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FORM CMS-1728-94
3290 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result
in all interim payments made since the beginning of the cost reporting period being deemed
FORM APPROVED
as overpayments (42 USC 1395g).
OMB NO. 0938-0022
HOME HEALTH AGENCY COST REPORT
PROVIDER CCN:
PERIOD:
CERTIFICATION AND SETTLEMENT SUMMARY
From: ___________
_______________
WORKSHEET S
To: ___________
Contractor Use Only:
[ ] Audited
Date Received
____________
[ ] Initial
[ ] Desk Reviewed
Contractor No.
____________
[ ] Final
[ ] Re-opened
PART I - CERTIFICATION
Check
[ ]
Electronically filed cost report
Date: ___________
applicable box
[ ]
Manually submitted cost report
Time: ___________
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY
BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT
UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED
OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE
ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF THE PROVIDER(S)
I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically
filed or manually submitted Home Health Agency Cost Report and the Balance Sheet and Statement of Revenue and Expenses
prepared by _________________________________________(Provider name(s) and number(s)) for the cost reporting period
beginning _____________________and ending __________________________, and that to the best of my knowledge
and belief, this report and statement are true, correct, complete and prepared from the books and records of the
provider in accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws and
regulations regarding the provision of health care services, and that the services identified in this cost report were provided in
compliance with such laws and regulations.
(Signed) __________________________________________
Officer or Director
__________________________________________
Title
__________________________________________
Date
PART II - SETTLEMENT SUMMARY
TITLE XVIII
PART A
PART B
1
2
1
HOME HEALTH AGENCY
1
2
HOME HEALTH-BASED CORF
2
3
HOME HEALTH-BASED CMHC
3
3.5
HOME HEALTH-BASED RHC/FQHC
3.5
(specify)
4
TOTAL
4
"According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0022. The time required to complete this
information collection is estimated to average 227 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850." Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under
the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit
your documents, please contact 1-800-MEDICARE.
FORM CMS-1728-94 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION S. 3203 THROUGH 3203.2)
Rev.
32-303
3290 (Cont.)
HOME HEALTH AGENCY COMPLEX
IDENTIFICATION DATA
Home Health Agency Complex Address:
1
Street:
1.01
Intermediary
City:
Use Only:
FORM CMS-1728-94
PROVIDER CCN:
PERIOD:
From: ___________
________________
To: ___________
State:
DRAFT
WORKSHEET S-2
P.O. Box:
Zip Code:
1
1.01
Home Health Agency Component Identification
2
3
3.50
4
5
6
Component
0
Home Health Agency
HHA-based CORF
HHA-based Hospice
HHA-based CMHC
HHA- based RHC
HHA-based FQHC
7 Cost Reporting Period (mm/dd/yyyy)
Component Name
1
Provider CCN
2
Date Certified
3
2
3
3.50
4
5
6
From: ______________
To: ______________
7
8 Type of control (see instructions)
8
9 If this a low or no Medicare utilization cost report, enter "L" for Low or "N" for No Medicare Utilization.
9
Depreciation: Enter the amount of depreciation reported in this HHA for the methods indicated.
10 Straight Line
11 Declining Balance
12 Sum of the Years' Digits
13 Sum of lines 10, 11 and 12
10
11
12
13
14 Were there any disposals of capital assets during this cost reporting period?
15 Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period?
16 Was accelerated depreciation claimed on assets acquired on or after August l, l970 (See PRM 15-1,
Chapter l)?
17 If depreciation is funded, enter the balance at end of period.
18 Did the provider cease to participate in the Medicare program at the end of
the period to which this cost report applies (See PRM 15-1, Chapter 1)?
19 Was there substantial decrease in health insurance proportion of allowable
costs from prior cost reporting periods (See PRM 15-1, Chapter 1)?
20 Does the provider qualify as a small HHA (see 42 CFR 413.24(d))?
21 Does the HHA qualify as a nominal charge provider (see 42 CFR 409.3)?
22 Does the HHA contract with outside suppliers for physical therapy services?
22.01 Does the HHA contract with outside suppliers for occupational therapy services?
22.02 Does the HHA contract with outside suppliers for speech therapy services?
14
15
16
17
18
19
20
21
22
22.01
22.02
If this facility contains a non-public provider that qualifies for an exemption from the application of the
lower of costs or charges, enter "Y" for each component and type of service that qualifies for the exemption.
Part A
1
23
24
25
26
27
27.01
27.02
27.03
28
29
29.01
29.02
29.03
Part B
2
HHA
CORF
CMHC
If the HHA componentized (or fragmented) its administrative and general service
costs, indicate whether option one or option two is being utilized. (See Section 3214)
(Enter "1" for option one and "2" for option two)
List amounts of malpractice premiums and paid losses:
Premiums
Paid Losses
Self Insurance
Are malpractice premiums and/or paid losses reported in other than the Administrative and General
cost center? If yes, submit a supporting schedule listing cost centers and amounts contained therein.
If you are part of a chain organization, enter "Y" for yes and enter the name and address of the home
office, otherwise, enter "N" for no.
Home Office Name:
Home Office No. :
Contractor No. :
Street:
P.O. Box:
Contractor Name:
City:
State:
Zip Code:
23
24
25
26
27
27.01
27.02
27.03
28
29
29.01
29.02
29.03
FORM CMS 1728-94-S-2 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3204)
32-304
Rev.
DRAFT
FORM CMS-1728-94
HOME HEALTH AGENCY REIMBURSEMENT
PROVIDER CCN:
QUESTIONNAIRE
3290 (Cont.)
PERIOD:
WORKSHEET S-2-1
FROM: ___________
___________
TO: ___________
General Instruction: For all column 1 responses, enter "Y" for YES of "N" for NO
Enter all dates in the format (mm/dd/yyyy)
COMPLETED BY ALL HHAs
Y/N
Date
V/I
1
2
3
Provider Organization and Operation
1 Has the HHA changed ownership immediately prior to the beginning of the cost reporting period?
1
If column 1 is yes, enter the date of the change in column 2. (see instructions)
2 Has the HHA terminated participation in the Medicare program? If column 1 is yes, enter in column 2 the date
2
of termination and in column 3, "V" for voluntary or "I" for involuntary. (see instructions)
3 Is the HHA involved in business transactions, including management contracts, with individuals or entities
3
(e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers, medical
staff, management personnel, or members of the board of directors through ownership, control, or family and
other similar relationships? (see instructions)
Y/N
Type
Date
1
2
3
Financial Data and Reports
4 Column 1: Were the financial statements prepared by a Certified Public Accountant?
4
Column 2: If column 1 is yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter
date available in column 3. (see instructions) If no, see instructions.
5 Are the cost report total expenses and total revenues different from those on the filed financial statements?
5
Enter "Y" for yes or "N" for no in column 1. If yes, submit reconciliation.
Bad Debts
Y/N
6 Is the HHA or HHA-based entities seeking reimbursement for bad debts? If yes, see instructions.
6
7 If line 6 is yes, did the HHA's bad debt collection policy change during this cost reporting period? If yes, submit copy.
7
8 If line 6 is yes, were patient coinsurance amounts waived? If yes, see instructions.
8
PS&R Report Data
9 Was the cost report prepared using the PS&R Report only? If column 1 is yes, enter the
Y/N
Date
1
2
9
paid-through date of the PS&R Report used in column 2. (see instructions)
10 Was the cost report prepared using the PS&R Report for totals and the HHA's records for allocation?
10
If column 1 is yes, enter the paid-through date in column 2. (see instructions)
11 If line 9 or 10 is yes, were adjustments made to PS&R Report data for additional claims that have been
11
billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions.
12 If line 9 or 10 is yes, were adjustments made to PS&R Report data for corrections of other
12
PS&R Report information? If yes, see instructions.
13 If line 9 or 10 is yes, were adjustments made to PS&R Report data for Other?
Describe the other adjustments:
13
________________________________________
14 Was the cost report prepared only using the HHA's records? If yes, see instructions.
14
Cost Report Preparer Contact Information
15 First name:
Last name:
Title:
16 Employer:
17 Phone number:
15
16
E-mail Address:
17
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3204.1)
Rev.
32-304.1
DRAFT
HOME HEALTH AGENCY
STATISTICAL DATA
FORM CMS-1728-94
PROVIDER CCN :
______________
PART I - STATISTICAL DATA
DESCRIPTION
COUNTY
Title XVIII
Visits
Patients
1
2
PERIOD:
From: ___________
To: ___________
Cook
Other
Visits
3
3290 (Cont.)
WORKSHEET S-3
PARTS I - III
Total
Patients
4
Visits
5
Patients
6
1
2
3
4
5
6
7
8
9
10
Skilled Nursing
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Service
Home Health Aide
All Other Services
Total Visits
Home Health Aide Hours
Unduplicated Census Count Full Cost Reporting Period
10.01 Unduplicated Census Count Pre 10/1/2000
10.02 Unduplicated Census Count Post 9/30/2000
1
2
3
4
5
6
7
8
9
10
10.01
10.02
PART II - EMPLOYMENT DATA
(FULL TIME EQUIVALENT)
Number of hours in
your normal work week __________
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Staff
1
Contract
2
Total
3
Administrator and Assistant Administrator(s)
Director and Assistant Director(s)
Other Administrative Personnel
Direct Nursing Service
Nursing Supervisor
Physical Therapy Service
Physical Therapy Supervisor
Occupational Therapy Service
Occupational Therapy Supervisor
Speech Pathology Service
Speech Pathology Supervisor
Medical Social Service
Medical Social Supervisor
Home Health Aide
Home Health Aide Supervisor
PART III - METROPOLITAN STATISTICAL AREA (MSA) AND CORE BASED STATISTICAL AREA (CBSA) CODES
1
1.01
Enter the total number of MSAs in column 1 and/or CBSAs in column 2 where Medicare
28 covered services were provided during the cost reporting period.
List all MSA and CBSA codes in which Medicare covered home health services were
MSA Codes CBSA Codes
29 provided during the cost reporting period (line 29 contains the first code):
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
29.01
29.02
29.03
29.04
29.05
29.06
29.07
29.08
29.09
FORM CMS-1728-94 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3205)
Rev.
32-305
3290 (Cont.)
HOME HEALTH AGENCY
STATISTICAL DATA
FORM CMS-1728-94
PROVIDER CCN :
______________
PART IV - PPS ACTIVITY DATA - Applicable for Services Rendered on or After October 1, 2000
DESCRIPTION
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
Full Episodes
without Outliers
1
Full Episodes
with Outliers
2
DRAFT
WORKSHEET S-3
PART IV
PERIOD:
From: ______________
To: ______________
Cook
LUPA Episodes
3
PEP Only
Episodes
4
Skilled Nursing Visits
Skilled Nursing Visit Charges
Physical Therapy Visits
Physical Therapy Visit Charges
Occupational Therapy Visits
Occupational Therapy Visit Charges
Speech Pathology Visits
Speech Pathology Visit Charges
Medical Social Service Visits
Medical Social Service Visit Charges
Home Health Aide Visits
Home Health Aide Visit Charges
Total Visits (Sum of lines 30,32,34,36,38,40)
Other Charges
Total Charges (Sum of lines 31,33,35,37,39,41,43)
Total Number of Episodes
Total Number of Outlier Episodes
Total Non-Routine Medical Supply Charges
SCIC within a
PEP
5
SCIC Only
Episodes
6
Totals
7
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
FORM CMS-1728-94 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3205)
32-305.1
Rev.
DRAFT
HHA-BASED RHC/FQHC
STATISTICAL DATA
Check
Applicable Box
FORM CMS-1728-94
PROVIDER CCN:
_____________
FQHC/RHC CCN:
_____________
3290 (Cont.)
WORKSHEET S-4
[ ] HHA-Based RHC
[ ] HHA-Based FQHC
Clinic/Center Address and Identification:
1 Street:
1.01 City:
State:
2 Designation (for FQHCs only) - Enter "R" for rural or "U" for urban
Source of Federal Funds:
3
4
5
6
7
8
PERIOD:
FROM: __________
TO: ___________
Zip Code:
1
1.01
2
County:
Grant Award
1
Date
2
Community Health Center (Section 330(d), PHS Act)
Migrant Health Center (Section 329(d), PHS Act)
Health Services for the Homeless (Section 340(d), PHS Act)
Appalachian Regional Commission
Look-Alikes
Other (specify)
Physician Information:
3
4
5
6
7
8
Physician
Name
Billing
Number
9 Physician(s) furnishing services at the clinic/center or under agreement (see instructions)
9
Physician
Name
Hours of
Supervision
10 Supervisory physician(s) and hours of supervision during period (see instructions)
10
11 Does the HHA-based RHC/FQHC operate as other than an RHC or FQHC? If yes, indicate number of other operations in column 2 and
list the other type(s) of operation(s) and hours on subscripts of line 12.
11
12
12.01
12.02
12.03
Enter the clinic/center hours on line 12 and list the other type(s) of operation(s) and hours on subscripts of line 12. (1)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
from
to
from
to
from
to
from
to
from
to
from
to
0
1
2
3
4
5
6
7
8
9
10
11
12
Clinic
Specify:
Specify:
Specify:
Saturday
from
to
13
14
12
12.01
12.02
12.03
(1) List hours of operation based on a 24 hour clock. For example, 8:30am is 0830, 5:30pm is 1730 and 12 midnight is 2400.
13 Has the HHA-based RHC/FQHC been approved for an exception to the productivity standard?
14 Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)? If yes, enter in column 2 the
number of clinics/centers included in this report. List all clinic/centers names and numbers below.
Clinic/Center number: _______________
15 Clinic/Center name: ______________________________
Clinc/Center number: _______________
15.01 Clinic/Center name: ______________________________
Clinic/Center number: _______________
15.02 Clinic/Center name: ______________________________
Clinic/Center number: _______________
15.03 Clinic/Center name: ______________________________
16 Are you claiming allowable GME costs as a result of "substantial payment" for interns
and residents? If yes, enter the number of Medicare visits in column 2 and total visits in column 3
performed by interns and residents and complete Worksheet RF-1, lines 20 and 27 as applicable.
13
14
Y/N
1
15
15.01
15.02
15.03
XVIII TOTAL 16
2
3
FORM CMS-1728-94-S4 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3233)
Rev.
32-305.2
3290 (Cont.)
HHA-BASED HOSPICE IDENTIFICATION DATA
FORM CMS-1728-94
PROVIDER CCN:
_____________
HOSPICE CCN:
_____________
DRAFT
PERIOD:
FROM: _____________
TO: ________________
PART I - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2015
Title XVIII
Unduplicated
Skilled
Unduplicated
Nursing
Enrollment Days
Days
Facility Days
1
2
1 Hospice Continuous Home Care
2 Hospice Routine Home Care
3 Hospice Inpatient Respite Care
4 Hospice General Inpatient Care
5 Total Hospice Days
WORKSHEET S-5
Other
Unduplicated
Days
3
Total
Unduplicated
Days
(sum of
cols. 1 & 3)
4
1
2
3
4
5
PART II - CENSUS DATA FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2015
Census Data
Title XVIII
1
Title XVIII
Skilled
Nursing
Facility
2
Other
3
Total
(sum of
cols. 1 & 3)
4
6 Number of Patients Receiving
Hospice Care
7 Total Number of Unduplicated
Continuous Care Hours
Billable to Medicare
8 Average Length of Stay (line 5 divided by line 6)
9 Unduplicated Census Count
6
7
8
9
NOTE: Parts I & II, column 1 also includes the days reported in column 2.
PART III - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015
Unduplicated Days
Title XVIII
Title XIX
Medicare
Medicaid
Other
1
2
3
10 Hospice Continuous Home Care
11 Hospice Routine Home Care
12 Hospice Inpatient Respite Care
13 Hospice General Inpatient Care
14 Total Hospice Days
PART IV - CONTRACTED STATISTICAL DATA FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015
Title XVIII
Title XIX
Medicare
Medicaid
Other
1
2
3
15 Hospice Inpatient Respite Care
16 Hospice General Inpatient Care
Total
4
10
11
12
13
14
Total
4
15
16
FORM CMS-1728-94 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 3239.1 THROUGH 3239.4 )
32-306
Rev.
Removed and Reserved
Pages 32-307
3290 (Cont.)
FORM CMS-1728-94
DRAFT
PROVIDER CCN :
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
PERIOD:
_______________
From: ___________
WORKSHEET A
To: ___________
CONTRACTED
EMPLOYEE
RECLASSI-
TRANSPOR- PURCHASED
EXPENSES
RECLASSI-
FIED TRIAL
FICATION
BALANCE
ADJUST-
ALLOCATION
FOR COST
SALARIES
BENEFITS
TATION (See
SERVICES
OTHER
(Fr Wks A-1)
(Fr Wks A-2)
Instructions)
(Fr Wks A-3)
COSTS
TOTAL
(Fr Wks A-4)
(Cols 6 + 7)
MENTS
(Col 8 + 9)
1
2
3
4
5
6
7
8
9
10
GENERAL SERVICE COST CENTER
1
0100
Capital Related - Bldg. & Fix.
1
2
0200
Capital Related - Movable Equip
2
3
0300
Plant Operation & Maintenance
3
4
0400
Transportation (See Instructions)
4
5
0500
Administrative and General
5
HHA REIMBURSABLE SERVICES
6
0600
Skilled Nursing Care
6
7
0700
Physical Therapy
7
8
0800
Occupational Therapy
8
9
0900
Speech Pathology
9
10
1000
Medical Social Services
10
11
1100
Home Health Aide
11
12
1200
Supplies (See Instructions)
12
13
1300
Drugs
13
13.20
1320
Cost of Administering Vaccines
13.20
14
1400
DME
14
HHA NONREIMBURSABLE SERVICES
15
1500
Home Dialysis Aide Services
15
16
1600
Respiratory Therapy
16
17
1700
Private Duty Nursing
17
18
1800
Clinic
18
19
1900
Health Promotion Activities
19
20
2000
Day Care Program
20
21
2100
Home Delivered Meals Program
21
22
2200
Homemaker
22
Other
23
23
SPECIAL PURPOSE COST CENTERS
24
2400
CORF
24
25
2500
Hospice
25
26
2600
CMHC
26
27
2700
RHC
27
28
2800
FQHC
28
Total
29
29
FORM CMS-1728-94 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3206)
32-308
Rev.
DRAFT
FORM CMS-1728-94
3290 (Cont.)
COMPENSATION ANALYSIS
PROVIDER CCN :
SALARIES AND WAGES
_______________
PERIOD:
From: ___________
WORKSHEET A-1
To: ___________
ADMINISTRATORS
DIRECTORS
1
2
CONSULTANTS SUPERVISORS
3
ALL
TOTAL
NURSES
THERAPISTS
AIDES
OTHER
(1)
5
6
7
8
9
4
GENERAL SERVICE COST CENTER
1
Capital Related - Bldg. and Fixtures
1
2
Capital Related - Movable Equipment
2
3
Plant Operation & Maintenance
3
4
Transportation (See Instructions)
4
5
Administrative and General
5
HHA REIMBURSABLE SERVICES
6
Skilled Nursing Care
6
7
Physical Therapy
7
8
Occupational Therapy
8
9
Speech Pathology
9
10
Medical Social Services
10
11
Home Health Aide
11
12
Supplies
12
13
Drugs
13
14
DME
14
HHA NONREIMBURSABLE SERVICES
15
Home Dialysis Aide Services
15
16
Respiratory Therapy
16
17
Private Duty Nursing
17
18
Clinic
18
19
Health Promotion Activities
19
20
Day Care Program
20
21
Home Delivered Meals Program
21
22
Homemaker Service
22
23
Other
23
SPECIAL PURPOSE COST CENTERS
24
CORF
24
25
Hospice
25
26
CMHC
26
27
RHC
27
28
FQHC
28
29
Total
29
(1) Transfer the amounts in column 9 to Wkst. A, column 1
FORM CMS-1728-94-A-1 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3207)
Rev.
32-309
3290 (Cont.)
FORM CMS-1728-94
DRAFT
COMPENSATION ANALYSIS
PROVIDER CCN :
EMPLOYEE BENEFITS (PAYROLL RELATED)
_______________
PERIOD:
From: ___________
WORKSHEET A-2
To: ___________
ADMINIS-
ALL
TOTAL
TRATORS
DIRECTORS
CONSULTANTS
SUPERVISORS
NURSES
THERAPISTS
AIDES
OTHER
(1)
1
2
3
4
5
6
7
8
9
GENERAL SERVICE COST CENTER
1
Capital Related - Bldg. and Fixtures
1
2
Capital Related - Movable Equipment
2
3
Plant Operation & Maintenance
3
4
Transportation (See Instructions)
4
5
Administrative and General
5
HHA REIMBURSABLE SERVICES
6
Skilled Nursing Care
6
7
Physical Therapy
7
8
Occupational Therapy
8
9
Speech Pathology
9
10
Medical Social Services
10
11
Home Health Aide
11
12
Supplies
12
13
Drugs
13
14
DME
14
HHA NONREIMBURSABLE SRVS
15
Home Dialysis Aide Services
15
16
Respiratory Therapy
16
17
Private Duty Nursing
17
18
Clinic
18
19
Health Promotion Activities
19
20
Day Care Program
20
21
Home Delivered Meals Program
21
22
Homemaker Services
22
23
Other
23
SPECIAL PURPOSE COST CENTERS
24
CORF
24
25
Hospice
25
26
CMHC
26
27
RHC
27
28
FQHC
28
29
Total
29
(1) Transfer the amounts in column 9 to Wkst. A, column 2
FORM CMS-1728-94-A-2 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3208)
32-310
Rev.
DRAFT
FORM CMS-1728-94
3290 (Cont.)
COMPENSATION ANALYSIS
PROVIDER CCN :
CONTRACTED SERVICES/PURCHASED SERVICES
_______________
PERIOD:
From: ___________
WORKSHEET A-3
To: ___________
ADMINISTRATORS
DIRECTORS
1
2
CONSULTANTS SUPERVISORS
3
4
ALL
TOTAL
NURSES
THERAPISTS
AIDES
OTHER
(1)
5
6
7
8
9
GENERAL SERVICE COST CENTER
1
Capital Related - Bldg. and Fixtures
1
2
Capital Related - Movable Equipment
2
3
Plant Operation & Maintenance
3
4
Transportation (See Instructions)
4
5
Administrative and General
5
HHA REIMBURSABLE SERVICES
6
Skilled Nursing Care
6
7
Physical Therapy
7
8
Occupational Therapy
8
9
Speech Pathology
9
10
Medical Social Services
10
11
Home Health Aide
11
12
Supplies
12
13
Drugs
13
14
DME
14
HHA NONREIMBURSABLE SERVICES
15
Home Dialysis Aide Services
15
16
Respiratory Therapy
16
17
Private Duty Nursing
17
18
Clinic
18
19
Health Promotion Activities
19
20
Day Care Program
20
21
Home Delivered Meals Program
21
22
Homemaker Services
22
23
Other
23
SPECIAL PURPOSE COST CENTERS
24
CORF
24
25
Hospice
25
26
CMHC
26
27
RHC
27
28
FQHC
28
29
Total
29
(1) Transfer the amounts in column 9 to Wkst. A, column 4
FORM CMS-1728-94 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3209)
Rev.
32-311
3290 (Cont.)
FORM CMS-1728-94
DRAFT
PROVIDER CCN :
RECLASSIFICATIONS
_______________
PERIOD:
WORKSHEET A-4
From: ___________
To: ___________
CODE
EXPLANATION OF RECLASSIFICATION ENTRY
INCREASE
DECREASE
(1)
COST CENTER
LINE NO.
AMOUNT(2)
COST CENTER
LINE NO.
AMOUNT(2)
1
2
3
4
5
6
7
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23
23
24
24
25
25
26
26
27
27
28
28
29
30
29
TOTAL RECLASSIFICATIONS (Sum of col. 4 must equal sum of col. 7)
30
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer to Worksheet A, column 7, line as appropriate.
FORM CMS-1728-94-A-4 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3210)
32-312
Rev.
DRAFT
FORM CMS-1728-94
ADJUSTMENTS TO EXPENSES
3290 (Cont.)
PROVIDER CCN :
PERIOD:
_______________
From: __________
WORKSHEET A-5
To: __________
Expense Classification on Worksheet A
To/From Which The Amount is to be Adjusted
Description (1)
1 Excess funds generated from operations,
(2)
BASIS/CODE
Amount
Cost Center
1
2
3
B
(3,985) A&G Shared Costs
Line No.
4
5.01
1
other than net income
2 Trade, quantity, time and other discounts
B
2
on purchases (Chap. 8)
3 Rebates and refunds of expenses (Chap. 8)
B
4 Home office costs (Chap. 21)
A
3
15,250 A&G Reimb. Costs
5.02
#REF!
4
5 Adjustments resulting from transaction
From Wks
with related organization (Chap. 10)
A-6
5
6 Sale of medical records and abstracts
B
6
7 Income from imposition of interest,
B
7
A
8
finance or penalty charges (Chap. 21)
8 Sale of medical and surgical supplies to
other than patients
9 Sale of Drugs to other than patients
10 Physical therapy adjustment (Chap. 14)
A
9
From Supp
10
Wks A-8-3
10.1 Occupational therapy adjustment (Chap. 14)
Occupational Therapy
8
Speech Pathology
9
From Supp
10.2
Wks A-8-3
11 Interest expense on Medicare overpayments and
7
10.1
Wks A-8-3
10.2 Speech pathology adjustment (Chap. 14)
Physical Therapy
From Supp
A
11
borrowings to repay Medicare overpayments
12 Lobbying Activities
A
(2,050) A&G Nonreimb. Costs
5.03
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21 TOTAL (Sum of lines 1-20)
#REF!
21
(1) Description - All line references in this column pertain to the Provider
Reimbursement Manual, Part I.
(2) Basis for adjustment (See Instructions)
A. Costs - if cost, including applicable overhead, can be determined
B. Amount Received - If cost cannot be determined
FORM CMS-1728-94-A-5 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3211)
Rev.
32-313
3290 (Cont.)
FORM CMS-1728-94
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result
in all interim payments made since the beginning of the cost reporting period being deemed
as overpayments (42 USC 1395g).
PROVIDER CCN : PERIOD:
STATEMENT OF COSTS OF
SERVICES FROM
From: ___________
RELATED ORGANIZATIONS
____________
To: ___________
A. Are there any costs included on Worksheet A which resulted from transactions
with related organizations as defined in CMS Pub. 15-I, chapter 10?
[ ] Yes [ ] No (If "Yes," complete Parts B and C)
B. Costs incurred and adjustment required as result of transactions with related organizations
LOCATION AND AMOUNT INCLUDED ON WKST A, COL. 8
LINE NO.
1
COST CENTER
2
EXPENSE ITEMS
3
AMOUNT
4
DRAFT
WORKSHEET A-6
AMOUNT
ALLOWABLE
IN COST
5
NET
ADJUSTMENT
(col 4 -5)
6
1
2
3
4
TOTALS (Sum of lines 1-3)(Transfer col. 6, lines 1-3 to Wkst A, Col. 9,
lines as appropriate)(Transfer col. 6, line 4 to Wkst A-5, col. 2, line 5)
C. Interrelationship of provider to related organization(s):
The Secretary, by virtue of authority granted under section 1814(b)(1) of the Social Security Act,
requires the provider to furnish the information requested on Part C of this worksheet.
The information will be used by the CMS and its intermediaries in determining that the costs applicable to services,
facilities and supplies furnished by organizations related to the provider by common ownership or control,
represent reasonable costs as determined under section 1861 of the Social Security Act.
If the provider does not provide all or any part of the requested information, the cost report will be considered
incomplete and not acceptable for purposes of claiming reimbursement under title XVIII.
SYMBOL
(1)
1
1
2
3
4
5
Name
2
Address
3
Percent
Owned
by
Provider
4
Percent
Ownership
of
Provider
5
Type of
Business
6
(1) Use the following symbols to indicate the interrelationship of the provider to related organizations:
A.
B.
C.
D.
Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider.
Corporation, partnership or other organization has financial interest in provider.
Provider has financial interest in corporation, partnership or other organization.
Director, officer, administrator or key person of provider or relative of such person has financial interest in
related organization.
E. Individual is director, officer, administrator or key person of provider and related organization.
F. Director, officer, administrator or key person of related organization or relative of such person has financial
interest in provider.
G. Other (financial or nonfinancial) specify.
FORM CMS-1728-94-A-6 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2,
SECTION 3212)
32-314
Rev.
DRAFT
FORM CMS-1728-94
PROVIDER CCN :
ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCE
_______________
Description
1
2
3
4
5
6
7
Beginning
Balances
1
Purchases
2
3290 (Cont.)
PERIOD:
From: ___________
To: ___________
Acquisitions
Donations
3
WORKSHEET A-7
Total
4
Land
Land Improvements
Buildings and Fixtures
Building Improvements
Fixed Equipment
Movable Equipment
TOTAL
Disposals
and
Retirements
5
Ending
Balance
6
1
2
3
4
5
6
7
FORM CMS-1728-94-A-7 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3213)
Rev.
32-315
3290 (Cont.)
REASONABLE COST DETERMINATION FOR THERAPY
SERVICES FURNISHED BY OUTSIDE SUPPLIERS
Check applicable box:
FORM CMS-1728-94
PROVIDER CCN :
DRAFT
WORKSHEET A-8-3
PARTS I - III
PERIOD:
From: ___________
To: ___________
________________
[ ] Physical Therapy services rendered before 4/10/98 [ ] Occupational Therapy [ ] Speech Pathology
[ ] Physical Therapy services rendered on or after 4/10/98
PART I - GENERAL INFORMATION
Total number of weeks worked (During which outside suppliers (excluding aides) worked)
Line 1 multiplied by 15 hours per week
Number of unduplicated HHA visits - supervisors or therapists (See Instructions)
Number of unduplicated HHA visits - therapy assistants (Include only visits made by therapy assistants and on which
supervisor and/or therapist was not present during the visit) (See Instructions)
5 Standard travel expense rate
6 Optional travel expense rate per mile
1
2
3
4
1
2
3
4
5
6
Supervisors
1
7
8
9
10
11
Total hours worked
AHSEA (See Instructions)
Standard Travel Allowance (Cols 1 and 2, one-half of col 2, line 8; col 3, one-half of col 3, line 8)
Number of travel hours (HHA only)
Number of miles driven (HHA only)
PART II - SALARY EQUIVALENCY COMPUTATIONS
12 Supervisors (Col 1, line 7 times col 1, line 8)
13 Therapists (Col 2, line 7 times col 2, line 8)
14 Assistants (Col 3, line 7 times col 3, line 8)
15 Subtotal Allowance Amount (Sum of lines 12-14)
16 Aides (Col 4, line 7 times col 4, line 8)
17 Total Allowance Amount (Sum of lines 15 and 16)
If the sum of cols 1-3, line 7, is greater than line 2, make no entries on lines 18 and 19
and enter on line 20 the amount from line 17. Otherwise, complete lines 18-20.
18 Weighted average rate excluding aides (Line 15 divided by the sum of cols 1-3, line 7)
19 Weighted allowance excluding aides (Line 2 times line 18)
20 Total Salary Equivalency (Line 17 or sum of lines 16 plus 19)
21
22
23
24
25
26
27
28
29
30
31
PART III - TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - HHA SERVICES
Standard Travel Allowance and Standard Travel Expense
Therapists (Line 3 times col 2, line 9)
Assistants (Line 4 times col 3, line 9)
Subtotal (Sum of lines 21 and 22)
Standard Travel Expense (Line 5 times sum of lines 3 and 4)
Optional Travel Allowance and Optional Travel Expense
Therapists (Sum of cols 1 and 2, line 10 times col 2, line 8)
Assistants (Col 3, line 10 times col 3, line 8)
Subtotal (Sum of lines 25 and 26)
Optional Travel Expense (Line 6 times sum of cols 1-3, line 11)
Total Travel Allowance and Travel Expenses - HHA Services; Complete one of the following
three lines 29, 30 or 31, as appropriate
Standard Travel Allowance and Standard Travel Expenses (Sum of lines 23 and 24 - See Instructions)
Optional Travel Allowance and Standard Travel Expenses (Sum of lines 27 and 24 - See Instructions)
Optional Travel Allowance and Optional Travel Expenses (Sum of lines 27 and 28 - See Instructions)
Therapists
2
Assistants
3
Aides
4
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
FORM CMS-1728-94-A-8-3 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 3219 THROUGH 3219.3)
32-316
Rev.
DRAFT
REASONABLE COST DETERMINATION FOR THERAPY
SERVICES FURNISHED BY OUTSIDE SUPPLIERS
FORM CMS-1728-94
PROVIDER CCN :
________________
Check applicable box:
3290 (Cont.)
WORKSHEET A-8-3
PART IV & V
PERIOD:
From: ___________
To: ___________
[ ] Physical Therapy services rendered before 4/10/98 [ ] Occupational Therapy [ ] Speech Pathology
[ ] Physical Therapy services rendered on or after 4/10/98
PART IV - OVERTIME COMPUTATION
37
38
39
40
41
Description
Overtime hours worked during cost reporting period (If col 4, line 32, is zero or equal to or greater
than 2,080, do not complete lines 33-40 and enter zero in each column of line 41)
Overtime rate (Multiply the amounts in cols 2-4, line 8 (AHSEA) times 1.5)
Total overtime (Including base and overtime allowance) (Multiply line 32 times line 33)
CALCULATION OF LIMIT
Percentage of overtime hours by category (Divide the hours in each column on line 32 by the total
overtime worked - col. 4, line 32)
Allocation of provider's standard workyear for one full-time employee times the percentage on line 35)
(See Instructions)
DETERMINATION OF OVERTIME ALLOWANCE
Adjusted hourly salary equivalency amount (AHSEA) (From Part I, cols 2-4, line 8)
Overtime cost limitation (Line 36 times line 37)
Maximum overtime cost (Enter the lesser of line 34 or line 38)
Portion of overtime already included in hourly computation at the AHSEA (Multiply line 32 times line 37)
Overtime allowance (Line 39 minus line 40 - if negative enter zero) (Col 4, sum of cols 1-3)
42
43
44
45
46
47
48
49
PART V - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
Salary equivalency amount (from Part II, line 20)
Travel allowance and expense - HHA services (from Part III, lines 29, 30 or 31)
Overtime allowance (from Part IV, col. 4, line 41)
Equipment cost (See Instructions)
Supplies (See Instructions)
Total allowance (Sum of lines 42-46)
Total cost of outside supplier services (from provider records)
Excess over limitation (line 48 minus line 47 - transfer amount to A-5, line 10, 10.1, or 10.2 as applicable - if negative, enter zero -- See Instructions)
32
33
34
35
36
Therapists
1
Assistants
2
Aides
3
TOTAL
4
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
FORM CMS-1728-94-A-8-3 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 3219.4 AND 3219.5)
Rev.
32-317
3290 (Cont.)
FORM CMS-1728-94
DRAFT
PROVIDER CCN :
PERIOD:
COST ALLOCATION - GENERAL SERVICE COST
From: ___________
_____________
NET EXPENSES
CAPITAL
FOR COST
RELATED COSTS
WORKSHEET B
To: ___________
PLANT
ALLOCATION
OPERATION
ADMINISTRA-
(FR.WKST
BLDGS &
MOVABLE
&
TRANS-
SUBTOTAL
TIVE
A, COL10)
& FIXTURES
EQUIPMENT
MAINTENANCE
PORTATION
(cols. 0-4)
& GENERAL
TOTAL
0
1
2
3
4
4A
5
6
GENERAL SERVICE COST CENTERS
1
Capital Related - Bldg. and Fixtures
1
2
Capital Related - Movable Equipment
2
3
Plant Operation & Maintenance
3
4
Transportation (See Instructions)
4
5
Administrative and General
5
HHA REIMBURSABLE SERVICES
6
Skilled Nursing Care
6
7
Physical Therapy
7
8
Occupational Therapy
8
9
Speech Pathology
9
10
Medical Social Services
10
11
Home Health Aide
11
12
Supplies (See Instructions)
12
13
Drugs
13
13.20
Cost of Administering Vaccines
13.20
14
DME
14
HHA NONREIMBURSABLE SERVICES
15
Home Dialysis Aide Services
15
16
Respiratory Therapy
16
17
Private Duty Nursing
17
18
Clinic
18
19
Health Promotion Activities
19
20
Day Care Program
20
21
Home Delivered Meals Program
21
22
Homemaker Services
22
23
Other
23
SPECIAL PURPOSE COST CENTER
24
CORF
24
25
Hospice
25
26
CMHC
26
27
RHC
27
28
FQHC
28
29
Total
29
FORM CMS-1728-94-B (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3214)
32-318
Rev.
DRAFT
FORM CMS-1728-94
3290 (Cont.)
PROVIDER CCN :
PERIOD:
COST ALLOCATION - STATISTICAL BASIS
From: ___________
_____________
WORKSHEET B-1
To: ___________
CAPITAL
RELATED COSTS
COST CENTER
PLANT
ADMINISTRA-
BLDGS &
MOVABLE
OPERATION
& FIXTURES
EQUIPMENT
MAINTENANCE
TRANS-
TIVE
(SQUARE
(DOLLAR
(SQUARE
PORTATION
RECONCIL-
(ACCUMU-
FEET)
VALUE)
FEET)
(MILEAGE)
IATION
LATED COST)
TOTAL
1
2
3
4
5A
5
6
& GENERAL
GENERAL SERVICE COST CENTER
1
Capital Related - Bldg. and Fixtures
1
2
Capital Related - Movable Equipment
2
3
Plant Operation & Maintenance
3
4
Transportation (See Instructions)
4
5
Administrative and General
5
HHA REIMBURSABLE SERVICES
6
Skilled Nursing Care
6
7
Physical Therapy
7
8
Occupational Therapy
8
9
Speech Pathology
9
10
Medical Social Services
10
11
Home Health Aide
11
12
Supplies (See Instructions)
12
13
Drugs
13
13.20
Cost of Administering Vaccines
13.20
14
DME
14
HHA NONREIMBURSABLE SERVICES
15
Home Dialysis Aide Services
15
16
Respiratory Therapy
16
17
Private Duty Nursing
17
18
Clinic
18
19
Health Promotion Activities
19
20
Day Care Program
20
21
Home Delivered Meals Program
21
22
Homemaker Services
22
23
Other
23
SPECIAL PURPOSE COST CENTER
24
CORF
24
25
Hospice
25
26
CMHC
26
27
RHC
27
28
FQHC
28
29
Total
29
30
Cost To Be Allocated (Per Wkst B)
30
31
Unit Cost Multiplier
31
FORM CMS-1728-94-B-1 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3214)
Rev.
32-319
3290 (Cont.)
FORM CMS-1728-94
APPORTIONMENT OF PATIENT SERVICE COSTS
DRAFT
PROVIDER CCN:
PERIOD:
WORKSHEET C
From: ______________
______________
PARTS I & II
To: ______________
PART I - AGGREGATE AGENCY COST PER VISIT COMPUTATION
Average
Cost Per Visit Computation
From Wkst
Cost
B, Col. 6,
Patient Services
Total
Per Visit
Line:
Cost
Visits
(Cols 2 ÷ 3) (1)
1
2
3
4
1
Skilled Nursing
6
1
2
Physical Therapy
7
2
3
Occupational Therapy
8
3
4
Speech Pathology
9
4
5
Medical Social Services
10
5
6
Home Health Aide Services
11
6
7
Total (Sum of lines 1-6)
7
PART II - COMPUTATION OF THE AGGREGATE MEDICARE COST AND THE AGGREGATE OF THE MEDICARE LIMITATION (2)
Medicare Program Visits
MSA/CBSA CODE:
Total Medicare Patient Service Cost Computation
Cost of Medicare Services
Part B
Part B
From Wkst. C,
Average
Not Subject
Subject
Not Subject
Subject
Total
Part I, Col. 4,
Cost
to Deductibles
to Deductibles
to Deductibles
to Deductibles
(Sum of
Line:
Per Visit
Part A
& Coinsurance
& Coinsurance
Part A
& Coinsurance
& Coinsurance
Cols 8 & 9)
4
5
6
7
8
9
10
11
1
Skilled Nursing
1
1
2
Physical Therapy
2
2
3
Occupational Therapy
3
3
4
Speech Pathology
4
4
5
Medical Social Services
5
5
6
Home Health Aide Services
6
6
7
Total (Sum of lines 1-6)
7
Medicare Program Visits
Cost of Medicare Services
Part B
Total Medicare Patient Service Cost Limitation Computation
Part B
Program
Not Subject
Subject
Not Subject
Subject
Total
Cost
to Deductibles
to Deductibles
to Deductibles
to Deductibles
(Sum of
Limits
Part A
& Coinsurance
& Coinsurance
Part A
& Coinsurance
& Coinsurance
Cols 8 & 9
4
5
6
7
8
9
10
11
8
Skilled Nursing
9
Physical Therapy
8
9
10
Occupational Therapy
10
11
Speech Pathology
11
12
Medical Social Services
12
13
Home Health Aide Services
13
14
Total (Sum of lines 8-13 plus the subscripts of lines 1-6, respectively)
14
(1) Compute the average cost per visit one time for each discipline (column 4, lines 1 through 6) for the entire home health agency.
(2) Complete Worksheet C, Part II once for each MSA where Medicare covered services were furnished during the cost reporting period.
FORM CMS-1728-94-C (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 3215 - 3215.5)
32-320
Rev.
DRAFT
FORM CMS-1728-94
APPORTIONMENT OF PATIENT SERVICE COSTS
3290 (Cont.)
PROVIDER CCN:
PERIOD:
WORKSHEET C
From: ______________
______________
PARTS III, IV & V
To: ______________
PART III - SUPPLIES AND DRUGS COST COMPUTATION
Medicare Covered Charges
Total
From Wkst
Other Patient Services
Cost of Services
Part B
Charges
Part B
Not Subject
Subject
Not Subject
Subject
to Deductibles
to Deductibles
to Deductibles
to Deductibles
B, Col. 6,
Total
from HHA
Ratio
Line:
Cost
Record)
(Col 2 ÷ 3)
Part A
& Coinsurance
& Coinsurance
Part A
& Coinsurance
& Coinsurance
1
2
3
4
5
6
7
8
9
10
15
Cost of Medical Supplies
12
15
16
Cost of Drugs
13
16
16.20
Cost of Drugs
13.20
16.20
PART IV - COMPARISON OF THE LESSER OF THE AGGREGATE MEDICARE COST, THE AGGREGATE OF THE MEDICARE COST PER VISIT LIMITATION AND THE AGGREGATE PER BENEFICIARY COST LIMITATION
Medicare Program
17
Per Beneficiary
Unduplicated
Annual
Census Count
Limitation Per
For Each
MSA/Non-MSA
Cost of Medicare Services
Part B
MSA/CBSA
CBSA/Non-CBSA
Not Subject
Pre 10/1/2000
(From Your
to Deductibles
to Deductibles
(Sum of
(4)
Contractor)
Part A
& Coinsurance
& Coinsurance
Subject
Cols 3 & 4
Total
1
2
3
4
5
6
Total Cost of Medicare Services (Sum of the amounts from each Wkst. C, Pt. II, cols. 8, 9 & 11, respectively, lines
17
1-6 (exculsive of subscripts))
18
Cost of Medical Supplies (from Part III, columns 8 and 9, line 15 (exclusive of line 15.01))
18
19
Total (Sum of lines 17 and 18)
19
20
Total Cost Per Visit Limitation for Medicare Services (Sum of the amounts from each Wkst. C, Pt. II, cols. 8, 9 &11, respectively, line 14)
20
21
Cost of Medical Supplies (from Part III, columns 8 and 9, line 15 (exclusive of line 15.01))
21
22
Total (Sum of lines 20 and 21)
22
MSA/CBSA
Code (3)
(Col 1 x 2)
0
1
2
3
4
5
6
23
Per Beneficiary Cost Limitation for MSA/CBSA:
23
23.01
Per Beneficiary Cost Limitation for MSA/CBSA:
23.01
23.02
Per Beneficiary Cost Limitation for MSA/CBSA:
23.02
23.03
Per Beneficiary Cost Limitation for MSA/CBSA:
23.03
23.04
Per Beneficiary Cost Limitation for MSA/CBSA:
23.04
23.05
Per Beneficiary Cost Limitation for MSA/CBSA:
23.05
23.06
Per Beneficiary Cost Limitation for MSA/CBSA:
23.06
23.07
Per Beneficiary Cost Limitation for MSA/CBSA:
23.07
23.08
Per Beneficiary Cost Limitation for MSA/CBSA:
23.08
23.09
Per Beneficiary Cost Limitation for MSA/CBSA:
23.09
24
Aggregate Per Beneficiary Cost Limitation (Sum of lines 23 and subscripts thereof)
24
PART V - OUTPATIENT THERAPY REDUCTION COMPUTATION
Part B
Subject to Deductibles and Coinsurance
Patient Services
Medicare
Medicare
Medicare
Medicare
Medicare
Medicare
From Wkst. C,
Average
Program Visits
Program Costs
Program Visits
Program Visits
Program Visits
Program Costs
Application of
Reasonable
Part I, Col. 4,
Cost
for Services
for Services
for Services
for Services
for Services on
for Services
the Reasonable
Costs Net of
Line:
Per Visit
Before 1/1/98
Before 1/1/98
1/1/98-12/31/98
1/1/99-9/30/00
or after 10/1/00
1/1/98-12/31/98
Cost Reduction
Adjustments
1
2
3
4
5
5.01
5.02
6
7
8
25
Physical Therapy
2
25
26
Occupational Therapy
3
26
27
Speech Pathology
4
27
28
Total (Sum of lines 25-27)
28
(3) The MSA/CBSA codes flow from Worksheet S-3, Part III, line 29 and subscripts as indicated.
(4) The sum of column 1, line 24 must equal Worksheet S-3, Part I, column 2, line 10.01.
FORM CMS-1728-94-C (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 3215 - 3215.5)
Rev.
32-321
3290 (Cont.)
FORM CMS-1728-94
CALCULATION OF REIMBURSEMENT SETTLEMENT -
DRAFT
PROVIDER CCN:
PART A AND PART B SERVICES
PERIOD:
From: ___________
________________
WORKSHEET D
To: ___________
PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES
PART B
Description
Not Subject
Subject
to Deductibles
to Deductibles
PART A
& Coinsurance
& Coinsurance
1
2
3
Reasonable Cost of Title XVIII - Part A & Part B Services
1
Reasonable Cost of Services (See Instructions)
1
2
Cost of Services, RHC & FQHC
2
3
Sum of Lines 1 and 2
3
4
Total charges for title XVIII - Part A and Part B Services - Pre 10/1/2000
4
4.01
Total charges for title XVIII - Part A and Part B Services - Post 9/30/2000
4.01
Customary Charges
5
Amount actually collected from patients liable for payment for services on a
5
charge basis (From your records)
6
Amount that would have been realized from patients liable for payment for services on
6
a charge basis had such payment been made in accordance with 42 CFR 413.13(b)
7
Ratio of line 5 to 6 (Not to exceed 1.000000)
7
8
Total customary charges - title XVIII (Multiply line 7 by line 4 for column 1) (Multiply line 7
8
by the sum of lines 4 & 4.01 for columns 2 & 3, respectively) (See Instructions)
9
Excess of total customary charges over total reasonable cost (Complete only if
9
line 8 exceeds line 3)
10
Excess of reasonable cost over customary charges (Complete only if line 3 exceeds line 8)
10
11
Primary Payer Amounts
11
PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT
PART A
PART B
Services
Services
1
2
Description
12
Total reasonable cost (See Instructions)
12
12.01
Total PPS Payment - Full Episodes without Outliers
12.01
12.02
Total PPS Payment - Full Episodes with Outliers
12.02
12.03
Total PPS Payment - LUPA Episodes
12.03
12.04
Total PPS Payment - PEP Only Episodes
12.04
12.05
Total PPS Payment - SCIC within a PEP Episodes
12.05
12.06
Total PPS Payment - SCIC Only Episodes
12.06
12.07
Total PPS Outlier Payment - Full Episodes with Outliers
12.07
12.08
Total PPS Outlier Payment - PEP Only Episodes
12.08
12.09
Total PPS Outlier Payment - SCIC within a PEP Episodes
12.09
12.10
Total PPS Outlier Payment - SCIC Only Episodes
12.10
12.11
Total Other Payments
12.11
12.12
DME Payment
12.12
12.13
Oxygen Payment
12.13
12.14
Prosthetics and Orthotics Payment
12.14
13
Part B deductibles billed to Medicare patients (exclude coinsurance)
13
14
Subtotal (Sum of lines 12-12.14 minus line 13)
14
15
Excess reasonable cost (from line 10)
15
16
Subtotal (Line 14 minus line 15)
16
17
Coinsurance billed to Medicare patients (From your records)
17
18
Net cost (Line 16 minus line 17)
18
19
Reimbursable bad debts (From your records)
19
20
Pneumococcal Vaccine
20
21
Total Costs - Current cost reporting period (See Instructions)
21
22
Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets
22
23
Recovery of excess depreciation resulting from agencies' termination or decrease in Medicare utilization
23
24
Unrefunded charges to beneficiaries for excess costs erroneously collected based on correction of cost limit
24
25
Total cost before sequestration and other adjustments- (line 21
25
plus/minus line 22 minus sum of lines 23 and 24)
25.50
Other Adjustments (see instructions) (specify)
25.50
26
Sequestration Adjustment (See Instructions)
26
27
Amount reimbursable after sequestration and other adjustments (Line 25 plus line 25.5 minus line 26)
27
28
Total interim payments (From Worksheet D-1, line 4)
28
28.5
Tentative settlement (For contractor use only)
28.5
29
Balance due HHA/Medicare program (Line 27 minus line 28) (Indicate overpayments in brackets)
29
30
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2
30
31
Balance due HHA/Medicare program (Line 29 minus line 30) (Indicate overpayments in brackets)
31
FORM CMS-1728-94-D (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 3216 THROUGH 3216.2)
32-322
Rev.
DRAFT
ANALYSIS OF PAYMENTS TO HHAs
FOR SERVICES RENDERED TO
PROGRAM BENEFICIARIES
FORM CMS-1728-94
PROVIDER CCN :
_______________
Description
1
2
3
PART A
mm/dd/yyyy
Amount
1
2
Total interim payments paid to provider
Interim pymts payable on individual bills either submitted or to
be submitted to the contractor , for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
List separately each retroactive lump sum
adjustment amount based on subsequent revision
of the interim rate for the cost reporting period.
Program
Also show date of each payment. If none write
to
"NONE" or enter a zero.(1)
Provider
Provider
to
Program
4
PERIOD:
From: ___________
To: ___________
SUBTOTAL (Sum of lines 3.01-3.49, minus sum
of lines 3.50-3.98)
TOTAL INTERIM PAYMENTS (Sum of lines 1, 2
and 3.99)(Transfer to Wkst D, Part II,
column as appropriate, line 28)
PART B
mm/dd/yyyy
3
3290 (Cont.)
WORKSHEET D-1
Amount
4
1
2
.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99
3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4
TO BE COMPLETED BY CONTRACTOR
5
6
7
List separately each tentative settlement payment
after desk review. Also show date of each
payment. If none, write "NONE" or enter
a zero. (1)
"NONE" or enter a zero. (1)
SUBTOTAL (Sum of lines 5.01-5.49 minus sum
of lines 5.50-5.98)
Determine net settlement
amount (balance due) based
on the cost report (See
Instructions)
Program
to
Provider
Provider
to
Program
.01
.02
.03
.50
.51
.52
.99
5.01
5.02
5.03
5.50
5.51
5.52
5.99
Program
to
Provider
Provider
to
Program
.01
6.01
.02
6.02
7
TOTAL MEDICARE PROGRAM LIABILITY
(See Instructions)
Name of Contractor
Contractor Number
Signature of Authorized Person
Date: Month, Day, Year
(1) On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the provider
agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS-1728-94-D-1 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3217)
Rev.
32-323
3290 (Cont.)
BALANCE SHEET
(To be completed by all providers maintaining fund type
accounting records. Nonproprietary providers not
maintaining fund type accounting records, should
complete the "General Fund" column only.)
FORM CMS-1728-94
PROVIDER CCN :
___________
ASSETS
(Omit Cents)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
CURRENT ASSETS
Cash on hand and in banks
Temporary investments
Notes receivable
Accounts Receivable
Other Receivables
Less: Allowance for uncollectible notes
and accounts receivable
Inventory
Prepaid Expenses
Other current assets
Due from other funds
TOTAL CURRENT ASSETS (Sum of lines 1-10)
FIXED ASSETS
Land
Land Improvements
Less: Accumulated Depreciation
Buildings
Less: Accumulated Depreciation
Leasehold improvements
Less: Accumulated Depreciation
Fixed equipment
Less: Accumulated Depreciation
Automobiles and trucks
Less: Accumulated Depreciation
Major movable equipment
Less: Accumulated Depreciation
Minor equipment nondepreciable
Other fixed assets
TOTAL FIXED ASSETS (Sum of lines 12-26)
OTHER ASSETS
Investments
Deposits on leases
Due from owners/officers
DRAFT
PERIOD:
From: ___________
To: ___________
SPECIFIC
PURPOSE
FUND
2
GENERAL
FUND
1
ENDOWMENT
FUND
3
WORKSHEET F
PLANT
FUND
4
1
2
3
4
5
6
(
)
7
8
9
10
11
(
)
(
)
(
)
(
)
(
)
(
)
28
29
30
31
32 TOTAL OTHER ASSETS (Sum of lines 28-31)
33 TOTAL ASSETS (Sum of lines 11, 27 and 32)
LIABILITIES AND FUND BALANCE
(Omit Cents)
CURRENT LIABILITIES
34 Accounts payable
35 Salaries, wages & fees payable
36 Payroll taxes payable
37 Notes & loans payable (short term)
38 Deferred income
39 Accelerated payments
40 Due to other funds
41 Other (Specify)
42 TOTAL CURRENT LIABILITIES (Sum of lines 34-41)
LONG TERM LIABILITIES
43 Mortgage payable
44 Notes payable
45 Unsecured Loans
46 Loans from owners - prior to 7/1/66
47 Loans from owners - on or after 7/1/66
48 Other (Specify)
49 TOTAL LONG TERM LIABILITIES
(Sum of lines 43-48)
50 TOTAL LIABILITIES (Sum of lines 42 and 49)
CAPITAL ACCOUNTS
51 General fund balance
52 Specific purpose fund balance
53 Donor created--Endowment fund balance--restricted
54 Donor created--Endowment fund balance--unrestricted
55 Governing body created--Endowment fund balance
56 Plant fund balance--Invested in plant
57 Plant fund balance-- Reserve for plant improvement,
replacement and expansion
58 TOTAL FUND BALANCES (Sum of lines 51 thru 57)
59 TOTAL LIABILITIES AND FUND BALANCE (Sum
of lines 50 and 58)
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
(
) = contra amount
FORM CMS-1728-94-F (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3218)
32-324
Rev.
DRAFT
STATEMENT OF
REVENUE AND EXPENSES
FORM CMS-1728-94
PROVIDER CCN :
___________
3290 (Cont.)
PERIOD
From: ___________
To: ___________
WORKSHEET F-1
1
Total patient revenues
1
2
Less: Allowances and discounts on patients' accounts
2
3
Net patient revenues (Line 1 minus line 2)
3
4
Operating expenses (From Worksheet A, column 6, line 29)
4
5
Additions to operating expenses (Specify)
5
6
6
7
7
8
8
9
9
10
10
11
Subtractions from operating expenses (Specify)
11
12
12
13
13
14
14
15
15
16
16
17
Less total operating expenses (net of lines 4 thru 16)
17
18
Net income from service to patients (Line 3 minus line 17)
18
Other income:
19
Contributions, donations, bequests, etc.
19
20
Income from investments
20
21
Purchase discounts
21
22
Rebates and refunds of expenses
22
23
Sale of Medical and Nursing Supplies to other than patients
23
24
Sale of durable medical equipment to other than patients
24
25
Sale of drugs to other than patients
25
26
Sale of medical records and abstracts
26
27 Other revenues (Specify)
27
28
28
29
29
30
30
31
31
32
Total Other Income (Sum of lines 19 thru 31)
32
33
Net Income or Loss for the period (Line 18 plus line 32)
33
FORM CMS-1728-94 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3218)
Rev.
32-325
3290 (Cont.)
FORM CMS-1728-94
DRAFT
PROVIDER CCN :
STATEMENT OF CHANGES IN FUND BALANCES
GENERAL FUND
1
2
___________
SPECIFIC PURPOSE FUND
3
4
PERIOD:
From: ___________
To: ___________
ENDOWMENT FUND
5
6
WORKSHEET F-2
PLANT FUND
7
8
1
Fund balances at beginning of period
1
2
Net Income (loss) (From Worksheet F-1, line 33)
2
3
Total (Sum of line 1 and line 2)
3
4
Additions (Credit adjustments) (Specify)
4
5
5
6
6
7
7
8
8
9
Total Additions (Sum of lines 4-8)
9
10
Subtotal (line 3 plus line 9)
10
11
Deductions (Debit adjustments) (Specify)
11
12
12
13
13
14
14
15
15
16
17
Total Deductions (Sum of lines 11-15)
Fund balance at end of period per balance sheet
(line 10 minus line 16)
16
17
FORM CMS-1728-94-F-2 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3218)
32-326
Rev.
Removed and Reserved
Pages 32-327 - 32-331
3290 (Cont.)
ANALYSIS OF HOSPICE COSTS
COST CENTER DESCRIPTIONS
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34
FORM CMS-1728-94
PROVIDER CCN :
___________
HOSPICE CCN :
___________
SALARIES
(From
Wkst.K-1)
1
EMPLOYEE
BENEFITS TRANSPOR(From
TATION
Wkst. K-2)
(See inst.)
2
3
CONTRACTED
SERVICES
(From
Wkst. K-3)
4
OTHER
5
TOTAL
(cols. 1-5)
6
RECLASSIFICATION
7
GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
Inpatient - General Care
Inpatient - Respite Care
VISITING SERVICES
Physician Services
Nursing Care
Nursing Care - Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
Home Health Aide and Homemaker-Cont Home Care
Other
OTHER HOSPICE SERVICE COSTS
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives/Hypnotics
Other - specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
HOSPICE NONREIMBURSABLE SERV.
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Total (sum of line 1 thru 33)
The net expenses for cost allocation on Worksheet A for the Hospice cost center line must equal the total facility costs in column 10, line 34 of this worksheet.
PERIOD:
FROM: ____________
TO: _______________
SUBTOTAL
(col. 6
± col. 7)
8
ADJUSTMENTS
9
DRAFT
WORKSHEET K
TOTAL
(col. 8
± col. 9)
10
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34
FORM CMS-1728-94-K (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3240)
32-331.1
Rev.
DRAFT
HOSPICE COMPENSATION ANALYSIS - SALARIES AND WAGES
COST CENTER DESCRIPTIONS
ADMINIS
TRATOR
1
FORM CMS-1728-94
PROVIDER CCN :
_____________
HOSPICE CCN :
_____________
DIRECTOR
2
SOCIAL
SERVICES
3
SUPERVISORS
4
GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
10.20 Nursing Care - Continuous Home Care
11 Physical Therapy
12 Occupational Therapy
13 Speech/ Language Pathology
14 Medical Social Services
15 Spiritual Counseling
16 Dietary Counseling
17 Counseling - Other
18 Home Health Aide and Homemaker
18.20 Home Health Aide and Homemaker-Cont Home Care
19 Other
OTHER HOSPICE SERVICE COSTS
20 Drugs Biological and Infusion Therapy
20.30 Analgesics
20.31 Sedatives/Hypnotics
20.32 Other - specify
21 Durable Medical Equipment/ Oxygen
22 Patient Transportation
23 Imaging Services
24 Labs and Diagnostics
25 Medical Supplies
26 Outpatient Services (incl. E/R Dept.)
27 Radiation Therapy
28 Chemotherapy
29 Other
HOSPICE NONREIMBURSABLE SERV.
30 Bereavement Program Costs
31 Volunteer Program Costs
32 Fundraising
33 Other Program Costs
34 Total (sum of line 1 thru 33)
(1) Transfer the amount in column 9 to Wkst K, column 1
FORM CMS-1728-94-K-1 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3241)
1
2
3
4
5
6
Rev.
NURSES
5
TOTAL
THERAPISTS
6
PERIOD:
FROM: ____________
TO: _______________
AIDES
7
ALL OTHER
8
3290 (Cont.)
WORKSHEET K-1
TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34
32-331.2
3290 (Cont.)
HOSPICE COMPENSATION ANALYSIS - EMPLOYEE BENEFITS (PAYROLL RELATED)
COST CENTER DESCRIPTIONS
ADMINIS
TRATOR
1
DIRECTOR
2
FORM CMS-1728-94
PROVIDER CCN :
_____________
HOSPICE CCN :
_____________
SOCIAL
SERVICES
3
SUPERVISORS
4
GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
10.20 Nursing Care - Continuous Home Care
11 Physical Therapy
12 Occupational Therapy
13 Speech/ Language Pathology
14 Medical Social Services
15 Spiritual Counseling
16 Dietary Counseling
17 Counseling - Other
18 Home Health Aide and Homemaker
18.20 Home Health Aide and Homemaker-Cont Home Care
19 Other
OTHER HOSPICE SERVICE COSTS
20 Drugs Biological and Infusion Therapy
20.30 Analgesics
20.31 Sedatives/Hypnotics
20.32 Other - specify
21 Durable Medical Equipment/ Oxygen
22 Patient Transportation
23 Imaging Services
24 Labs and Diagnostics
25 Medical Supplies
26 Outpatient Services (incl. E/R Dept.)
27 Radiation Therapy
28 Chemotherapy
29 Other
HOSPICE NONREIMBURSABLE SERV.
30 Bereavement Program Costs
31 Volunteer Program Costs
32 Fundraising
33 Other Program Costs
34 Total (sum of line 1 thru 33)
(1) Transfer the amount in column 9 to Wkst K, column 2
FORM CMS-1728-94-K-2 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3242)
1
2
3
4
5
6
32-331.3
NURSES
5
TOTAL
THERAPISTS
6
PERIOD:
FROM: ____________
TO: _______________
AIDES
7
ALL OTHER
8
DRAFT
WORKSHEET K-2
TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34
Rev.
DRAFT
HOSPICE COMPENSATION ANALYSIS - CONTRACTED SERVICES/PURCHASED SERVICES
COST CENTER DESCRIPTIONS
ADMINIS
TRATOR
1
DIRECTOR
2
FORM CMS-1728-94
PROVIDER CCN :
_____________
HOSPICE CCN :
_____________
SOCIAL
SERVICES
3
SUPERVISORS
4
GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
10.20 Nursing Care - Continuous Home Care
11 Physical Therapy
12 Occupational Therapy
13 Speech/ Language Pathology
14 Medical Social Services
15 Spiritual Counseling
16 Dietary Counseling
17 Counseling - Other
18 Home Health Aide and Homemaker
18.20 Home Health Aide and Homemaker-Cont Home Care
19 Other
OTHER HOSPICE SERVICE COSTS
20 Drugs, Biological and Infusion Therapy
20.30 Analgesics
20.31 Sedatives/Hypnotics
20.32 Other - specify
21 Durable Medical Equipment/Oxygen
22 Patient Transportation
23 Imaging Services
24 Labs and Diagnostics
25 Medical Supplies
26 Outpatient Services (incl. E/R Dept.)
27 Radiation Therapy
28 Chemotherapy
29 Other
HOSPICE NONREIMBURSABLE SERV.
30 Bereavement Program Costs
31 Volunteer Program Costs
32 Fundraising
33 Other Program Costs
34 Total (sum of line 1 thru 33)
(1) Transfer the amount in column 9 to Wkst K, column 4
FORM CMS-1728-94-K-3 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3243)
1
2
3
4
5
6
Rev.
NURSES
5
TOTAL
THERAPISTS
6
PERIOD:
FROM: ____________
TO: _______________
AIDES
7
ALL OTHER
8
3290 (Cont.)
WORKSHEET K-3
TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34
32-331.4
3290 (Cont.)
HOSPICE COST ALLOCATION - GENERAL SERVICE COST
COST CENTER DESCRIPTIONS
FORM CMS-1728-94
PROVIDER CCN :
____________
HOSPICE CCN :
____________
NET
EXPENSES
FOR COST
ALLOC.
(FR. WKST K,
COL. 10)
0
CAPITAL RELATED
COST
BUILDINGS
MOVABLE
& FIXTURES EQUIPMENT
1
2
PLANT
OPERATION
& MAINT.
3
VOLUNTEER
SERVICES
TRANSCOORDIPORTATION
NATOR
4
5
GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
10.20 Nursing Care - Continuous Home Care
11 Physical Therapy
12 Occupational Therapy
13 Speech/ Language Pathology
14 Medical Social Services - Direct
15 Spiritual Counseling
16 Dietary Counseling
17 Counseling - Other
18 Home Health Aide and Homemakers
18.20 Home Health Aide and Homemaker-Cont Home Care
19 Other
OTHER HOSPICE SERVICE COSTS
20 Drugs, Biologicals and Infusion
20.30 Analgesics
20.31 Sedatives/Hypnotics
20.32 Other - specify
21 Durable Medical Equipment/Oxygen
22 Patient Transportation
23 Imaging Services
24 Labs and Diagnostics
25 Medical Supplies
26 Outpatient Services (incl. E/R Dept.)
27 Radiation Therapy
28 Chemotherapy
29 Other
HOSPICE NONREIMBURSABLE SERV.
30 Bereavement Program Costs
31 Volunteer Program Costs
32 Fundraising
33 Other Program Costs
34 Total (sum of line 1 thru 33)
FORM CMS-1728-94-K-4 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3244)
1
2
3
4
5
6
32-331.5
PERIOD:
FROM: ____________
TO: _______________
SUBTOTAL
(col. 0 - 5)
5A
ADMINISTRATIVE &
GENERAL
6
DRAFT
WORKSHEET K-4
PART I
TOTAL
7
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34
Rev.
DRAFT
HOSPICE COST ALLOCATION - STATISTICAL BASIS
COST CENTER DESCRIPTIONS
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
34
25
26
27
28
29
30
31
32
33
34
35
FORM CMS-1728-94
PROVIDER CCN :
_______________
HOSPICE CCN :
_______________
CAPITAL RELATED
COST
BUILDINGS
MOVABLE
& FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2
PLANT
OPERATION
& MAINT.
(SQ. FT.)
3
PERIOD:
FROM: ____________
TO: _______________
TRANSPORTATION
(MILEAGE)
4
GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Plant Operation and Maintenance
Transportation-staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
Inpatient - General Care
Inpatient - Respite Care
VISITING SERVICES
Physician Services
Nursing Care
Nursing Care - Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
Home Health Aide and Homemaker-Cont Home Care
Other
OTHER HOSPICE SERVICE COSTS
Drugs, Biologicals and Infusion
Analgesics
Sedatives/Hypnotics
Other - specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
HOSPICE NONREIMBURSABLE SERV.
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Cost To be Allocated (per Wkst K-4, Part I)
Unit Cost Multiplier
VOLUNTEER
SERVICES
COORDINATOR
(HOURS)
5
RECONCILIATION
6A
3290 (Cont.)
WORKSHEET K-4
PART II
ADMINISTRATIVE &
GENERAL
(ACC. COST)
6
1
2
3
4
5
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
19
20
20.30
20.31
20.32
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
FORM CMS-1728-94-K-4 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3244)
Rev.
32-331.6
3290 (Cont.)
ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS
HOSPICE COST CENTER
(omit cents)
1
2
3
4
5
5.20
6
7
8
9
10
11
12
13
13.20
14
15
15.30
15.31
15.32
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
FORM CMS-1728-94
DRAFT
PROVIDER CCN :
_________________
HOSPICE CCN :
_________________
From
Wkst. K-4
Part I,
col. 7,
line
6
7
8
9
10
10.20
11
12
13
14
15
16
17
18
18.20
HOSPICE
TRIAL
BALANCE
(1)
0
CAPITAL RELATED
COST
BUILDINGS
MOVABLE
& FIXTURES
EQUIPMENT
1
2
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care - Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
Home Health Aide and
Homemaker-Cont Home Care
Other
19
Drugs, Biologicals and Infusion
20
Analgesics
20.30
Sedatives/Hypnotics
20.31
Other - specify
20.32
Durable Medical Equipment/Oxygen
21
Patient Transportation
22
Imaging Services
23
Labs and Diagnostics
24
Medical Supplies
25
Outpatient Services (incl. E/R Dept.)
26
Radiation Therapy
27
Chemotherapy
28
Other
29
Bereavement Program Costs
30
Volunteer Program Costs
31
Fundraising
32
Other Program Costs
33
Totals (sum of lines 1-28) (2)
Unit Cost Multiplier: column 6, line 1 divided by the sum of column 6, line 29
minus column 6, line 1, rounded to 6 decimal places.
PLANT
OPERATION
& MAINTENANCE
3
TRANSPORTATION
4
SUBTOTAL
(cols. 0-4)
4A
PERIOD:
FROM: ____________
TO: _______________
ADMINISTRATIVE &
GENERAL
5
SUBTOTAL
6
WORKSHEET K-5
PART I
ALLOCATED
HOSPICE
A&G (see
Part II)
7
TOTAL
HOSPICE
COSTS
(col 6 + col. 7)
8
1
2
3
4
5
5.20
6
7
8
9
10
11
12
13
13.20
14
15
15.30
15.31
15.32
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
(1) Column 0, line 29 must agree with Wkst. A, column 10, line 25.
(2) Columns 0 through 5, line 29 must agree with the corresponding columns of Wkst. B, line 25.
FORM CMS 1728-94-K-5 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3245-3245.1)
32-331.7
Rev.
DRAFT
ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS
STATISTICAL BASIS
HOSPICE COST CENTER
1
2
3
4
5
5.20
6
7
8
9
10
11
12
13
13.20
14
15
15.30
15.31
15.32
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
FORM CMS-1728-94
PROVIDER CCN :
______________
HOSPICE CCN :
______________
CAPITAL RELATED
PLANT
COST
OPERATION
BUILDINGS
MOVABLE
& MAIN& FIXTURES
EQUIPMENT
TENANCE
(SQUARE
(DOLLAR
(SQUARE
FEET)
VALUE)
FEET)
1
2
3
Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care - Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemakers
Home Health Aide and Homemaker-Cont Home Care
Other
Drugs, Biologicals and Infusion
Analgesics
Sedatives/Hypnotics
Other - specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (incl. E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-28)
Total cost to be allocated
Unit Cost Multiplier
PERIOD:
FROM: ____________
TO: _______________
TRANSPORTATION
(MILAGE)
4
RECONCILIATION
5A
3290 (Cont.)
WORKSHEET K-5
PART II
ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5
1
2
3
4
5
5.20
6
7
8
9
10
11
12
13
13.20
14
15
15.30
15.31
15.32
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
FORM CMS-1728-94-K-5 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3245.2)
Rev.
32-331.8
3290 (Cont.)
APPORTIONMENT OF HOSPICE SHARED SERVICES
COST CENTER
ANCILLARY SERVICE COST CENTERS
1 Physical Therapy
2 Occupational Therapy
3 Speech/ Language Pathology
4 Medical Social Services - Direct
5 Durable Medical Equipment/Oxygen
6 Medical Supplies
7 Totals (sum of lines 1-7)
FORM CMS-1728-94
PROVIDER CCN : _____________
HOSPICE CCN : ____________
From Wkst B,
col. 6, line:
1
Total HHA
Costs
2
7
8
9
10
14
12
PERIOD:
FROM: ___________
TO: ___________
Total HHA
Charges
(from Provider
Records)
3
Cost to
Charge
Ratio
(col. 2/col.3)
4
Total
Hospice
Charges
(from Provider
Records)
5
DRAFT
WORKSHEET K-5
Part III
Hospice
Shared
Ancillary
Costs
(col. 4 x col. 5)
6
1
2
3
4
5
6
7
FORM CMS-1728-94-K-5 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3245.3)
32-331.9
Rev.
DRAFT
CALCULATION OF HOSPICE
FORM CMS-1728-94
PROVIDER CCN :
PER DIEM COST
_______________
HOSPICE CCN :
3290 (Cont.)
PERIOD:
WORKSHEET K-6
FROM: ____________
TO: _______________
_______________
COMPUTATION OF PER DIEM COST
TITLE XVIII
TITLE XIX
OTHER
TOTAL
1
2
3
4
1 Total cost (Worksheet K-5, Part I, col. 8, line 29 less col. 8, line 28
1
plus Worksheet K-5, Part III, col. 6, line 7) (see instructions)
2 Total Unduplicated Days (Worksheet S-5, line 5, col. 4)
2
3 Average cost per diem (line 1 divided by line 2)
3
4 Unduplicated Medicare Days (Worksheet S-5, line 5, col. 1)
4
5 Aggregate Medicare cost (line 3 times line 4)
5
6 Unduplicated Medicaid Days (Not Applicable)
6
7 Aggregate Medicaid cost (Not Applicable)
7
8 Unduplicated SNF days (Worksheet S-5, line 5, col. 2)
8
9
Aggregate SNF cost (line 3 times line 8)
9
10 Unduplicated NF days (Not Applicable)
10
11 Aggregate NF cost (Not Applicable)
11
12 Other unduplicated days (Worksheet S-5, line 5, col. 3)
12
13 Aggregate cost for other days (line 3 times line 12)
13
NOTE: The data for the SNF on line 8 & 9 are included in the Medicare lines 4 & 5.
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3246)
Rev.
32-331.10
3290 (Cont.)
FORM CMS-1728-94
DRAFT
PROVIDER CCN :
PERIOD:
WORKSHEET CM-1
ALLOCATION OF GENERAL SERVICE
___________________
FROM: _______________
PARTS I & II
COSTS TO HHA-BASED CMHC COST CENTERS
CMHC CCN :
TO: _________________
___________________
PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HHA-BASED CMHC COST CENTERS
CMHC COST CENTER
(OMIT CENTS)
NET
CAPITAL
PLANT
EXPENSES
RELATED COSTS
OPERATION
FOR COST
ALLOCATION (1)
0
ALLOCATED
ADMINISTRA-
CMHC
TOTAL
BLDGS &
MOVABLE
& MAINTE-
TRANSPOR-
SUBTOTAL
TIVE
SUB-
A&G (SEE
(SUM OF
FIXTURES
EQUIPMENT
NANCE
TATION
(cols. 0-4)
& GENERAL
TOTAL
PART II)
COLS 6 & 7)
1
2
3
4
4A
5
6
7
8
1
Administrative and General
1
2
Drugs and Biologicals
2
3
Occupational Therapy
3
4
Psychiatric/Psychological Services
4
5
Individual Therapy
5
6
Group Therapy
6
7
Family Counseling
7
8
Individualized Activity Therapy
8
9
Diagnostic Therapy
9
10
Patient Training and Education
10
11
Other Part B Services
11
12
TOTALS (Sum of lines 1-11) (2)
12
(1) Column 0, line 12 must agree with Wkst. A, column 10, line 26.
(2) Columns 0 through 5, line 12 must agree with the corresponding columns of Wkst. B, line 26.
PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF HHA-BASED CMHC ADMINISTRATIVE AND GENERAL COSTS
1
Amount from Part I, column 6, line 12
1
2
Amount from Part I, column 6, line 1
2
3
Line 1 minus line 2
3
4
Unit cost multiplier for HHA-Based CMHC A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,
4
lines 2 through 11, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)
FORM CMS 1728-94-CM-1 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SECTION S 3225 THROUGH 3 225.2)
32-332
Rev.
3290 (Cont.)
FORM CMS-1728-94
COMPUTATION OF HHA-BASED CMHC COSTS
DRAFT
PROVIDER CCN :
PERIOD:
___________________
FROM: _______________
CMHC CCN :
TO: __________________
WORKSHEET CM-2
___________________
PART I - APPORTIONMENT OF HHA-BASED CMHC COST CENTERS
RATIO OF
TOTAL COSTS
TOTAL
TITLE XVIII
TITLE XVIII
COSTS TO
TOTAL
TITLE XVIII
CMHC
CMHC COSTS
TITLE XVIII
(FROM SUPP.
TOTAL
CHARGES
TITLE XVIII
CMHC COSTS
CHARGES ON
ON OR AFTER
CMHC
CMHC COST CENTER
WKST. CM-1, PT.
CMHC
(COL. 1 /
CMHC
(COL. 3 x
OR AFTER
8/1/00, 1/1/02,
COSTS PRIOR
(OMIT CENTS)
I, COL. 8) (1)
CHARGES (2)
COL. 2)
CHARGES
COL. 3.01)
1
2
3
3.01
3.02
8/1/00, 1/1/02,
1/1/03, or 1/1/04
8/1/00, 1/1/02,
1/1/03, or 1/1/04
(COL 3 xCOL. 4)
1/1/03, or 1/1/04
4
5
6
1
Administrative and General
1
2
Drugs and Biologicals
2
3
Occupational Therapy
3
4
Psychiatric/Psychological Services
4
5
Individual Therapy
5
6
Group Therapy
6
7
Family Counseling
7
8
Individualized Activity Therapy
8
9
Diagnostic Therapy
10
Patient Training and Education
10
11
Other Part B Services
11
12
TOTALS (Sum of lines 2-11)
12
9
PART II - APPORTIONMENT OF COST OF HHA-BASED CMHC
SERVICES FURNISHED BY SHARED HHA DEPARTMENTS
Fr. Wkst. B,
Col 6, Line:
13
Occupational Therapy
8
13
14
Medical Social Services
10
14
15
Supplies
12
15
16
Total (Sum of lines 13-15)
16
(1) Cost for Part II, lines 13-15 are obtained from Worksheet B, column 6, lines as appropriate
(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records
PART III - TOTAL HHA-BASED CMHC COSTS
17
Total HHA-based CMHC costs - Add the amount from Part I, column 6, line 12 and the amount from Part II, column 6, line 16.
3.01
3.02
4
5
6
17
Add the amounts from Part I, line 12 and Part II, line 16 for columns 3.01, 3.02 and 4 through 6, respectively.
Transfer the amount in Part III, column 6 to Worksheet CM-3, line 1, column 1. (see instructions)
FORM CMS 1728-94-CM-2 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SECTION S 3226 THROUGH 3226.3)
32-333
Rev.
DRAFT
FORM CMS-1728-94
3290 (Cont.)
ALLOCATION OF GENERAL SERVICE
PROVIDER CCN :
PERIOD:
WORKSHEET CM-1
COSTS TO HHA-BASED CMHC COST CENTERS
___________________
FROM: _____________
PART III
CMHC CCN :
TO: ______________
___________________
PART III - ALLOCATION OF GENERAL SERVICE COSTS TO HHA-BASED CMHC COST CENTERS - STATISTICAL BASIS
CAPITAL
RELATED COSTS
PLANT
OPERATION
BLDGS &
MOVABLE
& MAINTE-
FIXTURES
EQUIPMENT
NANCE
TRANSPOR-
ADMINISTRATIVE
CMHC COST CENTER
(SQUARE
(SQUARE
(SQUARE
TATION
RECONCIL-
(ACCUMULATED
(OMIT CENTS)
FEET)
FEET)
FEET)
(MILEAGE)
IATION
COST)
1
2
3
4
5A
5
& GENERAL
1
Administrative and General
1
2
Drugs and Biologicals
2
3
Occupational Therapy
3
4
Psychiatric/Psychological Services
4
5
Individual Therapy
5
6
Group Therapy
6
7
Family Counseling
7
8
Individualized Activity Therapy
8
9
Diagnostic Therapy
9
10
Patient Training and Education
10
11
Other Part B Services
11
12
TOTALS (Sum of lines 1-11)
12
13
Total Cost to be Allocated
13
14
Unit Cost Multiplier
14
FORM CMS 1728-94-CM-1 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-2, SECTION 3225.3)
Rev.
32-334
DRAFT
FORM CMS-1728-94
3290 (Cont.)
PROVIDER CCN:
PERIOD:
CALCULATION OF REIMBURSEMENT
___________________
FROM: _______________
SETTLEMENT - HHA-BASED CMHC SERVICES
CMHC CCN:
TO: _________________
WORKSHEET CM-3
PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES
DESCRIPTION
1
1
1.01
Total reasonable cost (see instructions)
1
1.01
CMHC PPS payments including outlier payments
1.01
1.02
1996 CMHC specific payment to cost ratio (obtain this ratio from your contractor )
1.02
1.03
Line 1, column 1 times 1.02
1.03
1.04
Line 1.01 divided by line 1.03
1.04
1.05
CMHC transitional corridor payment (see instructions)
1.05
2
Total charges for HHA-based CMHC Services
CUSTOMARY CHARGES
3
2
1
1.01
Amounts actually collected from patients liable
3
for payments for services on a charge basis (from
your records)
4
Amount that would have been realized from patients
4
liable for payment for services on a charge basis
had such payment been made in accordance with
42 CFR 413.13(b)
5
Ratio of line 3 to line 4 (not to exceed 1.000000)
5
6
Total Customary charges - title XVIII
6
(see instructions)
7
Excess of total customary charges over total
7
reasonable cost (complete only if line 6
exceeds line 1)
8
Excess of reasonable costs over customary charges
8
(complete only if line 1 exceeds line 6)
9
Primary payer amounts
PART II - COMPUTATION OF HHA-BASED CMHC REIMBURSEMENT SETTLEMENT
9
1
1.01
10
Cost of HHA-based CMHC services (see instructions)
10
11
Part B deductible billed to Program patients (exclude coinsurance amounts)
11
12
Excess of reasonable costs (see instructions)
12
13
Net cost (line10 minus lines 11 and 12)
13
14
80% of Part B cost (80% x line 13) (see instructions)
14
15
Actual coinsurance billed to Program patients (from your records)
15
16
Net cost less actual billed coinsurance (Line 13 minus line 15)
16
17
Reimbursable bad debts (see instructions)
17
17.01
Adjusted reimbursable bad debts (see instructions)
17.01
17.02
Allowable bad debts for dual eligible beneficiaries (see instructions)
17.02
18
Net reimbursable amount (see instructions)
18
19
Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets
19
20
Recovery of excess depreciation resulting from facility's termination or a decrease in Program utilization
20
21
Other adjustments (specify)
21
22
Total Cost (Sum of line 18, columns 1 and 2, minus lines 19 and 20, plus or minus line 21)
22
23
Sequestration adjustment (see instructions)
23
24
Amount due provider (Line 22 minus line 23)
24
25
Interim payments
25
25.5
Tentative settlement (for contractor use only)
25.5
26
Balance due HHA-based CMHC/Program (Line 24 minus line 25) (Indicate overpayments in brackets)
26
27
Protested amounts (see instructions)
27
28
Balance due HHA-based CMHC/Program (Line 26 minus line 27) (Indicate overpayments in brackets)
28
FORM CMS 1728-94-CM-3 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 3227 THROUGH 3227.2)
Rev.
32-335
3290 (Cont.)
FORM CMS-1728-94
DRAFT
ANALYSIS OF PAYMENTS TO
PROVIDER CCN:
PERIOD:
WORKSHEET CM-4
HHA-BASED CMHC FOR SERVICES RENDERED
___________________
FROM: _______________
TO PROGRAM BENEFICIARIES
CMHC CCN:
TO: _________________
PART B
1
2
mm/dd/yyyy
Amount
1
Total interim payments paid to HHA-based CMHC
1
2
Interim payments payable on individual bills either, submitted or to
2
be submitted to the contractor, for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
3
List separately each retroactive lump sum
.01
3.01
adjustment amount based on subsequent revision
Program
.02
3.02
of the interim rate for the cost reporting period.
to
.03
3.03
Also show date of each payment. If none write
Provider
.04
3.04
.05
3.05
.50
3.50
Provider
.51
3.51
to
.52
3.52
Program
.53
3.53
.54
3.54
.99
3.99
"NONE" or enter a zero. (1)
SUBTOTAL (Sum of lines 3.01-3.05, minus sum
of lines 3.50-3.54)
4
TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)
4
(Transfer to Supp. Wkst CM-3, Part II, line 25)
TO BE COMPLETED BY CONTRACTOR
5
List separately each tentative settlement payment
Program
.01
5.01
after desk review. Also show date of each
to
.02
5.02
payment. If none, write "NONE" or enter
Provider
.03
5.03
a zero. (1)
Provider
.50
5.50
to
.51
5.51
Program
.52
5.52
.99
5.99
.01
6.01
.02
6.02
SUBTOTAL (Sum of lines 5.01-5.03, minus sum
of lines 5.50-5.52)
6
Determine net settlement amount (balance due) based
Program
on the cost report (SEE INSTRUCTIONS). (1)
to
Provider
Provider
to
Program
7
TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)
7
Name of Contractor
Contractor Number
Signature of Authorized Person
Date: (Month, Day, Year)
(1) On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the HHA-based CMHC
agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS-1728-94-CM-4 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3228
32-336
Rev.
Removed and Reserved
Pages 32-337 - 32- 342
DRAFT
FORM CMS-1728-94
3290 (Cont.)
ANALYSIS OF HHA-BASED RHC/FQHC COSTS
PROVIDER CCN:
PERIOD:
WORKSHEET RF-1
_______________
FROM: ____________
RHC/FQHC CCN:
TO: ____________
_______________
Check
[ ] HHA-Based RHC
Applicable Box:
[ ] HHA-Based FQHC
RECLASSIFIED
CONTRACTED/
TOTAL
(sum of col. 1
NET EXPENSES
TRIAL
FOR
RECLASSIFI-
BALANCE
ALLOCATION
EMPLOYEE
TRANSPOR-
PURCHASED
SALARIES
BENEFITS
TATION
SERVICES
OTHER COSTS
thru col. 5)
CATIONS
(col. 6 + col. 7)
ADJUSTMENTS
(col. 8 + col. 9)
1
2
3
4
5
6
7
8
9
10
HEALTH CARE STAFF COSTS
1
Physician
1
2
Physician Assistant
2
3
Nurse Practitioner
3
4
Visiting Nurse
4
5
Other Nurse
5
6
Clinical Psychologist
6
7
Clinical Social Worker
7
8
Laboratory Technician
8
9 Other Facility Health Care Staff Costs
10
Subtotal (sum of lines 1-9)
9
10
COSTS UNDER AGREEMENT
11
Physician Services Under Agreement
11
12
Physician Supervision Under Agreement
12
13
Other Costs Under Agreement
13
14 Subtotal (sum of lines 11-13)
14
OTHER HEALTH CARE COSTS
15
Medical Supplies
15
16
Transportation (Health Care Staff)
16
17
Depreciation-Medical Equipment
17
18
Professional Liability Insurance
18
19
Other Health Care Costs
19
20
Allowable GME Pass Through Costs
20
21
Subtotal (sum of lines 15-20)
21
22
Total Cost of Health Care Services (sum of
22
lines 10, 14, and 21)
COSTS OTHER THAN RHC/FQHC SERVICES
23
Pharmacy
23
24
Dental
24
25
Optometry
25
26
All other nonreimbursable costs
26
27
Non-allowable GME Pass Through Costs
27
28
Total Nonreimbursable Costs (sum of lines 23-27)
28
OVERHEAD
29
Facility Costs
29
30
Administrative Costs
30
31
Total Overhead (sum of lines 29 and 30)
31
32
Total costs (sum of lines 22, 28 and 31)
32
The net expenses for cost allocation on Worksheet A for the applicable HHA-based RHC/FQHC cost center line must equal the total costs in column 10, line 32 of this worksheet for cost reporting
periods beginning on or after January 1, 1998.
FORM CMS-1728-94-RF-1 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3234)
Rev.
32-343
3290 (Cont.)
FORM CMS-1728-94
DRAFT
ALLOCATION OF OVERHEAD
PROVIDER CCN:
PERIOD:
WORKSHEET RF-2
TO HHA-BASED RHC/FQHC SERVICES
_______________
FROM: ____________
RHC/FQHC CCN:
TO: ____________
_______________
Check
[ ] HHA-Based RHC
Applicable Box:
[ ] HHA-Based FQHC
VISITS AND PRODUCTIVITY
Number
Minimum
Greater of
of FTE
Total
Productivity
Visits
Col. 2 or
Personnel
Visits
Standard (1)
(col. 1x col. 3)
Col. 4
1
2
3
4
5
Positions
1 Physicians
1
2 Physician Assistants
2
3 Nurse Practitioners
3
4 Subtotal (sum of lines 1-3)
4
5 Visiting Nurse
5
6 Clinical Psychologist
6
7 Clinical Social Worker
7
7.01 Medical Nutrition Therapist (FQHC only)
7.01
7.02 Diabetes Self Management Training (FQHC only)
7.02
8 Total FTEs and Visits (sum of lines 4-7)
8
9 Physician Services Under Agreements
9
(1) Productivity standards established by CMS are: 4200 visits for each physician and 2100 visits for each nonphysician
practitioner. If an exception to the productivity standard has been granted, (Worksheet S-4, line 13 equals "Y"), then input
in column 3, lines 1-3, the productivity standards derived by the contractor .
DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO HHA-BASED RHC/FQHC SERVICES
10 Total costs of health care services (from Worksheet RF-1, column 10, line 22 less the amount
10
from Worksheet RF-1, column 10, line 20)
11 Total nonreimbursable costs (from Worksheet RF-1, column 10, line 28)
11
12 Cost of all services (excluding overhead) (sum of lines 10 and 11)
12
13 Ratio of HHA-based RHC/FQHC services (line 10 divided by line 12)
13
14 Total overhead - (from Worksheet RF-1, column 10, line 31) (see instructions)
14
15 Allowable GME Overhead (see instructions)
15
16 Net Overhead (line 14 minus line 15)
16
17
HHA overhead allocated to HHA-based RHC/FQHC (see instructions)
17
18 Total overhead of HHA-Based RHC/FQHC (sum of lines 16 and 17)
18
19 Overhead applicable to HHA-based RHC/FQHC services (line 13 x line 18)
19
20 Total allowable cost of HHA-based RHC/FQHC services (sum of lines 10 and 19)
20
FORM CMS-1728-94-RF-2 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 3235 THROUGH 3235.2)
32-344
Rev.
DRAFT
FORM CMS-1728-94
3290 (Cont.)
CALCULATION OF
PROVIDER CCN:
PERIOD:
WORKSHEET RF-3
REIMBURSEMENT SETTLEMENT
_______________
FROM: ___________
FOR HHA-BASED RHC/FQHC SERVICES
RHC/FQHC CCN:
TO: ___________
_______________
Check
[ ] HHA-Based RHC
Applicable Box:
[ ] HHA-Based FQHC
DETERMINATION OF RATE FOR HHA-BASED RHC/FQHC SERVICES
1
Total Allowable Cost of HHA-based RHC/FQHC Services (from Worksheet RF-2, line 20)
1
2
Cost of vaccines and their administration (from Worksheet RF-4, line 15)
2
3
Total allowable cost excluding vaccine (line 1 minus line 2)
3
4
Total FTEs and Visits (from Wkst. RF-2, col. 5, line 8)
4
5
Physicians visits under agreement (from Worksheet RF-2, column 5, line 9)
5
6
Total adjusted visits (line 4 plus line 5)
6
7
Adjusted cost per visit (line 3 divided by line 6)
7
Calculation of Limit (1)
Rate
Rate
Period 1
Period 2
1
2
8
Per visit payment limit (from your contractor )
8
9
Rate for Medicare covered visits (lesser of line 7 or line 8) (See instructions)
9
CALCULATION OF HHA-BASED RHC/FQHC SETTLEMENT
10
Medicare covered visits excluding mental health services (from the PS&R)
10
11
Medicare cost excluding costs for mental health services (line 9 x line 10)
11
12
Medicare covered visits for mental health services (from the PS&R)
12
13
Medicare covered cost for mental health services (line 9 x line 12)
13
14
Limit adjustment for mental health services (line 13 x the applicable percentage) (see instructions)
14
15
Graduate Medical Education Pass Through Cost (see instructions)
15.5
16
15
Primary Payer Amounts
15.5
Total Medicare cost (line 11, columns 1 & 2, plus line 14, columns 1 & 2, plus columns 1 and 2,
16
line 15 minus line 15.5, columns 1 and 2) (see instructions)
16.01
Total Program Charges (see instructions)(from contractor's records)
16.01
16.02
Total Program Preventive Charges (see instructions)(from provider's records)
16.02
16.03
Total Program Preventive Costs (see instructions)
16.03
16.04
Total Program Non-Preventive Costs (see instructions)
16.04
16.05
Total Program Cost (see instructions)
16.05
1
17
17.5
Less: Beneficiary deductible for RHC only (see instructions) (from contractor records)
Beneficiary coinsurance for HHA-based RHC/FQHC services (see instructions) (from contractor records)
17
17.5
18
Net Medicare cost excluding vaccines (see instrcutions)
18
19
Reimbursable cost of HHA-based RHC/FQHC services, excluding vaccine (see instructions)
19
20
Medicare cost of vaccines and their administration (from Worksheet. RF-4, line 16)
20
21
Total reimbursable Medicare cost (see instructions)
21
22
Reimbursable bad debts
22
22.01
Adjusted reimbursable bad debts (see instructions)
22.01
22.02
Allowable bad debts for dual eligible beneficiaries (see instructions)
22.02
23
Other adjustments (specify)
24
Net reimbursable amounts (see instructions)
24.01
25
Sequestration adjustment (see instructions)
Interim payments (From Worksheet RF-5, line 4)
25.5 Tentative settlement (For contractor use only)
23
24
24.01
25
25.5
26
Balance due HHA-based RHC and/or FQHC /program (line 24 minus lines 24.01 and 25)
26
27
Protested amounts (nonallowable cost report items) in accordance with CMS Pub.
27
15-2, chapter 1 , section 115.2
(1) Enter chronologically in columns 1, and 2, as applicable, the payment limit and corresponding data.
FORM CMS-1728-94-RF-3 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 3236 THROUGH 3236.1)
Rev.
32-345
3290 (Cont.)
COMPUTATION OF HHA-BASED RHC/FQHC PNEUMOCOCCAL AND
INFLUENZA VACCINE COST
Check
Applicable Box:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
FORM CMS-1728-94
PROVIDER CCN:
_______________
RHC/FQHC CCN:
_______________
PERIOD:
FROM: _______
TO: __________
DRAFT
WORKSHEET RF-4
[ ] HHA-Based RHC
[ ] HHA-based FQHC
CALCULATION OF COST
Health care staff cost
(Worksheet RF-1, column 10, line 10)
Ratio of pneumococcal and influenza vaccine
staff time to total health care staff time
Pneumococcal and influenza vaccine
health care staff cost (line 1 x line 2)
Medical supplies cost - pneumococcal and influenza
vaccine (from your records)
Direct cost of pneumococcal and influenza
vaccine (line 3 plus line 4)
Total direct cost of the HHA-based RHC/FQHC
(Worksheet RF-1, column 10, line 22)
Total HHA-based RHC/FQHC overhead
(Worksheet RF-2, line 18)
Ratio of pneumococcal and influenza vaccine
direct cost to total direct cost (line 5 divided by line 6)
Overhead cost - pneumococcal and influenza
vaccine (line 7 x line 8)
Total pneumococcal and influenza vaccine cost and
its (their) administration (sum of lines 5 and 9)
Total number of pneumococcal and influenza
vaccine injections (from your records)
Cost per pneumococcal and influenza
vaccine injection (line 10/ line 11)
Number of pneumococcal and influenza vaccine
injections administered to Medicare beneficiaries
Medicare cost of pneumococcal and influenza vaccine
and its (their) administration (line 12 x line 13)
PNEUMOCOCCAL
1
SEASONAL
INFLUENZA
ONLY
2
H1N1
ONLY
2.01
15 Total cost of pneumococcal and influenza vaccine and their administration (sum of columns
1, 2, 2.01 and 2.02, line 10) (transfer this amount to Worksheet RF-3, line 2)
16 Total Medicare cost of pneumococcal and influenza vaccine and their administration (sum
of columns 1, 2, 2.01 and 2.02, line 14) (transfer this amount to Worksheet RF-3, line 20)
INFLUENZA
& H1N1
(See instructions)
2.02
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
FORM CMS-1728-94-RF-4 (draft) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3237)
32-346
Rev.
DRAFT
ANALYSIS OF PAYMENTS TO HHA -BASED
RHC/FQHC FOR SERVICES RENDERED TO
PROGRAM BENEFICIARIES
FORM CMS-1728-94
PROVIDER CCN :
PERIOD:
_______________
FROM: __________
RHC/FQHC CCN :
TO: __________
_______________
[ ] HHA-based RHC [ ] HHA-based FQHC
Check Applicable Box:
3290 (Cont.)
SUPPLEMENTAL
WORKSHEET RF-5
PART B
1
mm/dd/yyyy
1
2
3
Total interim payments paid to HHA-based RHC/FQHC
Interim payments payable on individual bills either, submitted or to
be submitted to the contractor , for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
List separately each retroactive lump sum
adjustment amount based on subsequent revision
Program
of the interim rate for the cost reporting period.
to
Also show date of each payment. If none write
Provider
"NONE" or enter a zero. (1)
Provider
to
Program
4
SUBTOTAL (Sum of lines 3.01-3.49, minus sum
of lines 3.50-3.98)
TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)
(Transfer to Supp. Wkst RF-3, Part II, line 25)
2
Amount
1
2
.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
.99
3.99
4
TO BE COMPLETED BY CONTRACTOR
5
6
7
List separately each tentative settlement payment
after desk review. Also show date of each
payment. If none, write "NONE" or enter
a zero. (1)
SUBTOTAL (Sum of lines 5.01-5.49, minus sum
of lines 5.50-5.98)
Determine net settlement amount (balance due) based
on the cost report (SEE INSTRUCTIONS). (1)
Program
to
Provider
Provider
to
Program
Program
to
Provider
Provider
to
Program
TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)
Name of Contractor
Signature of Authorized Person
.01
.02
.03
.50
.51
.52
5.01
5.02
5.03
5.50
5.51
5.52
.99
5.99
.01
6.01
.02
6.02
7
Contractor Number
Date: (Month, Day, Year)
(1) On lines 3, 5 and 6, where an amount is due "HHA-Based RHC/FQHC to Program," show the amount and date on which the HHA-based RHC/FQHC
agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS-1728-94-RF-5 (draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3238
Rev.
32-347
3290 (Cont.)
ANALYSIS OF HHA-BASED HOSPICE COSTS
FORM CMS 1728-94
DRAFT
PROVIDER CCN:
____________
HOSPICE CCN:
____________
SALARIES
1
OTHER
2
GENERAL SERVICE COST CENTERS
1
0100 Cap Rel Costs-Bldg & Fixt*
2
0200 Cap Rel Costs-Mvble Equip*
3
0300 Employee Benefits Department*
4
0400 Administrative & General *
5
0500 Plant Operation & Maintenance*
6
0600 Laundry & Linen Service*
7
0700 Housekeeping*
8
0800 Dietary*
9
0900 Nursing Administration*
10
1000 Routine Medical Supplies*
11
1100 Medical Records*
12
1200 Staff Transportation*
13
1300 Volunteer Service Coordination*
14
1400 Pharmacy*
15
1500 Physician Administrative Services*
16
1600 Other General Service*
17
1700 Patient/Residential Care Services
DIRECT PATIENT CARE SERVICE COST CENTERS
25
2500 Inpatient Care-Contracted**
26
2600 Physician Services**
27
2700 Nurse Practitioner**
28
2800 Registered Nurse**
29
2900 LPN/LVN**
30
3000 Physical Therapy**
31
3100 Occupational Therapy**
32
3200 Speech/ Language Pathology**
33
3300 Medical Social Services**
34
3400 Spiritual Counseling**
35
3500 Dietary Counseling**
36
3600 Counseling - Other**
37
3700 Hospice Aide & Homemaker Services**
38
3800 Durable Medical Equipment/Oxygen**
39
3900 Patient Transportation**
SUBTOTAL
(col. 1 plus
col. 2)
3
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM: ____________
TO: ____________
ADJUSTMENTS
6
WORKSHEET O
TOTAL
(col. 5 ± col. 6)
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
* Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate.
** See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5.
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3247)
32-348
Rev.
DRAFT
ANALYSIS OF HHA-BASED HOSPICE COSTS
FORM CMS 1728-94
3290 (Cont.)
PROVIDER CCN:
____________
HOSPICE CCN:
____________
SALARIES
1
OTHER
2
DIRECT PATIENT CARE SERVICE COST CENTERS (Cont.)
40
4000 Imaging Services**
41
4100 Labs & Diagnostics**
42
4200 Medical Supplies-Non-routine**
43
4300 Outpatient Services**
44
4400 Palliative Radiation Therapy**
45
4500 Palliative Chemotherapy**
46
Other Patient Care Services**
NONREIMBURSABLE COST CENTERS
60
6000 Bereavement Program *
61
6100 Volunteer Program *
62
6200 Fundraising*
63
6300 Hospice/Palliative Medicine Fellows*
64
6400 Palliative Care Program*
65
6500 Other Physician Services*
66
6600 Residential Care *
67
6700 Advertising*
68
6800 Telehealth/Telemonitoring*
69
6900 Thrift Store*
70
7000 Nursing Facility Room & Board*
71
7100 Other Nonreimbursable*
100
Total
TOTAL
(col. 1 through
col. 5)
3
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM: ____________
TO: ____________
ADJUSTMENTS
6
WORKSHEET O
TOTAL
(col. 5 ± col. 6)
7
40
41
42
43
44
45
46
60
61
62
63
64
65
66
67
68
69
70
71
100
* Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate.
** See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5.
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3247)
Rev.
32-349
3290 (Cont.)
FORM CMS-1728-94
ANALYSIS OF HHA-BASED HOSPICE COSTS FOR HOSPICE CONTINUOUS HOME CARE
SALARIES
1
OTHER
2
SUBTOTAL
( col. 1 plus
col. 2 )
3
DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Svc
100 Total *
DRAFT
PROVIDER CCN:
____________
HOSPICE CCN:
____________
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM: _________
TO: ____________
ADJUSTMENTS
6
WORKSHEET O-1
TOTAL
(col. 5 ± col. 6)
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100
* Transfer the amount in column 7 to Wkst. O-5, column 1, line 50.
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3248)
32-350
Rev.
DRAFT
ANALYSIS OF HHA-BASED HOSPICE COSTS FOR HOSPICE ROUTINE HOME CARE
SALARIES
1
FORM CMS-1728-94
PROVIDER CCN:
____________
HOSPICE CCN:
____________
OTHER
2
SUBTOTAL
(col. 1 plus
col. 2)
3
DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Services (specify)
100 Total *
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM: __________
TO: ____________
ADJUSTMENTS
6
3290 (Cont.)
WORKSHEET O-2
TOTAL
(col. 5 ± col. 6)
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100
* Transfer the amount in column 7 to Wkst. O-5, column 1, line 51
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3248)
Rev.
32-351
3290 (Cont.)
ANALYSIS OF HHA-BASED HOSPICE COSTS FOR HOSPICE INPATIENT RESPITE CARE
SALARIES
1
FORM CMS-1728-94
DRAFT
PROVIDER CCN:
____________
HOSPICE CCN:
____________
OTHER
2
SUBTOTAL
(col. 1 plus
col. 2)
3
DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Services (specify)
100 Total *
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM: __________
TO: ____________
ADJUSTMENTS
6
WORKSHEET O-3
TOTAL
(col. 5 ± col. 6)
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100
* Transfer the amount in column 7 to Wkst. O-5, column 1, line 52
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3248)
32-352
Rev.
DRAFT
ANALYSIS OF HHA-BASED HOSPICE COSTS FOR HOSPICE GENERAL INPATIENT CARE
SALARIES
1
FORM CMS-1728-94
3290 (Cont.)
PROVIDER CCN:
____________
HOSPICE CCN:
____________
OTHER
2
SUBTOTAL
(col. 1 plus
col. 2)
3
DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Svc
100 Total *
RECLASSIFICATIONS
4
SUBTOTAL
5
PERIOD:
FROM: __________
TO: ____________
ADJUSTMENTS
6
WORKSHEET O-4
TOTAL
(col. 5 ± col. 6)
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100
* Transfer the amount in column 7 to Wkst. O-5, column 1, line 53
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3248)
Rev.
32-353
FORM CMS-1728-94
3290 (Cont.)
COST ALLOCATION - DETERMINATION OF HHA-BASED HOSPICE
NET EXPENSES FOR ALLOCATION
Descriptions
PROVIDER CCN:
____________
HOSPICE CCN:
____________
HOSPICE
DIRECT
EXPENSES
(see instructions)
1
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits Department
4 Administrative & General
5 Plant Operation & Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service
17 Patient/Residential Care Services
LEVEL OF CARE
50 Hospice Continuous Home Care
51 Hospice Routine Home Care
52 Hospice Inpatient Respite Care
53 Hospice General Inpatient Care
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable
99 Negative Cost Center
100 Total
PERIOD:
FROM: ____________
TO: ____________
GENERAL
SERVICE
EXPENSES
FROM WKST B
(see instructions)
2
DRAFT
WORKSHEET O-5
TOTAL
EXPENSES
(sum of cols. 1 + 2)
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3249)
32-354
Rev.
FORM CMS-1728-94
DRAFT
3290 (Cont.)
COST ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS
TOTAL
EXPENSES
0
PROVIDER CCN: ___________
HOSPICE CCN: ____________
CAP REL
BLDG
& FIX
1
CAP REL
MVBLE
EQUIP
2
EMPLOYEE
BENEFITS
DEPARTMENT
3
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits Department
4 Administrative & General
5 Plant Operation & Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service
17 Patient/Residential Care Services
LEVEL OF CARE
50 Hospice Continuous Home Care
51 Hospice Routine Home Care
52 Hospice Inpatient Respite Care
53 Hospice General Inpatient Care
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable
99 Negative Cost Center
100 Total
SUBTOTAL
3A
ADMINISTRATIVE &
GENERAL
4
PLANT
OP &
MAINT
5
PERIOD:
FROM: ____________
TO: ____________
LAUNDRY
& LINEN
6
WORKSHEET O-6
PART I
HOUSEKEEPING
DIETARY
7
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3250)
Rev.
32-355
FORM CMS-1728-94
4090 (Cont.)
DRAFT
COST ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS
Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits Department
4 Administrative & General
5 Plant Operation & Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service
17 Patient/Residential Care Services
LEVEL OF CARE
50 Continuous Home Care
51 Routine Home Care
52 Inpatient Respite Care
53 General Inpatient Care
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable
99 Negative Cost Center
100 Total
NURSING
ADMINISTRATION
9
PROVIDER CCN: ____________
HOSPICE CCN: ____________
ROUTINE
MEDICAL
SUPPLIES
10
MEDICAL
RECORDS
11
STAFF
TRANSPORTATION
12
VOLUNTEER
SVC COORDINATION
13
PHARMACY
14
PHYSICIAN
ADMINISTRATIVE SVCS
15
PERIOD:
FROM: ____________
TO: ____________
OTHER
PATIENT /
GENERAL
RESIDENTIAL
SERVICE
CARE SVCS
16
17
WORKSHEET O-6
PART I
TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3250)
32-356
Rev.
FORM CMS-1728-94
DRAFT
3290 (Cont.)
COST ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS STATISTICAL BASIS
Cost Center Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits Department
4 Administrative & General
5 Plant Operation & Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service
17 Patient/Residential Care Services
LEVEL OF CARE
50 Hospice Continuous Home Care
51 Hospice Routine Home Care
52 Hospice Inpatient Respite Care
53 Hospice General Inpatient Care
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable
99 Negative Cost Center
100 Total (sum of lines 1 through 99)
101 Cost to be allocated (per Wkst. O-6, Part I)
102 Unit cost multiplier
CAP REL
BLDG
& FIX
( Square
Feet )
1
CAP REL
MVBLE
EQUIP
( Dollar
Value )
2
PROVIDER CCN: ___________
HOSPICE CCN: ____________
EMPLOYEE
BENEFITS
DEPARTMENT
( Gross
Salaries )
3
RECONCILIATION
4A
ADMINISTRATIVE &
GENERAL
( Accum.
Cost )
4
PLANT
OP &
MAINT
( Square
Feet )
5
PERIOD:
FROM: ____________
TO: ____________
LAUNDRY
HOUSE& LINEN
KEEPING
( In-Facility
Days )
6
( Square
Feet )
7
WORKSHEET O-6
PART II
DIETARY
( In-Facility
Days )
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100
101
102
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3250)
Rev.
32-357
FORM CMS-1728-94
3290 (Cont.)
DRAFT
COST ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS STATISTICAL BASIS
Cost Center Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits Department
4 Administrative & General
5 Plant Operation & Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service
17 Patient/Residential Care Services
LEVEL OF CARE
50 Continuous Home Care
51 Routine Home Care
52 Inpatient Respite Care
53 General Inpatient Care
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable
99 Negative Cost Center
100 Total (sum of lines 1 through 99)
101 Cost to be allocated (per Wkst. O-6, Part I)
102 Unit cost multiplier
NURSING
ADMINISTRATION
( Direct
Nurs. Hrs. )
9
ROUTINE
MEDICAL
SUPPLIES
( Patient
Days )
10
MEDICAL
RECORDS
( Patient
Days )
11
PROVIDER CCN: ____________
HOSPICE CCN: ____________
STAFF
TRANSPORTATION
( Mileage )
12
VOLUNTEER
SVC COORDINATION
( Hours of
Service )
13
PHARMACY
( Charges )
14
PHYSICIAN
ADMINISTRATIVE SVCS
( Patient
Days )
15
PERIOD:
FROM ____________
TO ____________
OTHER
PATIENT /
GENERAL
RESIDENTIAL
SERVICE
CARE SVCS
( Specify
( In-Facility
Basis )
Days )
16
17
WORKSHEET O-6
PART II
TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100
101
102
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3250)
32-358
Rev.
DRAFT
FORM CMS-1728-94
APPORTIONMENT OF HHA-BASED HOSPICE SHARED SERVICE COSTS BY LEVEL OF CARE
1
2
3
4
5
6
7
Cost Center Descriptions
ANCILLARY SERVICE COST CENTERS
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services - Direct
Medical Supplies
Durable Medical Equipment/Oxygen
Totals (sum of lines 1-7)
Wkst. B,
col. 6,
line
0
Total HHA
Costs
1
Total HHA
Charges
(from Provider
Records)
2
3290 (Cont.)
PROVIDER CCN: ____________
HOSPICE CCN: ____________
Cost to
Charge
Ratio
3
7
8
9
10
12
14
Charges by LOC (from Provider Records)
HCHC
4
HRHC
5
HIRC
6
HGIP
7
HCHC
(col. 3 x col. 4 )
8
PERIOD:
FROM: ____________
TO: ____________
Shared Service Costs by LOC
HRHC
HIRC
(col. 3 x col. 5)
(col. 3 x col. 6)
9
10
WORKSHEET O-7
HGIP
(col. 3 x col. 7)
11
1
2
3
4
5
6
7
FORM CMS-1728-94 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3251)
Rev.
32-359
3290 (Cont.)
CALCULATION OF HHA-BASED HOSPICE PER DIEM COST
FORM CMS-1728-94
PROVIDER CCN:
________________
HOSPICE CCN:
________________
TITLE XVIII
MEDICARE
1
HOSPICE CONTINUOUS HOME CARE
1 Total cost (Wkst. O-6, Part I, col. 18, line 50 plus Wkst. O-7, col. 8, line 7)
2 Total unduplicated days (Wkst. S-5, col. 4, line 10)
3 Total average cost per diem (line 1 divided by line 2)
4 Unduplicated program days (Wkst. S-5 col. as appropriate, line 10)
5 Program cost (line 3 times line 4)
HOSPICE ROUTINE HOME CARE
6 Total cost (Wkst. O-6, Part I, col. 18, line 51 plus Wkst. O-7, col. 9, line 7)
7 Total unduplicated days (Wkst. S-5, col. 4, line 11)
8 Total average cost per diem (line 6 divided by line 7)
9 Unduplicated program days (Wkst. S-5, col. as appropriate, line 11)
10 Program cost (line 8 times line 9)
HOSPICE INPATIENT RESPITE CARE
11 Total cost (Wkst. O-6, Part I, col. 18, line 52 plus Wkst. O-7, col. 10, line 7)
12 Total unduplicated days (Wkst. S-5, col. 4, line 12)
13 Total average cost per diem (line 11 divided by line 12)
14 Unduplicated program days (Wkst. S-5, col. as appropriate, line 12)
15 Program cost (line 13 times line 14)
HOSPICE GENERAL INPATIENT CARE
16 Total cost (Wkst. O-6, Part I, col. 18, line 53 plus Wkst. O-7, col. 11, line 7)
17 Total unduplicated days (Wkst. S-5, col. 4, line 13)
18 Total average cost per diem (line 16 divided by line 17)
19 Unduplicated program days (Wkst. S-5, col. as appropriate, line 13)
20 Program cost (line 18 times line 19)
TOTAL HOSPICE CARE
21 Total cost (sum of line 1 + line 6 + line 11 + line 16)
22 Total unduplicated days (Wkst. S-5, col. 4, line 14)
23 Average cost per diem (line 21 divided by line 22)
DRAFT
PERIOD:
FROM: __________
TO: _____________
TITLE XIX
MEDICAID
2
WORKSHEET O-8
TOTAL
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
FORM CMS-1728-94 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3252)
32-360
Rev.
| File Type | application/pdf |
| Author | BCBSA |
| File Modified | 2015-09-18 |
| File Created | 2015-09-18 |