| This worksheet is for entering provider information. The top section is for Medicaid ID, NPI, reporting period, and rate period, and will be automatically populated in all other tabs. Following that, Part 1 is for single site or consolidated information. Part 2 is for reporting specific information for each site. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| CCBHC Cost Report | ||||||||||
| This top section is for Medicaid ID, NPI, reporting period, and rate period, and will be automatically populated in all other tabs. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| MEDICAID ID: | ||||||||||
| NPI: | ||||||||||
| REPORTING PERIOD: | From: | To: | ||||||||
| RATE PERIOD: | From: | To: | ||||||||
| WORKSHEET: | Provider Information | |||||||||
| PPS METHODOLOGY: | ||||||||||
| This box for state use only - LEAVE BLANK | ||||||||||
| Select type of oversight: | Audited | Desk Reviewed | ||||||||
| Date reviewed: | ||||||||||
| Part 1 is for single site or consolidated information. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 1 - PROVIDER INFORMATION (Consolidated) | ||||||||||
| 1. Name: | ||||||||||
| 2. Street: | P.O. Box: | |||||||||
| 3. City: | State: | Zip Code: | ||||||||
| 4. County: | ||||||||||
| 5. Medicaid ID: | ||||||||||
| 6. NPI: | ||||||||||
| 7. Location designation (see Cost Report Instructions): | ||||||||||
| 8. Organizational authority (see Cost Report Instructions): | ||||||||||
| 9. Behavioral health professionals (see Cost Report Instructions): | ||||||||||
| Name 1 |
NPI 2 |
|||||||||
| 9a | ||||||||||
| 9b | ||||||||||
| 9c | ||||||||||
| 9d | ||||||||||
| 9e | ||||||||||
| 9f | ||||||||||
| 9g | ||||||||||
| 9h | ||||||||||
| 9I | ||||||||||
| 9j | ||||||||||
| 9k | ||||||||||
| 9l | ||||||||||
| 9m | ||||||||||
| 9n | ||||||||||
| 9o | ||||||||||
| 10. Is the CCBHC dually certified as a 1905(a)(9) clinic? | ||||||||||
| 11. Does the site operate as other than CCBHC? | ||||||||||
| 12. If line 11 is "Yes" specify the type of operation (e.g., clinic, FQHC, other): | ||||||||||
| 13. Identify days and hours the site operates as a CCBHC by listing the time next to the applicable day: | ||||||||||
| Days | Hours of Operation From |
Hours of Operation To |
Total Hours | |||||||
| 13a Sunday | ||||||||||
| 13b Monday | ||||||||||
| 13c Tuesday | ||||||||||
| 13d Wednesday | ||||||||||
| 13e Thursday | ||||||||||
| 13f Friday | ||||||||||
| 13g Saturday | ||||||||||
| 14. Identify days and hours the site operates as other than a CCBHC by listing the time next to the applicable day: | ||||||||||
| Days | Hours of Operation From |
Hours of Operation To |
Total Hours | |||||||
| 14a Sunday | ||||||||||
| 14b Monday | ||||||||||
| 14c Tuesday | ||||||||||
| 14d Wednesday | ||||||||||
| 14e Thursday | ||||||||||
| 14f Friday | ||||||||||
| 14g Saturday | ||||||||||
| 15 | List any excluded satellite facilities and reasons for exclusion. Use the Comments Sheet for additional details. | |||||||||
| 16. Is this site filing a consolidated cost report for multiple locations? If yes, see Cost Report Instructions. | ||||||||||
| 17. How many sites are reported for the consolidated entity? | ||||||||||
| Part 2 is for reporting specific information for each site. Copy and complete this section for each site reported and include as an attachment. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 2 - PROVIDER INFORMATION FOR CLINICS FILING UNDER CONSOLIDATED COST REPORTING (For additional satellite sites, create new tab and copy and paste Part 2 for each additional site included) | ||||||||||
| Site-Specific Information | ||||||||||
| 1. Was this site in existence before April 1, 2014? (No payment will be made to satellite facilities of CCBHCs established after April 1, 2014). |
||||||||||
| 2. Name: | ||||||||||
| 3. Street: | P.O. Box: | |||||||||
| 4. City: | State: | Zip Code: | ||||||||
| 5. County: | ||||||||||
| 6. Medicaid ID: | ||||||||||
| 7. NPI: | ||||||||||
| 8. Location designation (see Cost Report Instructions): | ||||||||||
| 9. Organizational authority (see Cost Report Instructions): | ||||||||||
| 10. Is the CCBHC dually certified as a 1905(a)(9) clinic? | ||||||||||
| 11. Does the site operate as other than CCBHC? | ||||||||||
| 12. If line 11 is "Yes", specify the type of operation (e.g., clinic, FQHC, other): | ||||||||||
| 13. Identify days and hours the site operates as a CCBHC by listing the time next to the applicable day | ||||||||||
| Days | Hours of Operation From |
Hours of Operation To |
Total Hours | |||||||
| 13a Sunday | ||||||||||
| 13b Monday | ||||||||||
| 13c Tuesday | ||||||||||
| 13d Wednesday | ||||||||||
| 13e Thursday | ||||||||||
| 13f Friday | ||||||||||
| 13g Saturday | ||||||||||
| 14. Identify days and hours the site operates as other than a CCBHC by listing the time next to the applicable day | ||||||||||
| Days | Hours of Operation From |
Hours of Operation To |
Total Hours | |||||||
| 14a Sunday | ||||||||||
| 14b Monday | ||||||||||
| 14c Tuesday | ||||||||||
| 14d Wednesday | ||||||||||
| 14e Thursday | ||||||||||
| 14f Friday | ||||||||||
| 14g Saturday | ||||||||||
| End of Worksheet | ||||||||||
| This worksheet is for entering costs from the trial balance, as well as summarize reclassifications, adjustments, and anticipated costs. The top section is for Medicaid ID, NPI, reporting period, and rate period, and is automatically populated from the Provider Information tab. Following that, Part 1 is for entering direct costs for CCBHC services. Part 2 is for entering indirect costs. Part 3 is for entering direct costs for non-CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| CCBHC Cost Report | ||||||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| MEDICAID ID: | ||||||||||
| NPI: | ||||||||||
| REPORTING PERIOD: | From: | To: | ||||||||
| RATE PERIOD: | From: | To: | ||||||||
| WORKSHEET: | Trial Balance | |||||||||
| Part 1 is for entering direct costs for CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 1 - DIRECT CCBHC EXPENSES | ||||||||||
| Part 1A is for entering direct CCBHC staff costs. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 1A - CCBHC STAFF COSTS | ||||||||||
| Description | Compensation 1 |
Other 2 |
Total (Col. 1 + 2) 3 |
Reclassifications 4 |
Reclassified Trial Balance (Col. 3 + 4) 5 |
Adjustments Increases (Decreases) 6 |
Adjusted Amount (Col. 5 + 6) 7 |
Adjustments for Anticipated Cost Changes 8 |
Net Expenses (Col. 7 + 8) 9 |
|
| 1. Psychiatrist | $0 | $0 | $0 | $0 | ||||||
| 2. Psychiatric nurse | $0 | $0 | $0 | $0 | ||||||
| 3. Child psychiatrist | $0 | $0 | $0 | $0 | ||||||
| 4. Adolescent psychiatrist | $0 | $0 | $0 | $0 | ||||||
| 5. Substance abuse specialist | $0 | $0 | $0 | $0 | ||||||
| 6. Case manager | $0 | $0 | $0 | $0 | ||||||
| 7. Recovery coach | $0 | $0 | $0 | $0 | ||||||
| 8. Peer specialist | $0 | $0 | $0 | $0 | ||||||
| 9. Family support specialist | $0 | $0 | $0 | $0 | ||||||
| 10. Licensed clinical social worker | $0 | $0 | $0 | $0 | ||||||
| 11. Licensed mental health counselor | $0 | $0 | $0 | $0 | ||||||
| 12. Mental health professional (trained and credentialed for psychological testing) |
$0 | $0 | $0 | $0 | ||||||
| 13. Licensed marriage and family therapist |
$0 | $0 | $0 | $0 | ||||||
| 14. Occupational therapist | $0 | $0 | $0 | $0 | ||||||
| 15. Interpreter or linguistic counselor | $0 | $0 | $0 | $0 | ||||||
| 16. General practice (performing CCBHC services) |
$0 | $0 | $0 | $0 | ||||||
| 17. Subtotal other staff costs (specify details in Comments tab) |
$0 | $0 | $0 | $0 | ||||||
| 18. Subtotal staff costs (sum of lines 1-17) |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| Part 1B is for entering direct CCBHC costs under agreement. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 1B - CCBHC COSTS UNDER AGREEMENT | ||||||||||
| Description | Compensation 1 |
Other 2 |
Total (Col. 1 + 2) 3 |
Reclassifications 4 |
Reclassified Trial Balance (Col. 3 + 4) 5 |
Adjustments Increases (Decreases) 6 |
Adjusted Amount (Col. 5 + 6) 7 |
Adjustments for Anticipated Cost Changes 8 |
Net Expenses (Col. 7 + 8) 9 |
|
| 19. CCBHC costs from DCO | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 20. Subtotal other CCBHC costs (specify details in Comments tab) |
This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 21. Subtotal costs under agreement (sum of lines 19-20) |
This cell is left intentionally blank. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| Part 1C is for entering other direct CCBHC costs. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 1C - OTHER DIRECT CCBHC COSTS | ||||||||||
| Description | Compensation 1 |
Other 2 |
Total (Col. 1 + 2) 3 |
Reclassifications 4 |
Reclassified Trial Balance (Col. 3 + 4) 5 |
Adjustments Increases (Decreases) 6 |
Adjusted Amount (Col. 5 + 6) 7 |
Adjustments for Anticipated Cost Changes 8 |
Net Expenses (Col. 7 + 8) 9 |
|
| 22. Medical supplies | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 23. Transportation (health care staff) | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 24. Depreciation - medical equipment | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 25. Professional liability insurance | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 26. Telehealth | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 27. Subtotal other direct costs not already included (specify details in Comments tab) |
This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 28. Subtotal other direct CCBHC costs (sum of lines 22-27) |
This cell is left intentionally blank. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| 29. Total cost of CCBHC services (other than overhead) (sum of lines 18, 21, and 28) |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| Part 2 is for entering indirect costs. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 2 - INDIRECT COSTS | ||||||||||
| Part 2A is for entering indirect facility costs. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 2A - SITE COSTS | ||||||||||
| Description | Compensation 1 |
Other 2 |
Total (Col. 1 + 2) 3 |
Reclassifications 4 |
Reclassified Trial Balance (Col. 3 + 4) 5 |
Adjustments Increases (Decreases) 6 |
Adjusted Amount (Col. 5 + 6) 7 |
Adjustments for Anticipated Cost Changes 8 |
Net Expenses (Col. 7 + 8) 9 |
|
| 30. Rent | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 31. Insurance | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 32. Interest on mortgage or loans | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 33. Utilities | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 34. Depreciation - buildings and fixtures | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 35. Depreciation - equipment | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 36. Housekeeping and maintenance | $0 | $0 | $0 | $0 | ||||||
| 37. Property tax | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 38. Subtotal other site costs (specify details in Comments tab) |
$0 | $0 | $0 | $0 | ||||||
| 39. Subtotal site costs (sum of lines 30-38) |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| Part 2B is for entering indirect administrative costs. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 2B - ADMINISTRATIVE COSTS | ||||||||||
| Description | Compensation 1 |
Other 2 |
Total (Col. 1 + 2) 3 |
Reclassifications 4 |
Reclassified Trial Balance (Col. 3 + 4) 5 |
Adjustments Increases (Decreases) 6 |
Adjusted Amount (Col. 5 + 6) 7 |
Adjustments for Anticipated Cost Changes 8 |
Net Expenses (Col. 7 + 8) 9 |
|
| 40. Office salaries | $0 | $0 | $0 | $0 | ||||||
| 41. Depreciation - office equipment | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 42. Office supplies | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 43. Legal | $0 | $0 | $0 | $0 | ||||||
| 44. Accounting | $0 | $0 | $0 | $0 | ||||||
| 45. Insurance | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 46. Telephone | This cell is left intentionally blank. | $0 | $0 | $0 | $0 | |||||
| 47. Subtotal other administrative costs (specify details in Comments tab) |
$0 | $0 | $0 | $0 | ||||||
| 48. Subtotal administrative costs (sum of lines 40-47) |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| 49. Total overhead (sum of lines 39 and 48) |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| Part 3 is for entering direct costs for non-CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 3 - DIRECT COSTS FOR NON-CCBHC SERVICES | ||||||||||
| Part 3A is for entering direct costs for non-CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 3A - DIRECT COSTS FOR SERVICES OTHER THAN CCHBC SERVICES | ||||||||||
| Description | Compensation 1 |
Other 2 |
Total (Col. 1 + 2) 3 |
Reclassifications 4 |
Reclassified Trial Balance (Col. 3 + 4) 5 |
Adjustments Increases (Decreases) 6 |
Adjusted Amount (Col. 5 + 6) 7 |
Adjustments for Anticipated Cost Changes 8 |
Net Expenses (Col. 7 + 8) 9 |
|
| 50. Subtotal direct costs for non-CCBHC services covered by Medicaid (specify details in Comments tab) |
$0 | $0 | $0 | $0 | ||||||
| Part 3B is for entering direct costs that are for non-reimbursable services. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| PART 3B - NON-REIMBURSABLE COSTS | ||||||||||
| Description | Compensation 1 |
Other 2 |
Total (Col. 1 + 2) 3 |
Reclassifications 4 |
Reclassified Trial Balance (Col. 3 + 4) 5 |
Adjustments Increases (Decreases) 6 |
Adjusted Amount (Col. 5 + 6) 7 |
Adjustments for Anticipated Cost Changes 8 |
Net Expenses (Col. 7 + 8) 9 |
|
| 51. Subtotal direct costs for non-CCBHC services not covered by Medicaid (specify details in Comments tab) |
$0 | $0 | $0 | $0 | ||||||
| 52. Total costs for non-CCBHC services (sum of lines 50-51) |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| 53. Total costs (sum of lines 29, 49, and 52) |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| End of Worksheet | ||||||||||
| This worksheet is for entering reclassifications for the trial balance. The top section is for Medicaid ID, NPI, reporting period, and rate period, and is automatically populated from the Provider Information tab. The bottom section is for entering detail to support the reclassification of expenses. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||||
| CCBHC Cost Report | |||||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||||
| MEDICAID ID: | |||||||||
| NPI: | |||||||||
| REPORTING PERIOD: | From: | To: | |||||||
| RATE PERIOD: | From: | To: | |||||||
| WORKSHEET: | Trial Balance Reclassifications | ||||||||
| The bottom section is for entering detail to support the reclassification of expenses. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||||
| Explanation of Entry | Increase: Expense Category 1 |
Increase: Line Number 2 |
Increase: Amount* 3 |
Decrease: Expense Category 4 |
Decrease: Line Number 5 |
Decrease: Amount* 6 |
|||
| 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. | Subtotal of additional reclassifications from the Comments tab | ||||||||
| 36. Total reclassifications (sum of column 3 must equal sum of column 6) |
This cell is left intentionally blank. | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | This cell is left intentionally blank. | $0 | |||
| * Transfer to Trial Balance worksheet, column 4 as appropriate | |||||||||
| End of Worksheet | |||||||||
| This worksheet is for entering detail for adjustments to the trial balance. The top section is for Medicaid ID, NPI, reporting period, and rate period, and is automatically populated from the Provider Information tab. Part 1 is for entering common adjustments. Part 2 is for entering costs not allowed. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||
| CCBHC Cost Report | ||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||
| MEDICAID ID: | ||||||
| NPI: | ||||||
| REPORTING PERIOD: | From: | To: | ||||
| RATE PERIOD: | From: | To: | ||||
| WORKSHEET: | Trial Balance Adjustments | |||||
| Part 1 is for entering common adjustments. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||
| PART 1 - COMMON ADJUSTMENTS | ||||||
| Description | Basis for Adjustment* 1 |
Amount** 2 |
Expense Classification*** 3 |
Line Number 4 |
||
| 1. Investment income on commingled restricted and unrestricted funds |
||||||
| 2. Trade, quantity, and time discounts on purchases | ||||||
| 3. Rebates and refunds of expenses | ||||||
| 4. Rental of building or office space to others | ||||||
| 5. Home office costs | ||||||
| 6. Adjustment resulting from transactions with related organizations |
||||||
| 7. Vending machines | ||||||
| 8. Practitioner assigned by National Health Service Corps | ||||||
| 9. Depreciation - buildings and fixtures | ||||||
| 10. Depreciation - equipment | ||||||
| 11. Subtotal of other common adjustments (specify details in Comments tab) |
This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | |||
| 12. Subtotal of common adjustments (sum of lines 1-11) | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | This cell is left intentionally blank. | ||
| Part 2 is for entering costs not allowed. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||
| PART 2 - COSTS NOT ALLOWED (Must be removed from allowable costs) | ||||||
| Description | Basis for Adjustment* 1 |
Amount** 2 |
Expense Classification*** 3 |
Line Number 4 |
||
| 13. Bad debts | A | |||||
| 14. Charitable contributions | A | |||||
| 15. Entertainment costs, including costs of alcoholic beverages |
A | |||||
| 16. Federal, state, or local sanctions or fines | A | |||||
| 17. Fund-raising costs | A | |||||
| 18. Goodwill, organization costs, or other amortization | A | |||||
| 19. Legal fees related to criminal investigations | A | |||||
| 20. Lobbying costs | A | |||||
| 21. Selling and marketing costs | A | |||||
| 22. Subtotal of other costs not allowed (specify details in Comments tab) |
A | This cell is left intentionally blank. | This cell is left intentionally blank. | |||
| 23. Subtotal of costs not allowed (sum of lines 13-22) |
A | $0 | This cell is left intentionally blank. | This cell is left intentionally blank. | ||
| 24. Total Adjustments (sum of lines 12 and 23) | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | This cell is left intentionally blank. | ||
| *Basis for adjustment A. Costs - if cost (including applicable overhead) can be determined B. Amount received - if cost cannot be determined |
||||||
| ** Transfer to Trial Balance worksheet, column 6 as appropriate | ||||||
| *** Expense classification on Trial Balance worksheet from which amount is to be deducted or to which the amount is to be added | ||||||
| End of Worksheet | ||||||
| This worksheet is for identifying anticipated costs not incurred, but necessary to provide CCBHC services. The top section is for Medicaid ID, NPI, reporting period, and rate period, and is automatically populated from the Provider Information tab. Following that, Part 1 is for entering direct costs for CCBHC services. Part 2 is for entering indirect costs. Part 3 is for entering direct costs for non-CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| CCBHC Cost Report | |||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| MEDICAID ID: | |||||
| NPI: | |||||
| REPORTING PERIOD: | From: | To: | |||
| RATE PERIOD: | From: | To: | |||
| WORKSHEET: | Anticipated Costs | ||||
| Part 1 is for entering direct CCBHC expenses. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 1 - DIRECT CCBHC EXPENSES | |||||
| Part 1A is for entering anticipated direct CCBHC staff costs. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 1A - CCBHC STAFF COSTS | |||||
| Description | Additional Required Full-Time Equivalent (FTE) Staff 1 |
Additional Expense Amount 2 |
Reduced Expense Amount 3 |
Anticipated Changes in Costs Due to Addition of CCBHC Services* (Col. 2 - 3) 4 |
|
| 1. Psychiatrist | $0 | ||||
| 2. Psychiatric nurse | $0 | ||||
| 3. Child psychiatrist | $0 | ||||
| 4. Adolescent psychiatrist | $0 | ||||
| 5. Substance abuse specialist | $0 | ||||
| 6. Case manager | $0 | ||||
| 7. Recovery coach | $0 | ||||
| 8. Peer specialist | $0 | ||||
| 9. Family support specialist | $0 | ||||
| 10. Licensed clinical social worker | $0 | ||||
| 11. Licensed mental health counselor | $0 | ||||
| 12. Mental health professional (trained and credentialed for psychological testing) |
$0 | ||||
| 13. Licensed marriage and family therapist |
$0 | ||||
| 14. Occupational therapist | $0 | ||||
| 15. Interpreters or linguistic counselor | $0 | ||||
| 16. General practice (performing CCBHC services) |
$0 | ||||
| 17. Subtotal other staff costs (specify details in Comments tab) |
$0 | ||||
| 18. Subtotal staff costs (sum of lines 1-17) |
0 | $0 | $0 | $0 | |
| Part 1B is for entering anticipated direct CCBHC costs under agreement. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 1B - CCBHC COSTS UNDER AGREEMENT | |||||
| Description | Additional Required Full-Time Equivalent (FTE) Staff 1 |
Additional Expense Amount 2 |
Reduced Expense Amount 3 |
Anticipated Changes in Costs Due to Addition of CCBHC Services* (Col. 2 - 3) 4 |
|
| 19. CCBHC costs from DCO | This cell is left intentionally blank. | $0 | |||
| 20. Subtotal other CCBHC costs (specify details in Comments tab) |
This cell is left intentionally blank. | $0 | |||
| 21. Subtotal costs under agreement (sum of lines 19-20) |
This cell is left intentionally blank. | $0 | $0 | $0 | |
| Part 1C is for entering anticipated other direct CCBHC costs. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 1C - OTHER DIRECT CCBHC COSTS | |||||
| Description | Additional Required Full-Time Equivalent (FTE) Staff 1 |
Additional Expense Amount 2 |
Reduced Expense Amount 3 |
Anticipated Changes in Costs Due to Addition of CCBHC Services* (Col. 2 - 3) 4 |
|
| 22. Medical supplies | This cell is left intentionally blank. | $0 | |||
| 23. Transportation (health care staff) | This cell is left intentionally blank. | $0 | |||
| 24. Depreciation - medical equipment | This cell is left intentionally blank. | $0 | |||
| 25. Professional liability insurance | This cell is left intentionally blank. | $0 | |||
| 26. Telehealth | This cell is left intentionally blank. | $0 | |||
| 27. Subtotal other direct costs not already included (specify details in Comments tab) |
This cell is left intentionally blank. | $0 | |||
| 28. Subtotal other direct CCBHC costs (sum of lines 22-27) |
This cell is left intentionally blank. | $0 | $0 | $0 | |
| 29. Total cost of CCBHC services (other than overhead) (sum of lines 18, 21, and 28) |
$0 | $0 | $0 | $0 | |
| Part 2 is for entering indirect costs. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 2 - INDIRECT COSTS | |||||
| Part 2A is for entering anticipated indirect facility costs. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 2A - SITE COSTS | |||||
| Description | Additional Required Full-Time Equivalent (FTE) Staff 1 |
Additional Expense Amount 2 |
Reduced Expense Amount 3 |
Anticipated Changes in Costs Due to Addition of CCBHC Services* (Col. 2 - 3) 4 |
|
| 30. Rent | This cell is left intentionally blank. | $0 | |||
| 31. Insurance | This cell is left intentionally blank. | $0 | |||
| 32. Interest on mortgage or loans | This cell is left intentionally blank. | $0 | |||
| 33. Utilities | This cell is left intentionally blank. | $0 | |||
| 34. Depreciation - buildings and fixtures | This cell is left intentionally blank. | $0 | |||
| 35. Depreciation - equipment | This cell is left intentionally blank. | $0 | |||
| 36. Housekeeping and maintenance | This cell is left intentionally blank. | $0 | |||
| 37. Property tax | This cell is left intentionally blank. | $0 | |||
| 38. Subtotal other site costs (specify details in Comments tab) |
This cell is left intentionally blank. | $0 | |||
| 39. Subtotal site costs (sum of lines 30-38) |
This cell is left intentionally blank. | $0 | $0 | $0 | |
| Part 2B is for entering anticipated indirect administrative costs. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 2B - ADMINISTRATIVE COSTS | |||||
| Description | Additional Required Full-Time Equivalent (FTE) Staff 1 |
Additional Expense Amount 2 |
Reduced Expense Amount 3 |
Anticipated Changes in Costs Due to Addition of CCBHC Services* (Col. 2 - 3) 4 |
|
| 40. Office salaries | This cell is left intentionally blank. | $0 | |||
| 41. Depreciation - office equipment | This cell is left intentionally blank. | $0 | |||
| 42. Office supplies | This cell is left intentionally blank. | $0 | |||
| 43. Legal | This cell is left intentionally blank. | $0 | |||
| 44. Accounting | This cell is left intentionally blank. | $0 | |||
| 45. Insurance | This cell is left intentionally blank. | $0 | |||
| 46. Telephone | This cell is left intentionally blank. | $0 | |||
| 47. Subtotal other administrative costs (specify details in Comments tab) |
This cell is left intentionally blank. | $0 | |||
| 48. Subtotal administrative costs (sum of lines 40-47) |
This cell is left intentionally blank. | $0 | $0 | $0 | |
| 49. Total overhead (sum of lines 39 and 48) |
This cell is left intentionally blank. | $0 | $0 | $0 | |
| Part 3 is for entering anticipated direct costs for non-CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 3 - DIRECT COSTS FOR NON-CCBHC SERVICES | |||||
| Part 3a is for entering anticipated direct costs for non-CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 3A - DIRECT COSTS FOR SERVICES OTHER THAN CCHBC SERVICES | |||||
| Description | Additional Required Full-Time Equivalent (FTE) Staff 1 |
Additional Expense Amount 2 |
Reduced Expense Amount 3 |
Anticipated Changes in Costs Due to Addition of CCBHC Services* (Col. 2 - 3) 4 |
|
| 50. Subtotal direct costs for non-CCBHC services covered by Medicaid (specify details in Comments tab) |
This cell is left intentionally blank. | $0 | |||
| Part 3B is for entering anticipated direct costs that are for non-reimbursable services. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 3B - NON-REIMBURSABLE COSTS | |||||
| Description | Additional Required Full-Time Equivalent (FTE) Staff 1 |
Additional Expense Amount 2 |
Reduced Expense Amount 3 |
Anticipated Changes in Costs Due to Addition of CCBHC Services* (Col. 2 - 3) 4 |
|
| 51. Subtotal direct costs for non-CCBHC services not covered by Medicaid (specify details in Comments tab) |
This cell is left intentionally blank. | $0 | |||
| 52. Subtotal costs for non-CCBHC services (sum of 50-51) |
This cell is left intentionally blank. | $0 | $0 | $0 | |
| 53. Total costs (sum of lines 29, 49, and 52) |
0 | $0 | $0 | $0 | |
| * Transfer to Trial Balance worksheet, column 8 as appropriate | |||||
| End of Worksheet | |||||
| This worksheet is for allocating indirect costs. The top section is for Medicaid ID, NPI, reporting period, and rate period, and is automatically populated from the Provider Information tab. The bottom section is used for identifying the method for allocating indirect costs. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| CCBHC Cost Report | |||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| MEDICAID ID: | |||||||
| NPI: | |||||||
| REPORTING PERIOD: | From: | To: | |||||
| RATE PERIOD: | From: | To: | |||||
| WORKSHEET: | Indirect Cost Allocation | ||||||
| The bottom section is used for identifying the method for allocating indirect costs. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| Description | This cell is left intentionally blank. | ||||||
| 1. Does the CCBHC have a indirect cost rate approved by a cognizant agency (see Cost Report Instructions)? If no, go to line 7. |
|||||||
| 2. Which cognizant agency approved the rate? | |||||||
| 3. Describe the base rate with respect to the indirect cost rate. | |||||||
| 4. Enter the basis amount subject to the rate agreement | |||||||
| 5. Enter the approved rate amount | |||||||
| 6. Calculated indirect costs allocable to CCBHC services (line 4 multiplied by line 5) | $0 | ||||||
| 7. Does the CCBHC qualify to use the federal minimum rate and elect to use the rate for all federal awards? See instructions for qualifications. If no, go to line 11. |
|||||||
| 8. Direct costs for CCBHC services (Trial Balance, column 9, line 29) | $0 | ||||||
| 9. Minimum rate | 10.0% | ||||||
| 10. Calculated indirect costs allocable to CCBHC services (line 8 multiplied by line 9) | $0 | ||||||
| 11. Will the CCBHC allocate indirect costs proportionally by the percentage of direct costs for CCBHC services versus total allowable costs less indirect costs? If no, go to line 15. |
|||||||
| 12. Percentage of direct costs versus total allowable direct costs (Trial Balance, column 9, line 29 divided by the sum of Trial Balance, column 9, line 29 and Trial Balance, column 9, line 52) |
0.0% | ||||||
| 13. Indirect costs to be allocated (Trial Balance, column 9, line 49) | $0 | ||||||
| 14. Calculated indirect costs allocable to CCBHC services (line 12 multiplied by line 13) | $0 | ||||||
| 15. If none of the lines 1, 7, or 11 are entered as Yes, provide a thorough description of the cost allocation method used. Include attachments for descriptions and calculations. Include references to line items included in the Trial Balance tab. Enter the amount of indirect costs allocated to providing CCBHC services here: |
|||||||
| 16. Total indirect costs allocated to CCBHC services | $0 | ||||||
| End of Worksheet | |||||||
| This worksheet is for entering descriptions of allocation methods for direct and indirect costs. The top section is for Medicaid ID, NPI, reporting period, and rate period, and is automatically populated from the Provider Information tab. The bottom section is used for entering the description of allocations. The descriptions should include the tab in which the allocation is referenced, the method for allocation and the amounts allocated. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||
| CCBHC Cost Report | ||||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||
| MEDICAID ID: | ||||||||
| NPI: | ||||||||
| REPORTING PERIOD: | From: | To: | ||||||
| RATE PERIOD: | From: | To: | ||||||
| WORKSHEET: | Allocation Descriptions | |||||||
| The bottom section is used for entering the description of allocations. The descriptions should include the tab in which the allocation is referenced, the method for allocation and the amounts allocated. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||
| PLEASE EXPLAIN METHODS USED FOR ALLOCATING RESOURCES TO DIRECT OR INDIRECT COSTS | ||||||||
| Justification for allocation: | ||||||||
| End of Worksheet | ||||||||
| This worksheet is for entering daily visits. The top section is for Medicaid ID, NPI, reporting period, and rate period, and is automatically populated from the Provider Information tab. The bottom section is used for identifying the number of days patients received CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| CCBHC Cost Report | |||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| MEDICAID ID: | |||||||
| NPI: | |||||||
| REPORTING PERIOD: | From: | To: | |||||
| RATE PERIOD: | From: | To: | |||||
| WORKSHEET: | Daily Visits | ||||||
| The bottom section is used for identifying the number of days patients received CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| PATIENT DEMOGRAPHICS CONSOLIDATED | |||||||
| Include ALL visits for CCBHC services; do not limit it to those covered by Medicaid. | Total Daily Patient Visits 1 |
||||||
| 1. Number of daily visits for patients receiving CCBHC services provided directly from staff | |||||||
| 2. Number of daily visits for patients receiving CCBHC services directly from DCO (not included above) |
|||||||
| 3. Number of additional anticipated daily visits for patients receiving CCBHC services | |||||||
| 4. Total daily visits for patients receiving CCBHC services (sum of lines 1-3) | 0 | ||||||
| End of Worksheet | |||||||
| This worksheet is for entering monthly visits. The top section is for Medicaid ID, NPI, reporting period, and rate period, and is automatically populated from the Provider Information tab. The bottom section is used for identifying the number of months each patient received CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||||||||||||||
| CCBHC Cost Report | ||||||||||||||||||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||||||||||||||
| MEDICAID ID: | ||||||||||||||||||||||
| NPI: | ||||||||||||||||||||||
| REPORTING PERIOD: | From: | To: | ||||||||||||||||||||
| RATE PERIOD: | From: | To: | ||||||||||||||||||||
| WORKSHEET: | Monthly Visits | |||||||||||||||||||||
| The bottom section is used for identifying the number of months each patient received CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||||||||||||||
| PATIENT DEMOGRAPHICS CONSOLIDATED | ||||||||||||||||||||||
| Patient demographics should be analyzed to identify Certain Conditions. Because CC PPS-2 requires monthly detail, patient data must be aggregated by patient by month to determine eligibility for Certain Conditions. Months should be captured for ALL CCBHC services provided; do not limit the information to Medicaid members. | ||||||||||||||||||||||
| Description | Standard Population Visit Months All 1a |
Standard Population Visit Months Above the Outlier Threshold 1b |
Certain Conditions 1 Visit Months All 2a |
Certain Conditions 1 Visit Months Above the Outlier Threshold 2b |
Certain Conditions 2 Visit Months All 3a |
Certain Conditions 2 Visit Months Above the Outlier Threshold 3b |
Certain Conditions 3 Visit Months All 4a |
Certain Conditions 3 Visit Months Above the Outlier Threshold 4b |
Certain Conditions 4 Visit Months All 5a |
Certain Conditions 4 Visit Months Above the Outlier Threshold 5b |
Certain Conditions 5 Visit Months All 6a |
Certain Conditions 5 Visit Months Above the Outlier Threshold 6b |
Certain Conditions 6 Visit Months All 7a |
Certain Conditions 6 Visit Months Above the Outlier Threshold 7b |
Certain Conditions 7 Visit Months All 8a |
Certain Conditions 7 Visit Months Above the Outlier Threshold 8b |
Certain Conditions 8 Visit Months All 9a |
Certain Conditions 8 Visit Months Above the Outlier Threshold 9b |
Certain Conditions 9 Visit Months All 10a |
Certain Conditions 9 Visit Months Above the Outlier Threshold 10b |
Monthly Patient Visit (Sum of col. a's) Total |
|
| 1. Describe population |
This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | This cell is left intentionally blank. | ||||||||||
| 2. Number of months patients received CCBHC services directly from staff |
0 | |||||||||||||||||||||
| 3. Number of months patients received CCBHC services directly from DCO (not included above) |
0 | |||||||||||||||||||||
| 4. Number of additional anticipated months patients received CCBHC services (not included above) |
0 | |||||||||||||||||||||
| 5. Total months patients received CCBHC services (sum of lines 2-4) |
0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| End of Worksheet | ||||||||||||||||||||||
| This worksheet is for entering information about services provided. The top section is for Medicaid ID, NPI, reporting period, and rate period, and will be automatically populated into all other tabs. Part 1 is for single site or consolidated information for services provided. Part 2 is for reporting specific information for each site. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| CCBHC Cost Report | |||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| MEDICAID ID: | |||||||
| NPI: | |||||||
| REPORTING PERIOD: | From: | To: | |||||
| RATE PERIOD: | From: | To: | |||||
| WORKSHEET: | Services Provided | ||||||
| Part 1 is for single site or consolidated information for services provided. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| PART 1 - SERVICES PROVIDED (Consolidated) | |||||||
| Part 1A is for consolidated information for services provided by CCBHC staff. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| PART 1A - CCBHC STAFF SERVICES | |||||||
| Description | Number of Full-Time Equivalent (FTE) Staff 1 |
Total Number of Services Provided for CCBHC Services 2 |
Direct Cost (from Trial Balance, Col. 9) 3 |
Average Cost per Service by Position (Col. 3 divided by Col. 2) 4 |
|||
| 1. Psychiatrist | $- | $- | |||||
| 2. Psychiatric nurse | $- | $- | |||||
| 3. Child psychiatrist | $- | $- | |||||
| 4. Adolescent psychiatrist | $- | $- | |||||
| 5. Substance abuse specialist | $- | $- | |||||
| 6. Case manager | $- | $- | |||||
| 7. Recovery coach | $- | $- | |||||
| 8. Peer specialist | $- | $- | ` | ||||
| 9. Family support specialist | $- | $- | |||||
| 10. Licensed clinical social worker | $- | $- | |||||
| 11. Licensed mental health counselor | $- | $- | |||||
| 12. Mental health professional (trained and credentialed for psychological testing) |
$- | $- | |||||
| 13. Licensed marriage and family therapist |
$- | $- | |||||
| 14. Occupational therapist | $- | $- | |||||
| 15. Interpreters or linguistic counselor | $- | $- | |||||
| 16. General practice (performing CCBHC services) |
$- | $- | |||||
| 17. Subtotal other staff services (specify details in Comments tab) |
$- | $- | |||||
| 18. Subtotal staff services (sum of lines 1-17) |
0 | 0 | $- | $- | |||
| Part 1B is for consolidated information for services provided under agreement. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| PART 1B - CCBHC SERVICES UNDER AGREEMENT | |||||||
| Description | Number of Full-Time Equivalent (FTE) Staff 1 |
Total Number of Services Provided for CCBHC Services 2 |
Direct Cost (from Trial Balance, Col. 9) 3 |
Average Cost per Service by Position (Col. 3 divided by Col. 2) 4 |
|||
| 19. CCBHC services from DCO | This cell is left intentionally blank. | $- | $- | ||||
| 20. Subtotal other CCBHC services (specify details in Comments tab) |
This cell is left intentionally blank. | $- | $- | ||||
| 21. Subtotal services under agreement (sum of lines 19-20) |
This cell is left intentionally blank. | 0 | $- | $- | |||
| 22. Total services (sum of lines 18 and 21) |
0 | 0 | $- | $- | |||
| Part 2 is for reporting specific information for each site. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| PART 2 - SERVICES PROVIDED BY SITE (For additional satellite sites, create new tab and copy and paste Part 2 for each additional site included) | |||||||
| Part 2A is for site-specific information for services provided by CCBHC staff. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| PART 2A - CCBHC STAFF SERVICES | |||||||
| Description | Number of Full-Time Equivalent (FTE) Staff 1 |
Total Number of Services Provided for CCBHC Services 2 |
|||||
| 1. Psychiatrist | |||||||
| 2. Psychiatric nurse | |||||||
| 3. Child psychiatrist | |||||||
| 4. Adolescent psychiatrist | |||||||
| 5. Substance abuse specialist | |||||||
| 6. Case manager | |||||||
| 7. Recovery coach | |||||||
| 8. Peer specialist | |||||||
| 9. Family support specialist | |||||||
| 10. Licensed clinical social worker | |||||||
| 11. Licensed mental health counselor | |||||||
| 12. Mental health professional (trained and credentialed for psychological testing) |
|||||||
| 13. Licensed marriage and family therapist |
|||||||
| 14. Occupational therapist | |||||||
| 15. Interpreters or linguistic counselor | |||||||
| 16. General practice (performing CCBHC services) |
|||||||
| 17. Subtotal other staff services (specify details in Comments tab) |
|||||||
| 18. Subtotal staff services (sum of lines 1-17) |
0 | 0 | |||||
| Part 2B is for site-specific information for services provided under agreement. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||
| PART 2B - CCBHC SERVICES UNDER AGREEMENT | |||||||
| Description | Number of Full-Time Equivalent (FTE) Staff 1 |
Total Number of Services Provided for CCBHC Services 2 |
|||||
| 19. CCBHC services from DCO | This cell is left intentionally blank. | ||||||
| 20. Subtotal other CCBHC services (specify details in Comments tab) |
This cell is left intentionally blank. | ||||||
| 21. Subtotal services under agreement (sum of lines 19-20) |
This cell is left intentionally blank. | 0 | |||||
| 22. Total services (sum of lines 18 and 21) |
0 | 0 | |||||
| End of Worksheet | |||||||
| This worksheet is for entering comments and additional information. The top section is for Medicaid ID, NPI, reporting period, and rate period, and is automatically populated from the Provider Information tab. The bottom section is used to identify the worksheet, line and comments. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| CCBHC Cost Report | ||||||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| MEDICAID ID: | ||||||||||
| NPI: | ||||||||||
| REPORTING PERIOD: | From: | To: | ||||||||
| RATE PERIOD: | From: | To: | ||||||||
| WORKSHEET: | Comments | |||||||||
| The bottom section is used to identify the worksheet, line and comments. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||
| Please explain or comment on any additional considerations that should be taken into account in determining the appropriate payment rate | ||||||||||
| Worksheet | Line | Comment 1 | Comment 2 | Comment 3 | Comment 4 | Comment 5 | Comment 6 | Comment 7 | Comment 8 | Comment 9 |
| End of Worksheet | ||||||||||
| This worksheet is the CC PPS 1 tab. Most of the worksheet is populated from other tabs except for the Medicare economic index in number 7 of part 2. The top section is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Following that, Part 1 automatically populates the direct and indirect costs for CCBHC services. Part 2 calculates the CC PPS 1 rate after the MEI is entered. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| CCBHC Cost Report | |||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| MEDICAID ID: | |||||
| NPI: | |||||
| REPORTING PERIOD: | From: | To: | |||
| RATE PERIOD: | From: | To: | |||
| WORKSHEET: | CC PPS-1 Rate | ||||
| Part 1 is automatically populated with the direct and indirect costs for CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 1 - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO THE CCBHC | |||||
| Description | Amount 1 |
||||
| 1. Total direct cost of CCBHC services (Trial Balance, column 9, line 29) | $0 | ||||
| 2. Indirect cost applicable to CCBHC services (Indirect Cost Allocation, line 16) | $0 | ||||
| 3. Total allowable CCBHC costs (sum of lines 1-2) | $0 | ||||
| Part 2 calculates the CC PPS 1 rate after the MEI is entered in line 7. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||
| PART 2 - DETERMINATION OF CC PPS-1 RATE | |||||
| Description | Amount 1 |
||||
| 4. Total allowable CCBHC costs (line 3) | $0 | ||||
| 5. Total CCBHC visits* (Daily Visits, column 1, line 4) | 0 | ||||
| 6. Unadjusted PPS rate (line 4 divided by line 5) | $0 | ||||
| 7. Medicare Economic Index (MEI) adjustment from midpoint of the cost period to the midpoint of the rate period |
0.000% | ||||
| 8. CC PPS-1 rate (line 6 adjusted by factor from line 7) | $0 | ||||
| * Total should reflect the total count of CCBHC visits provided and not be restricted to Medicaid visits | |||||
| End of Worksheet | |||||
| This worksheet is the CC PPS 2 tab. The top section is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Following that, Part 1 is used to determine the cost-to-charge ratio allocation by population group. Part 2 is used to calculate CC PPS-2 rates for the state's review. Other than the MEI, Part 2 is populated from other tabs . Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||||||||||||||
| CCBHC Cost Report | ||||||||||||||||||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||||||||||||||
| MEDICAID ID: | ||||||||||||||||||||||
| NPI: | ||||||||||||||||||||||
| REPORTING PERIOD: | From: | To: | ||||||||||||||||||||
| RATE PERIOD: | From: | To: | ||||||||||||||||||||
| WORKSHEET: | CC PPS-2 Rate | |||||||||||||||||||||
| Part 1 is used to determine the cost-to-charge ratio allocation by population group. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||||||||||||||
| PART 1 - COST-TO-CHARGE RATIO ALLOCATION | ||||||||||||||||||||||
| Description | Standard Population Charges and Costs for CCBHC Services: At or Below the Outlier Threshold 1a |
Standard Population Charges and Costs for CCBHC Services: Above the Outlier Threshold 1b |
Certain Conditions 1 Charges and Costs for CCBHC Services: At or Below the Outlier Threshold 2a |
Certain Conditions 1 Charges and Costs for CCBHC Services: Above the Outlier Threshold 2b |
Certain Conditions 2 Charges and Costs for CCBHC Services: At or Below the Outlier Threshold 3a |
Certain Conditions 2 Charges and Costs for CCBHC Services: Above the Outlier Threshold 3b |
Certain Conditions 3 Charges and Costs for CCBHC Services: At or Below the Outlier Threshold 4a |
Certain Conditions 3 Charges and Costs for CCBHC Services: Above the Outlier Threshold 4b |
Certain Conditions 4 Charges and Costs for CCBHC Services: At or Below the Outlier Threshold 5a |
Certain Conditions 4 Charges and Costs for CCBHC Services: Above the Outlier Threshold 5b |
Certain Conditions 5 Charges and Costs for CCBHC Services: At or Below the Outlier Threshold 6a |
Certain Conditions 5 Charges and Costs for CCBHC Services: Above the Outlier Threshold 6b |
Certain Conditions 6 Charges and Costs for CCBHC Services: At or Below the Outlier Threshold 7a |
Certain Conditions 6 Charges and Costs for CCBHC Services: Above the Outlier Threshold 7b |
Certain Conditions 7 Charges and Costs for CCBHC Services: At or Below the Outlier Threshold 8a |
Certain Conditions 7 Charges and Costs for CCBHC Services: Above the Outlier Threshold 8b |
Certain Conditions 8 Charges and Costs for CCBHC Services: At or Below the Outlier Threshold 9a |
Certain Conditions 8 Charges and Costs for CCBHC Services: Above the Outlier Threshold 9b |
Certain Conditions 9 Charges and Costs for CCBHC Services: At or Below the Outlier Threshold 10a |
Certain Conditions 9 Charges and Costs for CCBHC Services: Above the Outlier Threshold 10b |
Total Population Charges and Costs (Sum of all Columns) Total |
|
| 1. Actual charges | $0 | |||||||||||||||||||||
| 2. Anticipated additional charges (DY1 only) |
$0 | |||||||||||||||||||||
| 3. Total charges (sum of lines 1-2) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| 4. Total direct costs (Trial Balance, column 9, line 29) |
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| 5. Indirect cost applicable to CCBHC services (Indirect Cost Allocation, line 16) |
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| 6. Total allowable costs for CCBHC services (sum of lines 4-5) |
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| 7. Cost-to-charge ratio services (line 6 divided by line 3) |
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| 8. Total cost of CCBHC services (line 3 times line 7) |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| Cross Check: Total costs should tie to the total direct and indirect costs applicable to CCBHC services (line 6) | Difference | $0 | ||||||||||||||||||||
| Part 2 is used to calculate preliminary CC PPS-2 rates after MEI is entered in line 12. Use tab to move to input areas. Use the arrow keys to read through the document. | ||||||||||||||||||||||
| PART 2 - DETERMINATION OF CC PPS-2 RATE | ||||||||||||||||||||||
| Description | Standard Population Costs for CCBHC Services: At or Below the Outlier Threshold 1a |
Standard Population Costs for CCBHC Services: Above the Outlier Threshold 1b |
Certain Conditions 1 Costs for CCBHC Services: At or Below the Outlier Threshold 2a |
Certain Conditions 1 Costs for CCBHC Services: Above the Outlier Threshold 2b |
Certain Conditions 2 Costs for CCBHC Services: At or Below the Outlier Threshold 3a |
Certain Conditions 2 Costs for CCBHC Services: Above the Outlier Threshold 3b |
Certain Conditions 3 Costs for CCBHC Services: At or Below the Outlier Threshold 4a |
Certain Conditions 3 Costs for CCBHC Services: Above the Outlier Threshold 4b |
Certain Conditions 4 Costs for CCBHC Services: At or Below the Outlier Threshold 5a |
Certain Conditions 4 Costs for CCBHC Services: Above the Outlier Threshold 5b |
Certain Conditions 5 Costs for CCBHC Services: At or Below the Outlier Threshold 6a |
Certain Conditions 5 Costs for CCBHC Services: Above the Outlier Threshold 6b |
Certain Conditions 6 Costs for CCBHC Services: At or Below the Outlier Threshold 7a |
Certain Conditions 6 Costs for CCBHC Services: Above the Outlier Threshold 7b |
Certain Conditions 7 Costs for CCBHC Services: At or Below the Outlier Threshold 8a |
Certain Conditions 7 Costs for CCBHC Services: Above the Outlier Threshold 8b |
Certain Conditions 8 Costs for CCBHC Services: At or Below the Outlier Threshold 9a |
Certain Conditions 8 Costs for CCBHC Services: Above the Outlier Threshold 9b |
Certain Conditions 9 Costs for CCBHC Services: At or Below the Outlier Threshold 10a |
Certain Conditions 9 Costs for CCBHC Services: Above the Outlier Threshold 10b |
Total Population Costs (Sum of all Columns) Total |
|
| 9. Total allowable CCBHC costs (line 8) |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |
| 10. Total months patients received CCBHC services (Monthly Visits, line 5)* |
0 | This cell is left intentionally blank. | 0 | This cell is left intentionally blank. | 0 | This cell is left intentionally blank. | 0 | This cell is left intentionally blank. | 0 | This cell is left intentionally blank. | 0 | This cell is left intentionally blank. | 0 | This cell is left intentionally blank. | 0 | This cell is left intentionally blank. | 0 | This cell is left intentionally blank. | 0 | This cell is left intentionally blank. | 0 | |
| 11. Total allowable cost per visit (line 9 divided by line 10) |
$0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | |
| 12. Medicare Economic Index (MEI) adjustment from midpoint of the cost period to the midpoint of the rate period |
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| 13. CC PPS-2 rate (line 11 adjusted by factor from column Total, line 12) |
$0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | |
| 14. Outlier pool (line 9) | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | This cell is left intentionally blank. | $0 | $0 | |
| * Column "a" reflects the count for All visits. The total reflects the sum of "a" columns. | ||||||||||||||||||||||
| End of Worksheet | ||||||||||||||||||||||
| This worksheet is for entering certification information. The top section is for Medicaid ID, NPI, reporting period, and rate period, and is automatically populated from the Provider Information tab. The bottom section is used to certify the completeness and accuracy of the data in this workbook. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||||||
| CCBHC Cost Report | |||||||||||
| This is the top section. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||||||
| MEDICAID ID: | |||||||||||
| NPI: | |||||||||||
| REPORTING PERIOD: | From: | To: | |||||||||
| RATE PERIOD: | From: | To: | |||||||||
| WORKSHEET: | Certification | ||||||||||
| The bottom section is used to certify the completeness and accuracy of the data in this workbook. Use tab to move to input areas. Use the arrow keys to read through the document. | |||||||||||
| MEDICAID COST REPORT | |||||||||||
| for Certified Community Behavioral Health Clinics | |||||||||||
| 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 DIRECTLY OR INDIRECTLY THROUGH THE PAYMENT OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL, AND ADMINISTRATIVE ACTION; FINES; AND/OR IMPRISONMENT MAY RESULT. CERTIFICATION BY OFFICER OR ADMINISTRATOR IS REQUIRED. |
|||||||||||
| 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 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. |
|||||||||||
| Signature of Officer: | |||||||||||
| Title: | |||||||||||
| Clinic: | |||||||||||
| Medicaid ID: | |||||||||||
| From Period: | |||||||||||
| To Period: | |||||||||||
| Preparer (If other than Officer): | |||||||||||
| End of Worksheet | |||||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |