none, write "NONE" or enter
a zero. (1)
SUBTOTAL (Sum of lines 5.01-5.49, minus sum
'of lines 5.50-5.98)
Determine net settlement amount (balance due) based
'on the cost report (SEE INSTRUCTIONS). (1)

Program
to
Provider
Provider
to
Program
Program
to
Provider
Provider
to
Program

.01
.02
.03
.50
.51
.52

5.01
5.02
5.03
5.50
5.51
5.52

.99

5.99

.01

6.01

.02

6.02
7

TOTAL MEDICARE PROGRAM LIABILITY (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-J-4 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2,
SEC. 3224

Rev. 13

32-331

3290 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

COST CENTER DESCRIPTIONS

1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34

SALARIES
(From
Wkst.K-1)
1

EMPLOYEE
BENEFITS TRANSPOR(From
TATION
Wkst. K-2)
(See inst.)
2
3

FORM CM S-1728-94
PROVIDER NO:
____________
HOSPICE NO.:
____________
CONTRACTED
SERVICES
(From
Wkst. K-3)
4

OTHER
5

TOTAL
(cols. 1-5)
6

RECLASSIFICATION
7

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
Inpatient - General Care
Inpatient - Respite Care
VISITING SERVICES
Physician Services
Nursing Care
Nursing Care - Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
Home Health Aide and Homemaker-Cont Home Care
Other
OTHER HOSPICE SERVICE COSTS
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives/Hypnotics
Other - specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
HOSPICE NONREIMBURSABLE SERV.
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Total (sum of line 1 thru 33)
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.

PERIOD:
FROM: ____________
TO: _______________

SUBTOTAL
(col. 6
± col. 7)
8

ADJUSTMENTS
9

05-07
WORKSHEET K

TOTAL
(col. 8
± col. 9)
10
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34

FORM CMS-1728-94-K (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3240)
32-331.1

Rev. 13

05-07
COMPENSATION ANALYSIS - SALARIES AND WAGES

COST CENTER DESCRIPTIONS
(omit cents)

FORM CM S-1728-94
PROVIDER NO:
____________
HOSPICE NO.:
____________
ADMINIS
TRATOR
1

DIRECTOR
2

SOCIAL
SERVICES
3

SUPERVISORS
4

NURSES
5

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
10.20 Nursing Care - Continuous Home Care
11 Physical Therapy
12 Occupational Therapy
13 Speech/ Language Pathology
14 Medical Social Services
15 Spiritual Counseling
16 Dietary Counseling
17 Counseling - Other
18 Home Health Aide and Homemaker
18.20 Home Health Aide and Homemaker-Cont Home Care
19 Other
OTHER HOSPICE SERVICE COSTS
20 Drugs Biological and Infusion Therapy
20.30 Analgesics
20.31 Sedatives/Hypnotics
20.32 Other - specify
21 Durable Medical Equipment/ Oxygen
22 Patient Transportation
23 Imaging Services
24 Labs and Diagnostics
25 Medical Supplies
26 Outpatient Services (incl. E/R Dept.)
27 Radiation Therapy
28 Chemotherapy
29 Other
HOSPICE NONREIMBURSABLE SERV.
30 Bereavement Program Costs
31 Volunteer Program Costs
32 Fundraising
33 Other Program Costs
34 Total (sum of line 1 thru 33)
(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. 15-2, SECTION 3241)
1
2
3
4
5
6

Rev. 13

PERIOD:
FROM: ____________
TO: _______________

TOTAL
THERAPISTS
6

AIDES
7

ALL OTHER
8

3290 (Cont.)
WORKSHEET K-1

TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34

32-331.2

3290 (Cont.)
COMPENSATION ANALYSIS - EMPLOYEE BENEFITS (PAYROLL RELATED)

COST CENTER DESCRIPTIONS
(omit cents)

ADMINIS
TRATOR
1

FORM CM S-1728-94
PROVIDER NO:
____________
HOSPICE NO.:
____________

DIRECTOR
2

SOCIAL
SERVICES
3

SUPERVISORS
4

NURSES
5

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
10.20 Nursing Care - Continuous Home Care
11 Physical Therapy
12 Occupational Therapy
13 Speech/ Language Pathology
14 Medical Social Services
15 Spiritual Counseling
16 Dietary Counseling
17 Counseling - Other
18 Home Health Aide and Homemaker
18.20 Home Health Aide and Homemaker-Cont Home Care
19 Other
OTHER HOSPICE SERVICE COSTS
20 Drugs Biological and Infusion Therapy
20.30 Analgesics
20.31 Sedatives/Hypnotics
20.32 Other - specify
21 Durable Medical Equipment/ Oxygen
22 Patient Transportation
23 Imaging Services
24 Labs and Diagnostics
25 Medical Supplies
26 Outpatient Services (incl. E/R Dept.)
27 Radiation Therapy
28 Chemotherapy
29 Other
HOSPICE NONREIMBURSABLE SERV.
30 Bereavement Program Costs
31 Volunteer Program Costs
32 Fundraising
33 Other Program Costs
34 Total (sum of line 1 thru 33)
(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. 15-2, SECTION 3242)
1
2
3
4
5
6

32-331.3

PERIOD:
FROM: ____________
TO: _______________

TOTAL
THERAPISTS
6

AIDES
7

ALL OTHER
8

05-07
WORKSHEET K-2

TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34

Rev. 13

05-07
COMPENSATION ANALYSIS - CONTRACTED SERVICES/PURCHASED SERVICES

COST CENTER DESCRIPTIONS
(omit cents)

ADMINIS
TRATOR
1

DIRECTOR
2

FORM CM S-1728-94
PROVIDER NO:
____________
HOSPICE NO.:
____________
SOCIAL
SERVICES
3

SUPERVISORS
4

NURSES
5

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
10.20 Nursing Care - Continuous Home Care
11 Physical Therapy
12 Occupational Therapy
13 Speech/ Language Pathology
14 Medical Social Services
15 Spiritual Counseling
16 Dietary Counseling
17 Counseling - Other
18 Home Health Aide and Homemaker
18.20 Home Health Aide and Homemaker-Cont Home Care
19 Other
OTHER HOSPICE SERVICE COSTS
20 Drugs, Biological and Infusion Therapy
20.30 Analgesics
20.31 Sedatives/Hypnotics
20.32 Other - specify
21 Durable Medical Equipment/Oxygen
22 Patient Transportation
23 Imaging Services
24 Labs and Diagnostics
25 Medical Supplies
26 Outpatient Services (incl. E/R Dept.)
27 Radiation Therapy
28 Chemotherapy
29 Other
HOSPICE NONREIMBURSABLE SERV.
30 Bereavement Program Costs
31 Volunteer Program Costs
32 Fundraising
33 Other Program Costs
34 Total (sum of line 1 thru 33)
(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. 15-2, SECTION 3243)
1
2
3
4
5
6

Rev. 13

TOTAL
THERAPISTS
6

PERIOD:
FROM: ____________
TO: _______________

AIDES
7

ALL OTHER
8

3290 (Cont.)
WORKSHEET K-3

TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34

32-331.4

3290 (Cont.)
COST ALLOCATION - HOSPICE GENERAL SERVICE COST

COST CENTER DESCRIPTIONS

FORM CM S-1728-94
PROVIDER NO:
____________
HOSPICE NO.:
____________
NET
EXPENSES
FOR COST
ALLOC.
(FR. WKST K,
COL. 10)
0

CAPITAL RELATED
COST
BUILDINGS
MOVABLE
& FIXTURES EQUIPMENT
1
2

PLANT
OPERATION
& MAINT.
3

VOLUNTEER
SERVICES
TRANSCOORDIPORTATION
NATOR
4
5

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
10.20 Nursing Care - Continuous Home Care
11 Physical Therapy
12 Occupational Therapy
13 Speech/ Language Pathology
14 Medical Social Services - Direct
15 Spiritual Counseling
16 Dietary Counseling
17 Counseling - Other
18 Home Health Aide and Homemakers
18.20 Home Health Aide and Homemaker-Cont Home Care
19 Other
OTHER HOSPICE SERVICE COSTS
20 Drugs, Biologicals and Infusion
20.30 Analgesics
20.31 Sedatives/Hypnotics
20.32 Other - specify
21 Durable Medical Equipment/Oxygen
22 Patient Transportation
23 Imaging Services
24 Labs and Diagnostics
25 Medical Supplies
26 Outpatient Services (incl. E/R Dept.)
27 Radiation Therapy
28 Chemotherapy
29 Other
HOSPICE NONREIMBURSABLE SERV.
30 Bereavement Program Costs
31 Volunteer Program Costs
32 Fundraising
33 Other Program Costs
34 Total (sum of line 1 thru 33)
FORM CMS-1728-94-K-4 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3244)
1
2
3
4
5
6

32-331.5

PERIOD:
FROM: ____________
TO: _______________

SUBTOTAL
(col. 0 - 5)
5A

ADMINISTRATIVE &
GENERAL
6

05-07
WORKSHEET K-4
PART I

TOTAL
7
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34

Rev. 13

05-07
COST ALLOCATION - HOSPICE STATISTICAL BASIS

COST CENTER DESCRIPTIONS

1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
34
25
26
27
28
29
30
31
32
33
34
35

FORM CM S-1728-94
PROVIDER NO:
_______________
HOSPICE NO.:
_______________
CAPITAL RELATED
COST
BUILDINGS
MOVABLE
& FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

PLANT
OPERATION
& MAINT.
(SQ. FT.)
3

PERIOD:
FROM: ____________
TO: _______________

TRANSPORTATION
(MILEAGE)
4

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Plant Operation and Maintenance
Transportation-staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
Inpatient - General Care
Inpatient - Respite Care
VISITING SERVICES
Physician Services
Nursing Care
Nursing Care - Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
Home Health Aide and Homemaker-Cont Home Care
Other
OTHER HOSPICE SERVICE COSTS
Drugs, Biologicals and Infusion
Analgesics
Sedatives/Hypnotics
Other - specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
HOSPICE NONREIMBURSABLE SERV.
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Cost To be Allocated (per Wkst K-4, Part I)
Unit Cost Multiplier

VOLUNTEER
SERVICES
COORDINATOR
(HOURS)
5

RECONCILIATION
6A

3290 (Cont.)
WORKSHEET K-4
PART II

ADMINISTRATIVE &
GENERAL
(ACC. COST)
6
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

FORM CMS-1728-94-K-4 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3244)
Rev. 13

32-331.6

3290 (Cont.)

FORM CM S-1728-94

05-07

ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS

PROVIDER NO:

PERIOD:

_________________

FROM: ____________

HOSPICE NO.:

TO: _______________

WORKSHEET K-5
PART I

_________________

HOSPICE COST CENTER
(omit cents)

1
2
3
4
5
5.20
6
7
8
9
10
11
12
13
13.20

Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care - Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
Home Health Aide and

From
Wkst. K-4
Part I,
col. 7,
line
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20

HOSPICE
TRIAL
BALANCE
(1)
0

CAPITAL RELATED
COST
BUILDINGS
MOVABLE
& FIXTURES
EQUIPMENT
1
2

PLANT
OPERATION
& MAINTENANCE
3

TRANSPORTATION
4

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE &
GENERAL
5

SUBTOTAL
6

ALLOCATED
HOSPICE
A& G (see
Part II)
7

TOTAL
HOSPICE
COSTS
(col 6 + col. 7)
8
1
2
3
4
5
5.20
6
7
8
9
10
11
12
13
13.20

Homemaker-Cont Home Care

14
15
15.30
15.31
15.32
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Other
19
Drugs, Biologicals and Infusion
20
Analgesics
20.30
Sedatives/Hypnotics
20.31
Other - specify
20.32
Durable Medical Equipment/Oxygen
21
Patient Transportation
22
Imaging Services
23
Labs and Diagnostics
24
Medical Supplies
25
Outpatient Services (incl. E/R Dept.)
26
Radiation Therapy
27
Chemotherapy
28
Other
29
Bereavement Program Costs
30
Volunteer Program Costs
31
Fundraising
32
Other Program Costs
33
Totals (sum of lines 1-28) (2)
Unit Cost Multiplier: column 6, line 1 divided by the sum of column 6, line 29
minus column 6, line 1, rounded to 6 decimal places.

14
15
15.30
15.31
15.32
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

(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. 15-2, SECTION 3245-3245.1)

32-331.7

Rev. 13

05-07
ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS
STATISTICAL BASIS

HOSPICE COST CENTER

1
2
3
4
5
5.20
6
7
8
9
10
11
12
13
13.20
14
15
15.30
15.31
15.32
16
17
18

19
20
21
22
23
24
25
26
27
28
29
30
31

FORM CM S-1728-94
PROVIDER NO:
______________
HOSPICE NO.:
______________
CAPITAL RELATED
COST
BUILDINGS
MOVABLE
& FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care - Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
Home Health Aide and Homemaker-Cont Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedatives/Hypnotics
Other - specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-28)
Total cost to be allocated
Unit Cost Multiplier

PERIOD:
FROM: ____________
TO: _______________
PLANT
OPERATION
& MAINTENANCE
(SQUARE
FEET)
3

TRANSPORTATION
(MILAGE)
4

RECONCILIATION
5A

3290 (Cont.)
WORKSHEET K-5
PART II

ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5
1
2
3
4
5
5.20
6
7
8
9
10
11
12
13
13.20
14
15
15.30
15.31
15.32
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

FORM CMS-1728-94-K-5 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3245.2)
Rev. 13

32-331.8

3290 (Cont.)
ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS
COMPUTATION OF TOTAL HOSPICE SHARED COSTS
Hospice shared cost computation

COST CENTER
ANCILLARY SERVICE COST CENTERS
1 Physical Therapy
2 Occupational Therapy
3 Speech/ Language Pathology
4 Medical Social Services - Direct
5 Durable Medical Equipment/Oxygen
6 Medical Supplies
7 Totals (sum of lines 1-7)

05-07

FORM CM S-1728-94
PROVIDER NO.: _____________
HOSPICE NO.: ____________

From Wkst B,
col. 6, line:
1

Total HHA
Costs
2

7
8
9
10
14
12

PERIOD:
FROM: ___________
TO: ___________
Total HHA
Charges
(from Provider
Records)
3

Cost to
Charge
Ratio
(col. 2/col.3)
4

Total
Hospice
Charges
(from Provider
Records)
5

WORKSHEET K-5
Part III
Hospice
Shared
Ancillary
Costs
(col. 4 x col. 5)
6
1
2
3
4
5
6
7

FORM CMS-1728-94-K-5 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3245.3)

32-331.9

Rev. 13

06-01

FORM CMS-1728-94

CALCULATION OF PER DIEM COST

PROVIDER NO:
_______________
HOSPICE NO.:
_______________

COMPUTATION OF PER DIEM COST

3290 (Cont.)
PERIOD:
FROM: ____________
TO: _______________

TITLE XVIII
1

TITLE XIX
2

1 Total cost (Worksheet K-5, Part I, col. 8, line 29 less col. 8, line 28
plus Worksheet K-5, Part III, col. 6, line 7) (see instructions)
2 Total Unduplicated Days (Worksheet S-5, line 5, col. 4)
3 Average cost per diem (line 1 divided by line 2)
4 Unduplicated Medicare Days (Worksheet S-5, line 5, col. 1)
5 Aggregate Medicare cost (line 3 times line 4)
6 Unduplicated Medicaid Days (Not Applicable)
7 Aggregate Medicaid cost (Not Applicable)
8 Unduplicated SNF days (Worksheet S-5, line 5, col. 2)
9 Aggregate SNF cost (line 3 times line 8)
10 Unduplicated NF days (Not Applicable)
11 Aggregate NF cost (Not Applicable)
12 Other unduplicated days (Worksheet S-5, line 5, col. 3)
13 Aggregate cost for other days (line 3 times line 12)

WORKSHEET K-6

OTHER
3

TOTAL
4
1
2
3
4
5
6
7
8
9
10
11
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. 15-2, SECTION 3246)

Rev. 10

32-331.10

3290 (Cont.)
ALLOCATION OF GENERAL SERVICE
COSTS TO CMHC COST CENTERS

FORM CM S-1728-94
PROVIDER NO.:
___________________
CMHC NO.:
___________________

PART I - ALLOCATION OF GENERAL SERVICE COSTS TO CMHC COST CENTERS
NET
CAPITAL
EXPENSES
RELATED COSTS
CMHC COST CENTER
FOR COST
BLDGS &
MOVABLE
ALLOCATION (1 FIXTURES
EQUIPMENT
(OMIT CENTS)
0
1
2
1 Administrative and General
2 Drugs and Biologicals
#REF!
3 Occupational Therapy
#REF!
4 Psychiatric/Psychological Services
#REF!
5 Individual Therapy
#REF!
6 Group Therapy
#REF!
7 Family Counseling
#REF!
8 Individualized Activity Therapy
#REF!
9 Diagnostic Therapy
#REF!
10 Patient Training and Education
#REF!
11 Other Part B Services
12 TOTALS (Sum of lines 1-11) (2)
#REF!
(1) Column 0, line 12 must agree with Wkst. A, column 10, line 26.
(2) Columns 0 through 5, line 12 must agree with the corresponding columns of Wkst. B, line 26.

PLANT
OPERATION
& MAINTENANCE
3

TRANSPORTATION
4

#REF!
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
2 Amount from Part I, column 6, line 1
3 Line 1 minus line 2
4 Unit cost multiplier for CMHC A& G costs (Line 2 divided by line 3)(multiply each amount in column 6,
lines 2 through 11, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)

06-01
WORKSHEET CM-1
PARTS I & II

PERIOD:
FROM: _______________
TO: _________________

ADMINISTRATIVE
& GENERAL
5

SUBTOTAL
(cols. 0-4)
4A

SUBTOTAL
6

ALLOCATED
CMHC
A& G (SEE
PART II)
7

TOTAL
(SUM OF
COLS 6 & 7)
8
1
2
3
4
5
6
7
8
9
10
11
12

#REF!

0
1
2
3
4

FORM CMS 1728-94-CM-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SECS. 3225-3225.2)
32-332

Rev. 10

3290 (Cont.)

FORM CM S-1728-94
PROVIDER NO.:
___________________
CMHC NO.:
___________________

COMPUTATION OF CMHC COSTS

03-04
WORKSHEET CM-2

PERIOD:
FROM: _______________
TO: __________________

PART I - APPORTIONMENT OF CMHC COST CENTERS

CMHC COST CENTER
(OMIT CENTS)

1
2
3
4
5
6
7
8
9
10
11
12

Administrative and General
Drugs and Biologicals
Occupational Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Family Counseling
Individualized Activity Therapy
Diagnostic Therapy
Patient Training and Education
Other Part B Services
TOTALS (Sum of lines 2-11)

PART II - APPORTIONMENT OF COST OF CMHC
SERVICES FURNISHED SHARED BY HHA DEPARTMENTS
13
14
15
16

TOTAL
CMHC
CHARGES (2)

RATIO OF
COSTS TO
CHARGES
(COL. 1 /
COL. 2)

TOTAL
TITLE XVIII
CMHC
CHARGES

TOTAL
TITLE XVIII
CMHC COSTS
(COL. 3 x
COL. 3.01)

1

2

3

3.01

3.02

100,000

120,000

0.833333

47,000
52,000
26,000

59,000
65,000
37,000

0.796610
0.800000
0.702703

TOTAL COSTS
(FROM SUPP.
WKST. CM-1, PT
I, COL. 8) (1)

75000

TITLE XVIII
TITLE XVIII
CMHC
CMHC COSTS
TITLE XVIII
CHARGES ON ON OR AFTER
CMHC
COSTS PRIOR
OR AFTER
8/1/00, 1/1/02,
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
4
5
6

62,500

0

0

62,500

Fr. Wkst. B,
Col 6, Line:
8
10
12

Occupational Therapy
Medical Social Services
Supplies
Total (Sum of lines 13-15)
(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
17 Total CMHC costs - Add the amount from Part I, column 6, line 12 and the amount from Part II, column 6, line 16.
Add the amounts from Part I, line 12 and Part II, line 16 for columns 3.01, 3.02 and 4 through 6, respectively.

1
2
3
4
5
6
7
8
9
10
11
12

13
14
15
16

3.01

3.02

4

5

6
17

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.15-2, SECS. 3226-3226.3)
32-334

Rev. 12

03-04

FORM CM S-1728-94

3290 (Cont.)

ALLOCATION OF GENERAL SERVICE
COSTS TO CMHC COST CENTERS

PROVIDER NO.:
___________________
CMHC NO.:
___________________

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

CMHC COST CENTER
(OMIT CENTS)
1
2
3
4
5
6
7
8
9
10
11
12
13
14

BLDGS &
FIXTURES
(SQUARE
FEET)
1

MOVABLE
EQUIPMENT
(SQUARE
FEET)
2

PLANT
OPERATION
& MAINTENANCE
(SQUARE
FEET)
3

Administrative and General
Drugs and Biologicals
Occupational Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Family Counseling
Individualized Activity Therapy
Diagnostic Therapy
Patient Training and Education
Other Part B Services
TOTALS (Sum of lines 1-11)
Total Cost to be Allocated
Unit Cost Multiplier

TRANSPORTATION
(MILEAGE)
4

PERIOD:
FROM: _____________
TO: ______________

RECONCILIATION
5A

WORKSHEET CM-1
PART III

ADMINISTRATIVE
& GENERAL
(ACCUMULATED
COST)
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14

FORM CMS 1728-94-CM-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SEC. 3225.3)

Rev. 12

32-333

05-13

FORM CM S-1728-94

CALCULATION OF REIMBURSEMENT
SETTLEMENT - CMHC SERVICES

PROVIDER CCN:
___________________
CMHC CCN:

3290 (Cont.)
PERIOD:
FROM: _______________
TO: _________________

WORKSHEET CM-3

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

1
1.01
1.02
1.03
1.04
1.05
2

3

4

5
6
7

8
9

DESCRIPTION
Total reasonable cost (see instructions)
CMHC PPS payments including outlier payments
1996 CMHC specific payment to cost ratio (obtain this ratio from your intermediary)
Line 1, column 1 times 1.02
Line 1.01 divided by line 1.03
CMHC transitional corridor payment (see instructions)
Total charges for CMHC Services

1

CUSTOMARY CHARGES
Amounts actually collected from patients liable
for payments for services on a charge basis (from
your records)
Amount that would have been realized from patients
liable for payment for services on a charge basis
had such payment been made in accordance with
42 CFR 413.13(b)
Ratio of line 3 to line 4 (not to exceed 1.000000)
Total Customary charges - title XVIII
(see instructions)
Excess of total customary charges over total
reasonable cost (complete only if line 6
exceeds line 1)
Excess of reasonable costs over customary charges
(complete only if line 1 exceeds line 6)
Primary payer amounts

1

PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT
10
Cost of CMHC services (see instructions)
11
Part B deductible billed to Program patients (exclude coinsurance amounts)
12
Excess of reasonable costs (see instructions)
13
Net cost (line10 minus lines 11 and 12)
14
80% of Part B cost (80% x line 13) (see instructions)
15
Actual coinsurance billed to Program patients (from your records)
16
Net cost less actual billed coinsurance (Line 13 minus line 15)
17
Reimbursable bad debts (see instructions)

17.01
17.02
18
19
20
21
22
23
24
25
25.5
26
27
28

1.01
1
1.01
1.02
1.03
1.04
1.05
2
1.01
3

4

5
6
7

8
9

1

1.01

Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)

Net reimbursable amount (see instructions)
Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets
Recovery of excess depreciation resulting from facility's termination or a decrease in Program utilization
Other adjustments (specify)
Total Cost (Sum of line 18, columns 1 and 2, minus lines 19 and 20, plus or minus line 21)
Sequestration adjustment (see instructions)
Amount due provider (Line 22 minus line 23)
Interim payments
Tentative settlement (for contractor use only)
Balance due CMHC/Program (Line 24 minus line 25) (Indicate overpayments in brackets)
Protested amounts (see instructions)
Balance due CMHC/Program (Line 26 minus line 27) (Indicate overpayments in brackets)

10
11
12
13
14
15
16
17

17.01
17.02
18
19
20
21
22
23
24
25
25.5
26
27
28

FORM CMS 1728-94-CM-3 (5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC.
3227-3227.2)

Rev. 16

32-335

3290 (Cont.)
ANALYSIS OF PAYMENTS TO PROVIDER
FOR CMHC SERVICES RENDERED
TO PROGRAM BENEFICIARIES

FORM CM S-1728-94
PROVIDER CCN:
___________________
CMHC CCN:

05-13

PERIOD:
FROM: _______________
TO: _________________

WORKSHEET CM-4

PART B
1
2
mm/dd/yyyy
Amount
1
2
3

Total interim payments paid to provider (CMHC services)
Interim payments payable on individual bills either, submitted or to
be submitted to the contractor , for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
List separately each retroactive lump sum
adjustment amount based on subsequent revision
of the interim rate for the cost reporting period.
Also show date of each payment. If none write
"NONE" or enter a zero. (1)

1
2

Program
to
Provider

Provider
to
Program

4

SUBTOTAL (Sum of lines 3.01-3.05, minus sum
of lines 3.50-3.54)
TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)
(Transfer to Supp. Wkst CM-3, Part II, line 25)

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54

.99

3.99
4

TO BE COMPLETED BY CONTRACTOR
5

6

7

List separately each tentative settlement payment
after desk review. Also show date of each
payment. If none, write "NONE" or enter
a zero. (1)

SUBTOTAL (Sum of lines 5.01-5.03, minus sum
of lines 5.50-5.52)
Determine net settlement amount (balance due) based
on the cost report (SEE INSTRUCTIONS). (1)

Program
to
Provider
Provider
to
Program

Program
to
Provider
Provider
to
Program

.01
.02
.03
.50
.51
.52

5.01
5.02
5.03
5.50
5.51
5.52

.99

5.99

.01

6.01

.02

6.02
7

TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)

Name of Contractor

Contractor 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 (5-2013 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
PUB. 15-2, SEC. 3228

32-336

Rev. 16

08-99

FORM CM S-1728-94

3290 (Cont.)

PROVIDER NO.:
___________________
RHC NO.:
___________________

ALLOCATION OF GENERAL SERVICE
COSTS TO RHC COST CENTERS

PERIOD:
FROM: _______________
TO: _________________

WORKSHEET RH-1
PARTS I & II

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

CMHC COST CENTER
(OMIT CENTS)

NET
EXPENSES
FOR COST
ALLOCATION (1)

0
1
2
3
4
5
6
7
8
9
10
11

CAPITAL
RELATED COSTS
BLDGS &
MOVABLE
FIXTURES
EQUIPMENT
1
2

PLANT
OPERATION
& MAINTENANCE
3

TRANSPORTATION
4

A& G
SHARED
COSTS
5

SUBTOTAL
(cols. 0-4)
4A

Administrative and General
Physicians
Nurse Practitioner
Physician Assistant
Clinical Psychologist
Clinical Social Worker
Visiting Nurses
Other Part B Services

TOTAL
(SUM OF
COLS 6 & 7)
8
1
2
3
4
5
6
7
8
9
10
11

Drugs Charged to Patients
TOTALS (Sum of lines 1-10) (2)
(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
PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF RHC ADMINISTRATIVE AND GENERAL COSTS
1 Amount from Part I, column 6, line 11
2 Amount from Part I, column 6, line 1
3 Line 1 minus line 2
4 Unit cost multiplier for RHC A& G costs (Line 2 divided by line 3)(multiply each amount in column 6,
lines 2 through 10, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)

SUBTOTAL
6

ALLOCATED
RHC
A& G (SEE
PART II)
7

0

0
1
2
3
4

FORM CMS 1728-94-RH-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SECS. 3229-3229.2)

Rev. 7

32-337

08-99

FORM CM S-1728-94

COMPUTATION OF RHC COSTS

3290 (Cont.)

PROVIDER NO.:
___________________
RHC NO.:
___________________

PERIOD:
FROM: _______________
TO: __________________

WORKSHEET RH-2

PART I - APPORTIONMENT OF RHC COST CENTERS
TOTAL COSTS
(FROM SUPP.
WKST. RH-1, PT.
I, COL. 8) (1)
1

RHC COST CENTER
(OMIT CENTS)

1
2
3
4
5
6
7
8
9
10
11

Administrative and General
Physicians
Nurse Practitioner
Physician Assistant
Clinical Psychologist
Clinical Social Worker
Visiting Nurses
Other Part B Services
Subtotal (sum of lines 1-8)
Drugs Charged to Patients (Transfer col. 5 to Worksheet D, col. 2, line 20)
TOTALS (Sum of lines 9 and 10)

PART II - APPORTIONMENT OF COST OF RHC SERVICES FURNISHED BY HHA DEPARTMENTS
12
13
14
15

Physical Therapy
Occupational Therapy
Speech Pathology
Supplies

17

Total (Sum of lines 12-15)
(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

RATIO OF
TOTAL
COSTS TO
RHC
CHARGES
CHARGES (2) (COL. 1 / COL. 2)
2
3

TITLE XVIII
RHC
CHARGES
4

TITLE XVIII
RHC COSTS
(COL. 3 X
COL. 4)
5
1
2
3
4
5
6
7
8
9
10
11

Fr. Wkst. B
Col 6, Line:
7
8
9
12

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

12
13
14
15
17

18

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

Rev. 7

32-339

3290 (Cont.)

FORM CM S-1728-94

ALLOCATION OF GENERAL SERVICE
COSTS TO RHC COST CENTERS

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

RHC COST CENTER
(OMIT CENTS)
1
2
3
4
5
6
7
8
9
10
11
12
13

08-99
PROVIDER NO.:
___________________
RHC NO.:
___________________

BLDGS &
FIXTURES
(SQUARE
FEET)
1

MOVABLE
EQUIPMENT
(SQUARE
FEET)
2

PLANT
OPERATION
& MAINTENANCE
(SQUARE
FEET)
3

Administrative and General
Physicians
Nurse Practitioner
Physician Assistant
Clinical Psychologist
Clinical Social Worker
Visiting Nurses
Other Part B Services
Drugs Charged to Patients
TOTALS (Sum of lines 1-10)
Total Cost to be Allocated
Unit Cost Multiplier

TRANSPORTATION
(MILEAGE)
4

PERIOD:
FROM: _____________
TO: _____________

RECONCILIATION
5A

WORKSHEET RH-1
PART III

ADMINISTRATIVE
& GENERAL
(ACCUMULATED
COST)
5
1
2
3
4
5
6
7
8
9
10
11
12
13

FORM CMS 1728-94-RH-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SEC. 3229.3)

32-338

Rev. 7

3290 (Cont.)

FORM CM S-1728-94

ALLOCATION OF GENERAL SERVICE
COSTS TO FQHC COST CENTERS
PART I - ALLOCATION OF GENERAL SERVICE COSTS TO FQHC COST CENTERS
NET
CAPITAL
EXPENSES
RELATED COSTS
FQHC COST CENTER
FOR COST
BLDGS &
MOVABLE
ALLOCATION (1)
FIXTURES
EQUIPMENT
(OMIT CENTS)
0
1
2
1
Administrative and General
2
Physicians
3
Nurse Practitioner
4
Physician Assistant
5
Clinical Psychologist
6
Clinical Social Worker
7
Visiting Nurses
8
Preventative Primary Services
9
Other Part B Services
10
11 Drugs Charged to Patients
12 TOTALS (Sum of lines 1-11) (2)
(1) Column 0, line 12 must agree with Wkst. A, column 10, line 28.
(2) Columns 0 through 5, line 12 must agree with the corresponding columns of Wkst. B, line 28.

08-99

PROVIDER NO.:
___________________
FQHC NO.:
___________________
PLANT
OPERATION
& MAINTENANCE
3

PERIOD:
FROM: _______________
TO: _________________

TRANSPORTATION
4

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
2 Amount from Part I, column 6, line 1
3 Line 1 minus line 2
4 Unit cost multiplier for FQHC A& G costs (Line 2 divided by line 3)(multiply each amount in column 6,
lines 2 through 11, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)

A& G
SHARED
COSTS
5

SUBTOTAL
(cols. 0-4)
4A

SUBTOTAL
6

WORKSHEET FQ-1
PARTS I & II

ALLOCATED
FQHC
A& G (SEE
PART II)
7

TOTAL
(SUM OF
COLS 6 & 7)
8
1
2
3
4
5
6
7
8
9
10
11
12

#REF!

0

0
1
2
3
4

FORM CMS 1728-94-FQ-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SECS. 3231-3231.2)

32-340

Rev. 7

3290 (Cont.)

FORM CM S-1728-94

COMPUTATION OF FQHC COSTS

08-99

PROVIDER NO.:
___________________
FQHC NO.:
___________________

PERIOD:
FROM: _______________
TO: __________________

WORKSHEET FQ-2

PART I - APPORTIONMENT OF RHC COST CENTERS
TOTAL COSTS
(FROM SUPP.
WKST. FQ-1, PT.
I, COL. 8) (1)
1

FQHC COST CENTER
(OMIT CENTS)

RATIO OF
TOTAL
COSTS TO
FQHC
CHARGES
CHARGES (2) (COL. 1 / COL. 2)
2
3

TITLE XVIII
FQHC
CHARGES
4

TITLE XVIII
FQHC COSTS
(COL. 3 X
COL. 4)
5

1
2
3
4
5
6
7
8
9
10

Administrative and General
Physicians
Nurse Practitioner
Physician Assistant
Clinical Psychologist
Clinical Social Worker
Visiting Nurses
Preventative Primary Services
Other Part B Services
Subtotal (sum of lines 1-9)

1
2
3
4
5
6
7
8
9
10

11
12

Drugs Charged to Patients (Transfer col. 5 to Worksheet D, col. 2, line 20)
TOTALS (Sum of lines 10and 11)

11
12

PART II - APPORTIONMENT OF COST OF FQHC SERVICES FURNISHED BY HHA DEPARTMENTS
13
14
15
16

Physical Therapy
Occupational Therapy
Speech Pathology
Supplies

18

Total (Sum of lines 13-16)
(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

Fr. Wkst. B
Col 6, Line:
7
8
9
12

13
14
15
16
18

PART III - TOTAL FQHC COSTS

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

32-342

Rev. 7

08-99

FORM CM S-1728-94

3290 (Cont.)

ALLOCATION OF GENERAL SERVICE
COSTS TO FQHC COST CENTERS

PROVIDER NO.:
___________________
FQHC NO.:
___________________

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

FQHC COST CENTER
(OMIT CENTS)
1
2
3
4
5
6
7
8
9
10
11
12
13
14

BLDGS &
FIXTURES
(SQUARE
FEET)
1

MOVABLE
EQUIPMENT
(SQUARE
FEET)
2

PLANT
OPERATION
& MAINTENANCE
(SQUARE
FEET)
3

Administrative and General
Physicians
Nurse Practitioner
Physician Assistant
Clinical Psychologist
Clinical Social Worker
Visiting Nurses
Preventative Primary Services
Other Part B Services
Drugs Charged to Patients
TOTALS (Sum of lines 1-11)
Cost to be Allocated
Unit Cost Multiplier

TRANSPORTATION
(MILEAGE)
4

PERIOD:
FROM: _____________
TO: ________________

RECONCILIATION
5A

WORKSHEET FQ-1
PART III

ADMINISTRATIVE
& GENERAL
(ACCUMULATED
COST)
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14

FORM CMS 1728-94-FQ-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SEC. 3231.3)

Rev. 7

32-341

05-13

FORM CM S-1728-94

ANALYSIS OF HHA-BASED RURAL HEALTH CLINIC/
FEDERALLY QUALIFIED HEALTH CENTER COSTS

Check
Applicable Box:

11
12
13
14
15
16
17
18
19
20
21
22

23
24
25
26
27
28
29
30
31
32

PERIOD:
FROM: ____________
TO: ____________

WORKSHEET RF-1

[ ] RHC
[ ] FQHC

SALARIES
1
1
2
3
4
5
6
7
8
9
10

3290 (Cont.)
PROVIDER CCN:
_______________
COMPONENT CCN:
_______________

EMPLOYEE
BENEFITS
2

TRANSPORTATION
3

CONTRACTED/
PURCHASED
SERVICES
OTHER COSTS
4
5

TOTAL
(sum of col. 1
thru col. 5)
6

RECLASSIFIED
NET EXPENSES
TRIAL
FOR
RECLASSIFIBALANCE
ALLOCATION
CATIONS
(col. 6 + col. 7) ADJUSTMENTS (col. 8 + col. 9)
7
8
9
10

FACILITY HEALTH CARE STAFF COSTS
Physician
Physician Assistant
Nurse Practitioner
Visiting Nurse
Other Nurse
Clinical Psychologist
Clinical Social Worker
Laboratory Technician
Other Facility Health Care Staff Costs
Subtotal (sum of lines 1-9)
COSTS UNDER AGREEMENT
Physician Services Under Agreement
Physician Supervision Under Agreement
Other Costs Under Agreement
Subtotal (sum of lines 11-13)
OTHER HEALTH CARE COSTS
Medical Supplies
Transportation (Health Care Staff)
Depreciation-Medical Equipment
Professional Liability Insurance
Other Health Care Costs
Allowable GME Pass Through Costs
Subtotal (sum of lines 15-20)
Total Cost of Health Care Services (sum of
lines 10, 14, and 21)
COSTS OTHER THAN RHC/FQHC SERVICES
Pharmacy
Dental
Optometry
All other nonreimbursable costs
Non-allowable GME Pass Through Costs
Total Nonreimbursable Costs (sum of lines 23-27)
FACILITY OVERHEAD
Facility Costs
Administrative Costs
Total Facility Overhead (sum of lines 29 and 30)
Total facility costs (sum of lines 22, 28 and 31)
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.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

23
24
25
26
27
28
29
30
31
32

FORM CMS-1728-94-RF-1 (5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3234)

Rev. 16

32-343

3290 (Cont.)
ALLOCATION OF OVERHEAD
TO RHC/FQHC SERVICES

Check
Applicable Box:
VI SI TS AND PRODUCTI VI TY

FORM CM S-1728-94
PROVIDER CCN:
_______________
COMPONENT CCN:
_______________
[ ] RHC
[ ] FQHC

Number
of FTE
Personnel
1

1
2
3
4
5
6
7

7.01
7.02
8
9

Total
Visits
2

PERIOD:
FROM: ____________
TO: ____________

Minimum
Productivity
Visits
Standard (1) (col. 1x col. 3)
3
4

Positions
Physicians
Physician Assistants
Nurse Practitioners
Subtotal (sum of lines 1-3)
Visiting Nurse
Clinical Psychologist
Clinical Social Worker
Medical Nutrition Therapist (FQHC only)
Diabetes Self Management Training (FQHC only)
Total FTEs and Visits (sum of lines 4-7)
Physician Services Under Agreements
(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.

DETERM I NATI ON OF AL L OWABL E COST APPL I CABL E TO RHC/FQHC SERVI CES
10 Total costs of health care services (from Worksheet RF-1, column 10, line 22 less the amount
from Worksheet RF-1, column 10, line 20)
11 Total nonreimbursable costs (from Worksheet RF-1, column 10, line 28)
12 Cost of all services (excluding overhead) (sum of lines 10 and 11)
13 Ratio of RHC/FQHC services (line 10 divided by line 12)
14 Total facility overhead - (from Worksheet RF-1, column 10, line 31) (see instructions)
15 Allowable GME Overhead (see instructions)
16 Net Facility Overhead (line 14 minus line 15)
17 Parent provider overhead allocated to facility (see instructions)
18 Total overhead (sum of lines 16 and 17)
19 Overhead applicable to RHC/FQHC services (line 13 x line 18)
20 Total allowable cost of RHC/FQHC services (sum of lines 10 and 19)

05-13
WORKSHEET RF-2

Greater of
Col. 2 or
Col. 4
5
1
2
3
4
5
6
7

7.01
7.02
8
9

10
11
12
13
14
15
16
17
18
19
20

FORM CMS-1728-94-RF-2 (5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.
15-2, SECTION 3235 - 3235.2)

32-344

Rev. 16

05-13

FORM CMS-1728-94

CALCULATION OF
REIMBURSEMENT SETTLEMENT
FOR RHC/FQHC SERVICES

3290 (Cont.)
PROVIDER CCN:
_______________
COMPONENT CCN:
_______________

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET RF-3

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)
2 Cost of vaccines and their administration (from Worksheet RF-4, line 15)
3 Total allowable cost excluding vaccine (line 1 minus line 2)
4 Total FTEs and Visits (from Wkst. RF-2, col. 5, line 8)
5 Physicians visits under agreement (from Worksheet RF-2, column 5, line 9)
6 Total adjusted visits (line 4 plus line 5)
7 Adjusted cost per visit (line 3 divided by line 6)

1
2
3
4
5
6
7
Calculation of Limit (1)
Rate
Rate
Period 1
Period 2
1
2

8
9

Per visit payment limit (from your intermediary)
Rate for Medicare covered visits (lesser of line 7 or line 8) (See instructions)

8
9

CALCULATION OF SETTLEMENT
10 Medicare covered visits excluding mental health services ( from the PS&R )
11 Medicare cost excluding costs for mental health services (line 9 x line 10)
12 Medicare covered visits for mental health services ( from the PS&R )
13 Medicare covered cost for mental health services (line 9 x line 12)
14 Limit adjustment for mental health services (line 13 x the applicable percentage) (see instructions)
15 Graduate Medical Education Pass Through Cost (see instructions)
15.5 Primary Payer Amounts
16 Total Medicare cost (line 11, columns 1 & 2, plus line 14, columns 1 & 2, plus columns 1 and 2,
line 15 minus line 15.5, columns 1 and 2) (see instructions)
16.01 Total Program Charges (see instructions)(from contractor's records)
16.02 Total Program Preventive Charges (see instructions)(from provider's records)
16.03 Total Program Preventive Costs (see instructions)
16.04 Total Program Non-Preventive Costs (see instructions)
16.05 Total Program Cost (see instructions)

10
11
12
13
14
15
15.5
16
16.01
16.02
16.03
16.04
16.05
1

17
17.5
18
19
20
21
22
22.01
22.02
23
24
24.01
25
25.5
26
27

Less: Beneficiary deductible for RHC only (see instructions) (from contractor records)
Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor records)
Net Medicare cost excluding vaccines (see instrcutions)
Reimbursable cost of RHC/FQHC services, excluding vaccine (see instructions)
Medicare cost of vaccines and their administration (from Worksheet. RF-4, line 16)
Total reimbursable Medicare cost (see instructions )
Reimbursable bad debts
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Other adjustments (specify)
Net reimbursable amounts (see instructions)
Sequestration adjustment (see instructions)
Interim payments (From Worksheet RF-5, line 4)
Tentative settlement (For contractor use only)
Balance due component/program (line 24 minus lines 24.01 and 25)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub.
15-2 , chapter I, section 115.2

17
17.5
18
19
20
21
22
22.01
22.02
23
24
24.01
25
25.5
26
27

(1) Enter chronologically in columns 1, and 2, as applicable, the payment limit and corresponding data.
FORM CMS-1728-94-RF-3 (5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 3236 - 3236.1)

Rev. 16

32-345

3290 (Cont.)

FORM CMS-1728-94

COMPUTATION OF PNEUMOCOCCAL AND
INFLUENZA VACCINE COST

Check
Applicable Box:

1
2
3
4
5
6
7
8
9
10
11
12
13
14

05-13

PROVIDER CCN:
PERIOD:
_______________
FROM: _______
COMPONENT CCN: TO: __________
_______________

WORKSHEET RF-4

[ ] RHC
[ ] FQHC

CALCULATION OF COST
Health care staff cost
(Worksheet RF-1, column 10, line 10)
Ratio of pneumococcal and influenza vaccine
staff time to total health care staff time
Pneumococcal and influenza vaccine
health care staff cost (line 1 x line 2)
Medical supplies cost - pneumococcal and influenza
vaccine (from your records)
Direct cost of pneumococcal and influenza
vaccine (line 3 plus line 4)
Total direct cost of the facility
(Worksheet RF-1, column 10, line 22)
Total facility overhead
(Worksheet RF-2, line 18)
Ratio of pneumococcal and influenza vaccine
direct cost to total direct cost (line 5 divided by line 6)
Overhead cost - pneumococcal and influenza
vaccine (line 7 x line 8)
Total pneumococcal and influenza vaccine cost and
its (their) administration (sum of lines 5 and 9)
Total number of pneumococcal and influenza
vaccine injections (from your records)
Cost per pneumococcal and influenza
vaccine injection (line 10/ line 11)
Number of pneumococcal and influenza vaccine
injections administered to Medicare beneficiaries
Medicare cost of pneumococcal and influenza vaccine
and its (their) administration (line 12 x line 13)

PNEUMOCOCCAL
1

SEASONAL
INFLUENZA
ONLY
2

H1N1
ONLY
2.01

15 Total cost of pneumococcal and influenza vaccine and its (their) administration (sum of columns
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
of columns 1, 2, 2.01 and 2.02, line 14) (transfer this amount to Worksheet RF-3, line 20)

INFLUENZA
& H1N1
(See instructions)
2.02
1
2
3
4
5
6
7
8
9
10
11
12
13
14

15
16

FORM CMS-1728-94-RF-4 (1-2010) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3237)

32-346

Rev. 16

08-99

FORM CM S-1728-94

ANALYSIS OF PAYMENTS TO PROVIDER-BASED
RHC/FQHC FOR SERVICES RENDERED TO
PROGRAM BENEFICIARIES

3290 (Cont.)

PROVIDER NO.:
_______________
COMPONENT NO.:
_______________
[ ] RHC [ ] FQHC

Check Applicable Box:

PERIOD:
FROM: __________
TO: __________

SUPPLEMENTAL
WORKSHEET RF-5

PART B
DESCRIPTION
1
2

3

1
mm/dd/yyyy

Total interim payments paid to RHC/FQHC
Interim payments payable on individual bills either, submitted or to
be submitted to the intermediary, for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
List separately each retroactive lump sum
adjustment amount based on subsequent revision
Program
of the interim rate for the cost reporting period.
to
Also show date of each payment. If none write
Provider
"NONE" or enter a zero. (1)
Provider
to
Program

4

SUBTOTAL (Sum of lines 3.01-3.49, minus sum
of lines 3.50-3.98)
TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)
(Transfer to Supp. Wkst RF-3, Part II, line 25)

2
Amount
1
2

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54

.99

3.99
4

TO BE COMPLETED BY INTERMEDIARY
5

6

7

List separately each tentative settlement payment
after desk review. Also show date of each
payment. If none, write "NONE" or enter
a zero. (1)

SUBTOTAL (Sum of lines 5.01-5.49, minus sum
of lines 5.50-5.98)
Determine net settlement amount (balance due) based
on the cost report (SEE INSTRUCTIONS). (1)

Program
to
Provider
Provider
to
Program

Program
to
Provider
Provider
to
Program
TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)

.01
.02
.03
.50
.51
.52

5.01
5.02
5.03
5.50
5.51
5.52

.99

5.99

.01

6.01

.02

6.02
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. 15-2, SEC. 3238

Rev. 7

32-347