Form CMS-224-14 FQHC Cost Report Form (Worksheets)

Federally Qualified Health Center Cost Report Form (CMS-224-14)

CMS-224-14_Worksheets(30-day).xlsx

Federally Qualified Health Center Cost Report Form

OMB: 0938-1298

Document [xlsx]
Download: xlsx | pdf

Overview

S
S-1PI
S-1PII
S-2
S-3PI
S-3PII & III
A
A-1
A-2
A-2-1
B
B-1
E
E-1
F-1


Sheet 1: S

DRAFT



FORM CMS-224-14


4490
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim






FORM APPROVED
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).






OMB NO. 0938-XXXX
FEDERALLY QUALIFIED HEALTH CENTER COST REPORT




CCN: PERIOD: WORKSHEET S
CERTIFICATION AND SETTLEMENT SUMMARY




___________ FROM: ___________ PARTS I, II & III







TO: ___________

PART I - COST REPORT STATUS








Provider use only

1. [ ] Electronically filed cost report

Date: Time:



2. [ ] Manually submitted cost report







3. [ ] If this is an amended report enter the number of times the provider resubmitted this cost report.







4. [ ] Medicare Utilization. Enter "F" for full or "L" for low.




Contractor
5. [ ] Cost Report Status

6. Date Received:_________
10. NPR Date:___________

use only
(1) As Submitted

7. Contractor No.:________ 11. Contractors Vendor Code: ____________



(2) Settled without audit

8. [ ] Initial Report for this Provider CCN 12. [ ] If line 5, column 1 is 4: Enter the number of



(3) Settled with audit

9. [ ] Final Report for this Provider CCN
times reopened = 0-9.



(4) Reopened








(5) Amended






PART II - CERTIFICATION








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 OF PROVIDER(S)

















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(s)








and Number(s)}for the cost reporting 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 this cost report were provided in compliance with such laws and regulations.

































(Signed)









Officer or Administrator of Provider (s)


















Title


















Date































PART III - SETTLEMENT SUMMARY


























TITLE XVIII








1
1 FQHC






1
The above amount represents "due to" or "due from" the Medicare program.






































































































































































































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-XXXX. The time required to complete this information collection is estimated 58 hours per response, including the time to review instructions, search existing 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. Please do not send applications, claims, payments, medical records or any








documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under








the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,








please contact 1-800-MEDICARE.


















FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4404.1 - 4404.3)








Rev. 1







44-103

Sheet 2: S-1PI

4490 (Cont.)

FORM CMS-224-14





DRAFT

































FEDERALLY QUALIFIED HEALTH CENTER IDENTIFICATION DATA




CCN: PERIOD:
WORKSHEET S-1




















.











.






______________ FROM: ___________
PART I









































TO: ___________




































PART I - FEDERALLY QUALIFIED HEALTH CENTER IDENTIFICATION DATA














































Provider
Date Type of control





































CCN CBSA Certified (see instructions)



































1
2 3 4 5


































1 Site Name:







1

































2 Street: P.O. Box:






2

































3 City: State: Zip Code: County:
Designation - Enter "R" for rural or "U" for urban:


3

































4 Cost Reporting Period (mm/dd/yyyy) From: To:





4

































5 Is this FQHC part of an entity that owns, leases or controls multiple FQHCs? Enter "Y" for yes or "N" for no. If yes, enter the entity's information below.




5

































6 Name of Entity:


6

































7 Street:
P.O. Box:
HRSA Award Number:



7

































8 City: State:
Zip Code:




8

































9 Is this FQHC part of a chain organization as defined in §2150 of CMS Pub. 15-1 that claims home office costs in a







9


































Home Office Cost Statement? Enter "Y for yes or "N" for no in column 1. If yes, enter the chain organization's information below.










































10 Name of Chain Organization:







10

































11 Street:
P.O. Box:
Home Office CCN:



11

































12 City:
State: Zip Code:




12








































1 2 3


































Consolidated Cost Report





Y/N Date Requested Date Approved


































13 Is this FQHC filing a consolidated cost report per CMS Pub. 100-04, chapter 9, §30.8? Enter "Y" for yes or "N" for no in column 1. (see instructions) If yes, complete line 14. If no, leave line 14 blank.


13


































Site Name CCN CBSA Date Requested Date Approved



































1 2 3 4 5


































14








14

































FQHC Operations





1 2 3


































15 What type of organization is this FQHC? If you operate as more than one sub-type of an organization enter any or all of the applicable alpha characters in column 2. (see instructions)







15

































16 Did this FQHC receive a grant under §330 of the PHS Act during this cost reporting period? If this is a consolidated cost report, did the FQHC reported on line 1, column 2 receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. (complete line 17)


16

































17 If the response to line 16 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). Enter the date of the grant award in column 2 and enter the grant award number in column 3. If you received more than one grant subscript this line accordingly.


17

































Medical Malpractice





































18 Did this FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA? Enter "Y" for yes or "N" for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.


18

































19 Is this FQHC legally-required to carry malpractice insurance? Enter "Y" for yes or "N" for no.







19

































20 Is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.







20








































Premiums Paid Losses Self Insurance


































21 List amounts of malpractice premiums, paid losses or self-insurance in the applicable columns.







21

































22 Are malpractice premiums, paid losses or self-insurance reported in a cost center other than the Administrative and General cost center? Enter "Y" for yes or "N" for no. (see instructions)







22

































Interns and Residents











































23 Is this FQHC involved in training residents in an approved GME program in accordance with 42 CFR 405.2468(f)? Enter "Y" for yes or "N" for no.







23

































24 Is this FQHC involved in training residents in an unapproved GME program? Enter "Y" for yes or "N" for no.







24

































25 Did this FQHC receive a Primary Care Residency Expansion (PCRE) grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for no in column 1.







25


































If yes, enter in column 2 the number of primary care FTE residents that your FQHC trained in this cost reporting period for which your FQHC received PCRE funding and











































in column 3, enter the total number of visits performed by residents funded by the PCRE grant in this cost reporting period. (see instructions)










































26 Did this FQHC receive a Teaching Health Center development grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for no in column 1.







26


































If yes, enter in column 2 the number of FTE residents that your FQHC trained and received funding through your THC grant in this cost reporting period and











































in column 3, enter the total number of visits performed by residents funded by the THC grant in this cost reporting period. (see instructions)










































Capital Related Costs - Ownership/Lease of Building





































27 Do you own or lease the building or office space occupied by your FQHC? Enter "1" for owned or "2" for leased in column 1. If you enter "2" in column 1,







27


































enter the amount of rent/lease expense in column 2.


















































































































































































































































































































































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4405.1 )
























































































44-104








Rev. 1


































Sheet 3: S-1PII

DRAFT


FORM CMS-224-14




4490 (Cont.)
FEDERALLY QUALIFIED HEALTH CENTER IDENTIFICATION DATA




CCN: PERIOD:
WORKSHEET S-1






___________ FROM: ___________
PART II






CENTER CCN: __________ TO: ___________


PART II - FEDERALLY QUALIFIED HEALTH CENTER CONSOLIDATED COST REPORT PARTICIPANT IDENTIFICATION DATA











Date Type of control Date V/I Date of


Certified (see instructions) Decertified Decertification CHOW

1 2 3 4 5 6
1 Site Name:







1
2 Street: P.O. Box:






2
3 City: State: Zip Code: County:
Designation - Enter "R" for rural or "U" for urban:


3
FQHC Operations 1 2 3
4 What type of organization is this FQHC? If you operate as more than one sub-type of an organization enter any or all of the applicable alpha characters in column 2. (see instructions)







4
5 Did this FQHC receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. If yes, complete line 6.


5
6 If the response to line 5 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). Enter the date of the grant award in column 2 and enter the grant award number in column 3. If you received more than one grant subscript this line accordingly.


6
Medical Malpractice



7 Did this FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA? Enter "Y" for yes or "N" for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.


7
8 Is this FQHC legally-required to carry malpractice insurance? Enter "Y" for yes or "N" for no.







8
9 Is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.







9







Premiums Paid Losses Self Insurance
10 List amounts of malpractice premiums, paid losses or self-insurance in the applicable columns.







10
Interns and Residents









11 Is this FQHC involved in training residents in an approved GME program in accordance with 42 CFR 405.2468(f)? Enter "Y" for yes or "N" for no.







11
12 Is this FQHC involved in training residents in an unapproved GME program? Enter "Y" for yes or "N" for no.







12
13 Did this FQHC receive a Primary Care Residency Expansion (PCRE) grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for no in column 1.







13

If yes, enter in column 2 the number of primary care FTE residents that your FQHC trained in this cost reporting period for which your FQHC received PCRE funding and









in column 3, enter the total number of visits performed by residents funded by the PCRE grant in this cost reporting period. (see instuctions)








14 Did this FQHC receive a Teaching Health Center development grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for no in column 1.







14

If yes, enter in column 2 the number of FTE residents that your FQHC trained and received funding through your THC grant in this cost reporting period and









in column 3, enter the total number of visits performed by residents funded by the THC grant in this cost reporting period. (see instructions)








Capital Related Costs - Ownership/Lease of Building



15 Do you own or lease the building or office space occupied by your FQHC? Enter "1" for owned or "2" for leased in column 1. If you enter "2" in column 1,







15

enter the amount of rent/lease expense in column 2.



































































































































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4405.2)




















Rev. 1








44-105

Sheet 4: S-2

4490 (Cont.)

FORM CMS-224-14


DRAFT
FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT


CCN: PERIOD:
WORKSHEET S-2

QUESTIONNAIRE



FROM: ___________







___________ TO: ___________



General Instruction:
Enter Y for all YES responses. Enter N for all NO responses.








Enter all dates in the mm/dd/yyyy format.






COMPLETED BY ALL FQHCs














Y/N Date V/I
Provider Organization and Operation




1 2 3
1 Has the FQHC changed ownership immediately prior to the beginning of the cost reporting period?






1

If yes, enter the date of the change in column 2. (see instructions)







2 Has the FQHC terminated participation in the Medicare program? If yes, enter in column 2 the date






2

of termination and in column 3, "V" for voluntary or "I" for involuntary. (see instructions)







3 Is the FQHC involved in business transactions, including management contracts, with individuals or entities






3

(e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers, medical








staff, management personnel, or members of the board of directors through ownership, control, or family and








other similar relationships? (see instructions)























Y/N Type Date
Financial Data and Reports




1 2 3
4 Column 1: Were the financial statements prepared by a Certified Public Accountant?






4

Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter








date available in column 3. (see instructions) If no, see instructions.
























Y/N Y/N
Approved Educational Activities





1 2
5 Are costs for Intern-Resident programs claimed on the current cost report?






5
6 Was an Intern-Resident program initiated or renewed in the current cost reporting period? If yes, see instructions.






6
7 Are GME costs directly assigned to cost centers other than Allowable Intern and Resident Costs on Worksheet A?






7

If yes, see instructions.

















Bad Debts






Y/N
8 Is the FQHC seeking reimbursement for bad debts? If yes, see instructions.






8
9 If line 8 is yes, did the FQHC's bad debt collection policy change during this cost reporting period? If yes, submit copy.






9
10 If line 8 is yes, were patient coinsurance amounts waived? If yes, see instructions.






10















Y/N Date
PS&R Report Data





1 2
11 Was the cost report prepared using the PS&R Report only? If column 1 is yes, enter the






11

paid-through date of the PS&R Report used in column 2. (see instructions)







12 Was the cost report prepared using the PS&R Report for totals and the FQHC's records for allocation?






12

If column 1 is yes, enter the paid-through date in column 2. (see instructions)







13 If line 11or 12 is yes, were adjustments made to PS&R Report data for additional claims that have been






13

billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions.







14 If line 11 or 12 is yes, were adjustments made to PS&R Report data for corrections of other






14

PS&R Report information? If yes, see instructions.







15 If line 11 or 12 is yes, were adjustments made to PS&R Report data for Other?






15

Describe the other adjustments:
________________________________________





16 Was the cost report prepared only using the FQHC's records? If yes, see instructions.






16










Cost Report Preparer Contact Information








17 First name:
Last name:

Title:

17
18 Employer:






18
19 Phone number:

E-mail Address:



19


































































































































































































































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4406)


















44-106







Rev. 1

Sheet 5: S-3PI

DRAFT

FORM CMS-224-14



4490 (Cont.)
FEDERALLY QUALIFIED HEALTH CENTER DATA

CCN:
PERIOD:
WORKSHEET S-3





FROM: __________
PART I



___________
TO: ___________


PART I - FEDERALLY QUALIFIED HEALTH CENTER STATISTICAL DATA
































Total



CENTER
Title Title All



CCN Title V XVIII XIX Patients



0 1 2 3 4
1 Medical Visits





1
2 Total Medical Visits





2
3 Mental Health Visits





3
4 Total Mental Health Visits





4
5 Number of Visits Performed by Interns and Residents





5
6 Total Number of Visits Performed by Interns





6

and Residents












































































































































































































































































































































































































































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4407.1)
















Rev. 1






44-107

















































































































































































































































































































































































































































































































































































































































































































































Sheet 6: S-3PII & III

4490 (Cont.)

FORM CMS-224-14



DRAFT
FEDERALLY QUALIFIED HEALTH CENTER DATA

CCN:
PERIOD:
WORKSHEET S-3





FROM: __________
PART II & III



___________
TO: ___________


PART II - FEDERALLY QUALIFIED HEALTH CENTER CONTRACT LABOR AND BENEFIT COST













Contract Benefit






Labor Cost






1 2
1 Total facility contract labor and benefit cost





1
2 Physician





2
3 Physician Assistant





3
4 Nurse Practitioner





4
5 Registered Nurse





5
6 Licensed Practical Nurse





6
7 Certified Nurse Midwife





7
8 Clinical Psychologist





8
9 Clinical Social Worker





9
10 Laboratory Technician





10
11 Reg Dietician/Cert DSMT/MNT Educator





11
12 Other Allied Health Personnel





12
13 Interns & Residents





13









PART III - FEDERALLY QUALIFIED HEALTH CENTER EMPLOYEE DATA












Number of Employees
Enter the number of hours in



(Full Time Equivalent)
your normal work week ________



Staff Contract Total





1 2 3
14 Physician





14
15 Physician Assistant





15
16 Nurse Practitioner





16
17 Registered Nurse





17
18 Licensed Practical Nurse





18
19 Certified Nurse Midwife





19
20 Clinical Psychologist





20
21 Clinical Social Worker





21
22 Laboratory Technician





22
23 Reg Dietician/Cert DSMT/MNT Educator





23
24 Other Allied Health Personnel





24
25 Interns & Residents





25

































































































































































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4407.2 & 4407.3)
















44-108






Rev. 1

















































































































































































































































































































































































































































































































































































































































































































































Sheet 7: A

DRAFT


FORM CMS-224-14




4490 (Cont.)





RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES



CCN:
PERIOD:
WORKSHEET A













FROM: ___________













___________
TO: ___________

















NET













RECLASSIFIED
EXPENSES FOR








COST CENTER DESCRIPTIONS

TOTAL RECLASSIFI- TRIAL BALANCE
ALLOCATION








(omit cents) SALARIES OTHER (col. 1 + col. 2) CATIONS (col. 3 ± col. 4) ADJUSTMENTS (col. 5 ± col. 6)









1 2 3 4 5 6 7






GENERAL SERVICE COST CENTERS








1 0100 Cap Rel Costs-Bldg and Fix






1





2 0200 Cap Rel Costs-Mvble Equip






2





3 0300 Employee Benefits






3





4 0400 Administrative & General Services






4





5 0500 Plant Operation and Maintenance






5





6 0600 Janitorial






6





7 0700 Medical Records






7





8
Subtotal - Administrative Overhead






8





9 0900 Pharmacy






9





10 1000 Medical Supplies






10





11 1100 Transportation






11





12 1200 Other General Service (specify)






12





13
Subtotal - Total Overhead






13





DIRECT CARE COST CENTERS













23 2300 Physician






23





24 2400 Physician Services Under Agreement






24





25 2500 Physician Assistant






25





26 2600 Nurse Practitioner






26





27 2700 Visiting Registered Nurse






27





28 2800 Visiting Licensed Practical Nurse






28





29 2900 Certified Nurse Midwife






29





30 3000 Clinical Psychologist






30





31 3100 Clinical Social Worker






31





32 3200 Laboratory Technician






32





33 3300 Reg Dietician/Cert DSMT/MNT Educator






33





34 3400 Physical Therapist






34





35 3500 Occupational Therapist






35





36 3600 Other Allied Health Personnel






36





37
Subtotal - Direct Patient Care Services






37





















































































































































































































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4408)















Rev. 1








44-109





4490 (Cont.)


FORM CMS-224-14




DRAFT





RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES



CCN:
PERIOD:
WORKSHEET A













FROM ____________













____________
TO ____________

















NET













RECLASSIFIED
EXPENSES FOR








COST CENTER DESCRIPTIONS

TOTAL RECLASSIFI- TRIAL BALANCE
ALLOCATION








(omit cents) SALARIES OTHER (col. 1 + col. 2) CATIONS (col. 3 ± col. 4) ADJUSTMENTS (col. 5 ± col. 6)









1 2 3 4 5 6 7






REIMBURSABLE PASS THROUGH COSTS













47 4700 Allowable GME Costs






47





48 4800 Pneumococcal Vaccines & Med Supplies






48





49 4900 Influenza Vaccines & Med Supplies






49





50
Subtotal - Reimbursable Pass through Costs






50





OTHER FQHC SERVICES















60 6000 Medicare Excluded Services






60





61 6100 Diagnostic & Screening Lab Tests






61





62 6200 Radiology - Diagnostic






62





63 6300 Prosthetic Devices






63





64 6400 Durable Medical Equipment






64





65 6500 Ambulance Services






65





66 6600 Telehealth






66





67 6700 Other (Specify)






67





68
Subtotal - Other FQHC Services






68





NONREIMBURSABLE COST CENTERS















78 7800 Nonallowable GME Costs






78





79 7900 Other Nonreimbursable (Specify)






79





80
Subtotal - Non-Reimbursable Costs






80





100
TOTAL (sum of lines 13, 37, 50, 68 and 80)






100














































































































































































































































































































































































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4408)
































44-110








Rev. 1


















































































































































































































Sheet 8: A-1

DRAFT

FORM CMS-224-14




4490 (Cont.)
RECLASSIFICATIONS


CCN:
PERIOD:
WORKSHEET A-1






FROM: ___________






___________
TO: ___________





INCREASES DECREASES


CODE







EXPLANATION OF RECLASSIFICATION(S) (1) COST CENTER LINE # AMOUNT COST CENTER LINE # AMOUNT


1 2 3 4 5 6 7
1







1
2







2
3







3
4







4
5







5
6







6
7







7
8







8
9







9
10







10
11







11
12







12
13







13
14







14
15







15
16







16
17







17
18







18
19







19
20







20
21







21
22







22
23







23
24







24
25







25
26







26
27







27
28







28
29







29
30







30
31







31
32







32
33







33
34







34
35







35
100 Total reclassifications






100
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.








Transfer the amounts in columns 4 and 7 to Worksheet A, column 4, lines as appropriate.




























FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4409)


















Rev. 1







44-111

Sheet 9: A-2

4490 (Cont.)
FORM CMS-224-14




DRAFT
ADJUSTMENTS TO EXPENSES
CCN:
PERIOD:
WORKSHEET A-2





FROM: ___________





___________
TO: ___________
















EXPENSE CLASSIFICATION ON

DESCRIPTION (1)

WORKSHEET A TO/FROM WHICH


BASIS/CODE
THE AMOUNT IS TO BE ADJUSTED


(2) AMOUNT COST CENTER
LINE #


1 2 3

4
1 Investment income - buildings and fixtures (chapter 2)

Buildings and Fixtures

1 1
2 Investment income - movable equipment (chapter 2)

Movable Equipment

2 2
3 Investment income - other (chapter 2)





3
4 Trade, quantity, and time discounts (chapter 8)





4
5 Refunds and rebates of expenses (chapter 8)





5
6 Rental of building or office space to others (chapter 8)





6
7 Related organization transactions (chapter 10) Wkst A-2-1




7
8 Sale of drugs to other than patients





8
9 Vending machines





9
10 Practitioner assigned by Public Health Service





10
11 Depreciation - buildings and fixtures

Buildings and Fixtures

1 11
12 Depreciation - movable equipment

Movable Equipment

2 12
13 RCE adjustment to teaching physicians' cost

Allowable GME Costs

47 13
14 Other adjustments (specify) (3)





14
50 TOTAL (sum of lines 1 thru 49)





50














































































































































































































































































(1) Description - all chapter references in this column pertain to CMS Pub. 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.







(3) Additional adjustments may be made on lines 14 thru 49 and subscripts thereof.


































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4410)
















44-112






Rev. 1

Sheet 10: A-2-1

DRAFT

FORM CMS-224-14


4490 (Cont.)
STATEMENT OF COSTS OF SERVICES


CCN: PERIOD: WORKSHEET A-2-1
FROM RELATED ORGANIZATIONS AND



FROM: ___________

HOME OFFICE COSTS


___________ TO: ___________









PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS







OR CLAIMED HOME OFFICE COSTS










Amount Net




Amount of included in Adjustments




Allowable Wkst. A (col. 4 minus

Line No. Cost Center Expense Items Cost column 5 col. 5) *

1 2 3 4 5 6
1





1
2





2
3





3
4





4
5 TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet




5

A-2, column 2, line 7.













* The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as appropriate.






Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not






been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.














PART II - INTERRELATIONSHIP TO RELATED ORGANIZATIONS AND/OR HOME OFFICE






The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish






the information requested under Part B of this worksheet.














This information is used by the Centers for Medicare and Medicaid Services and its contractors 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 you do 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.


















Related Organization(s) and/or Home Office



Percentage
Percentage


Symbol
of
of Type of

(1) Name Ownership Name Ownership Business

1 2 3 4 5 6
6





6
7





7
8





8
9





9
10





10









(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 FQHC.






B. Corporation, partnership, or other organization has financial interest in FQHC.






C. FQHC has financial interest in corporation, partnership, or other organization.






D. Director, officer, administrator, or key person of FQHC or relative of such






person has financial interest in related organization.






E. Individual is director, officer, administrator, or key person of FQHC and






related organization.






F. Director, officer, administrator, or key person of related organization or relative






of such person has financial interest in FQHC.






G. Other (financial or non-financial) specify __________________________________________________




































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4411.1 - 4411.2)














Rev. 1





44-113

Sheet 11: B

4490 (Cont.)




FORM CMS-224-14







DRAFT





CALCULATION OF FEDERALLY QUALIFIED HEALTH CENTER COSTS








CCN:
PERIOD:
WORKSHEET B


















FROM: ___________
PARTS I & II
















___________
TO: ___________








PART I - CALCULATION OF FEDERALLY QUALIFIED HEALTH CENTER COST PER VISIT





























Total Visits Title XVIII Visits Title XVIII Costs































Direct Cost Total Medical Other Direct General









Col 4 must =
Col 6 must
Col 7 must



by & Mental Health Care Costs Service Cost Total Costs Average
Mental
Mental
Mental

Cols 6+7
be => col 8
be => col 9


From Wkst. Practitioner Visits (see (see by Cost Per Visit Medical Visits Health Visits Medical Visits Health Visits Medical Cost Health Cost








A, col. 7, from Wkst. A by Practitioner instructions) instructions) Practitioner by Practitioner by Practitioner by Practitioner by Practitioner by Practitioner by Practitioner by Practitioner







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






1 Physician 23











1
#REF!
OK
OK
2 Physician Services Under Agreement 24











2





3 Physician Assistant 25











3
#REF!
OK
OK
4 Nurse Practitioner 26











4
#REF!
OK
OK
5 Visiting Registered Nurse 27











5
#REF!
OK
OK
6 Visiting Licensed Practical Nurse 28











6
#REF!
OK
OK
7 Certified Nurse Midwife 29











7
#REF!
OK
OK
8 Clinical Psychologist 30











8
#REF!
OK
OK
9 Clinical Social Worker 31











9
#REF!
OK
OK
10 Reg Dietician/Cert DSMT/MNT Educator 33











10
#REF!
OK
OK
11 Totals












11
#REF!
OK
OK
12 Unit Cost Multiplier












12





13 Total Cost Per Visit












13

















































PART II - CALCULATION OF ALLOWABLE DIRECT GRADUATE MEDICAL EDUCATION COSTS





























Total




















Cost

Ratio of Allowable
















(from Wkst.

Title XVIII Title XVIII
















A col. 7, Total I & R Title XVIII Visits to Direct
















line 47) Visits I & R Visits Total Visits GME Costs
















1 2 3 4 5






14 Allowable GME Costs












14































































































































































































































































































































































































































































































































FORM CMS-214-14 (DRAFT) INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4412.1 - 4412.2)










































44-114













Rev. 1






Sheet 12: B-1

DRAFT

FORM CMS-224-14


4490 (Cont.)
COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA


CCN: PERIOD: WORKSHEET B-1
VACCINE COST



FROM: ____________





____________ TO: ____________














PNEUMOCOCCAL INFLUENZA





1 2
1 Health care staff cost (from Worksheet A, column 7, sum of lines 23, and 25 through 36)




1
2 Ratio of pneumococcal and influenza vaccine staff time to total




2

health care staff time





3 Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)




3
4 Vaccines and related medical supplies cost (from Worksheet A, column 7, lines 48 and 49, respectively)




4
5 Direct cost of pneumococcal and influenza vaccine (line 3 + line 4)




5
6 Total direct cost of the FQHC (from Worksheet A, column 7, line 100)




6
7 Total administrative overhead (from Worksheet A, column 7, line 8)




7
8 Ratio of pneumococcal and influenza vaccine direct cost to total direct




8

cost (line 5 / line 6)





9 Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)




9
10 Total cost of pneumococcal and influenza vaccine and their




10

administration (sum of lines 5 and 9)





11 Total number of pneumococcal and influenza vaccine injections




11

(from your records)





12 Cost per pneumococcal and influenza vaccine injection (line 10 / line 11)




12
13 Number of pneumococcal and influenza vaccine injections administered




13

to Medicare beneficiaries





14 Cost of pneumococcal and influenza vaccines and their




14

administration costs furnished to Medicare beneficiaries (line 12 x line 13)





15 Total cost of pneumococcal and influenza vaccines and their administration costs (sum of columns




15

1 and 2, line 10)





16 Total Medicare cost of pneumococcal and influenza vaccines and their administration costs (sum




16

of columns 1 and 2, line 14) (transfer this amount to Worksheet E, line 3)





























































































































































































































































































































































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4413)














Rev. 1





44-115

Sheet 13: E

4490 (Cont.)
FORM CMS-224-14


DRAFT
CALCULATION OF REIMBURSEMENT SETTLEMENT

CCN: PERIOD: WORKSHEET E




FROM: ___________




___________ TO: ___________






















1 FQHC PPS Amount



1
2 Direct graduate medical education payments (from Worksheet B, Part II, line 14, column 5)



2
3 Medicare cost of pneumococcal and influenza vaccine and their administration (From Worksheet B-1, line 16)



3
4 Medicare advantage supplemental payments (for information only)



4
5 Total (sum of amounts on lines 1 through 3)



5
6 Primary payer payments



6
7 Total amount payable for program beneficiaries (line 5 minus line 6)



7
8 Coinsurance billed to program beneficiaries



8
9 Net Medicare reimbursement excluding bad debts (line 7 minus line 8)



9
10 Allowable bad debts (see instructions)



10
11 Adjusted reimbursable bad debts (see instructions)



11
12 Allowable bad debts for dual eligible beneficiaries (see instructions)



12
13 Subtotal (line 9 plus line 11)



13
14 Other adjustments (specify) (see instructions)



14
15 Amount due FQHC prior to the sequestration adjustment (see instructions)



15
16 Sequestration adjustment (see instructions)



16
17 Amount due FQHC after sequestration adjustment (see instructions)



17
18 Interim payments



18
19 Tentative settlement (for contractor use only)



19
20 Balance due FQHC/program (line 17 minus lines 18 and 19)



20
21 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2



21


































































































































































































































































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4414)












44-116




Rev. 1

Sheet 14: E-1

DRAFT


FORM CMS-224-14



4490 (Cont.)
ANALYSIS OF PAYMENTS TO THE FEDERALLY QUALIFIED HEALTH CENTER FOR SERVICES RENDERED



CCN: PERIOD:
WORKSHEET E-1






FROM: ____________







___________ TO: ___________























Description




Part B







mm/dd/yyyy Amount







1 2
1 Total interim payments paid to FQHC






1
2 Interim payments payable on individual bills, either submitted or to be submitted to the contractor






2

for services rendered in the cost reporting period. If none, write "NONE" or enter a zero







3 List separately each retroactive



.01

3.01

lump sum adjustment amount based



.02

3.02

on subsequent revision of the


Program to .03

3.03

interim rate for the cost reporting period.


Provider .04

3.04

Also show date of each payment.



.05

3.05

If none, write "NONE" or enter a zero. (1)



.50

3.50






.51

3.51





Provider to .52

3.52





Program .53

3.53






.54

3.54

Subtotal (sum of lines 3.01- 3.49 minus sum of lines 3.50-3.98)



.99

3.99
4 Total interim payments (sum of lines 1, 2, and 3.99)






4

(transfer to Wkst. E, line 18)








TO BE COMPLETED BY CONTRACTOR







5 List separately each tentative settlement


Program to .01

5.01

payment after desk review. Also show


Provider .02

5.02

date of each payment.



.03

5.03

If none, write "NONE" or enter a zero. (1)



.50

5.50





Provider to .51

5.51





Program .52

5.52

Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50 -5.98)



.99

5.99
6 Determine net settlement amount (balance


Program to provider .01

6.01

due) based on the cost report (1)


Provider to program .02

6.02
7 Total Medicare program liability (see instructions)






7










(1) On lines 3, 5, and 6, where an amount is due FQHC to program, show the amount and date on which the FQHC agrees to the amount of repayment








even though total repayment is not accomplished until a later date.






















































































































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4415)


















Rev. 1







44-117

Sheet 15: F-1

4490 (Cont.)


FORM CMS-224-14


DRAFT
STATEMENT OF


CCN:
PERIOD

REVENUE AND EXPENSES




From: ___________ WORKSHEET F-1




___________
To: ___________





Title XVIII Title XIX






Medicare Medicaid Other Total




1 2 3 4
1 Gross patient revenues





1















1 2
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 3, line 100)





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 (sum of lines 4 through 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 Government Appropriations





27









28 Other revenues (Specify)





28









29






29









30






30









31






31









32 Total Other Income (Sum of lines 19 through 31)





32









33 Net Income or Loss for the period (Line 18 plus line 32)





33






















































FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4416)
















44-118






Rev. 1
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