Form CMS-224-14 FQHC Cost Report Worksheets

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Overview

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

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Sheet 1: S

DRAFT					FORM CMS-224-14				4490
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim								FORM APPROVED
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).								OMB NO. 0938-XXXX
FEDERALLY QUALIFIED HEALTH CENTER COST REPORT						CCN:	PERIOD:	WORKSHEET S
CERTIFICATION AND SETTLEMENT SUMMARY						___________	FROM: ___________	PARTS I, II & III
							TO: ___________
PART I - COST REPORT STATUS
Provider use only			1.	[ ] Electronically filed cost report			Date:	Time:
			2.	[ ] Manually submitted cost report
			3.	[ ] If this is an amended report enter the number of times the provider resubmitted this cost report.
			4.	[ ] Medicare Utilization. Enter "F" for full, "L" for low, or "N" for no utilization.
Contractor		5. [ ] Cost Report Status			6. Date Received:_________		10. NPR Date:___________
use only		(1) As Submitted			7. Contractor No.:________		11. Contractors Vendor Code: ____________
		(2) Settled without audit			8. [ ] Initial Report for this Provider CCN		12. [ ] If line 5, column 1 is 4: Enter the number of
		(3) Settled with audit			9. [ ] Final Report for this Provider CCN		times reopened = 0-9.
		(4) Reopened
		(5) Amended
PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL AND
ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE
PROVIDED OR PROCURED THROUGH THE PAYMENT, DIRECTLY OR INDIRECTLY, OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL,
CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
		CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
	I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually
	submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s)
	and Number(s)}for the cost reporting period beginning ______________ and ending ______________ and that to the best of my knowledge and belief,
	this report and statement are true, correct, complete and prepared from the books and records of the provider in accordance with applicable
	instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that
	the services identified in this cost report were provided in compliance with such laws and regulations.
						(Signed)
							Officer or Administrator of Provider (s)
							Title
							Date
PART III - SETTLEMENT SUMMARY
								TITLE XVIII
								1
1	FQHC								1
The above amount represents "due to" or "due from" the Medicare program.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-XXXX. The time required to complete this information collection is estimated 58 hours per response, including the time to review instructions, search existing resources, gather the
data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under
the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,
please contact 1-800-MEDICARE.
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4404.1 - 4404.3)
Rev. 1									44-103

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Sheet 2: S-1PI

4490 (Cont.)			FORM CMS-224-14							DRAFT
FEDERALLY QUALIFIED HEALTH CENTER IDENTIFICATION DATA						CCN:	PERIOD:		WORKSHEET S-1																						.													.
						______________	FROM: ___________		PART I
							TO: ___________
PART I - FEDERALLY QUALIFIED HEALTH CENTER IDENTIFICATION DATA
						Provider		Date	Type of control
						CCN	CBSA	Certified	(see instructions)
	1					2	3	4	5
1	Site Name:									1
2	Street:	P.O. Box:								2
3	City:	State:	Zip Code:	County:		Designation - Enter "R" for rural or "U" for urban:				3
4	Cost Reporting Period (mm/dd/yyyy)	From:	To:							4
5	Is this FQHC part of an entity that owns, leases or controls multiple FQHCs? Enter "Y" for yes or "N" for no. If yes, enter the entity's information below.									5
6	Name of Entity:									6
7	Street:		P.O. Box:		HRSA Award Number:					7
8	City:	State:		Zip Code:						8
9	Is this FQHC part of a chain organization as defined in §2150 of CMS Pub. 15-1 that claims home office costs in a									9
	Home Office Cost Statement? Enter "Y for yes or "N" for no in column 1. If yes, enter the chain organization's information below.
10	Name of Chain Organization:									10
11	Street:		P.O. Box:		Home Office CCN:					11
12	City:		State:	Zip Code:						12
						1	2	3	4
Consolidated Cost Report						Y/N	Date Requested	Date Approved	Number of FQHCs
13	Is this FQHC filing a consolidated cost report per CMS Pub. 100-04, chapter 9, §30.8? Enter "Y" for yes or "N" for no in column 1.									13
	If yes, complete line 14. If no, leave line 14 blank. (see instructions)
	Site Name					CCN	CBSA	Date Requested	Date Approved
	1					2	3	4	5
14										14
FQHC Operations							1	2	3
15	What type of organization is this FQHC? If you operate as more than one sub-type of an organization enter any or all of the applicable alpha characters in column 2. (see instructions)									15
16	Did this FQHC receive a grant under §330 of the PHS Act during this cost reporting period? If this is a consolidated cost report, did the FQHC reported on line 1, column 2 receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. (complete line 17)									16
17	If the response to line 16 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). Enter the date of the grant award in column 2 and enter the grant award number in column 3. If you received more than one grant subscript this line accordingly.									17
Medical Malpractice
18	Did this FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA? Enter "Y" for yes or "N" for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.									18
19	Is this FQHC legally-required to carry malpractice insurance? Enter "Y" for yes or "N" for no.									19
20	Is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.									20
							Premiums	Paid Losses	Self Insurance
21	List amounts of malpractice premiums, paid losses or self-insurance in the applicable columns.									21
22	Are malpractice premiums, paid losses or self-insurance reported in a cost center other than the Administrative and General cost center? Enter "Y" for yes or "N" for no. (see instructions)									22
Interns and Residents
23	Is this FQHC involved in training residents in an approved GME program in accordance with 42 CFR 405.2468(f)? Enter "Y" for yes or "N" for no.									23
24	Is this FQHC involved in training residents in an unapproved GME program? Enter "Y" for yes or "N" for no.									24
25	Did this FQHC receive a Primary Care Residency Expansion (PCRE) grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for no in column 1.									25
	If yes, enter in column 2 the number of primary care FTE residents that your FQHC trained in this cost reporting period for which your FQHC received PCRE funding and
	in column 3, enter the total number of visits performed by residents funded by the PCRE grant in this cost reporting period. (see instructions)
26	Did this FQHC receive a Teaching Health Center development grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for no in column 1.									26
	If yes, enter in column 2 the number of FTE residents that your FQHC trained and received funding through your THC grant in this cost reporting period and
	in column 3, enter the total number of visits performed by residents funded by the THC grant in this cost reporting period. (see instructions)
Capital Related Costs - Ownership/Lease of Building
27	Do you own or lease the building or office space occupied by your FQHC? Enter "1" for owned or "2" for leased in column 1. If you enter "2" in column 1,									27
	enter the amount of rent/lease expense in column 2.
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4405.1 )
44-104										Rev. 1

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Sheet 3: S-1PII

DRAFT				FORM CMS-224-14						4490 (Cont.)
FEDERALLY QUALIFIED HEALTH CENTER IDENTIFICATION DATA					CCN: ___________		PERIOD:		WORKSHEET S-1
							FROM: ___________		PART II
					CENTER CCN: __________		TO: ___________
PART II - FEDERALLY QUALIFIED HEALTH CENTER CONSOLIDATED COST REPORT PARTICIPANT IDENTIFICATION DATA
					Date	Type of control	Date	V/I	Date of
					Certified	(see instructions)	Decertified	Decertification	CHOW
	1				2	3	4	5	6
1	Site Name:									1
2	Street:	P.O. Box:								2
3	City:	State:	Zip Code:	County:		Designation - Enter "R" for rural or "U" for urban:				3
FQHC Operations							1	2	3
4	What type of organization is this FQHC? If you operate as more than one sub-type of an organization enter any or all of the applicable alpha									4
	characters in column 2. (see instructions)
5	Did this FQHC receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. If yes, complete line 6.									5
6	If the response to line 5 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). Enter the date of the grant award in column 2 and enter the grant award number in column 3. If you received more than one grant subscript this line accordingly.									6
Medical Malpractice
7	Did this FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA? Enter "Y" for yes or "N" for no in column 1. If column 1 is yes, enter the effective date of coverage in column 2.									7
8	Is this FQHC legally-required to carry malpractice insurance? Enter "Y" for yes or "N" for no.									8
9	Is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.									9
							Premiums	Paid Losses	Self Insurance
10	List amounts of malpractice premiums, paid losses or self-insurance in the applicable columns.									10
Interns and Residents
11	Is this FQHC involved in training residents in an approved GME program in accordance with 42 CFR 405.2468(f)? Enter "Y" for yes or "N" for no.									11
12	Is this FQHC involved in training residents in an unapproved GME program? Enter "Y" for yes or "N" for no.									12
13	Did this FQHC receive a Primary Care Residency Expansion (PCRE) grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for									13
	no in column 1. If yes, enter in column 2 the number of primary care FTE residents that your FQHC trained in this cost reporting period for which your FQHC received
	PCRE funding and in column 3, enter the total number of visits performed by residents funded by the PCRE grant in this cost reporting period. (see instuctions)
14	Did this FQHC receive a Teaching Health Center development grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for no									14
	in column 1. If yes, enter in column 2 the number of FTE residents that your FQHC trained and received funding through your THC grant in this cost reporting
	period and in column 3, enter the total number of visits performed by residents funded by the THC grant in this cost reporting period. (see instructions)
Capital Related Costs - Ownership/Lease of Building
15	Do you own or lease the building or office space occupied by your FQHC? Enter "1" for owned or "2" for leased in column 1. If you enter "2" in column 1,									15
	enter the amount of rent/lease expense in column 2.
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4405.2)
Rev. 1										44-105

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Sheet 4: S-2

4490 (Cont.)			FORM CMS-224-14						DRAFT
FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT				CCN:	PERIOD:		WORKSHEET S-2
QUESTIONNAIRE					FROM: ___________
				___________	TO: ___________
General Instruction:		Enter Y for all YES responses. Enter N for all NO responses.
		Enter all dates in the mm/dd/yyyy format.
COMPLETED BY ALL FQHCs
						Y/N	Date	V/I
Provider Organization and Operation						1	2	3
1	Has the FQHC changed ownership immediately prior to the beginning of the cost reporting period?								1
	If yes, enter the date of the change in column 2. (see instructions)
2	Has the FQHC terminated participation in the Medicare program? If yes, enter in column 2 the date								2
	of termination and in column 3, "V" for voluntary or "I" for involuntary. (see instructions)
3	Is the FQHC involved in business transactions, including management contracts, with individuals or entities								3
	(e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers, medical
	staff, management personnel, or members of the board of directors through ownership, control, or family and
	other similar relationships? (see instructions)
						Y/N	Type	Date
Financial Data and Reports						1	2	3
4	Column 1: Were the financial statements prepared by a Certified Public Accountant?								4
	Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter
	date available in column 3. (see instructions) If no, see instructions.
							Y/N	Y/N
Approved Educational Activities							1	2
5	Are costs for Intern-Resident programs claimed on the current cost report?								5
6	Was an Intern-Resident program initiated or renewed in the current cost reporting period? If yes, see instructions.								6
7	Are GME costs directly assigned to cost centers other than Allowable Intern and Resident Costs on Worksheet A?								7
	If yes, see instructions.
								Y/N
Bad Debts								1
8	Is the FQHC seeking reimbursement for bad debts? If yes, see instructions.								8
9	If line 8 is yes, did the FQHC's bad debt collection policy change during this cost reporting period? If yes, submit copy.								9
10	If line 8 is yes, were patient coinsurance amounts waived? If yes, see instructions.								10
							Y/N	Date
PS&R Report Data							1	2
11	Was the cost report prepared using the PS&R Report only? If column 1 is yes, enter the								11
	paid-through date of the PS&R Report used in column 2. (see instructions)
12	Was the cost report prepared using the PS&R Report for totals and the FQHC's records for allocation?								12
	If column 1 is yes, enter the paid-through date in column 2. (see instructions)
13	If line 11or 12 is yes, were adjustments made to PS&R Report data for additional claims that have been								13
	billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions.
14	If line 11 or 12 is yes, were adjustments made to PS&R Report data for corrections of other								14
	PS&R Report information? If yes, see instructions.
15	If line 11 or 12 is yes, were adjustments made to PS&R Report data for Other?								15
	Describe the other adjustments:		________________________________________
16	Was the cost report prepared only using the FQHC's records? If yes, see instructions.								16
Cost Report Preparer Contact Information
17	First name:		Last name:			Title:			17
18	Employer:								18
19	Phone number:			E-mail Address:					19
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4406)
44-106									Rev. 1

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Sheet 5: S-3PI

DRAFT			FORM CMS-224-14					4490 (Cont.)
FEDERALLY QUALIFIED HEALTH CENTER DATA			CCN:		PERIOD:		WORKSHEET S-3
					FROM: __________		PART I
			___________		TO: ___________
PART I - FEDERALLY QUALIFIED HEALTH CENTER STATISTICAL DATA
							Total
		CENTER		Title	Title		All
		CCN	Title V	XVIII	XIX	Other	Patients
		0	1	2	3	4	5
1	Medical Visits							1
2	Total Medical Visits							2
3	Mental Health Visits							3
4	Total Mental Health Visits							4
5	Number of Visits Performed by Interns and Residents							5
6	Total Number of Visits Performed by Interns							6
	and Residents
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4407.1)
Rev. 1								44-107

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Sheet 6: S-3PII & III

4490 (Cont.)			FORM CMS-224-14					DRAFT
FEDERALLY QUALIFIED HEALTH CENTER DATA			CCN:		PERIOD:		WORKSHEET S-3
					FROM: __________		PART II & III
			___________		TO: ___________
PART II - FEDERALLY QUALIFIED HEALTH CENTER CONTRACT LABOR AND BENEFIT COST
						Contract	Benefit
						Labor	Cost
						1	2
1	Total facility contract labor and benefit cost							1
2	Physician							2
3	Physician Assistant							3
4	Nurse Practitioner							4
5	Visiting Registered Nurse							5
6	Visiting Licensed Practical Nurse							6
7	Certified Nurse Midwife							7
8	Clinical Psychologist							8
9	Clinical Social Worker							9
10	Laboratory Technician							10
11	Reg Dietician/Cert DSMT/MNT Educator							11
12	Physical Therapist							12
13	Occupational Therapist							13
14	Other Allied Health Personnel							14
15	Interns & Residents							15
PART III - FEDERALLY QUALIFIED HEALTH CENTER EMPLOYEE DATA
					Number of Employees
Enter the number of hours in					(Full Time Equivalent)
your normal work week ________					Staff	Contract	Total
					1	2	3
16	Physician							16
17	Physician Assistant							17
18	Nurse Practitioner							18
19	Registered Nurse							19
20	Licensed Practical Nurse							20
21	Certified Nurse Midwife							21
22	Clinical Psychologist							22
23	Clinical Social Worker							23
24	Laboratory Technician							24
25	Reg Dietician/Cert DSMT/MNT Educator							25
26	Physical Therapist							26
27	Occupational Therapist							27
28	Other Allied Health Personnel							28
29	Interns & Residents							29
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4407.2 & 4407.3)
44-108								Rev. 1

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Sheet 7: A

DRAFT				FORM CMS-224-14						4490 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES					CCN:		PERIOD:		WORKSHEET A
							FROM: ___________
					___________		TO: ___________
									NET
							RECLASSIFIED		EXPENSES FOR
		COST CENTER DESCRIPTIONS			TOTAL	RECLASSIFI-	TRIAL BALANCE		ALLOCATION
		(omit cents)	SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
			1	2	3	4	5	6	7
GENERAL SERVICE COST CENTERS
1	0100	Cap Rel Costs-Bldg and Fix								1
2	0200	Cap Rel Costs-Mvble Equip								2
3	0300	Employee Benefits								3
4	0400	Administrative & General Services								4
5	0500	Plant Operation and Maintenance								5
6	0600	Janitorial								6
7	0700	Medical Records								7
8		Subtotal - Administrative Overhead								8
9	0900	Pharmacy								9
10	1000	Medical Supplies								10
11	1100	Transportation								11
12	1200	Other General Service (specify)								12
13		Subtotal - Total Overhead								13
DIRECT CARE COST CENTERS
23	2300	Physician								23
24	2400	Physician Services Under Agreement								24
25	2500	Physician Assistant								25
26	2600	Nurse Practitioner								26
27	2700	Visiting Registered Nurse								27
28	2800	Visiting Licensed Practical Nurse								28
29	2900	Certified Nurse Midwife								29
30	3000	Clinical Psychologist								30
31	3100	Clinical Social Worker								31
32	3200	Laboratory Technician								32
33	3300	Reg Dietician/Cert DSMT/MNT Educator								33
34	3400	Physical Therapist								34
35	3500	Occupational Therapist								35
36	3600	Other Allied Health Personnel								36
37		Subtotal - Direct Patient Care Services								37
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4408)
Rev. 1										44-109
4490 (Cont.)				FORM CMS-224-14						DRAFT
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES					CCN:		PERIOD:		WORKSHEET A
							FROM ____________
					____________		TO ____________
									NET
							RECLASSIFIED		EXPENSES FOR
		COST CENTER DESCRIPTIONS			TOTAL	RECLASSIFI-	TRIAL BALANCE		ALLOCATION
		(omit cents)	SALARIES	OTHER	(col. 1 + col. 2)	CATIONS	(col. 3 ± col. 4)	ADJUSTMENTS	(col. 5 ± col. 6)
			1	2	3	4	5	6	7
REIMBURSABLE PASS THROUGH COSTS
47	4700	Allowable GME Costs								47
48	4800	Pneumococcal Vaccines & Med Supplies								48
49	4900	Influenza Vaccines & Med Supplies								49
50		Subtotal - Reimbursable Pass through Costs								50
OTHER FQHC SERVICES
60	6000	Medicare Excluded Services								60
61	6100	Diagnostic & Screening Lab Tests								61
62	6200	Radiology - Diagnostic								62
63	6300	Prosthetic Devices								63
64	6400	Durable Medical Equipment								64
65	6500	Ambulance Services								65
66	6600	Telehealth								66
67	6700	Drugs Charged to Patients								67
68	6800	Other (Specify)								68
69		Subtotal - Other FQHC Services								69
NONREIMBURSABLE COST CENTERS
77	7700	Retail Pharmacy								77
78	7800	Nonallowable GME Costs								78
79	7900	Other Nonreimbursable (Specify)								79
80		Subtotal - Non-Reimbursable Costs								80
100		TOTAL (sum of lines 13, 37, 50, 69 and 80)								100
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4408)
44-110										Rev. 1

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Sheet 8: A-1

DRAFT			FORM CMS-224-14						4490 (Cont.)
RECLASSIFICATIONS				CCN:		PERIOD:		WORKSHEET A-1
						FROM: ___________
				___________		TO: ___________
			INCREASES			DECREASES
		CODE
	EXPLANATION OF RECLASSIFICATION(S)	(1)	COST CENTER	LINE #	AMOUNT	COST CENTER	LINE #	AMOUNT
		1	2	3	4	5	6	7
1									1
2									2
3									3
4									4
5									5
6									6
7									7
8									8
9									9
10									10
11									11
12									12
13									13
14									14
15									15
16									16
17									17
18									18
19									19
20									20
21									21
22									22
23									23
24									24
25									25
26									26
27									27
28									28
29									29
30									30
31									31
32									32
33									33
34									34
35									35
100	Total reclassifications								100
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
Transfer the amounts in columns 4 and 7 to Worksheet A, column 4, lines as appropriate.
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4409)
Rev. 1									44-111

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Sheet 9: A-2

4490 (Cont.)		FORM CMS-224-14						DRAFT
ADJUSTMENTS TO EXPENSES		CCN:		PERIOD:		WORKSHEET A-2
				FROM: ___________
		___________		TO: ___________
				EXPENSE CLASSIFICATION ON
	DESCRIPTION (1)			WORKSHEET A TO/FROM WHICH
		BASIS/CODE		THE AMOUNT IS TO BE ADJUSTED
		(2)	AMOUNT	COST CENTER			LINE #
		1	2	3			4
1	Investment income - buildings and fixtures (chapter 2)			Buildings and Fixtures			1	1
2	Investment income - movable equipment (chapter 2)			Movable Equipment			2	2
3	Investment income - other (chapter 2)							3
4	Trade, quantity, and time discounts (chapter 8)							4
5	Refunds and rebates of expenses (chapter 8)							5
6	Rental of building or office space to others (chapter 8)							6
7	Related organization transactions (chapter 10)	Wkst A-2-1						7
8	Sale of drugs to other than patients							8
9	Vending machines							9
10	Practitioner assigned by Public Health Service							10
11	Depreciation - buildings and fixtures			Buildings and Fixtures			1	11
12	Depreciation - movable equipment			Movable Equipment			2	12
13	RCE adjustment to teaching physicians' cost			Allowable GME Costs			47	13
14	Other adjustments (specify) (3)							14
50	TOTAL (sum of lines 1 thru 49)							50
(1) Description - all chapter references in this column pertain to CMS Pub. 15-1.
(2) Basis for adjustment (see instructions).
A. Costs - if cost, including applicable overhead, can be determined.
B. Amount Received - if cost cannot be determined.
(3) Additional adjustments may be made on lines 14 thru 49 and subscripts thereof.
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4410)
44-112								Rev. 1

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Sheet 10: A-2-1

DRAFT			FORM CMS-224-14				4490 (Cont.)
STATEMENT OF COSTS OF SERVICES				CCN:	PERIOD:	WORKSHEET A-2-1
FROM RELATED ORGANIZATIONS AND					FROM: ___________
HOME OFFICE COSTS				___________	TO: ___________
PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS
	OR CLAIMED HOME OFFICE COSTS
					Amount	Net
				Amount of	included in	Adjustments
				Allowable	Wkst. A	(col. 4 minus
	Line No.	Cost Center	Expense Items	Cost	column 5	col. 5) *
	1	2	3	4	5	6
1							1
2							2
3							3
4							4
5	TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet						5
	A-2, column 2, line 7.
* The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as appropriate.
Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not
been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.
PART II - INTERRELATIONSHIP TO RELATED ORGANIZATIONS AND/OR HOME OFFICE
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish
the information requested under Part B of this worksheet.
This information is used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable to services,
facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs as determined under
section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost report is considered incomplete and
not acceptable for purposes of claiming reimbursement under Title XVIII.
				Related Organization(s) and/or Home Office
			Percentage		Percentage
	Symbol		of		of	Type of
	(1)	Name	Ownership	Name	Ownership	Business
	1	2	3	4	5	6
6							6
7							7
8							8
9							9
10							10
	(1) Use the following symbols to indicate interrelationship to related organizations:
		A. Individual has financial interest (stockholder, partner, etc.) in both related
		organization and in FQHC.
		B. Corporation, partnership, or other organization has financial interest in FQHC.
		C. FQHC has financial interest in corporation, partnership, or other organization.
		D. Director, officer, administrator, or key person of FQHC or relative of such
		person has financial interest in related organization.
		E. Individual is director, officer, administrator, or key person of FQHC and
		related organization.
		F. Director, officer, administrator, or key person of related organization or relative
		of such person has financial interest in FQHC.
		G. Other (financial or non-financial) specify __________________________________________________
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4411.1 - 4411.2)
Rev. 1							44-113

---

Sheet 11: B

4490 (Cont.)

FORM CMS-224-14

DRAFT

CALCULATION OF FEDERALLY QUALIFIED HEALTH CENTER COSTS

CCN:

PERIOD:

WORKSHEET B

FROM: ___________

PARTS I & II

___________

TO: ___________

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

Total Visits

Title XVIII Visits

Title XVIII Costs

Other Direct

Direct Cost

Total Medical

Care Costs &

General

Col 4 must =

Col 6 must

Col 7 must

by

& Mental Health

Pharmacy Costs

Service Cost

Total Costs

Average

Mental

Mental

Mental

Cols 6+7

be => col 8

be => col 9

From Wkst.

Practitioner

Visits

(see

(see

by

Cost Per Visit

Medical Visits

Health Visits

Medical Visits

Health Visits

Medical Cost

Health Cost

A, col. 7,

from Wkst. A

by Practitioner

instructions)

instructions)

Practitioner

by Practitioner

by Practitioner

by Practitioner

by Practitioner

by Practitioner

by Practitioner

by Practitioner

Positions

line:

1

2

3

4

5

6

7

8

9

10

11

12

1

Physician

23

1

#REF!

OK

OK

2

Physician Services Under Agreement

24

2

3

Physician Assistant

25

3

#REF!

OK

OK

4

Nurse Practitioner

26

4

#REF!

OK

OK

5

Visiting Registered Nurse

27

5

#REF!

OK

OK

6

Visiting Licensed Practical Nurse

28

6

#REF!

OK

OK

7

Certified Nurse Midwife

29

7

#REF!

OK

OK

8

Clinical Psychologist

30

8

#REF!

OK

OK

9

Clinical Social Worker

31

9

#REF!

OK

OK

10

Reg Dietician/Cert DSMT/MNT Educator

33

10

#REF!

OK

OK

11

Totals

11

#REF!

OK

OK

12

Unit Cost Multiplier

12

13

Total Cost Per Visit

13

PART II - CALCULATION OF ALLOWABLE DIRECT GRADUATE MEDICAL EDUCATION COSTS

Total

Cost

Ratio of

Allowable

(from Wkst.

Title XVIII

Title XVIII

A col. 7,

Total I & R

Title XVIII

Visits to

Direct

line 47)

Visits

I & R Visits

Total Visits

GME Costs

1

2

3

4

5

14

Allowable GME Costs

14

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

44-114

Rev. 1

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Sheet 12: B-1

DRAFT			FORM CMS-224-14				4490 (Cont.)
COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA				CCN:	PERIOD:	WORKSHEET B-1
VACCINE COST					FROM: ____________
				____________	TO: ____________
					PNEUMOCOCCAL	INFLUENZA
					1	2
1	Health care staff cost (from Worksheet A, column 7, sum of lines 23, and 25 through 36)						1
2	Ratio of pneumococcal and influenza vaccine staff time to total						2
	health care staff time
3	Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)						3
4	Vaccines and related medical supplies cost (from Worksheet A, column 7, lines 48 and 49, respectively)						4
5	Direct cost of pneumococcal and influenza vaccine (line 3 + line 4)						5
6	Total direct cost of the FQHC (from Worksheet A, column 7, line 100)						6
7	Total administrative overhead (from Worksheet A, column 7, line 8)						7
8	Ratio of pneumococcal and influenza vaccine direct cost to total direct						8
	cost (line 5 / line 6)
9	Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)						9
10	Total cost of pneumococcal and influenza vaccine and their						10
	administration (sum of lines 5 and 9)
11	Total number of pneumococcal and influenza vaccine injections						11
	(from your records)
12	Cost per pneumococcal and influenza vaccine injection (line 10 / line 11)						12
13	Number of pneumococcal and influenza vaccine injections administered						13
	to Medicare beneficiaries
14	Cost of pneumococcal and influenza vaccines and their						14
	administration costs furnished to Medicare beneficiaries (line 12 x line 13)
15	Total cost of pneumococcal and influenza vaccines and their administration costs (sum of columns						15
	1 and 2, line 10)
16	Total Medicare cost of pneumococcal and influenza vaccines and their administration costs (sum						16
	of columns 1 and 2, line 14) (transfer this amount to Worksheet E, line 3)
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4413)
Rev. 1							44-115

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Sheet 13: E

4490 (Cont.)		FORM CMS-224-14				DRAFT
CALCULATION OF REIMBURSEMENT SETTLEMENT			CCN:	PERIOD:	WORKSHEET E
				FROM: ___________
			___________	TO: ___________
1	FQHC PPS Amount					1
2	Direct graduate medical education payments (from Worksheet B, Part II, line 14, column 5)					2
3	Medicare cost of pneumococcal and influenza vaccine and their administration (From Worksheet B-1, line 16)					3
4	Medicare advantage supplemental payments (for information only)					4
5	Total (sum of amounts on lines 1 through 3)					5
6	Primary payer payments					6
7	Total amount payable for program beneficiaries (line 5 minus line 6)					7
8	Coinsurance billed to program beneficiaries					8
9	Net Medicare reimbursement excluding bad debts (line 7 minus line 8)					9
10	Allowable bad debts (see instructions)					10
11	Adjusted reimbursable bad debts (see instructions)					11
12	Allowable bad debts for dual eligible beneficiaries (see instructions)					12
13	Subtotal (line 9 plus line 11)					13
14	Other adjustments (specify) (see instructions)					14
15	Amount due FQHC prior to the sequestration adjustment (see instructions)					15
16	Sequestration adjustment (see instructions)					16
17	Amount due FQHC after sequestration adjustment (see instructions)					17
18	Interim payments					18
19	Tentative settlement (for contractor use only)					19
20	Balance due FQHC/program (line 17 minus lines 18 and 19)					20
21	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2					21
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4414)
44-116						Rev. 1

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Sheet 14: E-1

DRAFT				FORM CMS-224-14					4490 (Cont.)
ANALYSIS OF PAYMENTS TO THE FEDERALLY QUALIFIED HEALTH CENTER FOR SERVICES RENDERED					CCN:	PERIOD:		WORKSHEET E-1
						FROM: ____________
					___________	TO: ___________
	Description						Part B
							mm/dd/yyyy	Amount
							1	2
1	Total interim payments paid to FQHC								1
2	Interim payments payable on individual bills, either submitted or to be submitted to the contractor								2
	for services rendered in the cost reporting period. If none, write "NONE" or enter a zero
3	List separately each retroactive					.01			3.01
	lump sum adjustment amount based					.02			3.02
	on subsequent revision of the				Program to	.03			3.03
	interim rate for the cost reporting period.				Provider	.04			3.04
	Also show date of each payment.					.05			3.05
	If none, write "NONE" or enter a zero. (1)					.50			3.50
						.51			3.51
					Provider to	.52			3.52
					Program	.53			3.53
						.54			3.54
	Subtotal (sum of lines 3.01- 3.49 minus sum of lines 3.50-3.98)					.99			3.99
4	Total interim payments (sum of lines 1, 2, and 3.99)								4
	(transfer to Wkst. E, line 18)
	TO BE COMPLETED BY CONTRACTOR
5	List separately each tentative settlement				Program to	.01			5.01
	payment after desk review. Also show				Provider	.02			5.02
	date of each payment.					.03			5.03
	If none, write "NONE" or enter a zero. (1)					.50			5.50
					Provider to	.51			5.51
					Program	.52			5.52
	Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50 -5.98)					.99			5.99
6	Determine net settlement amount (balance				Program to provider	.01			6.01
	due) based on the cost report (1)				Provider to program	.02			6.02
7	Total Medicare program liability (see instructions)								7
(1) On lines 3, 5, and 6, where an amount is due FQHC to program, show the amount and date on which the FQHC agrees to the amount of repayment
even though total repayment is not accomplished until a later date.
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4415)
Rev. 1									44-117

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Sheet 15: F-1

4490 (Cont.)				FORM CMS-224-14				DRAFT
STATEMENT OF				CCN:		PERIOD	WORKSHEET F-1
REVENUE AND EXPENSES						From: ___________
				___________		To: ___________
				Title XVIII	Title XIX
				Medicare	Medicaid	Other	Total
				1	2	3	4
1	Gross patient revenues							1
						1	2
2	Less: Allowances and discounts on patients' accounts							2
3	Net patient revenues (Line 1 minus line 2)							3
4	Operating expenses (From Worksheet A, column 3, line 100)							4
5	Additions to operating expenses (Specify)							5
6								6
7								7
8								8
9								9
10								10
11	Subtractions from operating expenses (Specify)							11
12								12
13								13
14								14
15								15
16								16
17	Less total operating expenses (sum of lines 4 through 16)							17
18	Net income from service to patients (Line 3 minus line 17)							18
	Other income:
19	Contributions, donations, bequests, etc.							19
20	Income from investments							20
21	Purchase discounts							21
22	Rebates and refunds of expenses							22
23	Sale of Medical and Nursing Supplies to other than patients							23
24	Sale of durable medical equipment to other than patients							24
25	Sale of drugs to other than patients							25
26	Sale of medical records and abstracts							26
27	Government Appropriations							27
28	Other revenues (Specify)							28
29								29
30								30
31								31
32	Total Other Income (Sum of lines 19 through 31)							32
33	Net Income or Loss for the period (Line 18 plus line 32)							33
FORM CMS-224-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4416)
44-118								Rev. 1