Cms-222-92 Independent Rural Health Clinic/freestanding Federally Q

5-13
Form CMS-222-92
This report is required by law (42 USC. 1395g: CFR 413.20(b)). Failure to report can result
in all payments made during the reporting period being deemed overpayments (42 USC 1395g).
PROVIDER CCN :
INDEPENDENT RURAL HEALTH CLINIC/FREESTANDING
FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET
STATISTICAL DATA AND CERTIFICATION STATEMENT
Intermediary Use Only:
[
] Audited
Date Received ________________
Contractor No. ______________
[
] Desk Reviewed
PART I - STATISTICAL DATA
[ ] Projected Cost Report
Check
[ ] Electronic filed cost report
applicable box
[ ] Manually submitted cost report
1 Name:
1.01 Street:
1.02 City:
State:
1.03 County:
2 CCN:
3 Designation:
4 Reporting Period: From
To

2990 (Cont.)
FORM APPROVED
OMB NO: 0938-0107
PERIOD:
FROM:
TO:
[
] Initial
[ ] Re-opened
[
] Final
[ ] Actual/Final Cost Report
Date:
Time:
1
1.01
1.02
1.03
2
3
4

P.O. Box:
Zip Code:

Type of Control
(see instructions)
1

WORKSHEET
S
PART I

Type of Provider
(see instructions)
3

2

Date Certified
4

5

5
Source of Federal Funds
(see instructions)
1

Grant Award Number
(see instructions)
3

2

Date
4

6

6

7 Names of Physicians Furnishing Services At The Health Facility or Under Agreement
(As Described in Instructions) and Medicare Billing Numbers (Include all Part B Billing Numbers)
Name
1
7.01
7.02
7.03
7.04
7.05
8

7
Billing Number
2
7.01
7.02
7.03
7.04
7.05

Supervisory Physicians

8
Hours of Supervision
For Reporting Period
2

Name
1
8.01
8.02
8.03
8.04
8.05
8.50 Are you claiming allowable GME costs as a result of "substantial payment" for interns and residents?
If yes, enter the number of Medicare visits performed by interns and residents in col. 2 and total visits in
col. 3 performed by interns and residents and complete Worksheet A, lines 20.50 and 53.50 as applicable.
8.51 Have you received an approval for an exception to the productivity standard?

Y/N
1

XVIII
2

TOTAL
3

8.01
8.02
8.03
8.04
8.05
8.50

8.51

FORM CMS-222-92 (05-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 2903 and 2903.1)
Rev. 11

29-303

2990 (Cont.)
Form CMS-222-92
PROVIDER CCN :
INDEPENDENT RURAL HEALTH CLINIC/
FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET
STATISTICAL DATA AND CERTIFICATION STATEMENT
PART I (CONT.) -STATISTICAL DATA
9 Does the facility operate as other than a RHC or FQHC? Enter "Y" for yes or "N" for no.
10 If line 9 is "Y ", specify type of operation. (i.e., physicians office, independent laboratory, etc.)
11 Identify days and hours by listing the time the facility operates as a RHC or FQHC next to the applicable day
Days

05-13
PERIOD:
FROM:
TO:

11.01
Sunday
11.02
Monday
11.03
Tuesday
11.04
Wednesday
11.05
Thursday
11.06
Friday
11.07
Saturday
12 Identify days and hours by listing the time the facility operates as other than a RHC or FQHC next to the applicable day.
Days

WORKSHEET S
PART I (Cont.) &
PART II
9
10
11

Hours of Operation
From
To
11.01
11.02
11.03
11.04
11.05
11.06
11.07
12
Hours of Operation
From
To

12.01
Sunday
12.02
Monday
12.03
Tuesday
12.04
Wednesday
12.05
Thursday
12.06
Friday
12.07
Saturday
13 If this is a low or no Medicare Utilization cost report, enter "L" for low or "N" for n o Medicare u tilization.
14 Is this facility filing a consolidated cost report under CMS Pub. 100-4, chapter 9, section
30.8? Enter "Y" for yes or "N" for no. If yes, see instructions.

12.01
12.02
12.03
12.04
12.05
12.06
12.07
13
14

PART II - CERTIFICATION BY OFFICER OR ADMINISTRATOR
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY
BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER
FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED
THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL,
CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY OFFICER OR ADMINISTRATOR
I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying
electronically filed or manually submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by
______________________________________ (Provider Name and Number) for the cost report period 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 the cost report
were provided in compliance with such laws and regulations.

(Signed)
Officer or Administrator of Facility

Title

Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-0107. The time required to complete this
information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have 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
Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

FORM CMS-222-92 (05-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 2903 and 2903.2)

29-304

Rev. 11

01-05

Form CMS-222-92

INDEPENDENT RURAL HEALTH CLINIC/FREESTANDING
FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET
STATISTICAL DATA AND CERTIFICATION STATEMENT

PROVIDER CCN:
CLINIC CCN:

2990 (Cont.)
PERIOD:
FROM:
TO:

WORKSHEET
S
PART III

PART III - STATISTICAL DATA FOR CLINICS FILING UNDER CONSOLIDATED COST REPORTING
1 Name:
2 Street:
P.O. Box:
3 City:
State:
Zip Code:
4 County:
5 Provider Number:
6 Designation:
Date Certified:
7 Names of physicians furnishing services at the health facility or under agreement
(as described in instructions) and Medicare billing numbers (include all Part B billing numbers)
Name
1
7.01
7.02
7.03
7.04
7.05
8

1
2
3
4
5
6
7
Billing Number
2
7.01
7.02
7.03
7.04
7.05

Supervisory Physicians
Name
1

8
Hours of Supervision
For Reporting Period
2

8.01
8.02
8.03
8.04
8.05
9 Does the facility operate as other than a RHC or FQHC? Enter "Y" for yes or "N" for no.
10 If yes, specify what type of operation. (i.e., physicians office, independent laboratory, etc.)
11 Identify days and hours by listing the time the facility operates as a RHC or FQHC next to the applicable day
Days
Hours of Operation
From
11.01
Sunday
11.02
Monday
11.03
Tuesday
11.04
Wednesday
11.05
Thursday
11.06
Friday
11.07
Saturday
12 Identify days and hours by listing the time the facility operates as other than a RHC or FQHC next to the applicable day.
Days
Hours of Operation
From
12.01
Sunday
12.02
Monday
12.03
Tuesday
12.04
Wednesday
12.05
Thursday
12.06
Friday
12.07
Saturday

8.01
8.02
8.03
8.04
8.05
9
10
11
To
11.01
11.02
11.03
11.04
11.05
11.06
11.07
12
To
12.01
12.02
12.03
12.04
12.05
12.06
12.07

FORM CMS-222-92 (1-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 2903.2)

Rev. 7

29-304.1

Form CMS-222-92
PROVIDER CCN :

05-13
RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES

COST CENTER

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

0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100

Compensation
1

Other
2

2990 (Cont.)
PERIOD:
FROM:
TO:

WORKSHEET A
Page 1
Reclassified

Adjustments

Net

Total

Reclassi-

Trial Balance

Increases

Expenses

(Col. 1 + 2)

fications

(Col. 3 +/- 4)

(Decreases)

(Col. 5 +/- 6)

3

4

5

6

7

FACILITY HEALTH CARE STAFF COSTS
Physician
Physician Assistant
Nurse Practitioner
Visiting Nurse
Other Nurse
Clinical Psychologist
Clinical Social Worker
Laboratory Technician
Other (Specify)

Subtotal-Facility Health Care Staff Costs
COSTS UNDER AGREEMENT
13 1300 Physician Services Under Agreement
14 1400 Physician Supervision Under Agreement
15 1500
16
Subtotal Under Agreement (Lines 13-15)
OTHER HEALTH CARE COSTS
17 1700 Medical Supplies
18 1800 Transportation (Health Care Staff)
19 1900 Depreciation-Medical Equipment
20 2000 Professional Liability Insurance
20.50 2050 Allowable GME Pass Through Costs
21 2100 Other (Specify)
22 2200
23 2300
24
Subtotal-Other Health Care Costs (Lines 17-23)
25
Total Cost of Services (Other Than
Overhead And Other RHC/FQHC Services)
Sum of Lines 12, 16, And 24
FACILITY OVERHEAD-FACILITY COST
26 2600 Rent
27 2700 Insurance
28 2800 Interest On Mortgage Or Loans
29 2900 Utilities

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20.50
21
22
23
24
25

26
27
28
29

FORM CMS-222-92 (05-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 2904)

Rev. 11

29-305

Form CMS-222-92
PROVIDER CCN :

2990 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES

COST CENTER

Compen-

Other

sation

1
30
31
32
33
34
35
36
37

3000
3100
3200
3300
3400
3500
3600

38
39
40
41
42
43
44
45
46
47
48
49
50

3800
3900
4000
4100
4200
4300
4400
4500
4600
4700
4800

51
52
53
53.50
54
55
56
57

5100
5200
5300
5350
5400
5500
5600

58
59
60
61
62

5800
5900
6000

2

05-13
PERIOD:
FROM:
TO:

WORKSHEET A
Page 2
Reclassified

Adjustments

Net

Total

Reclassi-

Trial Balance

Increases

Expenses

(Col. 1 + 2)

fications

(Col. 3 +/- 4)

(Decreases)

(Col. 5 +/- 6)

3

4

5

6

7

Depreciation-Buildings And Fixtures
Depreciation-Equipment
Housekeeping And Maintenance
Property Tax
Other(Specify)

30
31
32
33
34
35
36
37

Subtotal-Facility Costs (Lines 26-36)
FACILITY OVERHEAD-ADMINISTRATIVE COSTS
Office Salaries
Depreciation-Office Equipment
Office Supplies
Legal
Accounting
Insurance
Telephone
Fringe Benefits And Payroll Taxes
Other (Specify)

38
39
40
41
42
43
44
45
46
47
48
49
50

Subtotal-Administrative Cost (Lines 38-48)
Total Overhead (Lines 37 And 49)
COST OTHER THAN RHC/FQHC SERVICES
Pharmacy
Dental
Optometry
Non-allowable GME Pass Through Costs
Other (Specify)

51
52
53
53.50
54
55
56
57

Subtotal-Cost Other Than RHC/FQHC (Lines 51-56)
NON-REIMBURSABLE COSTS (Specify)

Subtotal Non-Reimbursable Costs (Lines 58-60)
TOTAL COSTS (Sum Of Lines 25, 50, 57, And 61)

-0-

58
59
60
61
62

FORM CMS-222-92 (05-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 2904)
29-306

Rev. 11

03-02
RECLASSIFICATIONS

Form CMS-222-92
PROVIDER CCN:

CODE

EXPLANATION OF ENTRY
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
33
34
35
36

(1)
1

COST
CENTER
2

2990 (Cont.)
WORKSHEET A-1

PERIOD:
FROM:
TO:

INCREASE
LINE
NO.
AMOUNT (2)
3
4

COST
CENTER
5

DECREASE
LINE
NO.
AMOUNT (2)
6
7

TOTAL RECLASSIFICATIONS (Sum of Column 4
must equal sum of Column 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
31
32
33
34
35
36

(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer to Worksheet A, Col 4, line as appropriate.
FORM CMS-222-92 (3/93) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 2905)
Rev. 5

29-307

2990 (Cont.)
ADJUSTMENTS TO EXPENSES

Form CMS-222-92
PROVIDER CCN:
PERIOD:

03-02
WORKSHEET A-2

FROM:
TO:
Basis for

Expense Classification on Worksheet A

Adjust-

Description (1)

or to which the amount is to be added

(2)
1
1 Investment income on commingled
restricted and unrestricted funds
(chapter 2)
2 Trade, quantity and time discounts
on purchases (chapter 8)
3 Rebates and refunds of
expenses (chapter 8)
4 Rental of building or office
space to others
5 Home office costs
(chapter 21)
6 Adjustment resulting from transactions
with related organizations
(chapter 10)
7 Vending machines
8 Practitioner Assigned by National
Health Service Corps
9 Depreciation - Buildings and Fixtures
10 Depreciation - Equipment
11 Other (Specify)

from which amount is to be deducted

ment

Amount
2

Cost Center
3

Line No.
4

Depreciation
Depreciation

30
31

B
B

From
Supp. Wkst.
A-2-1

12 Total
(1) Description - all line references in this column pertain to CMS Pub. PRM 15-1.
(2) Basis for adjustment (SEE INSTRUCTIONS)
A. Costs - if cost, including applicable overhead, can be determined.
B. Amount Received - if cost cannot be determined.

62

FORM CMS-222-92 (3/93) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
PUB 15-2, SECTION 2906)
29-308

Rev. 5

05-13

Form CMS-222-92

VISITS AND OVERHEAD COST FOR
RHC/FQHC SERVICES

PROVIDER CCN :

PART I - VISITS AND PRODUCTIVITY

Positions

2990 (Cont.)

1
Number of
FTE
Personnel

PERIOD:
WORKSHEET B
FROM:
PARTS I & II
TO:
Part A - Visits And Productivity
2
3
4
5
Minimum
Greater of
Total
Productivity
Visits
Col. 2 or
Visits
Standard (1) (Col. 1 x Col. 3)
Col. 4

1. Physicians

4200

2. Physician Assistants

2100

3. Nurse Practitioners

2100

4. Subtotal (Sum of lines 1-3)
5. Visiting Nurse
6. Clinical Psychologist
7. Clinical Social Worker
7.01. Medical Nutrition Therapist (FQHC only)
7.02. Diabetes Self Management Training (FQHC only)
8. Total Staff
9. Physician Services
Under Agreement
(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 (Wkst. S, line 8.51 equals "Y"), input
in col. 3, lines 1 through 3, the productivity standards derived by the contractor.
PART II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES
Amount
10. Cost of RHC/FQHC Services - excluding overhead - (Wkst. A, col. 7, line 25 minus wkst. A, col. 7, line 20.5)
11. Cost of Other Than RHC/FQHC Services - Excluding overhead (W/S A, Col. 7, Sum of
Lines 57 and 61)
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 Overhead - (Wkst. A, col. 7, line 50)
14.01. Allowable GME Overhead (See instructions)
14.02. Net Facility Overhead Costs
15. Overhead Applicable to RHC/FQHC Services (See instructions )
16. Total Allowable Cost of RHC/FQHC Services (sum of lines 10 and 15)

FORM CMS-222-92 (05-2013) INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
PUB. 15-2 SECTIONS 2907 THROUGH 2907.2)
Rev. 11

29-309

2990 (Cont. )

Form CMS-222-92

DETERMINATION OF MEDICARE

PROVIDER CCN: PERIOD:

PAYMENT

05-13
WORKSHEET C
PART I

FROM:
TO:

PART I- DETERMINATION OF RATE FOR RHC/FQHC SERVICES
1
2
3
4
5
6
7

AMOUNT

Total Allowable Costs(Worksheet B, Part II, Line 16)
Cost of Pneumococcal and Influenza Vaccine and Its ( Their) Administration
(From Supplemental Worksheet B-1, Line 15)
Total Allowable Cost Excluding Pneumococcal and Influenza Vaccine
(Line 1 - Line 2)
Greater of Minimum Visits or Actual Visits by Health Care Staff
(Worksheet B, Part 1, Column 5, Line 8
Physicians Visits Under Agreements
(Worksheet B, Part 1, Column 5, Line 9)
Total Adjusted Visits
(Line 4 + Line 5)
Adjusted Cost Per Visit
(Line 3 divided by Line 6)

1
2
3
4
5
6
7

1

2

2.01

Rate Period 1

Rate Period 2

Rate Period 3

3

Maximum Rate Per Visit (See Instructions)
9 Rate For Medicare Covered Visits
(Lessor of Line 7 or Line 8)
8

8
9

FORM CMS-222-93 (08-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,
SECTIONS 2908 AND 2908.1)
29-310

Rev. 11

05-13
DETERMINATION OF MEDICARE
PAYMENT
PART II - DETERMINATION OF TOTAL PAYMENT
10
Rate for Medicare Covered Visits (Part I, Line 9)
11 Medicare Covered Visits Excluding Mental Health
Services (From Intermediary Records)
12 Medicare Cost Excluding Costs for Mental Health
Services (Line 10 multiplied by Line 11)
13 Medicare Covered Visits for Mental Health
Services (From Intermediary Records)
14 Medicare Covered Cost for Mental Health
Services (Line 10 multiplied by Line 13)
15 Limit Adjustment
(Line 14 times the applicable percentage) (see instructions)
15.10 Graduate Medical Education Pass Through Cost
(see instructions)
16 Total Medicare Cost
(Line 12 plus line 15 plus line 15.10 )
17 Less: Beneficiary Deductible for RHC only (see instructions)
(From contractor records)
18 Net Medicare Cost Excluding Pneumococcal
and Influenza Vaccine and Its (Their) Administration
(see instructions)
18.01 Total Medicare charges (see instructions)(from
contractor's records (PS&R Report) )
18.02 Total Medicare preventive charges (see instructions)(from
provider's records)
18.03 Total Medicare preventive costs ((line 18.02/line 18.01)
times line 16 )
18.04 Total Medicare non-preventive costs ((line 18 minus
line 18.03) times 80%)
18.05 Net Medicare cost (see instructions)

Form CMS-222-92
PROVIDER PERIOD:
CCN :
FROM:
TO:
1
2
Rate period 1

Rate Period 2

2990 ( Cont. )
WORKSHEET C
PART II
2.01
Rate Period 3

3
10
11
12
13
14
15
15.10
16
17
18

18.01
18.02
18.03
18.04
18.05

18.06 Less: Beneficiary coinsurance for RHC/FQHC services
(see instructions) (from contractor records)
19 Reimbursable Cost of RHC/FQHC Services, Other Than Pneumococcal
and Influenza Vaccine (see instructions)
20 Medicare Cost of Pneumococcal and Influenza Vaccine and
Its (Their) Administration (From Supp. Worksheet B-1, line 16)

18.06

20.50 Other adjustments (specify)
21 Total Reimbursable Medicare Cost (see instructions)

20.50
21

22 Less Payments to RHC/FQHC During Reporting Period
23 Balance Due To/From The Medicare Program
Exclusive of Bad Debts (line 21 less line 22)
24 Total Reimbursable Bad Debts, Net of Bad Debt
Recoveries (From Provider Records)
24.01 Total Gross Reimbursable Bad Debts for Dual Eligible Beneficiaries
(From Provider Records)
24.02 Tentative settlement (for contractor use only)

19
20

22
23
24
24.01
24.02

24.10 Adjusted reimbursable bad debts (see instructions)

24.10

24.11 Sequestration adjustment (see instructions)

24.11

25 Total Amount Due To/From The Medicare Program (see instructions)

25

FORM CMS-222-92 (05-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,
SECTIONS 2908 AND 2908.2)
Rev. 11

29-311

2990 ( Cont. )

Form CMS-222-92

STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS

05-13

PROVIDER CCN:

SUPPLEMENTAL
WORKSHEET A-2-1
PARTS I-III

PERIOD:
FROM:
TO:

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

defined in the Provider Reimbursement Manual, Part I, Chapter 10?
[ ] Yes
[ ] No
(If "Yes", complete Parts II and III )
Part II. Costs incurred and adjustments required (as result of transactions with related organizations):
AMOUNT
ALLOWABLE
IN COST

LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COLUMN 6
Line No.
1

Cost Center
2

Expense Items
3

AMOUNT
4

5

NET
ADJUSTMENT
(COL.4 MINUS
COL. 5)
6

1

1

2

2

3

3

4
5

4
5

TOTALS (sum of lines 1-4) Transfer col. 6, line 1-4 to Wkst. A,col.6 as appropriate)
(Transfer col.6, line 5 to Wkst. A-2, col.2, line 6, Adjustment to Expenses)

Part III. Interrelationship of facility to related organization (s):

The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires the
provider to furnish the information requested on Part III of this worksheet.
This information is used by the Centers for Medicare & Medicaid Services and its intermediaries in determining that the
costs applicable to services, facilities, and supplies furnished by organizations related to you 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 is considered
incomplete and not acceptable for purposes of claiming reimbursement under title XVIII.

SYMBOL
(1)
1

Name
2

Percentage
of
Ownership

3

Name
4

RELATED ORGANIZATION (S)
Percentage
of
Type of
Ownership
Business
5
6

1

1

2

2

3

3

4

4

(1) Use the following symbols to indicate interrelationship to related organizations:
A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in the provider;
B. Corporation, partnership, or other organization has financial interest in the provider;
C. Provider has financial interest in corporation, partnership, or other organization(s);
D. Director, officer, administrator, or key person of the provider or relative of such person has financial interest
in related organization;
E. Individual is director, officer, administrator, or key person of the provider and related organization;
F. Director, officer, administrator, or key person of related organization or relative of such person has
financial interest in the provider;
G. Other (financial or non-financial) specify _____________________________

FORM CMS-222-92 (3-1993) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, Section 2909)
29-312

Rev. 11

01-10
COMPUTATION OF
PNEUMOCOCCAL AND INFLUENZA
VACCINE COST

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

PART 1 - CALCULATION OF COST
Health Care Staff Cost
(Worksheet A, Column 7, Line 12)
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 (Sum of Lines 3 & 4)
Total Direct Cost of the Facility
(Worksheet A, Column 7, Line 25 )
Total Facility Overhead
(Worksheet A, Column 7, Line 50)
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 & 9)
Total Number of Pneumococcal and Influenza
Vaccine Injections (From Provider Records)
Cost Per Pneumococcal and Influenza
Vaccine Injection (Line 10 divided by Line 11)
Number of Pneumococcal and Influenza Vaccine
Injections Administered to Medicare Beneficiaries

Form CMS-222-92
PROVIDER CCN:

1

2

PNEUMOCOCCAL

SEASONAL
INFLUENZA

PERIOD:
FROM:
TO:
2.01

H1N1

2990 ( Cont.)
SUPPLEMENTAL
WORKSHEET B-1
2.02
INFLUENZA
& H1N1
(See instructions)
1
2
3
4
5
6
7
8
9
10
11
12
13

14 Medicare Cost of Pneumococcal and Influenza Vaccine

14

and Its (Their) Administration (Line 12 Multiplied by Line 13)
15 Total Cost of Pneumococcal and Influenza Vaccine and Its (Their) Administration
(Sum of Line 10, Columns 1, 2, 2.01, and 2.02) Transfer to Wkst. C, Part I, Line 2

15

16 Total Medicare Cost of Pneumococcal and Influenza Vaccine and Its (Their) Administration

16

(Sum of Line 14, Columns 1, 2, 2.01, and 2.02) Transfer to Wkst. C, Part II, Line 20

FORM CMS-222-92 (1/2010) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB 15-2, SECTION 2910)
Rev. 8

29-313