CMS-276 4th Quarter Interim Report

version 4.0
FORM APPROVED
OMB NO. 0938-0165

This report is required by law (42 USC 1395mm and 42 USC 1995I).
Failure to report can result in all interim payments made since
the beginning of the cost reporting period being deemed overpayments.

PREPAID HEALTH PLAN COST REPORT
GENERAL INFORMATION
1

Name and Address of Plan:

2

Reporting Period:

WORKSHEET S

Plan Number:
From:
H-xxxx
To:

3

a. Type of Report:

b. Bill Processing Option:

[ ] Budget Forecast

c. Reimbursement Under:

Select Option

1876

[x] Interim Reports
[ ] Final Cost Report

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST
REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW
CERTIFICATION BY OFFICER OF THE PLAN
I HEREBY CERTIFY that I have examined the accompanying Statement of Reimbursable Cost, the allocation of
expenses and services, and the attached Worksheets for the period from
01/00/1900 to 01/00/1900
and that to the best of my knowledge and belief they are true and correct statements prepared from the books
and records of the Plan in accordance with applicable instructions.

SIGNATURE (Officer or Administrator of the Plan)

DATE

TITLE

PHONE NUMBER

FORM CMS 276-16 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2302)
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 0938-0165. The time required to complete this information is estimated to average as follows: (1) for HMOs/CMPs,
24 hours to complete the budget forecast, 80 hours to complete the fourth quarter and final cost reports, 4 hours to complete the semi-annual interim and 0 hours to complete the first,
second, and third quarterly reports; and (2) for HCPPs, 16 hours to complete the budget forecast, 60 hours to complete the final cost report, and 4 hours to complete the semi-annual
interim report. 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,
Mail Stop C3-14-16, Baltimore, Maryland 21244-1850 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

Form Expiration Date: 11/30/2019

PLAN STATISTICS
Name of Plan:
Plan #: H-xxxx

WORKSHEET D
PART I
Page 1

0
PERIOD FROM:
TO:

01/00/00
01/00/00

PROVIDER
NUMBER

RELATIONSHIP (1)

BILLS
PROCESSED
BY (2)

TOTAL
DAYS

TOTAL
MEDICARE
DAYS*

COV MED
PRIMARY
DAYS

COV MED
SECONDARY
DAYS

1

2

3

4

5

6

7

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

LIST OF PROVIDERS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52

A. Hospitals & SNF's:
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________

________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________

(1)
O - OWNED OR CONTROLLED
P - PURCHASED
FORM HCFA 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

* Note: Col 5 minus 6 & 7 = Non-covered
(2)
H - PROCESSED BY HCFA
P - PROCESSED BY PLAN

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

PLAN STATISTICS
Name of Plan:
Plan #: H-xxxx

WORKSHEET D
PART 1
Page 2

0
PERIOD FROM:
TO:

01/00/00
01/00/00

PROVIDER
NUMBER

RELATIONSHIP (1)

BILLS
PROCESSED
BY (2)

TOTAL
VISITS

TOTAL
MEDICARE
VISITS*

COV MED
PRIMARY
VISITS

COV MED
SECONDARY
VISITS

1

2

3

4

5

6

7

________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

LIST OF PROVIDERS

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
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

B. HHA's:
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
C. Other (Specify Name & Type):
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________

(1)
O - OWNED OR CONTROLLED
P - PURCHASED
FORM HCFA 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306)

* Note: Col 5 minus 6 & 7 = Non-covered
(2)
H - PROCESSED BY HCFA
P - PROCESSED BY PLAN

PLAN STATISTICS
Name of Plan:
Plan #: H-xxxx

WORKSHEET D
PART II
Page 1

0
PERIOD FROM:
TO:

TYPE OF
GROUP
(1)
1

LIST OF SUPPLIERS

A.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48

Physician Services:
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Physician Groups:
Fee For Service
Capitation
Other
Individual Physicians:
Fee For Service
Capitation
Other

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

HOW
PAYMENT
PHYSICIANS
MECHANISM
PAID
(2)
(2)
2
3

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

(1)
A - IPA
B - GROUP PRACTICE
C - STAFF
D - INDIVIDUAL PRACTITIONERS

01/00/00
01/00/00
STATISTICS
TOTAL
COVERED MED
MEDICARE *
PRIMARY

TOTAL
4

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

5

6

FORM HCFA 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306)

7

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

(2)
A - FEE-FOR-SERVICE
B - CAPITATION
C - OTHER-SPECIFY

*

COVERED MED
SECONDARY

Note Col 5 minus 6 & 7 = Non-covered

PLAN STATISTICS
Name of Plan:
Plan #: H-xxxx

WORKSHEET D
PART II
Page 2

0
PERIOD FROM:
TO:

TYPE OF
GROUP
(1)
1

LIST OF SUPPLIERS

1
2
3
4
5
6
7
8
9
10
11

B. Certified Labs:
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Certified Labs
Fee For Service
Capitation
Other

1
2
3
4
5
6
7
8
9
10
11

C. X-Ray Units:
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
X-Ray Units
Fee For Service
Capitation
Other

1
2
3
4
5
6
7
8
9
10
11
12
13
14

D. Others (Specify):
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
________________________________

_
_
_
_
_
_
_

_
_
_
_
_
_
_

_
_
_
_
_
_
_
_
_
_
_
_
_
_

HOW
PAYMENT
PHYSICIANS
MECHANISM
PAID
(2)
(2)
2
3

_
_
_
_
_
_
_

_
_
_
_
_
_
_

_
_
_
_
_
_
_
_
_
_
_
_
_
_

_
_
_
_
_
_
_

_
_
_
_
_
_
_

_
_
_
_
_
_
_
_
_
_
_
_
_
_

(1)
A - IPA
B - GROUP PRACTICE
C - STAFF
D - INDIVIDUAL PRACTITIONERS

01/00/00
01/00/00

TOTAL

TOTAL
MEDICARE*

4

5

STATISTICS
COVERED MED
PRIMARY

COVERED MED
SECONDARY

6

7

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

* Note: Col 5 minus 6 & 7 = Non-covered
(2)
A - FEE-FOR-SERVICE
B - CAPITATION
C - OTHER-SPECIFY

MEDICARE
PART A
1

E. MEMBERSHIP:
1
2

Total Medicare Member Months...........................................................................................................................................................
Medicare Secondary Liable (Employer Groups) Member Months..........................................................................................................

3
4

Medicare Primary Member Months (Line 1 minus Line 2).....................................................................................................................
Ratio (Line 3 & Line 1)..........................................................................................................................................................................

MEDICARE
PART B
2
0

__________
0
0.0000

0
__________
0
0.0000

(3)
Part B Member Months = Total Member Months

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2306)

SUMMARY TRIAL BALANCE

WORKSHEET E
Name of Plan:
Plan #:

0
H-xxxx
PERIOD FROM:
TO:

COST CENTER

TRIAL
BALANCE

RECLASSIFICATIONS
(WKST F)
2

1

ADJUSTMENTS
(WKST G)
3

01/00/00
01/00/00
A&G
ALLOCATION
(WKST I,
Part I)
5

ALLOWABLE
COST
(Col 1 thru 3)
4

TRANSFER
TO
WKST, LINE

TOTALS
(Col 4 + Col 5)
6

7

1 Inpatient Hospitals

0

0

0

0

0

J 2-47

2 Outpatient Hospitals

0

0

0

0

0

J 2-47

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

J
J
K
K
K
K
K
K
K
K

52-61
66-74
| 1
| 3-5
| 7-9
| 11-13
| 15-17
| 18
| 20
| 21

K
K
L
L
L
L

|
|
|
|
|
|

0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0

0

0
0
_____________
0

0
0
_____________
0

0
0
_____________
0

0
0
_____________
0

0
_____________

0
_____________

0
_____________

0
_____________

0
=========

0
=========

0
=========

0
=========

3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23

Skilled Nursing Facilities.......….…
Home Health Agencies........….….
Clinics..........……….........….......…
Physician Groups.......................…
Individual Physicians.....…...….…
Certified Labs..................…......…
X-Ray Units....................……....…
ESRD Facilities.........................…
Durable Medical Equipment.......…
Ambulance...............……….......…
Pharmacy (Outpatient).......…...…
Pharmacy-Medicare Covered Rx
Emergency-Urgent Needed Svcs..
Mental Health Services....….……
DED+CO on claims processed by MACs
Other - Medicare Bad Debts...…
Other - Blood Deductible.....…
Part B Cost Not Subj to Coins.
Non-Allowable Costs
Other - (Specify)...…….......…
Other - (Specify)...…….......…
Other - (Specify)...…….......…

24 Subtotal (Sum Lines 1-23)..........................
25 Plan Administration..............…..…
26 Special Admin Costs................…
27 Subtotal: (Sum Lns 25+26).........................
28 Admin & General Costs...…......…

29 Total Program Costs (24+27+28)...............

0
=========

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2307)

22
24
18
9
12
21

J&K |
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L | 3
L | 6

RECLASSIFICATIONS

WORKSHEET F
Page 1

Name of Plan:
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Plan #: H-xxxx

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EXPLANATION OF RECLASSIFICATION ENTRY

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CODE
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PERIOD FROM:
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51 Page total............................................................................. ................. ....................................................... ...............................
52 a. Subtotal from Page 2....................................................... ................. ....................................................... ...............................
b. Subtotal from Page 3....................................................... ................. ....................................................... ...............................
c. Subtotal from Page 4....................................................... ................. ....................................................... ...............................
53 Total Reclassifications (Col 4 must equal Col 5)................. ................. ....................................................... ...............................
(1) A Letter (A, B, etc.) Must Be Entered on Each Line to Identify Each Reclassification Entry.
(2) Transfer to Worksheet E, Col. 2, lines as appropriate.

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)

01/00/00
01/00/00
AMOUNT (2)
INCREASES
4
0
0
0
0
0
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0
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============
Net, must be 0

(DECREASES)
5

0
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0
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Summarized on Worksheet F, Page 3

RECLASSIFICATIONS

WORKSHEET F
Page 2

Name of Plan:
0
Plan #: H-xxxx

LINE
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EXPLANATION OF RECLASSIFICATION ENTRY
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CODE
(1)
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PERIOD FROM:
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2
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CC LINE
NUMBER
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3
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110 Total Page 2 (Col 4 must equal Col 5)................................. ................. ....................................................... ...............................
(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.
(2) Transfer to Worksheet E, Col. 2, lines as appropriate.
FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)

01/00/00
01/00/00

AMOUNT
INCREASES
4

(DECREASES)
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
0
============
============
Summarized on Worksheet F, Page 3

RECLASSIFICATIONS

WORKSHEET F
Page 3

Name of Plan:
0
Plan #: H-xxxx

LINE
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EXPLANATION OF RECLASSIFICATION ENTRY
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CODE
(1)
1
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PERIOD FROM:
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2
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CC LINE
NUMBER
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3
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167 Total Page 3 (Col 4 must equal Col 5)................................. ................. ....................................................... ...............................
(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.
(2) Transfer to Worksheet E, Col. 2, lines as appropriate.
FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)

01/00/00
01/00/00

AMOUNT
INCREASES
4

(DECREASES)
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
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0
0
============
============
Summarized on Worksheet F, Page 3

RECLASSIFICATIONS

WORKSHEET F
Page 4

Name of Plan:
0
Plan #: H-xxxx

LINE
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EXPLANATION OF RECLASSIFICATION ENTRY
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CODE
(1)
1
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PERIOD FROM:
TO:

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(Worksheet E)
2
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CC LINE
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224 Total Page 4 (Col 4 must equal Col 5)................................. ................. ....................................................... ...............................
(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.
(2) Transfer to Worksheet E, Col. 2, lines as appropriate.
FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)

01/00/00
01/00/00

AMOUNT
INCREASES
4

(DECREASES)
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
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0
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0
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0
0
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0
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0
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0
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0
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0
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0
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0
0
============
============
Summarized on Worksheet F, Page 3

SUMMARY OF RECLASSIFICATIONS
Name of Plan:
0
Plan #: H-xxxx

WORKSHEET F
Page 5
PERIOD FROM:
TO:

01/00/00
01/00/00

SUMMARY OF RECLASSIFICATIONS

CC
LINE COST CENTER DESCRIPTIONS
1 Inpatient Hospitals
2
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

INCREASES
(DECREASES)
(From Worksheet F, Pgs 1 & 2)
4
5

NET
6

……..
.......................................................
Outpatient Hospitals ………………………………………………………….......................................................
Skilled Nursing Facilities...................................................... ................. .......................................................
Home Health Agencies........................................................ ................. .......................................................
Clinics.................................................................................. ................. .......................................................
Physician Groups................................................................. ................. .......................................................
Individual Physicians............................................................ ................. .......................................................
Certified Labs....................................................................... ................. .......................................................
X-Ray Units.......................................................................... ................. .......................................................
ESRD Facilities.................................................................... ................. .......................................................
Durable Medical Equipment................................................. ................. .......................................................
Ambulances......................................................................... ................. .......................................................
Pharmacy (Outpatient)......................................................... ................. .......................................................
Pharmacy-Medicare Covered Rx......................................... ................. .......................................................
Emergency-Urgently Needed Svcs...................................... ................. .......................................................
Mental Health Services........................................................ ................. .......................................................
DED+CO on claims processed by MACs
................. .......................................................
Other - Medicare Bad Debts...…
................. .......................................................
Other - Blood Deductible.....…
................. .......................................................
Part B Cost Not Subj to Coins.
................. .......................................................
Non-Allowable Costs
................. .......................................................
Other - (Specify)...…….......…
................. .......................................................
Other - (Specify)...…….......…
................. .......................................................
Other - (Specify)...…….......…
................. .......................................................

0
0
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0
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0

0
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0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Plan Administration.............................................................. ................. .......................................................
Special Admin Costs............................................................ ................. .......................................................

0
0

0
0

0
0

Admin & General Costs....................................................... ................. .......................................................

29 Total Reclassifications (Lines 1 thru 28) (Col 6 must net to zero)......... .......................................................

DIFFERENCES from total of pages 1 & 2 on page 1, Line 53……………………………………………………

0
____________
0
=============

0
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0
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0
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0
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If these differences are not
zero there is a problem!!

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)

0
____________
0
=============

Must net to zero.
To Worksheet E
Column 2

SUPPLEMENT TO WORKSHEET F - RECLASSIFICATIONS
Name of Plan:
0
Plan #: H-xxxx

Period

From:
To:

01/00/00
01/00/00

THIS IS A SUPPLEMENTAL WORKSHEET TO SUM UP RECLASSIFICATIONS BY COST CENTER
CCNO
1
CCNO
2
CCNO
3
CCNO
4
CCNO
5
CCNO
6
CCNO
7
CCNO
8
CCNO
9
CCNO
10
CCNO
11
CCNO
12
CCNO
13
CCNO
14
CCNO
15
CCNO
16
CCNO
17
CCNO
18
CCNO
19
CCNO
21
CCNO
22
CCNO
24

IP Hosp

INCREASES
0

(DECREASES)
0

OP Hosp

0

0

SNF

0

0

HHA

0

0

Clinic

0

0

Physicians Groups

0

0

Ind Phy

0

0

Labs

0

0

Xray

0

0

ESRD

0

0

DME

0

0

Amb

0

0

Phrm

0

0

Emerg

0

0

Mental

0

0

Ded & Coins

0

0

0

0

Other

0

0

Nonallowable

0

0

Plan Admin

0

0

Spec Admin

0

0

A&G

0

0

------------

------------

0
=============

0
=============

AD181...AN240

ADJUSTMENTS TO EXPENSES
Name of Plan:
Plan #: H-xxxx

CC
LINE

1
2
3
4
5
6
7
8
9
10
10a
10b
10c
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

51
(1)

0

DESCRIPTIONS

PERIOD FROM:
TO:
BASIS
FOR
ADJ (1)
1

01/00/00
01/00/00
Amount (2)
(To Wkst E as
appropriate)
2

WORKSHEET G
PART I
Page 1

COST CENTER
(Wkst E)
3

_____________________________
0
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0
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0
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0
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0
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0
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0
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0
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0
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0
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0
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0
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0
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0
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0
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0
_____________________________
0
_____________________________
0
_____________________________
0
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0
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0
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0
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0
_____________________________
0
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0
_____________________________
0
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0
_____________________________
0
_____________________________
0
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0
_____________________________
0
_____________________________
0
_____________________________
0
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0
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0
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0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
____________
Page total..................................................... ........................................................... .............................
0
a. Subtotal from Page 2............................... ........................................................... .............................
0
b. Subtotal from Page 3............................... ........................................................... .............................
0
c. Subtotal from Page 4............................... ........................................................... .............................
0
____________
TOTAL ADJUSTMENTS......................................................................................... .............................
0
============
Basis for Adjustment:
(2) Transfer to Worksheet E lines as appropriate.
A = Cost - including applicable overhead, if determinable.
(3) From Worksheet H.
B = Amounts Received - if cost cannot be determined.
(4) See Chapter 4 of HCFA Pub 15-II; attach Worksheet A-8-3.

Investment income on commingled restricted & unrestricted funds........................
Trade, quantity, time & other discounts on purchases.............................................
Rebates & refunds of expenses...............................................................................
Rental of space by suppliers....................................................................................
Telephone service....................................................................................................
Television & radio service........................................................................................
Parking lot................................................................................................................
Home Office Costs (Attach copy of Home Office Cost Statement)..........
Sale of scrap, waste, etc..........................................................................................
Adj. resulting from transactions with related organizations (3)................................
Adj. resulting from transactions with related organizations (3)................................
Adj. resulting from transactions with related organizations (3)................................
Adj. resulting from transactions with related organizations (3)................................
Laundry and linen service........................................................................................
Cafeteria - employees, guests, etc...........................................................................
Rental of living quarters to employees and others...................................................
Sale of medical and surgical supplies to other than patients...............................
Sale of drugs to other than patients.........................................................................
Sale of medical records and abstracts.....................................................................
Nursing school (tuition, fees, uniforms, finance charges)........................................
Income from vending machines...............................................................................
Income from imposition of interest and finance charges.......................................
Payments - Physicians' assumption of operating costs........................................
Undistributed risk pool.............................................................................................
Charges in excess of MAC screens.........................................................................
Part B coinsurance on services processed by MACs.........................................
Adjustment for physicial therapy costs in excess of limit (4)....................................
Reinsurance.............................................................................................................
Depreciation in excess of limits (Attach worksheet) ................................................
Noncovered purchased service (Attach worksheet)................................................
Medicare Bad Debts
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)

CC LINE
NUMBER
(Wkst E)
4
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
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__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__

ADJUSTMENTS TO EXPENSES
Name of Plan:
Plan #: H-xxxx

CC
LINE

52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106

DESCRIPTIONS

WORKSHEET G
0
PERIOD FROM:
TO:
BASIS
FOR
ADJ(1)
1

_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
Page total (to Page 1, Line 51a).................. ........................................................... .............................

(1) Basis for Adjustment:
A = Cost - including applicable overhead, if determinable.
B = Amounts Received - if cost cannot be determined.

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)

01/00/00
01/00/00
Amount
(To Wkst E as
appropriate)
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
============

PART I
PAGE 2

COST CENTER
(Wkst E)
3
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
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_____________________________
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_____________________________
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_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________

CC LINE
NUMBER
(Wkst E)
4
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
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__
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__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__

ADJUSTMENTS TO EXPENSES
Name of Plan:
Plan #: H-xxxx

CC
LINE

107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161

DESCRIPTIONS

WORKSHEET G
0
PERIOD FROM:
TO:
BASIS
FOR
ADJ(1)
1

_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
Page total (to Page 1, Line 51b).................. ........................................................... .............................

(1) Basis for Adjustment:
A = Cost - including applicable overhead, if determinable.
B = Amounts Received - if cost cannot be determined.

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)

01/00/00
01/00/00
Amount
(To Wkst E as
appropriate)
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
============

PART I
PAGE 3

COST CENTER
(Wkst E)
3
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
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_____________________________
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_____________________________
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_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________

CC LINE
NUMBER
(Wkst E)
4
__
__
__
__
__
__
__
__
__
__
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__
__
__
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__
__
__
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__
__
__
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__
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__
__
__
__
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__
__
__
__
__
__
__
__
__

ADJUSTMENTS TO EXPENSES
Name of Plan:
Plan #: H-xxxx

CC
LINE

162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216

DESCRIPTIONS

WORKSHEET G
0
PERIOD FROM:
TO:
BASIS
FOR
ADJ(1)
1

_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
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_
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_
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_
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_
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_
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_
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_
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_
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_
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_
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_
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_
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_
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_
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_
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_
_________________________________________________
_
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_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
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_
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_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
Page total (to Page 1, Line 51c).................. ........................................................... .............................

(1) Basis for Adjustment:
A = Cost - including applicable overhead, if determinable.
B = Amounts Received - if cost cannot be determined.

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)

01/00/00
01/00/00
Amount
(To Wkst E as
appropriate)
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
============

PART I
PAGE 4

COST CENTER
(Wkst E)
3
_____________________________
_____________________________
_____________________________
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_____________________________
_____________________________
_____________________________
_____________________________
_____________________________

CC LINE
NUMBER
(Wkst E)
4
__
__
__
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__
__
__
__

SUMMARY OF ADJUSTMENTS TO EXPENSES
Name of Plan:
Plan #: H-xxxx

CC
LINE

COST CENTER DESCRIPTIONS

1 Inpatient
2
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

WORKSHEET G
PART II

0

...........................................................
...........................................................
Outpatient
Skilled Nursing Facilities.............................. ...........................................................
Home Health Agencies................................ ...........................................................
Clinics.......................................................... ...........................................................
Physician Groups....................................... ...........................................................
Individual Physicians.................................... ...........................................................
Certified Labs............................................... ...........................................................
X-Ray Units.................................................. ...........................................................
ESRD Facilities............................................ ...........................................................
Durable Medical Equipment......................... ...........................................................
Ambulances................................................. ...........................................................
Pharmacy (Outpatient)................................. ...........................................................
Pharmacy-Medicare Covered Rx.......
...........................................................
Emergency-Urgently Needed Svcs.............. ...........................................................
Mental Health Services............................ ...........................................................
DED+CO on claims processed by MACs……
...........................................................
Other - Medicare Bad Debts...…
...........................................................
Other - Blood Deductible.....…
...........................................................
Part B Cost Not Subj to Coins.
...........................................................
Non-Allowable Costs
...........................................................
Other - (Specify)...…….......…
...........................................................
Other - (Specify)...…….......…
...........................................................
Other - (Specify)...…….......…
...........................................................

PERIOD FROM:
TO:

LINE
NUMBERS
FROM
PART I
1

01/00/00
01/00/00

Amount
(To Wkst E as
appropriate)

TRANSFER TO
WORKSHEET E
LINE # AS SHOWN

2

3

___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Plan Administration...................................... ........................................................... ___________
Special Admin Costs.................................... ........................................................... ___________

0
0

Admin & General Costs............................... ........................................................... ___________

29 Total Adjustments (Lines 1 thru 28).......................................................................................................

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.2)

0
____________
0
============

CC LINE
NUMBER
Wkst E
4

1
2
3
4
5
6
7
8
9
10
11
12
13
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS
Name of Plan:
0
Plan #: H-xxxx
Are there any costs included on Worksheet E which resulted from transactions with related organizations?
(If "YES", complete Parts B and C.)
Select
Costs incurred and adjustments required as a result of transactions with related organizations.

A.
B.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

LINE
(Wkst E)
_____
_____
_____
_____
_____
_____
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_____
_____
_____
_____
_____
_____

17

COST CENTER (Worksheet E)
1
___________________________
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___________________________
___________________________
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___________________________
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___________________________

EXPENSE ITEMS
2
___________________________
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___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________

TOTALS.........................................................................…………………………………………

WORKSHEET H
PERIOD FROM:
TO:

AMOUNT
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0
=============

01/00/00
01/00/00

AMOUNT
ALLOWABLE
IN COST
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0
=============

NET
ADJUSTMENTS (1)
(5)
(5 = 4 - 3)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0
=============

(1) Transfer the amounts in column 5 to Worksheet G, Part I, Column 2 lines 10
C.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Interrelationship of Plan to related organization(s):
The Secretary, by virtue of authority granted under section 1814(b)(1) of the Health Insurance for the Aged and Disabled Act,
required organizations to furnish the information requested on Part C of this worksheet. The information will be used by the Health
Care Financing Administration in determining that the costs applicable to services, facilities and supplies furnished by
organizations related to the Plan by common ownership or control, represent reasonable costs as determined under section 1861 of the
Health Insurance for the Aged and Disabled Act. If the Plan 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 (2)

NAME OF INDIVIDUAL

OWNERSHIP OF PLAN

1

2

3

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________

_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

(2)
A
B
D
E
F
G

----------RELATED ORGANIZATION(S)-------ORGANIZATION
OWNERSHIP
NAME
%
4
5
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________

Use the following symbols to indicate the interrelationship of the Plan to related organizations:
Individual has financial interest (stockholder, partner, etc) in both related organization and in the Plan.
Corporation, partnership, or other organization has financial interest in the Plan.
Director, officer, administrator or key person of the Plan or relative of such person has financial interest
in related organization.
Individual is director, officer, administrator, or key person of the Plan and related organization.
Director, officer, administrator, or key person of related organization or relative of such person has
financial interest in the Plan.
Other (financial or nonfinancial) specify.

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2310)

0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%

TYPE OF
BUSINESS
6
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________

ADMINISTRATIVE AND GENERAL COST ALLOCATION
Name of Plan:
Plan #: # H-xxxx

COST CENTER

Outpatient Hospitals …………….
Skilled Nursing Facilities.......….…
Home Health Agencies........….….
Clinics..........……….........….......…
Physician Groups.......................…
Individual Physicians.....…...….…
Certified Labs..................…......…
X-Ray Units....................……....…
ESRD Facilities.........................…
Durable Medical Equipment.......…
Ambulance...............……….......…
Pharmacy (Outpatient).......…...…
Pharmacy-Medicare Covered Rx
Emergency-Urgent Needed Svcs..
Mental Health Services....….……
DED+CO on claims processed by MACs
Other - Medicare Bad Debts...…
Other - Blood Deductible.....…
Part B Cost Not Subj to Coins.
Non-Allowable Costs
Other - (Specify)...…….......…
Other - (Specify)...…….......…
Other - (Specify)...…….......…

24 Subtotal (Sum of Lines 1 thru 23)...........…

0

PART I
PERIOD FROM:
TO:

1
EMPLOYEE
BENEFITS
(Salaries)

1 Inpatient Hospitals ……………….
2
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23

WORKSHEET I

2
STATISTICS
& DATA
PROCESSING
(Time Spent)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

3
PHARMACY
&
SUPPLIES
(Cost Req's)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

01/00/00
01/00/00

4
OTHER
(SPECIFY)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

29 Net A&G Costs (Lines 24+27+28)..................

30 Computation - Fr Worksheet, Col........

0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
0
0
___________
0
___________
0
0
___________
0
===========

___________

___________

___________

___________
0

___________
0

___________
0

0
___________
0
==========

0
___________
0
==========

0
___________
0
==========

0
___________
0
============

Fr Wkst I,
Pt II, Col 1

Fr Wkst I,
Pt II, Col 2

Fr Wkst I,
Pt II, Col 3

31 To Worksheet, Column........................

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2311.1)

0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
0
0
___________
0
___________
0

27 Subtotal (Sum of 25 and 26) ...................

28 Admin & General Costs...............................

6
POOLED
ADMIN & GEN
COSTS

7
TOTALS
(Col 5 +
Col 6)

SEE-WKST I SUPPL

25 Plan Administration....................................
26 Special Administrative Costs............…

Total (Sum of Lines 24 & 27)..........................

5
TOTALS
(Sum Cols
1 Thru 4)

Fr Wkst I,
Pt II, Col 4

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

___________
0

0
0
___________
0
___________
0

0
___________
0
==========

0
___________
0
==========

___________

Fr Wkst I,
Pt II, Col 7
To Wkst I,
Pt II, Col 6

To Wkst E,
Col 5

ADMINISTRATIVE AND GENERAL STATISTICS

WORKSHEET I

Name of Plan: #
Plan #: # H-xxxx

COST CENTER

0

EMPLOYEE
BENEFITS
(Salaries)
1

1 Inpatient Hospitals ……………….
2 Outpatient Hospitals …………….
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23

Skilled Nursing Facilities.......….…
Home Health Agencies........….….
Clinics..........……….........….......…
Physician Groups.......................…
Individual Physicians.....…...….…
Certified Labs..................…......…
X-Ray Units....................……....…
ESRD Facilities.........................…
Durable Medical Equipment.......…
Ambulance...............……….......…
Pharmacy (Outpatient).......…...…
Pharmacy-Medicare Covered Rx
Emergency-Urgent Needed Svcs..
Mental Health Services....….……
DED+CO on claims processed by MACs
Other - Medicare Bad Debts...…
Other - Blood Deductible.....…
Part B Cost Not Subj to Coins.
Non-Allowable Costs
Other - (Specify)...…….......…
Other - (Specify)...…….......…
Other - (Specify)...…….......…

24 Subtotal (Sum of Lines 1 thru 23)...........…

PART II
PERIOD FROM:
TO:

0
0

STATISTICS
& DATA
PROCESSING
(Time Spent)
2
0
0

PHARMACY
&
SUPPLIES
(Cost Req's)
3

01/00/00
01/00/00

OTHER
(SPECIFY)

TOTALS
(From
Worksheet E
Column 4)
5

4

0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

___________

___________

___________

___________

___________
0

___________
0

___________
0

___________

___________
0
===========

___________
0
============

___________
0
============

___________

TOTALS
(From
Wkst I,
Pt I, Col 5)
6

POOLED
ADMIN & GEN
STATS
(Cols 5+6)
7

0
0

0
0

0
0

0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

___________
0

___________
0

___________
0

___________
0
============

___________
0
============

___________
0

25 Plan Administration....................................
26 Special Administrative Costs............…
27 Subtotal (Sum of 25 and 26) ...................
Total (Sum of Lines 24 & 27)....................

0
0

28 Administrative & General Costs..................
29 TOTAL STATS (Sum of 24 & 27)...........

0
=============

30 COSTS TO BE ALLOCATED.....................
(Input here)
31 UNIT COST MULTIPLIER..........................
(Line 30 / Line 29)

0

0.000000

0.000000

0.00000

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2311.1)

0.000000

___________
0
============
Col 5 - (1+2+3+4)
0

0.000000

SUMMARY OF PROVIDER COSTS

WORKSHEET J
PAGE 1

Name of Plan:
Plan #:

PROVIDERS

0
H-xxxx

PERIOD FROM:
TO:

1

2

PROVIDER
NUMBER

REIMBURSABLE
PART A

1 Medicare Memb Mos (WS D, Pt II, Sec E, Ln 3)

01/00/00
01/00/00

3
PART A
DEDUCTIBLE +
COINSURANCE

REIMBURSABLE
PART B

0
=========

0
=========

0
=========

0
0
0
=========

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
=========

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 #
=========

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
=========

0
=========

4

5
PART B
DEDUCTIBLE

2 Hospitals
3
__________________________________
____________
4
__________________________________
____________
5
__________________________________
____________
6
__________________________________
____________
7
__________________________________
____________
8
__________________________________
____________
9
____________
10
__________________________________
____________
__________________________________
11
____________
12
__________________________________
____________
__________________________________
13
____________
14
__________________________________
____________
15
__________________________________
____________
16
__________________________________
____________
17
__________________________________
____________
18
__________________________________
____________
19
__________________________________
____________
20
__________________________________
____________
21
__________________________________
____________
22
__________________________________
____________
23
__________________________________
____________
24
__________________________________
____________
25
__________________________________
____________
26
__________________________________
____________
27
__________________________________
____________
28
__________________________________
____________
29
__________________________________
____________
30
__________________________________
____________
31
__________________________________
____________
32
__________________________________
____________
33
__________________________________
____________
34
__________________________________
____________
35
__________________________________
____________
36
__________________________________
____________
37
__________________________________
____________
38
__________________________________
____________
39
__________________________________
____________
40
__________________________________
____________
41
__________________________________
____________
42
__________________________________
____________
43
__________________________________
____________
44
__________________________________
____________
45
__________________________________
____________
46
__________________________________
____________
47
__________________________________
____________
48 Total Hospital ……………………………………………………………

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

49

Cost PMPM (Line 48 / Line 1)..........................................................

0.0000
=========

0.0000
=========

0.0000
=========

0.0000
=========

50

Enter on Worksheet, Col, Line........................................................

M, 2, 1

M, 2, 1&8

M, 3, 1

M, 3, 1

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2312)

SUMMARY OF PROVIDER COSTS

Name of Plan:
Plan #:

WORKSHEET J
(Continued)
PAGE 2
0
H-xxxx

PERIOD FROM:
TO:

1
PROVIDERS

51 Skilled Nursing Facilities:
52
__________________________________
53
__________________________________
54
__________________________________
55
__________________________________
56
__________________________________
57
__________________________________
58
__________________________________
59
__________________________________
60
__________________________________
61
__________________________________
62 Total (Sum of Lines 52 thru 61)… … … … … … … …

PROVIDER
NUMBER

2
REIMBURSABLE
PART A

3
PART A
DEDUCTIBLE+
COINSURANCE

4

5
PART B
DEDUCTIBLE

REIMBURSABLE
PART B

0
0
0
0
0
0
0
0
0
0
0
=========
0.0000

0
0
0
0
0
0
0
0
0
0
0
=========
0.0000

0
0
0
0
0
0
0
0
0
0
0
=========
0.0000

63

Cost PMPM (Line 62 / Line 1)..........................................................

0
0
0
0
0
0
0
0
0
0
0
=========
0.0000

64

Enter on Wkst, Col, Line..................................................................

M, 2, 2

M, 2, 2&8

M, 3, 2

M, 3, 2

0
0
0
0
0
0
0
0
0
0
0
_____________
0
=========
0.0000

0
0
0
0
0
0
0
0
0
0
0
_____________
0
=========
0.0000

0
0
0
0
0
0
0
0
0
0
0
_____________
0
========
0.0000

M, 2, 4&8

M, 3, 4

M, 3, 4

65 Home Health Agencies:
66
__________________________________
67
__________________________________
68
__________________________________
69
__________________________________
70
__________________________________
71
__________________________________
72
__________________________________
73
__________________________________
74
__________________________________
75 Total (Sum of Lines 66 thru 74)… … … … … … … …

____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
… … … … … … … …

01/00/00
01/00/00

____________
____________
____________
____________
____________
____________
____________
____________
____________
… … … … … … … …

76

Cost PMPM (Line 75 / Line 1)......................................................................

77

Enter on Wkst, Col, Line.................................................................................

78 Other Providers (Specify Type):
__________________________________
79
80
__________________________________
81
__________________________________
82
__________________________________
83
__________________________________
84
__________________________________
85
__________________________________
86
__________________________________
87
__________________________________
88
__________________________________
89
__________________________________

____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________

90

Total (Sum Lines 79 thru 89)...........................................................

91

Cost PMPM (Line 90 / Line 1)..........................................................

0
0
0
0
0
0
0
0
0
0
0
_____________
0
=========
0.0000

92

Enter on Wkst, Col, Line.................................................................

M, 2, 4

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2312)

SUMMARY APPORTIONMENT OF NON-PROVIDER COSTS

Name of Plan:
Plan #: H-xxxx

COST CENTERS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34

Clinics (furnished directly)........................................
Physician Groups:
Fee For Service…………………………………………
Capitation………………………………………………
Other……………………………………………………
Individual Physicians:
Fee For Service…………………………………………
Capitation………………………………………………
Other……………………………………………………
Certified Labs:
Fee For Service…………………………………………
Capitation………………………………………………
Other……………………………………………………
X-Ray Units:
Fee For Service…………………………………………
Capitation………………………………………………
Other……………………………………………………
ESRD Facilities........................................................
_________________________________
Durable Medical Equipment.....................................
Ambulance...............................................................
Emergency-Urgently Needed Svcs..........................
_________________________________
Mental Health Svcs
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

Worksheet K

0
PERIOD FROM:
TO:

1

2

STATISTIC
USED

TOTAL
STATISTICS

3
COVERED PRIM
MED ENROLLEE
STATISTICS

01/00/00
01/00/00

4
SUBPART E
LIMITS IF
APPLICABLE

5
RATIO
Col 3 or Col
4 / Col 2

6
TOTAL COSTS
(Fr Wkst E
Col 6)

___________

0

0

___________
___________
___________

0
0
0

0
0
0

0
0
0

0.0000
0.0000
0.0000

0
0
0

0
0
0

___________
___________
___________

0
0
0

0
0
0

0
0
0

0.0000
0.0000
0.0000

0
0
0

0
0
0

___________
___________
___________

0
0
0

0
0
0

0
0
0

0.0000
0.0000
0.0000

0
0
0

0
0
0

___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

35 Total (Sum Lines 1 thru 34).....................................................................
36 Member Months - Part B (W/S D, Part II, Pg 2, Pt E, Col 2, Line 1).......
37 Cost PMPM (Line 35 / Line 36)..............................................................…
38 Enter on Worksheet, Col, Line................................................................
FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2313)

0.0000

7
MEDICARE
COSTS
Col 5 X Col 6
0

0
=========
0
=========
0.0000
M, 3, 5

SUMMARY OF MISCELLANEOUS ITEMS

Name of Plan:
Plan #: H-xxxx

WORKSHEET L

0

DESCRIPTION

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

Member Months (Wkst D, Pt II, Pg 2, Pt E, Col 1 and 2, Ln 1)
Plan Administration (Wkst E, Col 6, Ln 25).......................................
Cost PMPM (Line 3 / Line 1)..............................................................

PERIOD FROM:
TO:

01/00/00
01/00/00

1

2

3

4

5

6

MEDICARE
PART A

MEDICARE
PART B

TOTAL
Col 1+Col 2

NONMEDICARE

TOTAL
Col 2+Col 4

ENTER ON
WKST LINE

0

0

0

0.0000

0.0000

0
0.0000

Special Admin Costs (Wkst E, Col 6, Ln 26).....................................
Cost PMPM (Line 6 / Line 1)..............................................................

0
0.0000

M

6

M

14

0.0000

0
0.0000

M

15

0
0.0000

0
0.0000

M

10

0.0000

0
0.0000

M

18

Pt B DED on claims processed by MACs (Wkst E, Col 6, Ln 16).....
Cost PMPM (Line 18 / Line 1)............................................................

0
0.0000

0
0.0000

M 5a

Part B Cost Not Subject to Coinsurance (Wkst E, Col 6, Ln 19)…..……
Cost PMPM (Line 21 / Line 1)………………………………………………

0
0.0000

0
0.0000

M

Allowable Medicare Bad Debts (Wkst E, Col 6, Line 17)..................
Cost PMPM (Line 9 / Line 1)..............................................................

0.0000

Part B Blood Deductible (Wkst E, Col 6, Line 18).....................
Cost PMPM (Line 12 / Line 1)............................................................
Third Party Insurer Revenue (see Instructions).................................
Cost PMPM (Line 15 / Line 1)............................................................

0.0000

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2314)

16

SETTLEMENT SHEET

Name of Plan:
Plan #: H-xxxx

DESCRIPTION

1
2
3
4
5
5a
6

Hospital Costs………………………………………………………………………………
Skilled Nursing Facility Costs……………………………………………………………
Home Health Agency Costs………………………………………………………………
Other Provider's Costs ……………………………………………………………………
Nonprovider Costs…………………………………………………………………………
DED on claims processed by MACs……………………...……………..………………
Plan Administration Costs…………………………………………………………………

7

Totals (Sum Lines 1 - 6)…………………………………………………………………

8
9
10

Part A Deductible and Coinsurance……………………………………………………
Part B Standard Deductible………………………………………………………………
Part B Blood Deductible…………………………………………………………………

11

Line 7 Minus (The Sum of Lines 8 - 10)…………………………………………………

12

20% of (Col 3 Line 11 minus Col 3 Line 3)………………………………………………

13
14
15
16
17
18

Reimbursable Costs (Line 11 Minus Line 12)…………………………………………
Special Administrative Costs……………………………………………………………
Medicare Bad Debts………………………………………………………………………
Part B Cost Not Subject to Coinsurance………………………………………………
Total (Sum Lines 13 thru 16)……………………………………………………………
Less: Third Party Insurer Revenue………………………………………………………

19
20

Medicare Costs (Line 17 minus Line 18)………………………………………………
Medicare Primary Member Months………………………………………………………

21
22

Reimbursable Costs (Line 19 X Line 20)………………………………………………
Interim Payments (by) to CMS……………………………………………………………

PERIOD FROM:
TO:

FROM
WKST
1
J
J
J
J
K
L
L

J

0.0000
___________
0.0000

___________
0.0000

___________
0.0000
L
L
L
L

D

Balance Due Plan (CMS) (Line 23 + or - Lines 24-29).....……………………………

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2315)

MEDICARE
PART B
3
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
___________
0.0000

0

L

23 Balance (Line 21 plus Line 22)……………………………………………………………
Adjustments:
24 ____________________________________________
25 ____________________________________________
26 ____________________________________________
27 ____________________________________________
28 ____________________________________________
29 ____________________________________________
30

MEDICARE
PART A
2
0.0000
0.0000
0.0000
0.0000

01/00/00 WORKSHEET M
01/00/00

0.0000
0.0000
0.0000
0.0000
___________
0.0000
0
___________
0

0.0000
0.0000
___________
0.0000
0.0000
___________
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
___________
0.0000
0
___________
0

TOTAL
Col 2 + Col 3
4
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0
___________
0

0
=========

MEDICARE PREMIUM RECONCILIATION
Name of Plan: 0
Plan Number: H-xxxx

WORKSHEET N
Period From:
To:

01/00/00
01/00/00

Under and Over Collection of Medicare Premiums - Current Year
Premium Determinations Covered by this Part
0 Total Medicare Member Months

Member
Months
2

Totals
1
XXXXXXXXXXXX

1 Total Premiums/Dues collected during the period
2 Total Copayments collected during the period

-

3 Total Collections (Line 1 plus Line 2)

-

4 Less: Accounts Receivable for premiums/dues and copayments (beg of period)

-

5 Net Collections for period (Line 3 minus Line 4)
6 Add: Accounts Receivable for premiums/dues and copayments (end of period)

-

7 Net Collections and Amounts to be Collected (Line 5 plus Line 6)

-

8 Total Medicare Deductible and Coinsurance from Cost Report:
a. Deductible and copayments (Worksheet M, Col 2 + 3 , Sum lines 8 thru 10)
b. Part B Coinsurance (Worksheet M, Col 3, Line 12)
c. CO on claims processed by MACs (Worksheet G, Col 2, Line 23/Col 2, Ln 0)

9a
9b
9c
9d

Cost Per
Member Month Line
3
0 XXXXXXXXXXXX

XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX

0

-

1
2

-

3

-

4

-

5
6

-

7

XXXXXXXXXXXX XXXXXXXXXXXX
XXXXXXXXXXXX XXXXXXXXXXXX
XXXXXXXXXXXX XXXXXXXXXXXX

0.0000
0.0000
#DIV/0!

8
8a
8b
8c

d. Total (Sum of Lines 8a thru 8c)

XXXXXXXXXXXX XXXXXXXXXXXX

#DIV/0!

8d

(Over)/Involuntary Under collection from prior period (Worksheet N, Line 11/12b, respectively)
**Note**Prior Period = Current Period -2 Years
Prior Period Member Months (Worksheet N, Line 0)
Gross (over)/under collections from prior period
Adjusted (over)/under collection from the prior period

XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
0 XXXXXXXXXXXX XXXXXXXXXXXX
XXXXXXXXXXXX XXXXXXXXXXXX
#DIV/0!

9

10 Total amount allowed to be charged (Line 8d plus line 9d)

XXXXXXXXXXXX XXXXXXXXXXXX

#DIV/0!

10

11 Actual (Over) under collection for the period (Line 10 minus Line 7). Stop here if (over)collection

XXXXXXXXXXXX XXXXXXXXXXXX

#DIV/0!

11

XXXXXXXXXXXX XXXXXXXXXXXX
XXXXXXXXXXXX XXXXXXXXXXXX
XXXXXXXXXXXX XXXXXXXXXXXX

0.0000 12
#DIV/0!
12a
#DIV/0!
12b

12 Budgeted Voluntary under collection for the period (Worksheet B, Line 8)
12a Actual Voluntary under collection - No recoupment
12b Involuntary Under collection - may recoup during subsequent period
FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2316)

Special Administration Costs
Accretion/Deletion Cost
Certification Cost
Special Studies
Other (Specify)
Total Special Administration Cost

Amount

0

SUBPART E LIMITS
Name of Plan:
Plan #:

0
H-xxxx

Period From:
To:

Is this Plan an HCPP subject to the Subpart E Limits?
COMPARABLE
CARRIER
PAYMENTS

COST CENTERS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Physician Groups:
Fee For Service… … … … … … … … … … … … … … … … … …
Capitation… … … … … … … … … … … … … … … … … … … … … …
Other… … … … … … … … … … … … … … … … … … … … … … … …
Individual Physicians:
Fee For Service… … … … … … … … … … … … … … … … … …
Capitation… … … … … … … … … … … … … … … … … … … … … …
Other… … … … … … … … … … … … … … … … … … … … … … … …
Certified Labs:
Fee For Service… … … … … … … … … … … … … … … … … …
Capitation… … … … … … … … … … … … … … … … … … … … … …
Other… … … … … … … … … … … … … … … … … … … … … … … …
X-Ray Units:
Fee For Service… … … … … … … … … … … … … … … … … …
Capitation… … … … … … … … … … … … … … … … … … … … … …
Other… … … … … … … … … … … … … … … … … … … … … … … …
ESRD Facilities................................................................
_________________________________
Durable Medical Equipment.........................................
Ambulance..........................................................................
Emergency-Urgently Needed Svcs............................
Mental Health Svcs
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

..

..

..

..

0
0

Yes
No

STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS
Name of Plan:
Plan #: H-xxxx
C.

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
60
61
62
63
64
65
66
67
68
69

WORKSHEET H
0

PERIOD FROM:
TO:

01/00/00
01/00/00

Interrelationship of Plan to related organization(s):
The Secretary, by virtue of authority granted under section 1814(b)(1) of the Health Insurance for the Aged and Disabled Act,
required organizations to furnish the information requested on Part C of this worksheet. The information will be used by the Health
Care Financing Administration in determining that the costs applicable to services, facilities and supplies furnished by
organizations related to the Plan by common ownership or control, represent reasonable costs as determined under section 1861 of the
Health Insurance for the Aged and Disabled Act. If the Plan 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 (2)

NAME OF INDIVIDUAL

OWNERSHIP OF PLAN

1

2

3

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________

_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

(2)
A
B
D
E
F
G

----------RELATED ORGANIZATION(S)-------ORGANIZATION
OWNERSHIP
NAME
%
4
5
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________

Use the following symbols to indicate the interrelationship of the Plan to related organizations:
Individual has financial interest (stockholder, partner, etc) in both related organization and in the Plan.
Corporation, partnership, or other organization has financial interest in the Plan.
Director, officer, administrator or key person of the Plan or relative of such person has financial interest
in related organization.
Individual is director, officer, administrator, or key person of the Plan and related organization.
Director, officer, administrator, or key person of related organization or relative of such person has
financial interest in the Plan.
Other (financial or nonfinancial) specify.

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2310)

0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%

TYPE OF
BUSINESS
6
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________

A. If the Plan utilizes any allocation method other than pooled A&G allocation, provide a detailed explanation of the allocation methodology
for each cost center represented on Worksheet I (see 42 CFR 417.564 for guidance on A&G allocation). The Plan shall describe the
specific business component A&G cost, allocation statistic and justification logic used in determining reasonable allocation in relation
to the benefits received by component. Please provide response to Part B below as well. 

B. If the A&G allocation (Worksheet E, Column 5) exceeds the amount listed for the corresponding cost center
(Worksheet E, Column 4), then please provide further explanation below, specifically when allocating cost to Medicare only
lines such as Line 16 and Line 19.
A&G
COST CENTER

1
2
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23

Inpatient Hospitals ……………….
Outpatient Hospitals …………….
Skilled Nursing Facilities.......….…
Home Health Agencies........….….
Clinics..........……….........….......…
Physician Groups.......................…
Individual Physicians.....…...….…
Certified Labs..................…......…
X-Ray Units....................……....…
ESRD Facilities.........................…
Durable Medical Equipment.......…
Ambulance...............……….......…
Pharmacy (Outpatient).......…...…
Pharmacy-Medicare Covered Rx
Emergency-Urgent Needed Svcs..
Mental Health Services....….……
DED+CO on claims processed by MACs
Other - Medicare Bad Debts...…
Other - Blood Deductible.....…
Part B Cost Not Subj to Coins.
Non-Allowable Costs
Other - (Specify)...…….......…
Other - (Specify)...…….......…
Other - (Specify)...…….......…

24 Subtotal (Sum Lines 1-23)......................
25 Plan Administration..............…..…
26 Special Admin Costs................…
27 Subtotal: (Sum Lns 25+26).....................
28 Admin & General Costs...…......…

ALLOWABLE
COST

ALLOCATION TOTALS
(WKST I,

(Col 1 thru 3)
4

Part I)

(Col 4 + Col 5)
6

5

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
____________ ___________
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0

0
0
0
0
____________ ___________
0
0

0
0
___________
0

0
0
____________ ___________

0
___________

29 Total Program Costs (24+27+28)...........

0
=========

0
=========

0
=========

Explanation