Federally Qualified Health Center Cost Report Form

CHAPTER 44
FEDERALLY QUALIFIED HEALTH CENTER COST REPORT
CMS-224-14
TABLE OF CONTENTS
Section
General ................................................................................................................................ 4400
Rounding Standards for Fractional Computations ......................................................... 4400.1
Acronyms and Abbreviations .............................................................................................. 4401
Recommended Sequence for Completing Form CMS-224-14 ............................................ 4402
Sequence of Assembly ......................................................................................................... 4403
Worksheet S - Federally Qualified Health Center Cost Report
Certification and Settlement Summary ............................................................................ 4404
Part I - Cost Report Status ............................................................................................. 4404.1
Part II - Certification ...................................................................................................... 4404.2
Part III - Settlement Summary ....................................................................................... 4404.3
Worksheet S-1 - Federally Qualified Health Center Identification Data ............................. 4405
Part I - Federally Qualified Health Center Identification Data ...................................... 4405.1
Part II - Federally Qualified Health Center Consolidated Cost Report
Participant Identification Data .................................................................................... 4405.2
Worksheet S-2 - Federally Qualified Health Center Reimbursement Questionnaire .......... 4406
Worksheet S-3 - Federally Qualified Health Center Data ................................................... 4407
Part I - Federally Qualified Health Center Statistical Data............................................ 4407.1
Part II - Federally Qualified Health Center Contract Labor and Benefit Cost .............. 4407.2
Part III - Federally Qualified Health Center Employee Data ........................................ 4407.3
Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses.................. 4408
Worksheet A-1 - Reclassifications....................................................................................... 4409
Worksheet A-2 - Adjustments to Expenses ......................................................................... 4410
Worksheet A-2-1 - Statement of Costs of Services from Related Organizations and
Home Office Costs ............................................................................................................ 4411
Part I - Costs Incurred and Adjustments Required as a Result of Transactions
with Related Organizations or Claimed Home Office Costs ...................................... 4411.1
Part II - Interrelationship to Related Organizations and/or Home Office ...................... 4411.2
Worksheet B - Calculation of Federally Qualified Health Center Costs ............................. 4412
Part I - Calculation of Federally Qualified Health Center Cost Per Visit ...................... 4412.1
Part II - Calculation of Direct Graduate Medical Education Costs ............................... 4412.2
Worksheet B-1 - Computation of Pneumococcal and Influenza Vaccine Cost ................... 4413
Worksheet E - Calculation of Reimbursement Settlement .................................................. 4414
Worksheet E-1 - Analysis of Payments to the Federally Qualified Health Center
for Services Rendered ...................................................................................................... 4415
Worksheet F-1 - Statement of Revenue and Expenses ........................................................ 4416
Form CMS-224-14 Worksheets ........................................................................................... 4490
Electronic Reporting Specifications for Form CMS-224-14 ............................................... 4495

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4400.

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4400

GENERAL

The Paperwork Reduction Act of 1995 requires that the private sector be informed as to why
information is collected and what the information is used for by the government. In accordance
with §§1815(a) and 1861(v)(1)(A) of the Social Security Act (the Act), providers of medical and
other health services as defined under §1861(s), participating in the Medicare program are
required to submit annual information to achieve settlement of costs for health care services
rendered to Medicare beneficiaries. Federally qualified health centers (FQHCs) are required
under 42 CFR 405.2470, to maintain adequate financial and statistical records and provide
annual cost reports as the Secretary determines necessary to administer the program. The data
submitted on the cost reports supports management of Federal programs. The information
reported on Form CMS-224-14, must conform to the requirements and principles set forth in the
Provider Reimbursement Manual, (CMS Pub. 15), as well as those set forth in the Medicare
Benefit Policy Manual, CMS Pub. 100-02, chapter 13, and the Medicare Claims Processing
Manual, CMS Pub. 100-04, chapter 9.
Section 10501(i)(3)(A) of the Affordable Care Act (Pub. L. 111-148 and Pub. L. 111-152) added
§1834(o) of the Act to establish a new system of payment for the costs of FQHC services under
Medicare Part B based on prospectively set rates. The statute requires implementation of the
FQHC prospective payment system (FQHC PPS) for FQHCs with cost reporting periods
beginning on or after October 1, 2014. Form CMS-224-14 must be used by all freestanding
FQHCs for cost reporting periods beginning on or after October 1, 2014. The FQHC cost report
must be submitted to the Medicare administrative contractor (MAC) (hereafter referred to as
contractor) electronically in accordance with 42 CFR 413.24(f)(4). Cost reports are due on or
before the last day of the fifth month following the close of the period covered by the report. For
cost reports ending on a day other than the last day of the month, cost reports are due 150 days
after the last day of the cost reporting period, in accordance with 42 CFR 413.24(f)(2).
NOTE: This form is to be used by freestanding FQHCs only. FQHCs that are hospital-based
must use the Form CMS-2552.
The public reporting and recordkeeping burden for this cost report is estimated to average 58
hours per response. This includes time for reviewing instructions, gathering data, maintaining
records, and completing the forms. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing the burden, to:
Centers for Medicare and Medicaid Services
PRA Reports Clearance Officer
7500 Security Boulevard
Mail Stop C4-26-05
Baltimore, Md. 21244-1850

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4400.1 Rounding Standards for Fractional Computations.--Throughout the Medicare cost
report, required computations result in the use of fractions. Use the following rounding
standards for such computations:
1.

Round to 2 decimal places:
a. Rates
b. Cost per visit
c. Cost for pneumococcal and influenza vaccines

2.

Round to 6 decimal places:
a. Ratios
b. Unit cost multiplier

If a residual exists as a result of computing costs using a fraction, adjust the residual in the
largest amount resulting from the computation. For example, in cost finding, a unit cost
multiplier is applied to the statistics in determining costs. After rounding each computation, the
sum of the allocation may be more or less than the total cost allocated. This residual is adjusted
to the largest amount resulting from the allocation so that the sum of the allocated amounts
equals the amount allocated.
4401.

ACRONYMS AND ABBREVIATIONS

Throughout the Medicare cost report and instructions, a number of acronyms and abbreviations
are used. For your convenience, commonly used acronyms and abbreviations are summarized
below.
A&G
CAP REL
CBSA
CCN
CFR
CMS
ECR
FQHC
HCRIS
HRSA
I&R
MAC
NPR
PCRE
PS&R Report
RCE
THC

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Administrative and General
Capital-Related
Core Based Statistical Area
CMS Certification Number (formerly known as provider number)
Code of Federal Regulations
Centers for Medicare & Medicaid Services
Electronic Cost Report
Federally Qualified Health Center
Healthcare Cost Report Information System
Health Resources and Services Administration
Interns and Residents
Medicare Administrative Contractor
Notice of Program Reimbursement
Primary Care Residency Expansion
Provider Statistical and Reimbursement Report
Reasonable Compensation Equivalency Limit
Teaching Health Center

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4402

RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-224-14

Step
No.

Worksheet

Instructions

1

S, Parts I & II

Read §§4404.1 and 4404.2. Complete Parts I and II.

2

S-1, Part I

Read §4405.1. Complete entire worksheet.

3

S-1, Part II

Read §4405.2. Complete entire worksheet.

4

S-2

Read §4406. Complete entire worksheet if applicable.

5

S-3, Part I

Read §4407.1. Complete entire worksheet.

6

S-3, Part II

Read §4407.2. Complete entire worksheet.

7

S-3, Part III

Read §4407.3. Complete entire worksheet.

8

A

Read §4408. Complete columns 1 through 3.

9

A-1

Read §4409. Complete entire worksheet if applicable.

10

A

Read §4408. Complete columns 4 and 5.

11

A-2-1, Parts I & II

Read §4411.1 and 4411.2. Complete entire worksheet if
applicable.

12

A-2

Read §4410. Complete entire worksheet.

13

A

Read §4408. Complete columns 6 and 7.

14

B, Parts I & II

Read §§4412.1 and 4412.2. Complete entire worksheet.

15

B-1

Read §4413. Complete entire worksheet.

16

E

Read §4414. Complete lines 1 - 17.

17

E-1

Read §4415. Complete entire worksheet.

18

E

Read §4414. Complete lines 18 - 21 as applicable.

19

F-1

Read §4416. Complete entire worksheet.

20

S, Part III

Read §4404.3. Complete Part III.

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SEQUENCE OF ASSEMBLY

The following list of assembly of worksheets is provided so all FQHCs are consistent in the
order of submission of their annual cost report. All FQHCs using Form CMS-214-14 are to
adhere to this sequence. Where worksheets are not completed because they are not applicable,
blank worksheets are not included in the assembly of the cost report.
Worksheet

Part

S

I, II & III

S-1

I & II

S-2
S-3

I, II & III

A
A-1
A-2
A-2-1

I & II

B

I & II

B-1
E
E-1
F-1

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4404.

FORM CMS-224-14

4404.1

WORKSHEET S - FEDERALLY QUALIFIED HEALTH CENTER COST REPORT
CERTIFICATION AND SETTLEMENT SUMMARY

4404.1 Part I - Cost Report Status.--This section is to be completed by the FQHC and
contractor as indicated on the worksheet. If this is a consolidated cost report, the organization
must choose a primary FQHC whose CMS certification number (CCN) must be utilized
throughout the entire cost report.
Line 1.--Indicate if the cost report is an electronic submission by entering “Y” for yes or “N” for
no in column 1. If yes, enter the electronic file creation date and time in columns 2 and 3,
respectively. If no, line 2 must be completed.
Line 2.--If line 1 is no, indicate if this cost report is a manual submission by entering “Y” for yes
or “N” for no. This line is only completed by FQHCs filing low utilization cost reports in
accordance with CMS Pub. 15-2, chapter 1, §110 or FQHCs demonstrating financial hardship in
accordance with CMS Pub. 15-2, chapter 1, §133.
Line 3.--If this is an amended cost report, enter the number of times the cost report has been
amended.
Line 4.--Enter an “F” if this is full cost report or an “L” if this is a low Medicare utilization cost
report (“L” requires prior contractor approval, see CMS Pub. 15-2, chapter 1, §110).
Lines 5 through 12 are for contractor use only:
Line 5.--Enter the Healthcare Cost Report Information System (HCRIS) cost report status code
that corresponds to the filing status of the cost report: 1=As submitted; 2=Settled without audit;
3=Settled with audit; 4=Reopened; or 5=Amended.
Line 6.--Enter the date (mm/dd/yyyy) the accepted cost report was received from the FQHC.
Line 7.--Enter the 5 position contractor number.
Lines 8 and 9.--If this is an initial cost report, enter “Y” for yes in the box on line 8. If this is a
final cost report, enter “Y” for yes in the box on line 9; if neither, enter “N”. An initial report is
the very first cost report for a particular FQHC CCN. A final cost report is a terminating cost
report for a particular FQHC CCN.
Line 10.--Enter the Notice of Program Reimbursement (NPR) date (mm/dd/yyyy). The NPR date
must be present if the cost report status code is 2, 3 or 4.
Line 11.--Enter the software vendor code of the cost report software used by the contractor to
process this HCRIS cost report file; use “4” for HFS or “3” for KPMG.
Line 12.--Complete this line only if the cost report status code on line 5 is “4”. If this is a
reopened cost report (response to line 5 cost report status, is “4”), enter the number of times the
cost report has been reopened.
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4404.2 Part II - Certification.--This certification is read, prepared, and signed by an officer or
administrator of the FQHC after the cost report has been completed in its entirety
4404.3 Part III - Settlement Summary.--Enter the balance due to or due from the Medicare
program. Transfer the amount from Worksheet E, line 20.
4405.

WORKSHEET S-1 - FEDERALLY
IDENTIFICATION DATA

QUALIFIED

HEALTH

CENTER

This worksheet consists of two parts:
Part I - Federally Qualified Health Center Identification Data
Part II - Federally Qualified Health Center Consolidated Cost Report Participant
Identification Data
4405.1 Part I - Federally Qualified Health Center Identification Data.--The information
required on this worksheet is needed to properly identify the FQHC, or in the case of a
consolidated cost report, the primary FQHC. In the case of a consolidated cost report, only the
primary FQHC completes the entire Worksheet S-1, Part I. All other FQHCs filing under a
consolidated cost report must be listed on line 14 and its subscripts and must complete a separate
Worksheet S-1, Part II.
Line 1, columns 1 through 4.--Enter in the appropriate column the site name, CCN, core based
statistical area (CBSA) code (rural CBSA codes are assembled by placing the digits “999” in
front of the two digit state code, e.g., for the state of Maryland the rural CBSA code is 99921),
and certification date.
Line 1, column 5.--Indicate the type of control under which the FQHC operates by entering a
number from the list below:
1
2
3
4
5
6

= Voluntary Nonprofit, Corporation
= Voluntary Nonprofit, Other
= Proprietary, Individual
= Proprietary, Corporation
= Proprietary, Partnership
= Proprietary, Other

7 = Governmental, Federal
8 = Governmental, State
9 = Governmental, County
10 = Governmental, City
11 = Governmental, Other

Line 2.--Enter the FQHC’s street address in column 1 and the post office box in column 2 (if
applicable).
Line 3.--Enter the city in column 1, state in column 2, ZIP code in column 3, county in column 4,
and the appropriate designation (“U” for urban or “R” for rural) in column 5. See CMS Pub.
100-04, chapter 9, §20.6.2 for information regarding urban and rural designations. If you are
uncertain of your designation, contact your contractor.
Line 4.--Enter the inclusive dates covered by this cost report. Enter in column 1, the cost report
beginning date and enter in column 2, the cost report ending date.
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4405.1 (Cont.)

Line 5.--Indicate whether this FQHC is owned, leased or controlled by an entity that operates
multiple FQHCs. Enter a “Y” for yes or an “N” for no. If yes, complete lines 6 through 8.
Otherwise, skip to line 9.
Lines 6 through 8.--Enter the name of the entity that owns, leases or controls the FQHC, the
street address, post office box (if applicable), Health Resources Services Administration (HRSA)
grant award number assigned to the organization, city, state, and ZIP code.
Lines 9.--Indicate if this FQHC is part of a chain organization as defined in CMS Pub. 15-1,
chapter 21, §2150 that claimed home office costs in a home office cost statement. Enter “Y” for
yes or “N” for no. If yes, complete lines 10 through 12. Otherwise, skip to line 13.
Lines 10 through 12.--Enter the name of the chain organization, the street address, post office
box (if applicable), the home office CCN, city, state, and ZIP code.
Line 13.--Indicate whether this FQHC is filing a consolidated cost report under CMS
Pub. 100-04, chapter 9, §30.8. Enter “Y” for yes or “N” for no. If yes, enter in column 2 the
date the FQHC requested approval to file a consolidated cost report, and in column 3 the date the
contractor approved the FQHCs request to file a consolidated cost report.
Line 14.--If the response to line 13 is yes, list on line 14 and its subscripts, each FQHC that is
part of this consolidated cost report, excluding the FQHC listed on line 1. Enter in column 1 the
site name, column 2 the CCN, column 3 the CBSA, column 4 the date the FQHC requested
approval to file as part of a consolidated cost report, and column 5 the date the contractor
approved the FQHCs request to file as part of a consolidated cost report. Each FQHC listed on
line 14 and its subscripts must complete a separate Worksheet S-1, Part II.
Line 15.--There are 3 types of organizations that are eligible to enroll in Medicare as FQHCs.
Indicate in column 1, the type of organization this FQHC is by entering a number from the list
below. If your response in column 1 is “1” or “3”, enter any or all of the alpha character (s)
associated with the response in column 2. For example if you entered “1” in column 1, enter in
column 2, “A”, “B”, “C” and/or “D.” An organization receiving a grant under §330 of the Public
Health Service (PHS) Act or an outpatient health program/facility can operate as any or all of the
subcategories listed under the respective numeric options presented below.
1) An organization receiving a grant(s) under §330 of the PHS Act:
A) Community Health Centers
B) Migrant and Seasonal Agricultural Workers Health Centers
C) Health Care for the Homeless Health Centers
D) Health Centers for Residents of Public Housing
2) Health Center Program Look-Alikes; Organizations that have been identified by HRSA as
meeting the definition of “Health Center” under §330 of the PHS Act, but not receiving grant
funding under §330; or

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3) Outpatient health program/facility operated by:
A) A tribe or tribal organization under the Indian Self-Determination Act
B) An urban Indian organization under Title V of the Indian Health Care Improvement
Act
C) Other
Line 16.--Indicate if your FQHC received a grant under §330 of the PHS Act during this cost
reporting period. If this is a consolidated cost report, did the primary 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.
Line 17.--If the response to line 16 is yes, indicate in column 1, the type of grant that was
awarded from the list below. 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.
1 = Community Health Center (§330(e), PHS Act)
2 = Migrant and Seasonal Agricultural Workers Health Center (§330(g), PHS Act)
3 = Health Care for the Homeless Health Centers (§330(h), PHS Act)
4 = Health Centers for Residents of Public Housing (§330(i), PHS Act)
5 = Other
Line 18.--Indicate if your FQHC submitted an initial deeming or annual redeeming application
for medical malpractice coverage to HRSA under the Federal Tort Claims Act (FTCA). 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.
Line 19.--Indicate if your FQHC is legally required to carry malpractice coverage. Enter “Y for
yes or “No” for no. Malpractice insurance premiums are money paid by the FQHC to a
commercial insurer to protect the FQHC against potential negligence claims made by their
patients/clients.
Line 20.--If line 19 is yes, indicate if your malpractice insurance is a claims-made or occurrence
policy. A claims-made insurance policy covers claims first made (reported or filed) during the
year the policy is in force for any incidents that occur that year or during any previous period
during which the insured was covered under a “claims-made” contract. The occurrence policy
covers an incident occurring while the policy is in force regardless of when the claim arising out
of that incident is filed. Enter 1 if the malpractice insurance is a claims-made policy. Enter 2 if
the malpractice insurance is an occurrence policy.
Line 21.--Enter the total amount of malpractice premiums paid in column 1, enter the total
amount of paid losses in column 2, and enter the total amount of self-insurance paid in column 3.
Malpractice paid losses is money paid by the FQHC to compensate a patient/client for
professional negligence. Malpractice self-insurance is money paid by the FQHC where the
FQHC acts as its own insurance company (either as a sole or part-owner) to financially protect
itself against professional negligence. Often FQHCs will manage their own funds or purchase a
policy referred to as captive insurance, which provides insurance coverage the FQHC needs but
could not obtain economically through the mainstream insurance market.
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4405.2

Line 22.--Indicate if malpractice premiums paid, paid losses, or self-insurance are reported in a
cost center other than the Administrative and General (A&G) cost center. Enter “Y” for yes or
“N” for no. If yes, submit a supporting schedule listing cost centers and amounts.
Line 23.--Is this FQHC involved in training residents in an approved graduate medical education
(GME) program in accordance with 42 CFR 405.2468(f)? Enter “Y” for yes or “N” for no.
Line 24.--Is this FQHC involved in training residents in an unapproved GME program? Enter
“Y” for yes or “N” for no.
Line 25.--Indicate if the FQHC received a Primary Care Residency Expansion (PCRE) grant
from HRSA to train new residents in primary care residency programs. Enter “Y” for yes or “N”
for no in column 1. If yes, enter the number of primary care full time equivalent (FTE) residents
your FQHC trained using PCRE grant funding in column 2, and the total number of visits
performed by such residents in column 3, during this cost reporting period.
Line 26.--Indicate if the FQHC received a Teaching Health Center (THC) development grant
authorized under Part C of title VII of the PHS Act from HRSA for the purpose of establishing
new accredited or expanded primary care residency programs. Enter “Y” for yes or “N” for no
in column 1. If yes, enter the number of FTE residents your FQHC trained using THC funding
in column 2, and the total number of visits performed by such residents in column 3, during this
cost reporting period.
Line 27.--Indicate if you own or lease the building or office space occupied by your FQHC.
Enter a “1” for owned or a “2” for leased in column 1. If you lease the office space, enter the
rent/lease expense for this cost reporting period in column 2.
4405.2 Part II - Federally Qualified Health Center Consolidated Cost Report Participant
Identification Data.--Each FQHC that is included on Worksheet S-1, Part I, line 14, and
applicable subscripts, who is filing as part of a consolidated cost report must complete a separate
Worksheet S-1, Part II in the identical sequence that the consolidated FQHCs are reported on
Worksheet S-1, Part I, line 14 and its subscripts. Do not complete this worksheet for the primary
FQHC reported on Worksheet S-1, Part I, line 1.
Line 1.--Enter the FQHC site name in column 1 and the FQHC certification date in column 2.
Indicate the type of control under which the FQHC operates by entering a number from the list
below in column 3.
1
2
3
4
5
6

= Voluntary Nonprofit, Corporation
= Voluntary Nonprofit, Other
= Proprietary, Individual
= Proprietary, Corporation
= Proprietary, Partnership
= Proprietary, Other

7 = Governmental, Federal
8 = Governmental, State
9 = Governmental, County
10 = Governmental, City
11 = Governmental, Other

Enter the date the FQHC terminated its participation in the Medicare program (if applicable) in
column 4. In column 5, enter a “V” for a voluntary termination or an “I” for an involuntary
termination.
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If the FQHC changed ownership immediately prior to the beginning of the cost reporting period
enter the date of the change of ownership in column 6. Also submit the name and address of the
new owner and a copy of the sales agreement with the cost report.
Line 2.--Enter the FQHC’s street address in column 1 and the post office box in column 2 (if
applicable).
Line 3.--Enter the city in column 1, state in column 2, ZIP code in column 3, county in column 4,
and the appropriate designation (“U” for urban or “R” for rural) in column 5. See
CMS Pub. 100-04, chapter 9, §20.6.2 for information regarding urban and rural designations. If
you are uncertain of your designation, contact your contractor.
Line 4.--There are 3 types of organizations that are eligible to enroll in Medicare as an FQHC.
Indicate in column 1, the type of FQHC organization by entering a number from the list below.
If your response in column 1 is “1” or “3”, enter any or all of the alpha characters associated with
the response in column 2. For example if you entered “1” in column 1, enter in column 2, “A”,
“B”, “C” and/or “D”. An organization receiving a grant under §330 of the PHS Act or an
outpatient health program/facility can operate as any or all of the subcategories listed under the
respective numeric options below.
1) An organization receiving a grant(s) under §330 of the PHS Act:
A) Community Health Centers
B) Migrant and Seasonal Agricultural Workers Health Centers
C) Health Care for the Homeless Health Centers
D) Health Centers for Residents of Public Housing
2) Health Center Program Look-Alikes; Organizations that have been identified by HRSA as
meeting the definition of “Health Center” under §330 of the PHS Act, but not receiving grant
funding under §330; or
3) Outpatient health program/facility operated by:
A) A tribe or tribal organization under the Indian Self-Determination Act
B) An urban Indian organization under Title V of the Indian Health Care Improvement Act
C) Other

Line 5.--Indicate if your FQHC received a grant under §330 of the PHS Act during this cost
reporting period? Enter “Y” for yes or “N” for no.
Line 6.--If the response to line 5 is yes, indicate in column 1, the type of grant that was awarded
from the list below. 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.
1 = Community Health Center (§330(e), PHS Act)
2 = Migrant and Seasonal Agricultural Workers Health Center (§330(g), PHS Act)
3 = Health Care for the Homeless Health Centers (§330(h), PHS Act)
4 = Health Centers for Residents of Public Housing (§330(i), PHS Act)
5 = Other

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4405.2 (Cont.)

Line 7.--Indicate if your FQHC submitted an initial deeming or annual redeeming application for
medical malpractice coverage to HRSA under the FTCA. 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.
Line 8.--Indicate if your FQHC is legally required to carry malpractice coverage. Enter “Y for
yes or “N” for no. Malpractice insurance premiums are money paid by the FQHC to a
commercial insurer to protect the FQHC against potential negligence claims made by their
patients/clients.
Line 9.--If line 8 is yes, indicate if your malpractice insurance is a claims-made or occurrence
policy. A claims-made insurance policy covers claims first made (reported or filed) during the
year the policy is in force for any incidents that occur that year or during any previous period
during which the insured was covered under a “claims-made” contract. The occurrence policy
covers an incident occurring while the policy is in force regardless of when the claim arising out
of that incident is filed. Enter 1 if the malpractice insurance is a claims-made policy. Enter 2 if
the malpractice insurance is an occurrence policy.
Line 10.--Enter the total amount of malpractice premiums paid in column 1, enter the total
amount of paid losses in column 2, and enter the total amount of self-insurance paid in column 3.
Malpractice paid losses is money paid by the FQHC to compensate a patient/client for
professional negligence. Malpractice self-insurance is money paid by the FQHC where the
FQHC acts as its own insurance company (either as a sole or part-owner) to financially protect
itself against professional negligence. Often FQHCs will manage their own funds or purchase a
policy referred to as captive insurance, which provides insurance coverage the FQHC needs but
could not obtain economically through the mainstream insurance market.
Line 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.
Line 12.--Is this FQHC involved in training residents in an unapproved GME program? Enter
“Y” for yes or “N” for no.
Line 13.--Indicate if the FQHC received PCRE grant funding from HRSA to train new residents
in primary care residency programs. Enter “Y” for yes or “N” for no in column 1. If yes, enter
in column 2 the number of primary care FTE residents your FQHC trained using PCRE grant
funding, and enter in column 3 the total number of visits performed by such residents during this
cost reporting period.
Line 14.--Indicate if the FQHC received a THC development grant authorized under Part C of
title VII of the PHS Act from HRSA for the purpose of establishing new accredited or expanded
primary care residency programs. Enter “Y” for yes or “N” for no in column 1. If yes, enter in
column 2 the number of FTE residents your FQHC trained using THC funding and enter in
column 3 the total number of visits performed by such residents during this cost reporting period.
Line 15.--Indicate whether you own or lease the building or office space occupied by your
FQHC. Enter a “1” for owned or a “2” for leased in column 1. If you lease the office space,
enter the rent/lease expense for this cost reporting period in column 2.
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4406.

FORM CMS-224-14
WORKSHEET S-2 - FEDERALLY
REIMBURSEMENT QUESTIONNAIRE

QUALIFIED

DRAFT
HEALTH

CENTER

This worksheet collects organizational, financial and statistical information previously reported
on Form CMS-339. Where instructions for this worksheet direct the FQHC to submit
documentation/information, mail or otherwise transmit the requested documentation to the
contractor with submission of the electronic cost report (ECR). The contractor has the right
under §§1815(a) and 1883(e) of the Act to request any missing documentation. When filing a
consolidated cost report, this worksheet applies only to the primary FQHC.
To the degree that the information in the questionnaire constitutes commercial or financial
information which is confidential and/or is of a highly sensitive personal nature, the information
will be protected from release under the Freedom of Information Act. If there is any question
about releasing information, the contractor should consult with the CMS Regional Office.
NOTE: The responses on all lines are “yes” or “no” unless otherwise indicated. When the
instructions require documentation, indicate on the documentation the Worksheet S-2 line
number the documentation supports. Lines 1 through 19 are required to be completed by all
FQHCs reported on Worksheet S-1, Part I, line 1.
Line 1.--Indicate whether the FQHC has changed ownership immediately prior to the beginning
of the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
enter the date the change of ownership occurred in column 2. Also, submit the name and address
of the new owner and a copy of the sales agreement with the cost report.
Line 2.--Indicate whether the FQHC has terminated participation in the Medicare program.
Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter the date of termination in
column 2, and “V” for voluntary or “I” for involuntary in column 3.
Line 3.--Indicate whether the FQHC is involved in business transactions, including management
contracts, with individuals or entities (e.g., chain home offices, drug or medical supply
companies) that are related to the FQHC or its officers, medical staff, management personnel, or
members of the board of directors through ownership, control, or family and other similar
relationships. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a list of
the individuals, the organizations involved, and a description of the transactions with the cost
report.
NOTE: A related party transaction occurs when services, facilities, or supplies are furnished to
the provider by organizations related to the provider through common ownership or control.
(See Pub. 15-1, chapter 10 and 42 CFR 413.17.)

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Line 4.--Indicate in column 1 whether the financial statements were prepared by a certified
public accountant; enter “Y” for yes or “N” for no. If column 1 is yes, indicate the type of
financial statements in column 2 by entering “A” for audited, “C” for compiled, or “R” for
reviewed. Submit a complete copy of the financial statements (i.e., the independent public
accountant’s opinion, the statements themselves, and the footnotes) with the cost report. If the
financial statements are not available for submission with the cost report enter the date they will
be available in column 3.
If column 1 is no, submit a copy of the internally prepared financial statements, and written
statements of significant accounting policy and procedure changes affecting Medicare
reimbursement which occurred during the cost reporting period. You may submit the changed
accounting or administrative procedures manual in lieu of written statements.
Line 5.--Indicate whether Intern-Resident costs were claimed on the current cost report. Enter
“Y” for yes or “N” for no in column 1.
Line 6.--Indicate whether Intern-Resident program(s) have been initiated or renewed during the
cost reporting period. Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in
column 1, submit copies of the certification(s)/program approval(s) with the cost report. (See 42
CFR 413.79(l) for the definition of a new program.)
Line 7.--Indicate whether graduate medical education costs were directly assigned to cost centers
other than the “Allowable GME Costs” on Worksheet A, line 47. Enter “Y” for yes or “N” for
no in column 1. If you answer “Y” in column 1, submit a listing of the cost centers and amounts
with the cost report.
Line 8.--Indicate whether you are seeking reimbursement for bad debts resulting from Medicare
deductible and/or coinsurance amounts which are uncollectible from Medicare beneficiaries.
(See 42 CFR 413.89(e) and CMS Pub. 15-1, chapter 3, §§306 - 324 for the criteria for an
allowable bad debt.) Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column
1, submit a completed Exhibit 1 or internal schedule duplicating the documentation requested on
Exhibit 1 to support the bad debts claimed.
Exhibit 1 requires the following documentation:
Columns 1, 2, 3, 4 - Patient Names, Health Insurance Claim (HIC) Number, and Dates of Service
(From - To).--The documentation required for these columns is derived from the beneficiary’s
bill. Furnish the patient’s name, HIC number and dates of service that correlate to the claimed
bad debt. (See CMS Pub. 15-1, chapter 3, §314 and 42 CFR 413.89.)

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DRAFT

Columns 5 & 6--Indigency/Medicaid Beneficiary.--If the patient included in column 1 has been
deemed indigent, place a check in column 5. If the patient in column 1 has a valid Medicaid
number, include this number in column 6. See the criteria in CMS Pub. 15-1, chapter 3, §§312
and 322 and 42 CFR 413.89 for guidance on the billing requirements for indigent and Medicaid
beneficiary.
Columns 7 & 8--Date First Bill Sent to Beneficiary & Date Collection Efforts Ceased.--This
information should be obtained from the FQHC’s files and should correlate with the beneficiary
name, HIC number, and dates of service shown in columns 1, 2, 3 and 4 of this exhibit. The date
in column 8 represents the date that the unpaid account is deemed worthless, whereby all
collection efforts, both internal and by an outside entity, ceased and there is no likelihood of
recovery of the unpaid account. (See 42 CFR 413.89(e) and (f), and CMS Pub. 15-1, chapter 3,
§§308, 310, and 314.)
Column 9--Medicare Remittance Advice Dates.--Enter in this column the remittance advice
dates that correlate with the beneficiary name, HIC number, and dates of service shown in
columns 1, 2, 3 and 4 of this exhibit.
Column 10--Coinsurance/Total Medicare Bad Debts.--Record on each line of this column the
beneficiary’s unpaid coinsurance amount that relates to covered services. Calculate the total bad
debts by summing up the amounts on all lines of column 10. This “total” must agree with the
bad debts claimed on the cost report. Attach additional supporting schedules, if necessary, for
bad debt recoveries.
Line 9.--Indicate whether your bad debt collection policy changed during the cost reporting
period. Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, submit a
copy of the revised bad debt collection policy with the cost report.
Line 10.--Indicate whether patient coinsurance amounts were waived. Enter “Y” for yes or “N”
for no in column 1. If you answer “Y” in column 1, ensure that they are not included on the bad
debt listings (i.e., Exhibit 1 or your internal schedules) submitted with the cost report.
Line 11.--Indicate whether the cost report was prepared using the Provider Statistical &
Reimbursement (PS&R) Report only. Enter “Y” for yes or “N” for no in column 1. If column 1
is “Y” enter the paid through date of the PS&R in column 2. Also, submit a crosswalk between
revenue codes and visits found on the PS&R to the cost center groupings on the cost report. This
crosswalk will reflect a cost center to revenue code match only.

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Line 12.--Indicate whether the cost report was prepared using the PS&R for totals and the
FQHC’s records for allocation. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”
enter the paid through date of the PS&R used to prepare this cost report in column 2. Also,
submit a detailed crosswalk between revenue codes and visits on the PS&R to the cost center
groupings on the cost report. This crosswalk must show visits by cost center and include which
revenue codes were allocated to each cost center. The total visits on the cost report must match
the total visits on the PS&R (as appropriately adjusted for unpaid claims, etc.) to use this
method. Supporting work papers must accompany this crosswalk to provide sufficient
documentation as to the accuracy of the FQHC’s records.
Line 13.--If you entered “Y” on either line 11 or 12, indicate whether adjustments were made to
the PS&R data for additional claims that have been billed but not included on the PS&R used to
file this cost report. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, include a
schedule which supports any claims not included on the PS&R. This schedule should include
totals consistent with the breakdowns on the PS&R, and should reflect claims that are
unprocessed or unpaid as of the cut-off date of the PS&R used to file the cost report.
Line 14.--If you entered “Y” on either line 11 or 12, column 1, indicate whether adjustments
were made to the PS&R data for corrections of other PS&R information. Enter “Y” for yes or
“N” for no in column 1. If column 1 is “Y”, submit a detailed explanation and documentation
which provides an audit trail from the PS&R to the cost report.
Line 15.--If you entered “Y” on either line 11 or 12, column 1, indicate whether other
adjustments were made to the PS&R data. Enter “Y” for yes or “N” for no in column 1. If
column 1 is “Y”, include a description of the other adjustments and documentation which
provides an audit trail from the PS&R to the cost report.
Line 16.--Indicate whether the cost report was prepared using FQHC records only. Enter “Y” for
yes or “N” for no in column 1. If column 1 is “Y”, submit detailed documentation of the system
used to support the data reported on the cost report. If detail documentation was previously
supplied, submit only necessary updated documentation with the cost report.
The minimum requirements are:


Internal records supporting program utilization statistics, charges, prevailing rates
and payment information broken into each Medicare bill type in a manner
consistent with the PS&R report.



A reconciliation of remittance totals to the provider’s internal records.



The name of the system used and system maintainer (vendor or FQHC). If the
FQHC maintained the system, include date of last software update.

NOTE: Additional information may be supplied such as narrative documentation, internal flow
charts, or outside vendor informational material to further describe and validate the reliability of
your system.
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DRAFT

Line 17.--Enter the first name, last name and the title/position held by the cost report preparer in
columns 1, 2, and 3, respectively.
Line 18.--Enter the employer/company name of the cost report preparer.
Line 19.--Enter the telephone number and email address of the cost report preparer in columns 1
and 2, respectively.

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EXHIBIT 1
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
FQHC Name ____________________
FQHC CCN ______________________
FYE _________________________

Prepared By __________________________________
Date Prepared ________________________________

Dates of Service

Indigency& Medicaid
Beneficiary (Check if
applicable)

Patient Name

HIC. No.

From

To

Yes

Medicaid
Number

1

2

3

4

5

6

Date First
Bill Sent to
Beneficiary

Date
Collection
Efforts Ceased

Medicare
Remittance
Advice Dates

Co-Insurance/
Total Medicare
Bad Debts*

7

8

9

10

*These amounts must not be claimed unless the FQHC bills for these services with the intention of receiving payment.
See instructions for columns 5 and 6 - Indigency/Medicaid Beneficiary, for possible exception.
These amounts must not be claimed if they were included on a previous Medicare bad debt listing or cost report.

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FORM CMS-224-14

4407.

WORKSHEET S-3 - FEDERALLY QUALIFIED HEALTH CENTER DATA

DRAFT

This worksheet consists of three parts:
Part I - Federally Qualified Health Center Statistical Data
Part II - Federally Qualified Health Center Contract Labor and Benefit Cost
Part III - Federally Qualified Health Center Employee Data
4407.1 Part I - Federally Qualified Health Center Statistical Data.--This part collects statistical
data regarding the number and types of visits by title, as well as, the number of visits performed
by interns and residents. Only those visits associated with a beneficiary receiving services under
the Medicare fee for service program are included in column 2. However, visits attributable to
beneficiaries enrolled in a Medicare Advantage plan must be included in column 4. For the
purposes of the Medicare program, a beneficiary who receives care at an FQHC can be seen for
three types of visits:




Medical Visit
Medical Visit for Subsequent Illness or Injury
Mental Health Visit

All visits performed by interns and residents who are funded by a THC or PCRE grant from
HRSA must be excluded from lines 5 and 6 on this worksheet. Visits performed by an intern or
resident funded by a THC or PCRE grant from HRSA are separately reported on the Worksheet
S-1, Parts I and II.
Column 0.--Use this column only when you are filing a consolidated cost report to identify each
FQHC listed on Worksheet S-1, Part I, line 14 and subscripts in the exact same order.
Columns 1 through 3.--Enter the number of medical visits, mental health visits and visits
performed by interns and residents, if applicable, for each program (title V, title XVIII and title
XIX). Include dually eligible (Medicare/Medicaid) beneficiaries in column 2.
Column 4.--Enter the total medical visits, mental health visits and visits performed by interns and
residents, if applicable, for all patients. The total FQHC medical, mental health and intern and
resident visits in column 4 may not equal the sum of the visits reported in columns 1 through 3,
as visits paid by other insurers (i.e., private pay) are included in this column.
Line 1.--Enter the number of medical visits applicable to columns 1 through 4. Each visit to the
FQHC by the beneficiary counts as a single visit, even in the case where a beneficiary returns to
the FQHC in the same day for a subsequent illness or injury. If you are filing under a
consolidated cost report, line 1 must contain the medical visits exclusively for the primary CCN
and you must subscript line 1 to report the number of medical visits for each additional FQHC
included in this consolidated cost report. Each subscript of line 1, column 0, must contain a
corresponding CCN from Worksheet S-1, Part I, line 14 and subscripts in the exact same order.
Enter the number of medical visits applicable to columns 1 through 4, for each FQHC listed on
line 1 and its subscripts.
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4407.2

Line 2.--Enter the total number of medical visits (sum of line 1 and its subscripts) for each
applicable column.
Line 3.--Enter the number of mental health visits applicable to columns 1 through 4. Each visit
to the FQHC by the beneficiary counts as a single visit, even in the case where a beneficiary
returns to the FQHC in the same day for a subsequent illness or injury. If you are filing under a
consolidated cost report, line 3 must contain the mental health visits exclusively for the primary
CCN and you must subscript line 3 to report the number of mental health visits for each
additional FQHC included in this consolidated cost report. Each subscript of line 3, column 0,
must contain a corresponding CCN from Worksheet S-1, Part I, line 14 and subscripts in the
exact same order. Enter the number of mental health visits applicable to columns 1 through 4,
for each FQHC listed on line 3 and its subscripts.
Line 4.--Enter the total number of mental health visits (sum of line 3 and its subscripts) for each
applicable column.
Line 5.--Enter the total number of visits performed by interns and residents not funded by a THC
or PCRE grant from HRSA applicable to columns 1 through 4. If you are filing under a
consolidated cost report, line 5 must contain the visits performed by interns and residents
exclusively for the primary CCN and you must subscript line 5 to report the number of visits
performed by interns and residents for each additional FQHC included in this consolidated cost
report. Each subscript of line 5, column 0, must contain a corresponding CCN from Worksheet
S-1, Part I, line 14 and subscripts in the exact same order. Enter the number of visits performed
by interns and residents applicable to columns 1 through 4 for each FQHC listed on line 5 and its
subscripts.
Line 6.--Enter the total number of visits performed by interns and residents not funded by a THC
or PCRE grant from HRSA (sum of line 5 and its subscripts) for each applicable column.
NOTE: When reporting data for FQHCs reporting under the consolidated cost reporting
provisions, subscript lines 1, 3, and 5 in the identical sequence that the consolidated FQHCs are
reported on Worksheet S-1, Part I, line 14.
4407.2 Part II - Federally Qualified Health Center Contract Labor and Benefit Cost.--This
section identifies the contract labor and benefit costs relating to direct patient care and top level
management services.
DEFINITIONS
Column 1 - Contract Labor Costs.--Enter the amount paid for services furnished under contract,
rather than by employees, for direct patient care and top level management services for the
occupations on lines 1 through 13. DO NOT include cost for equipment, supplies, travel
expenses, and other miscellaneous or overhead items (non-labor costs).
Column 2 - Benefit Costs.--Enter the amount of employee benefit costs, also referred to as wagerelated costs, for services furnished under contract, rather than by employees, for direct patient
care and top level management services for the occupations listed on lines 1 through 13.
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DRAFT

4407.3 Part III - Federally Qualified Health Center Employee Data.--This section identifies
data related to the human resources of the FQHC. The human resources statistics are required
for each of the job categories specified in lines 14 through 25.
Enter the number of hours in your normal work week.
Report in column 1 the FTE employees on the FQHC’s payroll. These are staff for which an IRS
Form W-2 is used.
Report in column 2 the FTE contracted and consultant staff of the FQHC.
Complete staff FTEs for column 1 as follows: Add all hours for which employees were paid and
divide by 2080. Round to two decimal places, e.g., 04447 is rounded to .04. Compute contract
FTE’s for column 2 as follows: Add all hours for which contracted and consultant staff worked
and divide by 2080 hours. If employees are paid for unused vacation, unused sick leave, etc.,
exclude these paid hours from the numerator in the calculations.
Enter the total FTEs in column 3, by adding columns 1 and 2.

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4408

4408. WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES
Worksheet A provides for recording the trial balance of expense accounts from your accounting
books and records. It also provides for the necessary reclassifications and adjustments to certain
accounts. The cost centers listed may not apply to every FQHC using these forms. For example,
a FQHC that does not have an intern and resident program will not complete lines 47 and/or 78.
Complete only those lines that are applicable.
If the cost elements of a cost center are maintained separately on your accounting books, a
reconciliation of costs per the accounting books and records to those on this worksheet must be
maintained and are subject to review by your contractor.
Standard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If
additional or different cost center descriptions are needed, add (subscript) additional lines to the
cost report. Where an added cost center description bears a logical relationship to a standard line
description, the added label must be inserted immediately after the related standard line. The
added line is identified as a numeric subscript of the immediately preceding line. For example, if
two lines are added between lines 7 and 8, identify them as lines 7.01 and 7.02.
Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by health care entities on the Medicare cost reports. Form CMS-224-14 provides for preprinted
cost center descriptions on Worksheet A. In addition, a space is provided for a cost center code.
The preprinted cost center labels are automatically coded by CMS approved cost reporting
software. These cost center descriptions are hereafter referred to as the standard cost centers.
Additionally, nonstandard cost center descriptions have been identified through analysis of
frequently used labels.
This coding methodology allows FQHCs to continue to use labels for cost centers that have
meaning within the individual institution. The four digit cost center codes that are associated
with each FQHC’s label in the ECR file provide standardized meaning for data analysis. FQHCs
are required to compare any added or changed labels to the descriptions offered on the standard
or nonstandard cost center tables. A description of cost center coding and the table of cost center
codes are in §4495, table 5.

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DRAFT

COLUMN DESCRIPTIONS
Columns 1 through 3.--The expenses listed in these columns must be in accordance with your
accounting books and records.
Enter on the appropriate lines in columns 1 through 3 the total expenses incurred during the cost
reporting period. These expenses are detailed between salaries (column 1) and other than
salaries (column 2). The sum of columns 1 and 2 must equal column 3.
Column 1.--Salaries are the gross salaries paid to employees before taxes and other items are
withheld. Salaries include paid vacation, holiday, sick, other-paid-time off, severance and bonus
pay. (See CMS Pub. 15-1, chapter 21.) Enter salaries from the FQHC’s accounting books and
records.
Column 2.--Enter all costs other than salaries from the FQHC’s accounting books and records.
Column 3.--For each cost center, add the amounts in columns 1 and 2 and enter the total in
column 3.
Column 4.--For each cost center, enter the net amount of reclassifications from Worksheet A-1.
The net total of the entries in column 4 must equal zero on line 100. Show reductions to
expenses as negative numbers.
Column 5.--For each cost center, enter the total of the amount in column 3 plus or minus the
amount in column 4. The total on column 5, line 100 must equal the total on column 3, line 100.
Column 6.--For each cost center, enter the net of any increase and decrease amounts from
Worksheet A-2. The total on Worksheet A, column 6, line 100 must equal Worksheet A-2,
column 2, line 50.
Column 7.--For each cost center, enter the total of the amount in column 5 plus or minus the
amount in column 6.

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4408 (Cont.)

LINE DESCRIPTIONS
The Worksheet A segregates the trial balance of expenses into general service cost centers, direct
patient care cost centers, reimbursable pass through costs, other FQHC services, and
nonreimbursable cost centers to facilitate the transfer of costs to the various worksheets.
GENERAL SERVICE COST CENTERS
These cost centers include expenses incurred in operating the FQHC as a whole that are not
directly associated with furnishing patient care such as, but not limited to mortgage, rent, plant
operations, administrative salaries, utilities, telephone, and computer hardware and software
costs. General service cost centers furnish services to other general service cost centers and to
reimbursable and nonreimbursable cost centers in the FQHC.
Lines 1 and 2 - Cap Rel Costs-Bldg & Fix and Cap Rel Costs-Mvble Equip.--These cost centers
include the capital-related costs for buildings and fixtures and the capital-related costs for
movable equipment including depreciation, leases and rentals for the use of facilities and/or
equipment, including electronic health records systems, interest incurred in acquiring land and
depreciable assets used for patient care, insurance on depreciable assets used for patient care,
taxes on land or depreciable assets used for patient care, and software and hardware updates
attributable to electronic health records systems. Do not include in these cost centers costs
incurred for the repair or maintenance of equipment or facilities; amounts specifically included
in rentals or lease payments for repair and/or maintenance agreements; interest expense incurred
to borrow working capital or for any purpose other than the acquisition of land or depreciable
assets used for patient care; general liability insurance or any other form of insurance to provide
protection other than the replacement of depreciable assets; or taxes other than those assessed on
the basis of some valuation of land or depreciable assets used for patient care. However, if no
amount of the lease payment is identified in the lease agreement for maintenance, you are not
required to carve out a portion of the lease payment to represent the maintenance portion. Thus,
the entire lease payment is considered a capital-related cost subject to the provisions of 42 CFR
413.130(b).

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Line 3 - Employee Benefits.--This cost center includes the costs of the employee benefits
department. In addition, this cost center includes the fringe benefits paid to, or on behalf of, an
employee when an FQHC’s accounting system is not designed to accumulate the benefits on a
departmentalized or cost center basis. (See CMS Pub. 15-1, chapter 21, §2144).
Line 4 - Administrative and General (A&G) Services.--A&G includes a wide variety of
administrative costs such as but not limited to cost of fiscal services, legal and accounting
services, facility administrative services (not already included in other general services cost
centers), etcetera.
Line 5 - Plant Operation and Maintenance.--This cost center includes expenses incurred in the
plant operation and maintenance of the FQHC. These costs include the maintenance and service
of utility systems such as heat, light, water, air conditioning and air treatment. This cost center
also includes costs incurred in maintaining the facility and grounds, such as costs of routine
painting, plumbing, mowing, and snow removal.
Line 6 - Janitorial.--This cost center includes the cost of routine janitorial activities such as
mopping, vacuuming, cleaning restrooms, lobbies, waiting areas and otherwise maintaining
patient and non-patient care areas.
Line 7 - Medical Records.--This cost center includes the cost of the medical records department
where patient medical records are maintained. The general library and the medical library are
not included in this cost center but are included in the A&G cost center. None of the costs
associated with electronic health records systems are reported in this cost center.
Line 8 - Subtotal - Administrative Overhead.--Enter the total of lines 1 through 7.
Line 9 - Pharmacy.--This cost center includes the costs of routine drugs (both prescription and
over the counter), pharmacy supplies, pharmacy personnel, pharmacy services, and the nonroutine costs of drugs and pharmacy supplies that can be traced to individual patients. Do not
include the cost of influenza and pneumococcal vaccines on this line as these costs are reported
on lines 48 and 49, respectively.
Line 10 - Medical Supplies.--This cost center includes the routine cost of supplies used in the
normal course of caring for patients, such as gloves, masks, swabs, or glycerin sticks, and the
non-routine costs of medical supplies that can be traced to individual patients. Do not include
the cost of medical supplies used in administering influenza and pneumococcal vaccines on this
line as these costs are reported on lines 48 and 49, respectively.
Line 11 - Transportation.--This cost center includes the cost of owning or renting vehicles, public
transportation expenses, parking, tolls, or payments to employees for driving their private
vehicles to see patients or for other FQHC business.

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Line 12 - Other General Service (Specify).--Use this line to report the costs of other general
service costs not previously identified on lines 1 through 11. If more than one other general
service is offered, subscript this line. See Table 5 in §4495 for the proper cost center code for
this line.
Line 13 - Subtotal - Total Overhead.--Enter the sum of lines 8 and 9 through 12.
Line 14 through 22.--Reserved for future use.
DIRECT CARE COST CENTERS
Line 23 - Physician.--This cost center includes the costs incurred by the FQHC for physicians
providing direct patient care services and general supervisory services, participation in the
establishment of plans of care, supervision of care and services, periodic review and updating of
plans of care, and establishment of governing policies by the governing board. Reclassify the
cost for the portion of time physicians spent on general supervisory services or other FQHC
administrative activities to A&G (line 4). The costs incurred for teaching physicians and interns
and residents must be reported on line 47 or line 48, whichever is applicable.
Line 24 - Physician Services Under Agreement.--This cost center includes the costs incurred by
the FQHC for physicians who are providing services under agreement.
Line 25 - Physician Assistant.--This cost center includes the costs incurred by the FQHC for
physician assistants (PA), including the costs for PAs providing physician services.
Line 26 - Nurse Practitioner.--This cost center includes the costs of nursing care provided by
nurse practitioners (NP), including NPs providing physician services.
Line 27 - Visiting Registered Nurse.--This cost center only includes the costs of nursing care
provided by registered nurses (RNs) who perform visiting nurse services in accordance with
CMS Pub. 100-02, chapter 13, §180. Costs associated with RNs who provide services incident
to a physician, PA, NP, certified nurse midwife (CNM), clinical psychologist (CP) or clinical
social worker (CSW) (see CMS Pub. 100-02, chapter 13, §§110, 120 and 140) are included in
line 36.
Line 28 - Visiting Licensed Practical Nurse.--This cost center only includes the costs of nursing
care provided by licensed practical nurses (LPNs) who perform visiting nurse services in
accordance with CMS Pub. 100-02, chapter 13, §180. Costs associated with LPNs that provide
services incident to a physician, PA, NP, CNM, CP or CSW (see CMS Pub. 100-02, chapter 13,
§§110, 120 and 140) are included in line 36.
Line 29 - Certified Nurse Midwife.--This cost center includes the costs of nursing care provided
by CNMs.
Line 30 - Clinical Psychologist.--This cost center includes the costs of a CP who holds a
doctorate in psychology and is licensed or certified by the State in which he or she practices, for
diagnostic, assessment, preventative and therapeutic services directed at individuals.
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DRAFT

Line 31 - Clinical Social Worker.--This cost center includes the costs of a CSW who possesses a
master’s degree or doctorate in social work and meets specified criteria established by regulation.
The CSW must directly examine the patient, or directly review the patient’s medical information,
to provide diagnosis, treatment and consultation.
Line 32 - Laboratory Technician.--This cost center includes the costs of a person who, under the
supervision of a medical technologist or physician, performs microscopic and bacteriologic tests
of human blood, tissue, and fluid for diagnostic and research purposes.
Line 33 - Reg Dietician/Cert DSMT/MNT Educator.--This cost center includes the costs of a
person who is either a registered dietician or nutritionist who meets specified criteria for
providing diabetes self-management training (DSMT) or medical nutrition therapy (MNT)
services under the Program.
Line 34 - Physical Therapist.--This cost center includes the costs of physical or corrective
treatment of bodily or mental conditions by the use of physical, chemical, and other properties of
heat, light, water, electricity, sound massage, and therapeutic exercise by or under the direction
of a registered physical therapist as prescribed by a physician. Physical therapy services may be
provided for purposes of symptom control or to enable the individual to maintain activities of
daily living and basic functional skills.
Line 35 - Occupational Therapist.--This cost center includes the costs of purposeful goaloriented activities in the evaluation, diagnosis, and/or treatment of persons whose function is
impaired by physical illness or injury, emotional disorder, congenital or developmental
disability, or the aging process, in order to achieve optimum functioning, to prevent disability,
and to maintain health. Occupational therapy services may be provided for purposes of symptom
control or to enable the individual to maintain activities of daily living and basic functional
skills.
Line 36 - Other Allied Health Personnel.--This cost center includes the costs of RNs and LPNs
who provide services incident to a physician, PA, NP, CNM, CP or CSW in accordance with
CMS Pub. 100-02, chapter 13, §§110, 120 or 140 and the costs of other allied health personnel
that provide diagnostic, technical, therapeutic and direct patient care and support services to the
other health professionals they work with and the patients they serve. An example of other allied
health personnel is a medical assistant.
Line 37 - Subtotal Direct Patient Care Services.--Enter the total of lines 23 through 36.
Line 38 through 46.--Reserved for future use.

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4408 (Cont.)

REIMBURSABLE PASS THROUGH COSTS
Line 47 - Allowable GME Costs.--This cost center includes the costs associated with allowable
direct GME costs set forth in 42 CFR 405.2468(f). These include residents’ salaries and fringe
benefits (including travel and lodging expenses where applicable); the allowable portion of the
teaching physicians’ salaries and fringe benefits that are related to the time spent teaching and
supervising residents (i.e., lecture time, time spent filling out resident evaluations, mentoring,
and program development) subject to the reasonable compensation equivalency limits (RCEs)
(42 CFR 415.70); and overhead costs that are directly assigned to the intern and resident
program, excluding all overhead included in the general service cost centers paid under the
FQHC PPS.
An FQHC must include all allowable direct costs associated with an intern and/or resident
program funded by a THC and/or PCRE grant from HRSA on line 47, only if the program meets
the requirements set forth in 42 CFR 405.2468(f). If the direct costs associated with an intern
and/or resident who is funded by a THC and/or PCRE grant are included in line 47, the FQHC
must reclassify the direct costs associated with the THC and/or PCRE programs funded by
HRSA to line 78, nonallowable GME costs.
A “moonlighting” resident or fellow is a postgraduate medical trainee who is practicing
independently, outside the scope of his or her residency training program and would be treated as
a physician within the scope of the privileges granted by the FQHC. Therefore, costs associated
with a “moonlighting” intern or resident are reported in the physician services cost center, not the
allowable GME cost center.
Line 48 - Pneumococcal Vaccines & Med Supplies.--This cost center includes the cost of the
pneumococcal vaccines and the medical supplies attributable to pneumococcal vaccinations.
Line 49 - Influenza Vaccines & Med Supplies.--This cost center includes the cost of the
influenza vaccines and the medical supplies attributable to influenza vaccinations.
Line 50 - Subtotal - Reimbursable Pass Through Costs.--Enter the total of lines 47 through 49.
Line 51 through 59.--Reserved for future use.
OTHER FQHC SERVICES
Line 60 - Medicare Excluded Services.--This cost center includes the cost of routine dental care,
hearing tests, eye exams, etc. that are excluded from coverage under the Program.
Line 61 - Diagnostic & Screening Lab Tests.--This cost center includes the technical component
of diagnostic and laboratory tests such as electrocardiograms and certain preventative services
authorized by the Medicare statute or the national coverage determination process. (The
professional component is a FQHC service if performed by an FQHC practitioner or furnished
incident to an FQHC service). This does not include venipuncture, which is included in the
pharmacy cost center when furnished by the FQHC.

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DRAFT

Line 62 - Radiology - Diagnostic.--This cost center includes the technical component of
radiological diagnostic tests such as x-rays and imaging services.
Line 63 - Prosthetic Devices.--This cost center includes the costs of devices (other than dental)
which replace all or part of an internal body organ (including colostomy bags and supplies
directly related to colostomy care), replacement of such devices, and one pair of conventional
eyeglasses or contact lenses furnished subsequent to each cataract surgery with the insertion of
an intraocular lens.
Line 64 - Durable Medical Equipment.--This cost center includes the direct costs of durable
medical equipment rented or sold (DME, as defined in 42 CFR 410.38) furnished to an
individual patient and all direct expenses incurred in requisitioning and issuing DME to patients.
Line 65 - Ambulance Services.--Report all ambulance costs on this line for both owned and
operated services and services under arrangement. No subscripting is allowed for this line.
Line 66 - Telehealth.--This cost center includes the cost of telehealth distant-site services as
described in CMS Pub. 100-02, chapter 13, §190.
Line 67 - Other (Specify).--Use this line to report the costs of other FQHC services not previously
identified on lines 60 through 66. If more than one other service is offered, subscript this line. See
Table 5 in §4495 for the proper cost center code for this line.
Line 68 - Subtotal Other FQHC Services.--Enter the total of lines 60 through 67.
NONREIMBURSABLE COST CENTERS
Line 69 through 77.--Reserved for future use.
Line 78 - Nonallowable GME Costs.--This cost center includes the costs associated with an
intern and resident program not approved by Medicare.
Line 79 - Other Nonreimbursable (Specify).--Use this line to record the costs applicable to other
nonreimbursable cost centers not provided for on this worksheet.
Line 80 - Subtotal of Nonreimbursable Cost Centers.--Enter the total of lines 78 through 79.
Line 81 through 99.--Reserved for future use.
Line 100 - Total.--Enter the sum of lines 13, 37, 50, 68 and 80.

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4410

4409. WORKSHEET A-1 - RECLASSIFICATIONS
This worksheet provides for the reclassification of certain amounts to effect the proper cost
allocation. The cost centers affected must be specifically identifiable in your accounting records.
Use reclassifications in instances in which the expenses applicable to more than one of the cost
centers listed on Worksheet A are maintained in your accounting books and records in one cost
center.
Column 1.--Identify each reclassification adjustment by assigning an alpha character (e.g., A, B,
C) in column 1. Do not use numeric designations.
Columns 2, 3, and 4.--For each increase reclassification, enter the corresponding cost center
description in column 2, the Worksheet A cost center line number reference in column 3, and
reclassification amount in column 4.
Columns 5, 6, and 7.--For each decrease reclassification, enter the corresponding cost center
description in column 5, the Worksheet A cost center line number reference in column 6, and
reclassification amount in column 7.
4410. WORKSHEET A-2 - ADJUSTMENTS TO EXPENSES
This worksheet provides for adjusting the expenses listed on Worksheet A, column 5. Make
these adjustments, which are required under the Medicare principles of reimbursement, on the
basis of cost, or amount received. Enter the total amount received (revenue) only if the cost
(including the direct cost and all applicable overhead) cannot be determined. However, if total
direct and indirect cost can be determined, enter the cost. Once an adjustment to an expense is
made on the basis of cost, you may not, in future cost reporting periods determine the required
adjustment to the expense on the basis of revenue. Enter the following symbols in column 1 to
indicate the basis for adjustments: “A” for costs and “B” for amount received. Line descriptions
indicate the more common activities which affect allowable costs or result in costs incurred for
reasons other than patient care and, thus, require adjustments.
Types of items to be entered on this worksheet are (1) those needed to adjust expenses incurred,
(2) those items which constitute recovery of expenses through sales, charges, fees, etc., and (3)
those items needed to adjust expenses in accordance with the Medicare principles of
reimbursement. (See CMS Pub. 15-1, §2328.)
If an adjustment to an expense affects more than one cost center, record the adjustment to each
cost center on a separate line on this worksheet.
Columns 2, 3 and 4.--For each adjustment, enter the amount in column 2, enter the Worksheet A
cost center line number reference in column 4, and enter the corresponding cost center
description in column 3.
Lines 1 through 3.--Investment income on restricted and unrestricted funds which are
commingled with other funds must be applied together against, but should not exceed, the total
interest expense included in allowable costs. (See CMS Pub. 15-1, chapter 2.)
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DRAFT

Apply the investment income on restricted and unrestricted funds which are commingled with
other funds against the administrative and general, the capital-related - buildings and fixtures, the
capital-related - moveable equipment and any other appropriate cost centers on the basis of the
ratio that interest expense charged to each cost center bears to the total interest expense charged
to all of your cost centers.
Line 7.--Enter the amount from Worksheet A-2-1, column 6, line 5.
Line 10.--Enter the amount which represents the allowable cost of the services furnished by
Public Health Service personnel. Obtain this amount from your contractor.
Lines 11 and 12.--If depreciation expense computed in accordance with Medicare principles of
reimbursement differs from depreciation expenses per your books, enter the difference on lines
11 and/or 12.
Line 13--Enter RCE adjustment for teaching physicians. RCE limits apply to the portion of the
teaching physician’s salary associated with teaching residents (i.e., lecture time, time spent
filling out resident evaluations, mentoring, and program development, etcetera as these activities
are “direct GME” activities). See CMS Pub. 15-1, chapter 21.
Line 14 through 49.--Enter any additional adjustments required under the Medicare principles of
reimbursement. Label the lines appropriately to indicate the nature of the required adjustments.
Line 50--Enter the sum of lines 1 through 49. Transfer the amounts in column 2 to the
appropriate lines on Worksheet A, column 6.

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4411.

FORM CMS-224-14

4411.2

WORKSHEET A-2-1 - STATEMENT OF COSTS OF SERVICES FROM RELATED
ORGANIZATIONS AND HOME OFFICE COSTS

In accordance with 42 CFR 413.17, costs applicable to services, facilities, and supplies furnished
to the FQHC by organizations related to the FQHC by common ownership or control are
includable in your allowable cost at the cost to the related organization, except for the exceptions
outlined in 42 CFR 413.17(d). This worksheet provides for the computation of any needed
adjustments to costs applicable to services, facilities, and supplies furnished to the FQHC by
organizations related to the FQHC or costs associated with the home office. However, such cost
must not exceed the amount a prudent and cost conscious buyer pays for comparable services,
facilities, or supplies that are purchased elsewhere.
4411.1 Part I - Costs Incurred and Adjustments Required as a Result of Transactions with
Related Organizations or Claimed Home Office Costs.--This part of the worksheet provides for
the computation of adjustments needed to properly report costs of services, facilities, and
supplies furnished to the FQHC by related organizations or costs associated with the home
office.
Columns 1 and 2.--Enter in column 1 the Worksheet A cost center line number to be adjusted.
Enter the corresponding cost center description in column 2.
Column 3.--Enter the description of the related organization or home office expense.
Column 4.--Enter the allowable costs from the books and/or records of the related organization
or home office. Allowable costs are the actual costs incurred by the related organization or home
office for services, facilities, and/or supplies and exclude any markup, profit or amounts that
otherwise exceed the acquisition cost of such items.
Column 5.--Enter the amount included on Worksheet A for services, facilities, and/or supplies
acquired from related organizations and/or home office.
Column 6.--Enter the result of column 4 minus column 5.
4411.2 Part II - Interrelationship to Related Organizations and/or Home Office.-- This part of
the worksheet identifies the interrelationship between the FQHC and individuals, partnerships,
corporations, or other organizations having either a related interest to, a common ownership
with, or control over the FQHC as defined in CMS Pub. 15-1, chapter 10. Complete columns 1
through 6 as applicable for each interrelationship.

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Complete only those columns that are pertinent to the type of relationship that exists.
Column 1.--Enter the symbol that represents the interrelationship between the FQHC and the
related organization or home office. Select from the following choices:
Symbol
A
B
C
D
E
F
G

Relationship
Individual has financial interest (stockholder, partner, etc.) in both related
organization and in provider
Corporation, partnership or other organization has financial interest in
provider
Provider has financial interest in corporation, partnership, or other
organization
Director, officer, administrator or key person of provider or organization
Individual is director, officer, administrator or key person of provider and
related organization
Director, officer, administrator or key person of related organization or
relative of such person has financial interest in provider
Other (financial or non-financial) -- specify

Column 2.--If the symbol entered in column 1 is A, D, E, F, or G, enter the name of the related
individual in column 2.
Column 3.--If the individual reported in column 2, or the organization reported in column 4, has
a financial interest in the FQHC, enter the percent of ownership.
Column 4.--Enter the name of each related corporation, partnership, or other organization.
Column 5.--If the FQHC, or an individual reported in column 2, has a financial interest in the
organization reported in column 4, enter the percent of ownership.
Column 6.--Enter the type of business of the related organization (e.g., medical drugs and/or
supplies, janitorial services).

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4412.

FORM CMS-224-14

4412.1

WORKSHEET B - CALCULATION OF FEDERALLY QUALIFIED HEALTH
CENTER COSTS

Worksheet B consists of two parts. Part I is used to summarize (1) the FQHC medical and
mental health visits furnished by practitioners, including health care staff and physicians under
agreement, and (2) apportion overhead costs to FQHC services to determine the cost per visit for
a medical visit and a mental health visit, by practitioner. Part II is used to determine the FQHC’s
Medicare reimbursable direct GME costs, where applicable.
4412.1 Part I - Calculation of Federally Qualified Health Center Cost Per Visit.--The purpose
of Part I is to establish the FQHC medical and mental health Medicare cost per visit.
Column 1.--Enter the total cost for each practitioner from Worksheet A, column 7 as indicated
on the worksheet.
Column 2.--Enter the total medical and mental health visits actually furnished to all patients by
each practitioner during the cost reporting period. Each visit to the FQHC by the beneficiary
counts as a single visit, even in the case where a beneficiary returns to the FQHC in the same day
for a subsequent illness or injury. A beneficiary can have up to three medical visits in a day to
include the initial visit and two subsequent visits for illness or injury.
NOTE: Column 2, line 11 must equal Worksheet S-3, Part I, column 4, sum of lines 2 and 4.
For each line 1 through 10, column 2 must equal the sum of columns 7 and 8.
Column 3.--Use this column to allocate costs associated with other direct care costs, sum of
Worksheet A, column 7, lines 32, and 34 through 36. Calculate the unit cost multiplier (UCM)
related to other direct care costs by dividing the sum of Worksheet A, column 7, lines 32, 34, 35,
and 36, by Worksheet B, Part I, column 2, line 11, total medical and mental health visits, and
enter the result on line 12. Calculate the costs for lines 1 through 10 by multiplying the visits on
each corresponding line, column 2 times the UCM on line 12.
Column 4.--Use this column to allocate general service costs, on Worksheet A, column 7, line
13. Calculate the UCM by dividing Worksheet A, column 7, line 13, by Worksheet A, column 7,
line 100 minus line 13, and enter the result on line 12. Allocate the general service cost
attributable to each practitioner on lines 1 through 10, by multiplying the UCM times the sum of
the amounts in columns 1 and 3, for each corresponding line.
Column 5.--Enter the sum of columns 1, 3, and 4 for each practitioner.
Column 6.--Calculate the average cost per visit by each practitioner by dividing the total cost in
column 5 by the total visits in column 2. Enter the result in column 6.
Column 7.--Enter the total number of medical visits, included in column 2, provided to all
patients by each practitioner during the cost reporting period.
Column 8.--Enter the total number of mental health visits, included in column 2, provided to all
patients by each practitioner during the cost reporting period.
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Column 9.--Enter the total number of medical visits provided to Medicare beneficiaries by each
practitioner during the cost reporting period.
Column 10.--Enter the total number of mental health visits provided to Medicare beneficiaries by
each practitioner during the cost reporting period.
NOTE: Worksheet S-3, Part I, column 2, line 2, must equal column 9, line 11; and Worksheet
S-3, Part I, column 2, line 4, must equal column 10, line 11.
Column 11.--Calculate the Medicare cost per medical visit by practitioner by multiplying the
average cost per visit in column 6 by the Medicare visits in column 9.
Column 12.--Calculate the Medicare cost per mental health visit by practitioner by multiplying
the average cost per visit in column 6 by the Medicare visits in column 10.
Line 11.--Enter the sum of lines 1 through 10 for the applicable columns.
Line 13, column 6.--Calculate the FQHC average cost per visit by dividing column 5, line 11 by
column 2, line 11.
Line 13, column 11.--Calculate the Medicare average cost per medical visit by dividing column
11, line 11 by column 9, line 11.
Line 13, column 12.--Calculate the Medicare average cost per mental health visit by dividing
column 12, line 11 by column 10, line 11.
4412.2 Part II - Calculation of Allowable Direct Graduate Medical Education Costs.--The
purpose of Part II is to calculate the allowable cost of direct GME costs that will be reimbursed
by the Medicare program.
Column 1.--Enter the total amount of direct GME cost from Worksheet A, column 7, line 47.
Column 2.--Enter the total number of visits performed by interns and residents from
Worksheet S-3, Part I, line 6, column 4.
Column 3.--Enter the total number of title XVIII visits performed by interns and residents from
Worksheet S-3, Part I, line 6, column 2.
Column 4.--Divide column 3, by column 2. Enter the result in column 4 and round to six
decimal places.
Column 5.--Multiply the amount in column 1 by the result in column 4. Enter the result in
column 5. This is the amount that Medicare will reimburse the FQHC for its direct GME
activities.

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4413.

FORM CMS-224-14

4413

WORKSHEET B-1 - COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA
VACCINE COST

The cost and administration of pneumococcal and influenza vaccines to Medicare beneficiaries
are 100 percent reimbursable by Medicare. This worksheet provides for the computation of the
cost of the pneumococcal and influenza vaccines.
Line 1.--Enter the health care staff cost from Worksheet A, column 7, sum of lines 23, and 25
through 36, in columns 1 and 2, as applicable. Physician services under agreement are excluded
from this total.
Line 2.--Enter the ratio of the estimated percentage of time involved in administering
pneumococcal and influenza vaccine injections to the total health care staff time. Do not include
physician services under agreement time in this calculation. Obtain the estimated percentage of
time spent from your accounting books and records.
Line 3.--Multiply the amount on line 1 by the amount on line 2 and enter the result.
Line 4.--Enter the cost of pneumococcal and influenza vaccines and the cost of related medical
supplies from Worksheet A column 7, lines 48 and 49, in columns 1 and 2, respectively.
Line 5.--Enter the sum of lines 3 and 4.
Line 6.--Enter the total direct costs of the FQHC from Worksheet A, column 7, line 100.
Line 7.--Enter the administrative overhead of the FQHC from Worksheet A, column 7, line 8.
Line 8.--Divide the amount on line 5 by the amount on line 6 and enter the result.
Line 9.--Multiply the amount on line 7 by the ratio on line 8 and enter the result.
Line 10.--Enter the sum of the amounts on lines 5 and 9.
Line 11.--Enter in columns 1 and 2 respectively, the total number of pneumococcal and influenza
vaccine injections from your records.
Line 12.--Compute the FQHC cost per pneumococcal and influenza vaccine injection by
dividing the costs on line 10 by the number of injections on line 11 and entering the result.
Line 13.--Enter from your records the number of pneumococcal and influenza vaccine injections
administered to Medicare beneficiaries, in columns 1 and 2 respectively.
Line 14.--Enter the Medicare cost per pneumococcal and influenza vaccine injection by
multiplying the cost per vaccine on line 12 by the number of injections administered to Medicare
beneficiaries on line 13.
Line 15.--Enter the total cost of pneumococcal and influenza vaccines and their administration
by entering the sum of the amounts in columns 1 and 2, line 10.
Line 16.--Enter the Medicare cost of pneumococcal and influenza vaccines and their
administration by entering the sum of the amount in columns 1 and 2, line 14. Transfer this
amount to the Worksheet E, line 3.
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4414
4414.

FORM CMS-224-14

DRAFT

WORKSHEET E - CALCULATION OF REIMBURSEMENT SETTLEMENT

This worksheet provides for the reimbursement calculation of FQHC services rendered to
program patients under the FQHC PPS. It also provides for an accumulation of cost
reimbursable direct graduate medical education payments, pneumococcal and influenza vaccine
reimbursement, and Medicare Advantage (MA) supplemental payments.
Line 1.--FQHC services are paid in accordance with FQHC PPS. Enter the total PPS payments
paid for FQHC visits rendered during the cost reporting period. Obtain this amount from the
provider statistical and reimbursement (PS&R) report.
Line 2.--Enter the Medicare costs for direct graduate medical education from Worksheet B, Part
II, line 14, column 5.
Line 3.--Enter the Medicare costs for pneumococcal and influenza vaccines and their
administration from Worksheet B-1, line 16.
Line 4.--Medicare advantage supplemental payments are made to an FQHC when the amount
paid by the managed care organization is less than the amount paid under the FQHC PPS on a
per visit basis. Enter the total amount of Medicare advantage supplemental payments from the
PS&R, report type 778. This data is captured for information purposes only and does not impact
cost report settlement.
Line 5.--Enter the sum of lines 1 through 3.
Line 6.--Enter the primary payer amounts from the PS&R.
Line 7.--Enter the result of line 5 minus line 6.
Line 8--Enter the Part B coinsurance.
Line 9--Enter the result of line 7 minus line 8.
Line 10.--Enter Medicare allowable bad debts, reduced by bad debt recoveries. If recoveries
exceed the current year’s bad debts, lines 10 and 11 will be negative.
Line 11.--Multiply the amount (including negative amounts) from line 10 by 65 percent.
Line 12-- Enter the gross reimbursable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. These amounts also are included on line 10.
Line 13.--Enter the sum of lines 9 and 11.

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4414 (Cont.)

Line 14.--Enter any other adjustments. Provide a description in the space provided.
Line 15.--Enter the result of line 13 plus or minus line 14.
Line 16.--Enter the sequestration adjustment amount as [(2 percent times (total days in the cost
reporting period that occur during the sequestration period beginning on or after April 1, 2013,
divided by total days in the entire cost reporting period, rounded to four decimal places)) times
line 15]. Do not apply the sequestration calculation when gross reimbursement is less than zero.

Line 17.--Enter the result of line 15 minus line 16.
Line 18.--Enter the amount of interim payments from Worksheet E-1, column 2, line 4.
Line 19.--FOR CONTRACTOR USE ONLY.--Enter the tentative settlement amount from
Worksheet E-1, column 2, line 5.99.

Line 20.--Enter the total amount due to/from the program (line 17 minus lines 18 and 19).
Transfer this amount to Worksheet S, Part III, column 1, line 1.
Line 21.--Enter the Medicare reimbursement effect of protested items.
Estimate the
reimbursement effect of the non-allowable items by applying a reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the
supporting details and computations for this line.

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4415
4415.

FORM CMS-224-14

DRAFT

WORKSHEET E-1 - ANALYSIS OF PAYMENTS TO THE FEDERALLY
QUALIFIED HEALTH CENTER FOR SERVICES RENDERED

Complete lines 1 through 4 of this worksheet only for Medicare interim payments paid by the
contractor. Do not complete it for purposes of reporting interim payments for titles V or XIX.
The remainder of this worksheet is completed by your contractor. All amounts reported on this
worksheet must be for services rendered during the cost reporting period for which the costs are
included in this cost report.
Line Descriptions
Line 1.--Enter the total Medicare interim payments paid to the FQHC. The amount entered must
reflect the sum of all interim payments paid on individual bills (net of adjustment bills) for
services rendered in this cost reporting period. Do not include MA supplemental payments on
this worksheet. The amount entered must also include amounts withheld from your interim
payments due to an offset against overpayments applicable to the prior cost reporting periods.
Do not include (1) any retroactive lump sum adjustment amounts based on a subsequent revision
of the interim rate, (2) tentative or net settlement amounts, or (3) interim payments payable.
Line 2.--Enter the total Medicare interim payments payable on individual bills. Since the cost in
the cost report is on an accrual basis, this line represents the amount of services rendered in the
cost reporting period but not paid as of the end of the cost reporting period. It does not include
payments reported on line 1.
Line 3.--Enter the amount of each retroactive lump sum adjustment and the applicable date.
Line 4.--Enter the total amount of the interim payments (sum of lines 1, 2, and 3.99). Transfer
this amount to Worksheet E, line 18.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E-1. LINES 5 THROUGH 8
ARE FOR CONTRACTOR USE ONLY. (EXCEPTION: IF WORKSHEET S, PART I, LINE
5 is “5” (AMENDED COST REPORT), THE FQHC MAY COMPLETE THIS SECTION.)

Line 5.--List separately each tentative settlement payment after the cost report is accepted
together with the date of payment. If the cost report is reopened after the NPR has been issued,
report all settlement payments prior to the current reopening on this line.
Line 6.--Enter the net settlement amount (balance due the FQHC or balance due the program) for
the NPR, or, if this settlement is after a reopening of the NPR, for this reopening. Enter in
column 2 the amount from Worksheet E, line 20.
NOTE: On lines 3, 5, and 6, when an FQHC to program amount is due, 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.
Line 7.--Enter the sum of the amounts on lines 4, 5.99, and 6 in column 2. Enter amounts due
the program as a negative number. The amount in column 2 must equal the amount on
Worksheet E, line 17.

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4416.

FORM CMS-224-14

4416

WORKSHEET F-1 - STATEMENT OF REVENUE AND EXPENSES

This worksheet is prepared from your accounting books and records. It requires the reporting of
total patient revenues (specifically including Medicare, Medicaid and other revenues) for the
entire FQHC and operating expenses for the entire FQHC. Additional worksheets may be
submitted if necessary.
Line 1.--Enter total patient revenue from your accounting books and/or records in columns 1
through 3, by program as indicated. Enter the sum of columns 1 through 3 in column 4.
Line 2.-- Enter total patient revenues not received in column 2. This includes:
Provision for Bad Debts,
Contractual Adjustments,
Charity Discounts,
Teaching Allowances,
Policy Discounts,
Administrative Adjustments, and
Other Deductions from Revenue
Line 3.--Enter in column 2, the sum of line 1, column 4 minus line 2, column 2.
Line 4.--Enter in column 2, total operating expenses from Worksheet A, column 3, line 100.
Lines 5 through 10.--Enter any additions to operating expenses in column 1.
Lines 11 through 16.--Enter any subtractions to operating expenses in column 1.
Line 17.--Enter in column 2, the sum of line 4, column 2 and lines 5 through 16, column 1.
Line 18.--Enter in column 2, the sum of line 3, column 2 minus line 17, column 2.
Lines 19 through 31.--Enter all other income as specified in column 1.
Line 32.--Enter in column 2, the sum of the amounts on lines 19 through 31, column 1.
Line 33.--Enter in column 2, the sum of line 18 plus line 32 in column 2.

Rev. 1

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FORM CMS-224-14

DRAFT

This page is reserved for future use.

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FORM CMS-224-14

4490

Form CMS-224-14 Worksheets
The following is a listing of the Form CMS-224-14 worksheets and the page number location.
Changes to worksheets are indicated by redline on this and the subsequent page for this
transmittal. Where only the page number changes, no redlining is indicated.
Worksheets

Page(s)

Wkst. S, Parts I, II & III
Wkst. S-1, Part I
Wkst. S-1, Part II
Wkst. S-2
Wkst. S-3, Part I
Wkst. S-3, Part II & III
Wkst. A
Wkst. A-1
Wkst. A-2
Wkst. A-2-1, Parts I & II
Wkst. B, Parts I & II
Wkst. B-1
Wkst. E
Wkst. E-1
Wkst. F-1

44-103
44-104
44-105
44-106
44-107
44-108
44-109 - 44-110
44-111
44-112
44-113
44-114
44-115
44-116
44-117
44-118

Rev. 1

44-101

4490 (Cont.)

FORM CMS-224-14

DRAFT

This page is reserved for future use.

44-102

Rev. 1