CMS-276 Prepaid Health Plan Cost Report

Prepaid Health Plan Cost Report

Revised 4th Quarter Interim Cost Report.xlsx

Prepaid Health Plan Cost Report (HCPPS)

OMB: 0938-0165

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0165 can be found here:

Document [xlsx]

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Overview

Worksheet S
Worksheet D
Worksheet E
Worksheet F
Worksheet G
Worksheet H
Worksheet I
Worksheet J
Worksheet K
Worksheet L
Worksheet M
Worksheet N
Special Administration Costs
Subpart E Limits
H-part C, Supplemental
I-Supplemental Descriptions

Sheet 1: Worksheet S

						version 4.0
This report is required by law (42 USC 1395mm and 42 USC 1995I).						FORM APPROVED
Failure to report can result in all interim payments made since						OMB NO. 0938-0165
the beginning of the cost reporting period being deemed overpayments.



	PREPAID HEALTH PLAN COST REPORT					WORKSHEET S
	GENERAL INFORMATION

1	Name and Address of Plan:






2	Reporting Period:					Plan Number:
		From:
						H-xxxx
		To:

3	a. Type of Report:		b. Bill Processing Option:		c. Reimbursement Under:

	[ ] Budget Forecast	Budget Forecast		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

Sheet 2: Worksheet D

	PLAN STATISTICS											WORKSHEET D
												PART I
		Name of Plan:	0									Page 1
		Plan #:	H-xxxx
						PERIOD FROM:			12/30/99
							TO:		12/30/99

					BILLS				TOTAL		COV MED		COV MED
			PROVIDER	RELATION-	PROCESSED		TOTAL		MEDICARE		PRIMARY		SECONDARY
			NUMBER	SHIP (1)	BY (2)		DAYS		DAYS*		DAYS		DAYS
LIST OF PROVIDERS
			1	2	3		4		5		6		7

	A. Hospitals & SNF's:
1		________________________________	________	_	_		0		0		0		0
2		________________________________	________	_	_		0		0		0		0
3		________________________________	________	_	_		0		0		0		0
4		________________________________	________	_	_		0		0		0		0
5		________________________________	________	_	_		0		0		0		0
6		________________________________	________	_	_		0		0		0		0
7		________________________________	________	_	_		0		0		0		0
8		________________________________	________	_	_		0		0		0		0
9		________________________________	________	_	_		0		0		0		0
10		________________________________	________	_	_		0		0		0		0
11		________________________________	________	_	_		0		0		0		0
12		________________________________	________	_	_		0		0		0		0
13		________________________________	________	_	_		0		0		0		0
14		________________________________	________	_	_		0		0		0		0
15		________________________________	________	_	_		0		0		0		0
16		________________________________	________	_	_		0		0		0		0
17		________________________________	________	_	_		0		0		0		0
18		________________________________	________	_	_		0		0		0		0
19		________________________________	________	_	_		0		0		0		0
20		________________________________	________	_	_		0		0		0		0
21		________________________________	________	_	_		0		0		0		0
22		________________________________	________	_	_		0		0		0		0
23		________________________________	________	_	_		0		0		0		0
24		________________________________	________	_	_		0		0		0		0
25		________________________________	________	_	_		0		0		0		0
26		________________________________	________	_	_		0		0		0		0
27		________________________________	________	_	_		0		0		0		0
28		________________________________	________	_	_		0		0		0		0
29		________________________________	________	_	_		0		0		0		0
30		________________________________	________	_	_		0		0		0		0
31		________________________________	________	_	_		0		0		0		0
32		________________________________	________	_	_		0		0		0		0
33		________________________________	________	_	_		0		0		0		0
34		________________________________	________	_	_		0		0		0		0
35		________________________________	________	_	_		0		0		0		0
36		________________________________	________	_	_		0		0		0		0
37		________________________________	________	_	_		0		0		0		0
38		________________________________	________	_	_		0		0		0		0
39		________________________________	________	_	_		0		0		0		0
40		________________________________	________	_	_		0		0		0		0
41		________________________________	________	_	_		0		0		0		0
42		________________________________	________	_	_		0		0		0		0
43		________________________________	________	_	_		0		0		0		0
44		________________________________	________	_	_		0		0		0		0
45		________________________________	________	_	_		0		0		0		0
46		________________________________	________	_	_		0		0		0		0
47		________________________________	________	_	_		0		0		0		0
48		________________________________	________	_	_		0		0		0		0
49		________________________________	________	_	_		0		0		0		0
50		________________________________	________	_	_		0		0		0		0
51		________________________________	________	_	_		0		0		0		0
52		________________________________	________	_	_		0		0		0		0

									* Note: Col 5 minus 6 & 7 = Non-covered
			(1)				(2)
			O - OWNED OR CONTROLLED				H - PROCESSED BY HCFA
			P - PURCHASED				P - PROCESSED BY PLAN

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

	PLAN STATISTICS											WORKSHEET D
												PART 1
		Name of Plan:	0									Page 2
		Plan #:	H-xxxx
						PERIOD FROM:			12/30/99
							TO:		12/30/99

					BILLS				TOTAL		COV MED		COV MED
			PROVIDER	RELATION-	PROCESSED		TOTAL		MEDICARE		PRIMARY		SECONDARY
			NUMBER	SHIP (1)	BY (2)		VISITS		VISITS*		VISITS		VISITS
LIST OF PROVIDERS
			1	2	3		4		5		6		7

	B. HHA's:
1		________________________________	________	_	_		0		0		0		0
2		________________________________	________	_	_		0		0		0		0
3		________________________________	________	_	_		0		0		0		0
4		________________________________	________	_	_		0		0		0		0
5		________________________________	________	_	_		0		0		0		0
6		________________________________	________	_	_		0		0		0		0
7		________________________________	________	_	_		0		0		0		0
8		________________________________	________	_	_		0		0		0		0
9		________________________________	________	_	_		0		0		0		0
10		________________________________	________	_	_		0		0		0		0
11		________________________________	________	_	_		0		0		0		0
12		________________________________	________	_	_		0		0		0		0
13		________________________________	________	_	_		0		0		0		0
14		________________________________	________	_	_		0		0		0		0
15		________________________________	________	_	_		0		0		0		0
16		________________________________	________	_	_		0		0		0		0
17		________________________________	________	_	_		0		0		0		0
18		________________________________	________	_	_		0		0		0		0
19		________________________________	________	_	_		0		0		0		0
20		________________________________	________	_	_		0		0		0		0
21		________________________________	________	_	_		0		0		0		0
22		________________________________	________	_	_		0		0		0		0
23		________________________________	________	_	_		0		0		0		0
24		________________________________	________	_	_		0		0		0		0
25		________________________________	________	_	_		0		0		0		0
	C. Other (Specify Name & Type):
1		________________________________	________	_	_		0		0		0		0
2		________________________________	________	_	_		0		0		0		0
3		________________________________	________	_	_		0		0		0		0
4		________________________________	________	_	_		0		0		0		0
5		________________________________	________	_	_		0		0		0		0
6		________________________________	________	_	_		0		0		0		0
7		________________________________	________	_	_		0		0		0		0
8		________________________________	________	_	_		0		0		0		0
9		________________________________	________	_	_		0		0		0		0
10		________________________________	________	_	_		0		0		0		0
11		________________________________	________	_	_		0		0		0		0
12		________________________________	________	_	_		0		0		0		0
13		________________________________	________	_	_		0		0		0		0
14		________________________________	________	_	_		0		0		0		0
15		________________________________	________	_	_		0		0		0		0
16		________________________________	________	_	_		0		0		0		0
17		________________________________	________	_	_		0		0		0		0
18		________________________________	________	_	_		0		0		0		0
19		________________________________	________	_	_		0		0		0		0
20		________________________________	________	_	_		0		0		0		0
21		________________________________	________	_	_		0		0		0		0
22		________________________________	________	_	_		0		0		0		0
23		________________________________	________	_	_		0		0		0		0
24		________________________________	________	_	_		0		0		0		0
25		________________________________	________	_	_		0		0		0		0

									* Note: Col 5 minus 6 & 7 = Non-covered
			(1)				(2)
			O - OWNED OR CONTROLLED				H - PROCESSED BY HCFA
			P - PURCHASED				P - PROCESSED BY PLAN

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


	PLAN STATISTICS											WORKSHEET D
												PART II
		Name of Plan:	0									Page 1
		Plan #:	H-xxxx
						PERIOD FROM:			12/30/99
							TO:		12/30/99

					HOW					STATISTICS
			TYPE OF	PAYMENT	PHYSICIANS				TOTAL		COVERED MED		COVERED MED
			GROUP	MECHANISM	PAID		TOTAL		MEDICARE *		PRIMARY		SECONDARY
LIST OF SUPPLIERS			(1)	(2)	(2)
			1	2	3		4		5		6		7

	A.	Physician Services:
1		________________________________	_	_	_		0		0		0		0
2		________________________________	_	_	_		0		0		0		0
3		________________________________	_	_	_		0		0		0		0
4		________________________________	_	_	_		0		0		0		0
5		________________________________	_	_	_		0		0		0		0
6		________________________________	_	_	_		0		0		0		0
7		________________________________	_	_	_		0		0		0		0
8		________________________________	_	_	_		0		0		0		0
9		________________________________	_	_	_		0		0		0		0
10		________________________________	_	_	_		0		0		0		0
11		________________________________	_	_	_		0		0		0		0
12		________________________________	_	_	_		0		0		0		0
13		________________________________	_	_	_		0		0		0		0
14		________________________________	_	_	_		0		0		0		0
15		________________________________	_	_	_		0		0		0		0
16		________________________________	_	_	_		0		0		0		0
17		________________________________	_	_	_		0		0		0		0
18		________________________________	_	_	_		0		0		0		0
19		________________________________	_	_	_		0		0		0		0
20		________________________________	_	_	_		0		0		0		0
21		________________________________	_	_	_		0		0		0		0
22		________________________________	_	_	_		0		0		0		0
23		________________________________	_	_	_		0		0		0		0
24		________________________________	_	_	_		0		0		0		0
25		________________________________	_	_	_		0		0		0		0
26		________________________________	_	_	_		0		0		0		0
27		________________________________	_	_	_		0		0		0		0
28		________________________________	_	_	_		0		0		0		0
29		________________________________	_	_	_		0		0		0		0
30		________________________________	_	_	_		0		0		0		0
31		________________________________	_	_	_		0		0		0		0
32		________________________________	_	_	_		0		0		0		0
33		________________________________	_	_	_		0		0		0		0
34		________________________________	_	_	_		0		0		0		0
35		________________________________	_	_	_		0		0		0		0
36		________________________________	_	_	_		0		0		0		0
37		________________________________	_	_	_		0		0		0		0
38		________________________________	_	_	_		0		0		0		0
39		________________________________	_	_	_		0		0		0		0
40		________________________________	_	_	_		0		0		0		0
41		Physician Groups:
42		Fee For Service					0		0		0		0
43		Capitation					0		0		0		0
44		Other					0		0		0		0
45		Individual Physicians:
46		Fee For Service					0		0		0		0
47		Capitation					0		0		0		0
48		Other					0		0		0		0


		(1)				(2)
		A - IPA				A - FEE-FOR-SERVICE
		B - GROUP PRACTICE				B - CAPITATION
		C - STAFF				C - OTHER-SPECIFY
		D - INDIVIDUAL PRACTITIONERS
						*	Note Col 5 minus 6 & 7 = Non-covered


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

	PLAN STATISTICS											WORKSHEET D
												PART II
		Name of Plan:	0									Page 2
		Plan #:	H-xxxx
						PERIOD FROM:			12/30/99
							TO:		12/30/99

					HOW				STATISTICS
			TYPE OF	PAYMENT	PHYSICIANS				TOTAL		COVERED MED		COVERED MED
			GROUP	MECHANISM	PAID		TOTAL		MEDICARE*		PRIMARY		SECONDARY
LIST OF SUPPLIERS			(1)	(2)	(2)
			1	2	3		4		5		6		7

	B. Certified Labs:
1		________________________________	_	_	_		0		0		0		0
2		________________________________	_	_	_		0		0		0		0
3		________________________________	_	_	_		0		0		0		0
4		________________________________	_	_	_		0		0		0		0
5		________________________________	_	_	_		0		0		0		0
6		________________________________	_	_	_		0		0		0		0
7		________________________________	_	_	_		0		0		0		0
8		Certified Labs
9		Fee For Service					0		0		0		0
10		Capitation					0		0		0		0
11		Other					0		0		0		0

	C. X-Ray Units:
1		____________________________________________	_	_	_		0		0		0		0
2		____________________________________________	_	_	_		0		0		0		0
3		____________________________________________	_	_	_		0		0		0		0
4		____________________________________________	_	_	_		0		0		0		0
5		____________________________________________	_	_	_		0		0		0		0
6		____________________________________________	_	_	_		0		0		0		0
7		____________________________________________	_	_	_		0		0		0		0
8		X-Ray Units
9		Fee For Service					0		0		0		0
10		Capitation					0		0		0		0
11		Other					0		0		0		0

	D. Others (Specify):
1		____________________________________________	_	_	_		0		0		0		0
2		____________________________________________	_	_	_		0		0		0		0
3		____________________________________________	_	_	_		0		0		0		0
4		____________________________________________	_	_	_		0		0		0		0
5		____________________________________________	_	_	_		0		0		0		0
6		____________________________________________	_	_	_		0		0		0		0
7		____________________________________________	_	_	_		0		0		0		0
8		____________________________________________	_	_	_		0		0		0		0
9		____________________________________________	_	_	_		0		0		0		0
10		____________________________________________	_	_	_		0		0		0		0
11		____________________________________________	_	_	_		0		0		0		0
12		____________________________________________	_	_	_		0		0		0		0
13		____________________________________________	_	_	_		0		0		0		0
14		________________________________	_	_	_		0		0		0		0

									* Note: Col 5 minus 6 & 7 = Non-covered
(1)		(1)				(2)
A - IPA		A - IPA				A - FEE-FOR-SERVICE
B - GROUP PRACTICE		B - GROUP PRACTICE				B - CAPITATION
C - STAFF		C - STAFF				C - OTHER-SPECIFY
D - INDIVIDUAL PRACTITIONERS		D - INDIVIDUAL PRACTITIONERS

											MEDICARE		MEDICARE
	E. MEMBERSHIP:										PART A		PART B
											1		2
1	Total Medicare Member Months....................................................................................................................................................................................……………….										0		0
2	Medicare Secondary Liable (Employer Groups) Member Months................................................................................................................................................................................
											__________		__________
3	Medicare Primary Member Months (Line 1 minus Line 2).......................................................................................................................................................................................................										0		0
4	Ratio (Line 3 & Line 1)....................................................................................................................................................................................................................................										0.0000		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)

Sheet 3: Worksheet E

	SUMMARY TRIAL BALANCE						WORKSHEET E

		Name of Plan:	0
		Plan #:	H-xxxx
					PERIOD FROM:	12/30/99
					TO:	12/30/99

						A & G			TRANSFER
		TRIAL	RECLASSIFI-	ADJUSTMENTS	ALLOWABLE	ALLOCATION	TOTALS		TO
	COST CENTER	BALANCE	CATIONS		COST	(WKST I,		WKST, LINE
			(WKST F)	(WKST G)	(Col 1 thru 3)	Part I)	(Col 4 + Col 5)
		1	2	3	4	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
3	Skilled Nursing Facilities.......….…		0	0	0	0	0		J 52-61
4	Home Health Agencies........….….		0	0	0	0	0		J 66-74
5	Clinics..........……….........….......…		0	0	0	0	0		K \| 1
6	Physician Groups.......................…		0	0	0	0	0		K \| 3-5
7	Individual Physicians.....…...….…		0	0	0	0	0		K \| 7-9
8	Certified Labs..................…......…		0	0	0	0	0		K \| 11-13
9	X-Ray Units....................……....…		0	0	0	0	0		K \| 15-17
10	ESRD Facilities.........................…		0	0	0	0	0		K \| 18
11	Durable Medical Equipment.......…		0	0	0	0	0		K \| 20
12	Ambulance...............……….......…		0	0	0	0	0		K \| 21
13	Pharmacy (Outpatient).......…...…		0	0	0	0	0
13a	Pharmacy-Medicare Covered Rx		0	0	0	0	0
14	Emergency-Urgent Needed Svcs..		0	0	0	0	0		K \| 22
15	Mental Health Services....….……		0	0	0	0	0		K \| 24
16	DED+CO on claims processed by MACs		0	0	0	0	0		L \| 18
17	Other - Medicare Bad Debts...…		0	0	0	0	0		L \| 9
18	Other - Blood Deductible.....…		0	0	0	0	0		L \| 12
19	Part B Cost Not Subj to Coins.		0	0	0	0	0		L \| 21
20	Non-Allowable Costs		0	0	0	0	0
21	Other - (Specify)...…….......…		0	0	0	0	0		J&K \|
22	Other - (Specify)...…….......…		0	0	0	0	0		J&K \|
23	Other - (Specify)...…….......…		0	0	0	0	0		J&K \|
			_____________	_____________	_____________	_____________	___________
24	Subtotal (Sum Lines 1-23).................................................................................................	0	0	0	0	0	0

25	Plan Administration..............…..…		0	0	0	0	0		L \| 3
26	Special Admin Costs................…		0	0	0	0	0		L \| 6
			_____________	_____________	_____________	_____________	___________
27	Subtotal: (Sum Lns 25+26)...................................................................................................................................	0	0	0	0	0	0

28	Admin & General Costs...…......…		0	0	0	0	0
			_____________	_____________	_____________	_____________	___________

29	Total Program Costs (24+27+28)......................................................................................................................	0	0	0	0	0	0
		=========	=========	=========	=========	=========	=========

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

Sheet 4: Worksheet F

	RECLASSIFICATIONS						WORKSHEET F
	Name of Plan:	0					Page 1
	Plan #:	H-xxxx		PERIOD FROM:	12/30/99
				TO:	12/30/99

				CC LINE		AMOUNT (2)
		CODE	COST CENTER	NUMBER
LINE	EXPLANATION OF RECLASSIFICATION ENTRY	(1)	(Worksheet E)	(WKST E)	INCREASES		(DECREASES)
		1	2	3	4		5

1	____________________________________________	______	_________________________	___________	0		0
2	____________________________________________	______	_________________________	___________	0		0
3	____________________________________________	______	_________________________	___________	0		0
4	____________________________________________	______	_________________________	___________	0		0
5	____________________________________________	______	_________________________	___________	0		0
6	____________________________________________	______	_________________________	___________	0		0
7	____________________________________________	______	_________________________	___________	0		0
8	____________________________________________	______	_________________________	___________	0		0
9	____________________________________________	______	_________________________	___________	0		0
10	____________________________________________	______	_________________________	___________	0		0
11	____________________________________________	______	_________________________	___________	0		0
12	____________________________________________	______	_________________________	___________	0		0
13	____________________________________________	______	_________________________	___________	0		0
14	____________________________________________	______	_________________________	___________	0		0
15	____________________________________________	______	_________________________	___________	0		0
16	____________________________________________	______	_________________________	___________	0		0
17	____________________________________________	______	_________________________	___________	0		0
18	____________________________________________	______	_________________________	___________	0		0
19	____________________________________________	______	_________________________	___________	0		0
20	____________________________________________	______	_________________________	___________	0		0
21	____________________________________________	______	_________________________	___________	0		0
22	____________________________________________	______	_________________________	___________	0		0
23	____________________________________________	______	_________________________	___________	0		0
24	____________________________________________	______	_________________________	___________	0		0
25	____________________________________________	______	_________________________	___________	0		0
26	____________________________________________	______	_________________________	___________	0		0
27	____________________________________________	______	_________________________	___________	0		0
28	____________________________________________	______	_________________________	___________	0		0
29	____________________________________________	______	_________________________	___________	0		0
30	____________________________________________	______	_________________________	___________	0		0
31	____________________________________________	______	_________________________	___________	0		0
32	____________________________________________	______	_________________________	___________	0		0
33	____________________________________________	______	_________________________	___________	0		0
34	____________________________________________	______	_________________________	___________	0		0
35	____________________________________________	______	_________________________	___________	0		0
36	____________________________________________	______	_________________________	___________	0		0
37	____________________________________________	______	_________________________	___________	0		0
38	____________________________________________	______	_________________________	___________	0		0
39	____________________________________________	______	_________________________	___________	0		0
40	____________________________________________	______	_________________________	___________	0		0
41	____________________________________________	______	_________________________	___________	0		0
42	____________________________________________	______	_________________________	___________	0		0
43	____________________________________________	______	_________________________	___________	0		0
44	____________________________________________	______	_________________________	___________	0		0
45	____________________________________________	______	_________________________	___________	0		0
46	____________________________________________	______	_________________________	___________	0		0
47	____________________________________________	______	_________________________	___________	0		0
48	____________________________________________	______	_________________________	___________	0		0
49	____________________________________________	______	_________________________	___________	0		0
50	____________________________________________	______	_________________________	___________	0		0
					___________		___________
51	Page total......................................................................................................................	.	.	.	0		0
52	a. Subtotal from Page 2.................................................................................................................	.	.	.	0		0
	b. Subtotal from Page 3.................................................................................................................	.	.	.	0		0
	c. Subtotal from Page 4.................................................................................................................	.	.	.	0		0
53	Total Reclassifications (Col 4 must equal Col 5)......................................................................................................	.	.	.	0		0
					============		============
	(1) A Letter (A, B, etc.) Must Be Entered on Each Line to Identify Each Reclassification Entry.				Net, must be 0		0
	(2) Transfer to Worksheet E, Col. 2, lines as appropriate.						============
					Summarized on Worksheet F, Page 3

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


RECLASSIFICATIONS							WORKSHEET F
	Name of Plan:	0					Page 2
	Plan #:	H-xxxx		PERIOD FROM:	12/30/99
				TO:	12/30/99


				CC LINE		AMOUNT
		CODE	COST CENTER	NUMBER
LINE	EXPLANATION OF RECLASSIFICATION ENTRY	(1)	(Worksheet E)	(WKST E)	INCREASES		(DECREASES)
		1	2	3	4		5
54	____________________________________________	______	_________________________	___________	0		0
55	____________________________________________	______	_________________________	___________	0		0
56	____________________________________________	______	_________________________	___________	0		0
57	____________________________________________	______	_________________________	___________	0		0
58	____________________________________________	______	_________________________	___________	0		0
59	____________________________________________	______	_________________________	___________	0		0
60	____________________________________________	______	_________________________	___________	0		0
61	____________________________________________	______	_________________________	___________	0		0
62	____________________________________________	______	_________________________	___________	0		0
63	____________________________________________	______	_________________________	___________	0		0
64	____________________________________________	______	_________________________	___________	0		0
65	____________________________________________	______	_________________________	___________	0		0
66	____________________________________________	______	_________________________	___________	0		0
67	____________________________________________	______	_________________________	___________	0		0
68	____________________________________________	______	_________________________	___________	0		0
69	____________________________________________	______	_________________________	___________	0		0
70	____________________________________________	______	_________________________	___________	0		0
71	____________________________________________	______	_________________________	___________	0		0
72	____________________________________________	______	_________________________	___________	0		0
73	____________________________________________	______	_________________________	___________	0		0
74	____________________________________________	______	_________________________	___________	0		0
75	____________________________________________	______	_________________________	___________	0		0
76	____________________________________________	______	_________________________	___________	0		0
77	____________________________________________	______	_________________________	___________	0		0
78	____________________________________________	______	_________________________	___________	0		0
79	____________________________________________	______	_________________________	___________	0		0
80	____________________________________________	______	_________________________	___________	0		0
81	____________________________________________	______	_________________________	___________	0		0
82	____________________________________________	______	_________________________	___________	0		0
83	____________________________________________	______	_________________________	___________	0		0
84	____________________________________________	______	_________________________	___________	0		0
85	____________________________________________	______	_________________________	___________	0		0
86	____________________________________________	______	_________________________	___________	0		0
87	____________________________________________	______	_________________________	___________	0		0
88	____________________________________________	______	_________________________	___________	0		0
89	____________________________________________	______	_________________________	___________	0		0
90	____________________________________________	______	_________________________	___________	0		0
91	____________________________________________	______	_________________________	___________	0		0
92	____________________________________________	______	_________________________	___________	0		0
93	____________________________________________	______	_________________________	___________	0		0
94	____________________________________________	______	_________________________	___________	0		0
95	____________________________________________	______	_________________________	___________	0		0
96	____________________________________________	______	_________________________	___________	0		0
97	____________________________________________	______	_________________________	___________	0		0
98	____________________________________________	______	_________________________	___________	0		0
99	____________________________________________	______	_________________________	___________	0		0
100	____________________________________________	______	_________________________	___________	0		0
101	____________________________________________	______	_________________________	___________	0		0
102	____________________________________________	______	_________________________	___________	0		0
103	____________________________________________	______	_________________________	___________	0		0
104	____________________________________________	______	_________________________	___________	0		0
105	____________________________________________	______	_________________________	___________	0		0
106	____________________________________________	______	_________________________	___________	0		0
107	____________________________________________	______	_________________________	___________	0		0
108	____________________________________________	______	_________________________	___________	0		0
109	____________________________________________	______	_________________________	___________	0		0
					___________		___________
110	Total Page 2 (Col 4 must equal Col 5)..............................................................	.	.	.	0		0
					============		============
	(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.				Summarized on Worksheet F, Page 3
	(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)

RECLASSIFICATIONS							WORKSHEET F
	Name of Plan:	0					Page 3
	Plan #:	H-xxxx		PERIOD FROM:	12/30/99
				TO:	12/30/99


				CC LINE		AMOUNT
		CODE	COST CENTER	NUMBER
LINE	EXPLANATION OF RECLASSIFICATION ENTRY	(1)	(Worksheet E)	(WKST E)	INCREASES		(DECREASES)
		1	2	3	4		5
111	____________________________________________	______	_________________________	___________	0		0
112	____________________________________________	______	_________________________	___________	0		0
113	____________________________________________	______	_________________________	___________	0		0
114	____________________________________________	______	_________________________	___________	0		0
115	____________________________________________	______	_________________________	___________	0		0
116	____________________________________________	______	_________________________	___________	0		0
117	____________________________________________	______	_________________________	___________	0		0
118	____________________________________________	______	_________________________	___________	0		0
119	____________________________________________	______	_________________________	___________	0		0
120	____________________________________________	______	_________________________	___________	0		0
121	____________________________________________	______	_________________________	___________	0		0
122	____________________________________________	______	_________________________	___________	0		0
123	____________________________________________	______	_________________________	___________	0		0
124	____________________________________________	______	_________________________	___________	0		0
125	____________________________________________	______	_________________________	___________	0		0
126	____________________________________________	______	_________________________	___________	0		0
127	____________________________________________	______	_________________________	___________	0		0
128	____________________________________________	______	_________________________	___________	0		0
129	____________________________________________	______	_________________________	___________	0		0
130	____________________________________________	______	_________________________	___________	0		0
131	____________________________________________	______	_________________________	___________	0		0
132	____________________________________________	______	_________________________	___________	0		0
133	____________________________________________	______	_________________________	___________	0		0
134	____________________________________________	______	_________________________	___________	0		0
135	____________________________________________	______	_________________________	___________	0		0
136	____________________________________________	______	_________________________	___________	0		0
137	____________________________________________	______	_________________________	___________	0		0
138	____________________________________________	______	_________________________	___________	0		0
139	____________________________________________	______	_________________________	___________	0		0
140	____________________________________________	______	_________________________	___________	0		0
141	____________________________________________	______	_________________________	___________	0		0
142	____________________________________________	______	_________________________	___________	0		0
143	____________________________________________	______	_________________________	___________	0		0
144	____________________________________________	______	_________________________	___________	0		0
145	____________________________________________	______	_________________________	___________	0		0
146	____________________________________________	______	_________________________	___________	0		0
147	____________________________________________	______	_________________________	___________	0		0
148	____________________________________________	______	_________________________	___________	0		0
149	____________________________________________	______	_________________________	___________	0		0
150	____________________________________________	______	_________________________	___________	0		0
151	____________________________________________	______	_________________________	___________	0		0
152	____________________________________________	______	_________________________	___________	0		0
153	____________________________________________	______	_________________________	___________	0		0
154	____________________________________________	______	_________________________	___________	0		0
155	____________________________________________	______	_________________________	___________	0		0
156	____________________________________________	______	_________________________	___________	0		0
157	____________________________________________	______	_________________________	___________	0		0
158	____________________________________________	______	_________________________	___________	0		0
159	____________________________________________	______	_________________________	___________	0		0
160	____________________________________________	______	_________________________	___________	0		0
161	____________________________________________	______	_________________________	___________	0		0
162	____________________________________________	______	_________________________	___________	0		0
163	____________________________________________	______	_________________________	___________	0		0
164	____________________________________________	______	_________________________	___________	0		0
165	____________________________________________	______	_________________________	___________	0		0
166	____________________________________________	______	_________________________	___________	0		0
					___________		___________
167	Total Page 3 (Col 4 must equal Col 5)..............................................................	.	.	.	0		0
					============		============
	(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.				Summarized on Worksheet F, Page 3
	(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)

RECLASSIFICATIONS							WORKSHEET F
	Name of Plan:	0					Page 4
	Plan #:	H-xxxx		PERIOD FROM:	12/30/99
				TO:	12/30/99


				CC LINE		AMOUNT
		CODE	COST CENTER	NUMBER
LINE	EXPLANATION OF RECLASSIFICATION ENTRY	(1)	(Worksheet E)	(WKST E)	INCREASES		(DECREASES)
		1	2	3	4		5
168	____________________________________________	______	_________________________	___________	0		0
169	____________________________________________	______	_________________________	___________	0		0
170	____________________________________________	______	_________________________	___________	0		0
171	____________________________________________	______	_________________________	___________	0		0
172	____________________________________________	______	_________________________	___________	0		0
173	____________________________________________	______	_________________________	___________	0		0
174	____________________________________________	______	_________________________	___________	0		0
175	____________________________________________	______	_________________________	___________	0		0
176	____________________________________________	______	_________________________	___________	0		0
177	____________________________________________	______	_________________________	___________	0		0
178	____________________________________________	______	_________________________	___________	0		0
179	____________________________________________	______	_________________________	___________	0		0
180	____________________________________________	______	_________________________	___________	0		0
181	____________________________________________	______	_________________________	___________	0		0
182	____________________________________________	______	_________________________	___________	0		0
183	____________________________________________	______	_________________________	___________	0		0
184	____________________________________________	______	_________________________	___________	0		0
185	____________________________________________	______	_________________________	___________	0		0
186	____________________________________________	______	_________________________	___________	0		0
187	____________________________________________	______	_________________________	___________	0		0
188	____________________________________________	______	_________________________	___________	0		0
189	____________________________________________	______	_________________________	___________	0		0
190	____________________________________________	______	_________________________	___________	0		0
191	____________________________________________	______	_________________________	___________	0		0
192	____________________________________________	______	_________________________	___________	0		0
193	____________________________________________	______	_________________________	___________	0		0
194	____________________________________________	______	_________________________	___________	0		0
195	____________________________________________	______	_________________________	___________	0		0
196	____________________________________________	______	_________________________	___________	0		0
197	____________________________________________	______	_________________________	___________	0		0
198	____________________________________________	______	_________________________	___________	0		0
199	____________________________________________	______	_________________________	___________	0		0
200	____________________________________________	______	_________________________	___________	0		0
201	____________________________________________	______	_________________________	___________	0		0
202	____________________________________________	______	_________________________	___________	0		0
203	____________________________________________	______	_________________________	___________	0		0
204	____________________________________________	______	_________________________	___________	0		0
205	____________________________________________	______	_________________________	___________	0		0
206	____________________________________________	______	_________________________	___________	0		0
207	____________________________________________	______	_________________________	___________	0		0
208	____________________________________________	______	_________________________	___________	0		0
209	____________________________________________	______	_________________________	___________	0		0
210	____________________________________________	______	_________________________	___________	0		0
211	____________________________________________	______	_________________________	___________	0		0
212	____________________________________________	______	_________________________	___________	0		0
213	____________________________________________	______	_________________________	___________	0		0
214	____________________________________________	______	_________________________	___________	0		0
215	____________________________________________	______	_________________________	___________	0		0
216	____________________________________________	______	_________________________	___________	0		0
217	____________________________________________	______	_________________________	___________	0		0
218	____________________________________________	______	_________________________	___________	0		0
219	____________________________________________	______	_________________________	___________	0		0
220	____________________________________________	______	_________________________	___________	0		0
221	____________________________________________	______	_________________________	___________	0		0
222	____________________________________________	______	_________________________	___________	0		0
223	____________________________________________	______	_________________________	___________	0		0
					___________		___________
224	Total Page 4 (Col 4 must equal Col 5)..............................................................	.	.	.	0		0
					============		============
	(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.				Summarized on Worksheet F, Page 3
	(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)

	SUMMARY OF RECLASSIFICATIONS						WORKSHEET F
	Name of Plan:	0					Page 5
	Plan #:	H-xxxx		PERIOD FROM:	12/30/99
				TO:	12/30/99


				SUMMARY OF RECLASSIFICATIONS

				INCREASES	(DECREASES)		NET
CC				(From Worksheet F, Pgs 1 & 2)
LINE	COST CENTER DESCRIPTIONS			4	5		6

1	Inpatient Hospitals ………………………………………………………………..	………………..	.	0	0		0
2	Outpatient Hospitals ……………………………………………………………	…………………	.	0	0		0
3	Skilled Nursing Facilities.............................................................................................................................	.	.	0	0		0
4	Home Health Agencies..........................................................................................................................................	.	.	0	0		0
5	Clinics..........................................................................................................................................................	.	.	0	0		0
6	Physician Groups................................................................................................................................................	.	.	0	0		0
7	Individual Physicians...........................................................................................................................................	.	.	0	0		0
8	Certified Labs..................................................................................................................................................	.	.	0	0		0
9	X-Ray Units.................................................................................................................................................	.	.	0	0		0
10	ESRD Facilities........................................................................................................................	.	.	0	0		0
11	Durable Medical Equipment..............................................................................................................	.	.	0	0		0
12	Ambulances................................................................................................................................	.	.	0	0		0
13	Pharmacy (Outpatient)..........................................................................................................................................	.	.	0	0		0
13a	Pharmacy-Medicare Covered Rx...............................................................................................................................	.	.	0	0		0
14	Emergency-Urgently Needed Svcs.................................................................................................	.	.	0	0		0
15	Mental Health Services...........................................................................................................................................	.	.	0	0		0
16	DED+CO on claims processed by MACs	.	.	0	0		0
17	Other - Medicare Bad Debts...…	.	.	0	0		0
18	Other - Blood Deductible.....…	.	.	0	0		0
19	Part B Cost Not Subj to Coins.	.	.	0	0		0
20	Non-Allowable Costs	.	.	0	0		0
21	Other - (Specify)...…….......…	.	.	0	0		0
22	Other - (Specify)...…….......…	.	.	0	0		0
23	Other - (Specify)...…….......…	.	.	0	0		0
24
25	Plan Administration..................................................................................................	.	.	0	0		0
26	Special Admin Costs....................................................................................	.	.	0	0		0
27
28	Admin & General Costs.............................................................................	.	.	0	0		0
				____________	____________		____________
29	Total Reclassifications (Lines 1 thru 28) (Col 6 must net to zero)......................................		.	0	0		0
				=============	=============		=============

	DIFFERENCES from total of pages 1 & 2 on page 1, Line 53……………………………………………………………………………..			0	0
				=============	=============		Must net to zero.

							To Worksheet E
				If these differences are not			Column 2
				zero there is a problem!!


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



	SUPPLEMENT TO WORKSHEET F - RECLASSIFICATIONS
	Name of Plan:	0
	Plan #:	H-xxxx	Period	From:	12/30/99
				To:	12/30/99		AD181...AN240


	THIS IS A SUPPLEMENTAL WORKSHEET TO SUM UP RECLASSIFICATIONS BY COST CENTER

CCNO				INCREASES	(DECREASES)
1	IP Hosp			0	0
CCNO
2	OP Hosp			0	0
CCNO
3	SNF			0	0
CCNO
4	HHA			0	0
CCNO
5	Clinic			0	0
CCNO
6	Physicians Groups			0	0
CCNO
7	Ind Phy			0	0
CCNO
8	Labs			0	0
CCNO
9	Xray			0	0
CCNO
10	ESRD			0	0
CCNO
11	DME			0	0
CCNO
12	Amb			0	0
CCNO
13	Phrm			0	0
CCNO
14	Emerg			0	0
CCNO
15	Mental			0	0
CCNO
16	Ded & Coins			0	0
CCNO
17				0	0
CCNO
18	Other			0	0
CCNO
19	Nonallowable			0	0
CCNO
21	Plan Admin			0	0
CCNO
22	Spec Admin			0	0
CCNO
24	A&G			0	0
				------------	------------
				0	0
				=============	=============

Sheet 5: Worksheet G

		ADJUSTMENTS TO EXPENSES				WORKSHEET G
		Name of Plan:	0			PART I
		Plan #:	H-xxxx	PERIOD FROM:	12/30/99	Page 1
				TO:	12/30/99

				BASIS	Amount (2)		CC LINE
	CC			FOR	(To Wkst E as	COST CENTER	NUMBER
	LINE	DESCRIPTIONS		ADJ (1)	appropriate)	(Wkst E)	(Wkst E)
				1	2	3	4

	1	Investment income on commingled restricted & unrestricted funds.......................................................		_	0	_____________________________	__
	2	Trade, quantity, time & other discounts on purchases.......................................................		_	0	_____________________________	__
	3	Rebates & refunds of expenses......................................................................................................		_	0	_____________________________	__
	4	Rental of space by suppliers.................................................................................................		_	0	_____________________________	__
	5	Telephone service.....................................................................................................................		_	0	_____________________________	__
	6	Television & radio service....................................................................................................		_	0	_____________________________	__
	7	Parking lot...................................................................................................................................		_	0	_____________________________	__
	8	Home Office Costs (Attach copy of Home Office Cost Statement)..........		_	0	_____________________________	__
	9	Sale of scrap, waste, etc......................................................................................................		_	0	_____________________________	__
	10	Adj. resulting from transactions with related organizations (3).....................................		_	0	_____________________________	__
	10a	Adj. resulting from transactions with related organizations (3).....................................		_	0	_____________________________	__
	10b	Adj. resulting from transactions with related organizations (3).....................................		_	0	_____________________________	__
	10c	Adj. resulting from transactions with related organizations (3).....................................		_	0	_____________________________	__
	11	Laundry and linen service.........................................................................................................		_	0	_____________________________	__
	12	Cafeteria - employees, guests, etc...................................................................................		_	0	_____________________________	__
	13	Rental of living quarters to employees and others.....................................................		_	0	_____________________________	__
	14	Sale of medical and surgical supplies to other than patients...............................		_	0	_____________________________	__
	15	Sale of drugs to other than patients...............................................................................		_	0	_____________________________	__
	16	Sale of medical records and abstracts..........................................................................		_	0	_____________________________	__
	17	Nursing school (tuition, fees, uniforms, finance charges)........................................		_	0	_____________________________	__
	18	Income from vending machines..........................................................................................		_	0	_____________________________	__
	19	Income from imposition of interest and finance charges.......................................		_	0	_____________________________	__
	20	Payments - Physicians' assumption of operating costs........................................		_	0	_____________________________	__
	21	Undistributed risk pool........................................................................................................		_	0	_____________________________	__
	22	Charges in excess of MAC screens............................................................................		_	0	_____________________________	__
	23	Part B coinsurance on services processed by MACs.........................................		_	0	_____________________________	__
	24	Adjustment for physicial therapy costs in excess of limit (4)......................................................................................................................		_	0	_____________________________	__
	25	Reinsurance...........................................................................................................................		_	0	_____________________________	__
	26	Depreciation in excess of limits (Attach worksheet) ........................................................................................................		_	0	_____________________________	__
	27	Noncovered purchased service (Attach worksheet)...................................................................................................................		_	0	_____________________________	__
	28	Medicare Bad Debts		_	0	_____________________________	__
	29	..................................................................................................................................................................		_	0	_____________________________	__
	30	..................................................................................................................................................................		_	0	_____________________________	__
	31	..................................................................................................................................................................		_	0	_____________________________	__
	32	..................................................................................................................................................................		_	0	_____________________________	__
	33	..................................................................................................................................................................		_	0	_____________________________	__
	34	..................................................................................................................................................................		_	0	_____________________________	__
	35	..................................................................................................................................................................		_	0	_____________________________	__
	36	..................................................................................................................................................................		_	0	_____________________________	__
	37	..................................................................................................................................................................		_	0	_____________________________	__
	38	..................................................................................................................................................................		_	0	_____________________________	__
	39	..................................................................................................................................................................		_	0	_____________________________	__
	40	..................................................................................................................................................................		_	0	_____________________________	__
	41	..................................................................................................................................................................		_	0	_____________________________	__
	42	..................................................................................................................................................................		_	0	_____________________________	__
	43	..................................................................................................................................................................		_	0	_____________________________	__
	44	..................................................................................................................................................................		_	0	_____________________________	__
	45	..................................................................................................................................................................		_	0	_____________________________	__
	46	..................................................................................................................................................................		_	0	_____________________________	__
	47	..................................................................................................................................................................		_	0	_____________________________	__
	48	..................................................................................................................................................................		_	0	_____________________________	__
					____________
	49	Page total......................................................	.	.	0
	50	a. Subtotal from Page 2...........................................	.	.	0
		b. Subtotal from Page 3...........................................	.	.	0
		c. Subtotal from Page 4...........................................	.	.	0
					____________
	51	TOTAL ADJUSTMENTS.................................................	.	.	0
					============
	(1)	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.


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

		ADJUSTMENTS TO EXPENSES				WORKSHEET G
		Name of Plan:	0
		Plan #:	H-xxxx	PERIOD FROM:	12/30/99	PART I
				TO:	12/30/99	PAGE 2

				BASIS	Amount		CC LINE
	CC			FOR	(To Wkst E as	COST CENTER	NUMBER
	LINE	DESCRIPTIONS		ADJ(1)	appropriate)	(Wkst E)	(Wkst E)
				1	2	3	4

	52	_________________________________________________		_	0	_____________________________	__
	53	_________________________________________________		_	0	_____________________________	__
	54	_________________________________________________		_	0	_____________________________	__
	55	_________________________________________________		_	0	_____________________________	__
	56	_________________________________________________		_	0	_____________________________	__
	57	_________________________________________________		_	0	_____________________________	__
	58	_________________________________________________		_	0	_____________________________	__
	59	_________________________________________________		_	0	_____________________________	__
	60	_________________________________________________		_	0	_____________________________	__
	61	_________________________________________________		_	0	_____________________________	__
	62	_________________________________________________		_	0	_____________________________	__
	63	_________________________________________________		_	0	_____________________________	__
	64	_________________________________________________		_	0	_____________________________	__
	65	_________________________________________________		_	0	_____________________________	__
	66	_________________________________________________		_	0	_____________________________	__
	67	_________________________________________________		_	0	_____________________________	__
	68	_________________________________________________		_	0	_____________________________	__
	69	_________________________________________________		_	0	_____________________________	__
	70	_________________________________________________		_	0	_____________________________	__
	71	_________________________________________________		_	0	_____________________________	__
	72	_________________________________________________		_	0	_____________________________	__
	73	_________________________________________________		_	0	_____________________________	__
	74	_________________________________________________		_	0	_____________________________	__
	75	_________________________________________________		_	0	_____________________________	__
	76	_________________________________________________		_	0	_____________________________	__
	77	_________________________________________________		_	0	_____________________________	__
	78	_________________________________________________		_	0	_____________________________	__
	79	_________________________________________________		_	0	_____________________________	__
	80	_________________________________________________		_	0	_____________________________	__
	81	_________________________________________________		_	0	_____________________________	__
	82	_________________________________________________		_	0	_____________________________	__
	83	_________________________________________________		_	0	_____________________________	__
	84	_________________________________________________		_	0	_____________________________	__
	85	_________________________________________________		_	0	_____________________________	__
	86	_________________________________________________		_	0	_____________________________	__
	87	_________________________________________________		_	0	_____________________________	__
	88	_________________________________________________		_	0	_____________________________	__
	89	_________________________________________________		_	0	_____________________________	__
	90	_________________________________________________		_	0	_____________________________	__
	91	_________________________________________________		_	0	_____________________________	__
	92	_________________________________________________		_	0	_____________________________	__
	93	_________________________________________________		_	0	_____________________________	__
	94	_________________________________________________		_	0	_____________________________	__
	95	_________________________________________________		_	0	_____________________________	__
	96	_________________________________________________		_	0	_____________________________	__
	97	_________________________________________________		_	0	_____________________________	__
	98	_________________________________________________		_	0	_____________________________	__
	99	_________________________________________________		_	0	_____________________________	__
	100	_________________________________________________		_	0	_____________________________	__
	101	_________________________________________________		_	0	_____________________________	__
	102	_________________________________________________		_	0	_____________________________	__
	103	_________________________________________________		_	0	_____________________________	__
	104	_________________________________________________		_	0	_____________________________	__
	105	_________________________________________________		_	0	_____________________________	__
	106	Page total (to Page 1, Line 51a)......................................................................................	.	.	0
					============

	(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)

		ADJUSTMENTS TO EXPENSES				WORKSHEET G
		Name of Plan:	0
		Plan #:	H-xxxx	PERIOD FROM:	12/30/99	PART I
				TO:	12/30/99	PAGE 3

				BASIS	Amount		CC LINE
	CC			FOR	(To Wkst E as	COST CENTER	NUMBER
	LINE	DESCRIPTIONS		ADJ(1)	appropriate)	(Wkst E)	(Wkst E)
				1	2	3	4

	107	_________________________________________________		_	0	_____________________________	__
	108	_________________________________________________		_	0	_____________________________	__
	109	_________________________________________________		_	0	_____________________________	__
	110	_________________________________________________		_	0	_____________________________	__
	111	_________________________________________________		_	0	_____________________________	__
	112	_________________________________________________		_	0	_____________________________	__
	113	_________________________________________________		_	0	_____________________________	__
	114	_________________________________________________		_	0	_____________________________	__
	115	_________________________________________________		_	0	_____________________________	__
	116	_________________________________________________		_	0	_____________________________	__
	117	_________________________________________________		_	0	_____________________________	__
	118	_________________________________________________		_	0	_____________________________	__
	119	_________________________________________________		_	0	_____________________________	__
	120	_________________________________________________		_	0	_____________________________	__
	121	_________________________________________________		_	0	_____________________________	__
	122	_________________________________________________		_	0	_____________________________	__
	123	_________________________________________________		_	0	_____________________________	__
	124	_________________________________________________		_	0	_____________________________	__
	125	_________________________________________________		_	0	_____________________________	__
	126	_________________________________________________		_	0	_____________________________	__
	127	_________________________________________________		_	0	_____________________________	__
	128	_________________________________________________		_	0	_____________________________	__
	129	_________________________________________________		_	0	_____________________________	__
	130	_________________________________________________		_	0	_____________________________	__
	131	_________________________________________________		_	0	_____________________________	__
	132	_________________________________________________		_	0	_____________________________	__
	133	_________________________________________________		_	0	_____________________________	__
	134	_________________________________________________		_	0	_____________________________	__
	135	_________________________________________________		_	0	_____________________________	__
	136	_________________________________________________		_	0	_____________________________	__
	137	_________________________________________________		_	0	_____________________________	__
	138	_________________________________________________		_	0	_____________________________	__
	139	_________________________________________________		_	0	_____________________________	__
	140	_________________________________________________		_	0	_____________________________	__
	141	_________________________________________________		_	0	_____________________________	__
	142	_________________________________________________		_	0	_____________________________	__
	143	_________________________________________________		_	0	_____________________________	__
	144	_________________________________________________		_	0	_____________________________	__
	145	_________________________________________________		_	0	_____________________________	__
	146	_________________________________________________		_	0	_____________________________	__
	147	_________________________________________________		_	0	_____________________________	__
	148	_________________________________________________		_	0	_____________________________	__
	149	_________________________________________________		_	0	_____________________________	__
	150	_________________________________________________		_	0	_____________________________	__
	151	_________________________________________________		_	0	_____________________________	__
	152	_________________________________________________		_	0	_____________________________	__
	153	_________________________________________________		_	0	_____________________________	__
	154	_________________________________________________		_	0	_____________________________	__
	155	_________________________________________________		_	0	_____________________________	__
	156	_________________________________________________		_	0	_____________________________	__
	157	_________________________________________________		_	0	_____________________________	__
	158	_________________________________________________		_	0	_____________________________	__
	159	_________________________________________________		_	0	_____________________________	__
	160	_________________________________________________		_	0	_____________________________	__
	161	Page total (to Page 1, Line 51b)......................................................................................	.	.	0
					============

	(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)

		ADJUSTMENTS TO EXPENSES				WORKSHEET G
		Name of Plan:	0
		Plan #:	H-xxxx	PERIOD FROM:	12/30/99	PART I
				TO:	12/30/99	PAGE 4

				BASIS	Amount		CC LINE
	CC			FOR	(To Wkst E as	COST CENTER	NUMBER
	LINE	DESCRIPTIONS		ADJ(1)	appropriate)	(Wkst E)	(Wkst E)
				1	2	3	4

	162	_________________________________________________		_	0	_____________________________	__
	163	_________________________________________________		_	0	_____________________________	__
	164	_________________________________________________		_	0	_____________________________	__
	165	_________________________________________________		_	0	_____________________________	__
	166	_________________________________________________		_	0	_____________________________	__
	167	_________________________________________________		_	0	_____________________________	__
	168	_________________________________________________		_	0	_____________________________	__
	169	_________________________________________________		_	0	_____________________________	__
	170	_________________________________________________		_	0	_____________________________	__
	171	_________________________________________________		_	0	_____________________________	__
	172	_________________________________________________		_	0	_____________________________	__
	173	_________________________________________________		_	0	_____________________________	__
	174	_________________________________________________		_	0	_____________________________	__
	175	_________________________________________________		_	0	_____________________________	__
	176	_________________________________________________		_	0	_____________________________	__
	177	_________________________________________________		_	0	_____________________________	__
	178	_________________________________________________		_	0	_____________________________	__
	179	_________________________________________________		_	0	_____________________________	__
	180	_________________________________________________		_	0	_____________________________	__
	181	_________________________________________________		_	0	_____________________________	__
	182	_________________________________________________		_	0	_____________________________	__
	183	_________________________________________________		_	0	_____________________________	__
	184	_________________________________________________		_	0	_____________________________	__
	185	_________________________________________________		_	0	_____________________________	__
	186	_________________________________________________		_	0	_____________________________	__
	187	_________________________________________________		_	0	_____________________________	__
	188	_________________________________________________		_	0	_____________________________	__
	189	_________________________________________________		_	0	_____________________________	__
	190	_________________________________________________		_	0	_____________________________	__
	191	_________________________________________________		_	0	_____________________________	__
	192	_________________________________________________		_	0	_____________________________	__
	193	_________________________________________________		_	0	_____________________________	__
	194	_________________________________________________		_	0	_____________________________	__
	195	_________________________________________________		_	0	_____________________________	__
	196	_________________________________________________		_	0	_____________________________	__
	197	_________________________________________________		_	0	_____________________________	__
	198	_________________________________________________		_	0	_____________________________	__
	199	_________________________________________________		_	0	_____________________________	__
	200	_________________________________________________		_	0	_____________________________	__
	201	_________________________________________________		_	0	_____________________________	__
	202	_________________________________________________		_	0	_____________________________	__
	203	_________________________________________________		_	0	_____________________________	__
	204	_________________________________________________		_	0	_____________________________	__
	205	_________________________________________________		_	0	_____________________________	__
	206	_________________________________________________		_	0	_____________________________	__
	207	_________________________________________________		_	0	_____________________________	__
	208	_________________________________________________		_	0	_____________________________	__
	209	_________________________________________________		_	0	_____________________________	__
	210	_________________________________________________		_	0	_____________________________	__
	211	_________________________________________________		_	0	_____________________________	__
	212	_________________________________________________		_	0	_____________________________	__
	213	_________________________________________________		_	0	_____________________________	__
	214	_________________________________________________		_	0	_____________________________	__
	215	_________________________________________________		_	0	_____________________________	__
	216	Page total (to Page 1, Line 51c)......................................................................................	.	.	0
					============

	(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)

		SUMMARY OF ADJUSTMENTS TO EXPENSES				WORKSHEET G
		Name of Plan:	0			PART II
		Plan #:	H-xxxx	PERIOD FROM:	12/30/99
				TO:	12/30/99


				LINE	Amount	TRANSFER TO	CC LINE
	CC			NUMBERS	(To Wkst E as	WORKSHEET E	NUMBER
	LINE	COST CENTER DESCRIPTIONS		FROM	appropriate)	LINE # AS SHOWN	Wkst E
				PART I
				1	2	3	4


	1	Inpatient Hospitals………………………………	.	___________	0		1
	2	Outpatient Hospitals…………………………..	.	___________	0		2
	3	Skilled Nursing Facilities.................................	.	___________	0		3
	4	Home Health Agencies......................................	.	___________	0		4
	5	Clinics..............................................................................	.	___________	0		5
	6	Physician Groups.......................................	.	___________	0		6
	7	Individual Physicians.....................................	.	___________	0		7
	8	Certified Labs...............................................	.	___________	0		8
	9	X-Ray Units...................................................	.	___________	0		9
	10	ESRD Facilities........................................................................................................................	.	___________	0		10
	11	Durable Medical Equipment..............................................................................................................	.	___________	0		11
	12	Ambulances...................................................	.	___________	0		12
	13	Pharmacy (Outpatient)....................................	.	___________	0		13
	13a	Pharmacy-Medicare Covered Rx.......	.	___________	0		13
	14	Emergency-Urgently Needed Svcs.................................................................................................	.	___________	0		14
	15	Mental Health Services............................	.	___________	0		15
	16	DED+CO on claims processed by MACs………………………..	.	___________	0		16
	17	Other - Medicare Bad Debts...…	.	___________	0		17
	18	Other - Blood Deductible.....…	.	___________	0		18
	19	Part B Cost Not Subj to Coins.	.	___________	0		19
	20	Non-Allowable Costs	.	___________	0		20
	21	Other - (Specify)...…….......…	.	___________	0		21
	22	Other - (Specify)...…….......…	.	___________	0		22
	23	Other - (Specify)...…….......…	.	___________	0		23
	24						24
	25	Plan Administration......................................	.	___________	0		25
	26	Special Admin Costs.....................................	.	___________	0		26
	27						27
	28	Admin & General Costs......................................................................	.	___________	0		28
					____________
	29	Total Adjustments (Lines 1 thru 28).............................................................................................................			0		29
					============










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

Sheet 6: Worksheet H

	STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS					WORKSHEET H
		Name of Plan:	0	PERIOD FROM:	12/30/99
		Plan #:	H-xxxx	TO:	12/30/99
A.	Are there any costs included on Worksheet E which resulted from transactions with related organizations?
	Select		(If "YES", complete Parts B and C.)
B.	Costs incurred and adjustments required as a result of transactions with related organizations.
					AMOUNT	NET
					ALLOWABLE	ADJUSTMENTS (1)
	LINE	COST CENTER (Worksheet E)	EXPENSE ITEMS	AMOUNT	IN COST	(5)
	(Wkst E)	1	2	3	4	(5 = 4 - 3)
1	_____	___________________________	___________________________	0	0	0
2	_____	___________________________	___________________________	0	0	0
3	_____	___________________________	___________________________	0	0	0
4	_____	___________________________	___________________________	0	0	0
5	_____	___________________________	___________________________	0	0	0
6	_____	___________________________	___________________________	0	0	0
7	_____	___________________________	___________________________	0	0	0
8	_____	___________________________	___________________________	0	0	0
9	_____	___________________________	___________________________	0	0	0
10	_____	___________________________	___________________________	0	0	0
11	_____	___________________________	___________________________	0	0	0
12	_____	___________________________	___________________________	0	0	0
13	_____	___________________________	___________________________	0	0	0
14	_____	___________________________	___________________________	0	0	0
15	_____	___________________________	___________________________	0	0	0
16	_____	___________________________	___________________________	0	0	0
				_____________	_____________	_____________
17		TOTALS.........................................................................……………………………………………………………………………..		0	0	0
				=============	=============	=============
(1) Transfer the amounts in column 5 to Worksheet G, Part I, Column 2 lines 10

C.	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.

				----------RELATED ORGANIZATION(S)--------
	SYMBOL (2)	NAME OF INDIVIDUAL	OWNERSHIP OF PLAN	ORGANIZATION	OWNERSHIP	TYPE OF
				NAME	%	BUSINESS
	1	2	3	4	5	6

1	_	________________________________	_______________________________	______________	0.00%	_____________
2	_	________________________________	_______________________________	______________	0.00%	_____________
3	_	________________________________	_______________________________	______________	0.00%	_____________
4	_	________________________________	_______________________________	______________	0.00%	_____________
5	_	________________________________	_______________________________	______________	0.00%	_____________
6	_	________________________________	_______________________________	______________	0.00%	_____________
7	_	________________________________	_______________________________	______________	0.00%	_____________
8	_	________________________________	_______________________________	______________	0.00%	_____________
9	_	________________________________	_______________________________	______________	0.00%	_____________
10	_	________________________________	_______________________________	______________	0.00%	_____________
11	_	________________________________	_______________________________	______________	0.00%	_____________
12	_	________________________________	_______________________________	______________	0.00%	_____________
13	_	________________________________	_______________________________	______________	0.00%	_____________
14	_	________________________________	_______________________________	______________	0.00%	_____________
15	_	________________________________	_______________________________	______________	0.00%	_____________
16	_	________________________________	_______________________________	______________	0.00%	_____________
17	_	________________________________	_______________________________	______________	0.00%	_____________
18	_	________________________________	_______________________________	______________	0.00%	_____________
19	_	________________________________	_______________________________	______________	0.00%	_____________
20	_	________________________________	_______________________________	______________	0.00%	_____________

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

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

Sheet 7: Worksheet I

	ADMINISTRATIVE AND GENERAL COST ALLOCATION										WORKSHEET I

		Name of Plan:		0							PART I
		Plan #:	#REF!	H-xxxx			PERIOD FROM:	12/30/99
							TO:	12/30/99



				1	2		3	4	5	6	7
				EMPLOYEE	STATISTICS		PHARMACY	OTHER	TOTALS	POOLED	TOTALS
				BENEFITS	& DATA		&	(SPECIFY)	(Sum Cols	ADMIN & GEN	(Col 5 +
COST CENTER				(Salaries)	PROCESSING		SUPPLIES		1 Thru 4)	COSTS	Col 6)
					(Time Spent)		(Cost Req's)	SEE-WKST I SUPPL

	1	Inpatient Hospitals ……………….		0	0		0	0	0	0	0
	2	Outpatient Hospitals …………….		0	0		0	0	0	0	0
	3	Skilled Nursing Facilities.......….…		0	0		0	0	0	0	0
	4	Home Health Agencies........….….		0	0		0	0	0	0	0
	5	Clinics..........……….........….......…		0	0		0	0	0	0	0
	6	Physician Groups.......................…		0	0		0	0	0	0	0
	7	Individual Physicians.....…...….…		0	0		0	0	0	0	0
	8	Certified Labs..................…......…		0	0		0	0	0	0	0
	9	X-Ray Units....................……....…		0	0		0	0	0	0	0
	10	ESRD Facilities.........................…		0	0		0	0	0	0	0
	11	Durable Medical Equipment.......…		0	0		0	0	0	0	0
	12	Ambulance...............……….......…		0	0		0	0	0	0	0
	13	Pharmacy (Outpatient).......…...…		0	0		0	0	0	0	0
	13a	Pharmacy-Medicare Covered Rx		0	0		0	0	0	0	0
	14	Emergency-Urgent Needed Svcs..		0	0		0	0	0	0	0
	15	Mental Health Services....….……		0	0		0	0	0	0	0
	16	DED+CO on claims processed by MACs		0	0		0	0	0	0	0
	17	Other - Medicare Bad Debts...…		0	0		0	0	0	0	0
	18	Other - Blood Deductible.....…		0	0		0	0	0	0	0
	19	Part B Cost Not Subj to Coins.		0	0		0	0	0	0	0
	20	Non-Allowable Costs		0	0		0	0	0	0	0
	21	Other - (Specify)...…….......…		0	0		0	0	0	0	0
	22	Other - (Specify)...…….......…		0	0		0	0	0	0	0
	23	Other - (Specify)...…….......…		0	0		0	0	0	0	0
				___________	___________		___________	___________	___________	___________	___________
	24	Subtotal (Sum of Lines 1 thru 23)...........…		0	0		0	0	0	0	0

	25	Plan Administration....................................						0	0		0
	26	Special Administrative Costs............…						0	0		0
				___________	___________		___________	___________	___________	___________	___________
	27	Subtotal (Sum of 25 and 26) ...................						0	0		0
				___________	___________		___________	___________	___________	___________	___________
		Total (Sum of Lines 24 & 27)...........................		0	0		0	0	0	0	0

	28	Admin & General Costs...............................		0	0		0	0	0	0	0
				___________	___________		___________	___________	___________	___________	___________
	29	Net A&G Costs (Lines 24+27+28)....................................		0	0		0	0	0	0	0
				===========	===========	======	===========	============	============	===========	===========

	30	Computation - Fr Worksheet, Col........		Fr Wkst I,	Fr Wkst I,		Fr Wkst I,	Fr Wkst I,		Fr Wkst I,
				Pt II, Col 1	Pt II, Col 2		Pt II, Col 3	Pt II, Col 4		Pt II, Col 7

	31	To Worksheet, Column........................							To Wkst I,		To Wkst E,
									Pt II, Col 6		Col 5

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




	ADMINISTRATIVE AND GENERAL STATISTICS										WORKSHEET I

		Name of Plan:	#REF!	0							PART II
		Plan #:	#REF!	H-xxxx			PERIOD FROM:	12/30/99
							TO:	12/30/99



				EMPLOYEE	STATISTICS		PHARMACY	OTHER	TOTALS	TOTALS	POOLED
				BENEFITS	& DATA		&	(SPECIFY)	(From	(From	ADMIN & GEN
		COST CENTER		(Salaries)	PROCESSING		SUPPLIES		Worksheet E	Wkst I,	STATS
					(Time Spent)		(Cost Req's)		Column 4)	Pt I, Col 5)	(Cols 5+6)
				1	2		3	4	5	6	7

	1	Inpatient Hospitals ……………….		0	0		0	0	0	0	0
	2	Outpatient Hospitals …………….		0	0		0	0	0	0	0
	3	Skilled Nursing Facilities.......….…		0	0		0	0	0	0	0
	4	Home Health Agencies........….….		0	0		0	0	0	0	0
	5	Clinics..........……….........….......…		0	0		0	0	0	0	0
	6	Physician Groups.......................…		0	0		0	0	0	0	0
	7	Individual Physicians.....…...….…		0	0		0	0	0	0	0
	8	Certified Labs..................…......…		0	0		0	0	0	0	0
	9	X-Ray Units....................……....…		0	0		0	0	0	0	0
	10	ESRD Facilities.........................…		0	0		0	0	0	0	0
	11	Durable Medical Equipment.......…		0	0		0	0	0	0	0
	12	Ambulance...............……….......…		0	0		0	0	0	0	0
	13	Pharmacy (Outpatient).......…...…		0	0		0	0	0	0	0
	13a	Pharmacy-Medicare Covered Rx		0	0		0	0	0	0	0
	14	Emergency-Urgent Needed Svcs..		0	0		0	0	0	0	0
	15	Mental Health Services....….……		0	0		0	0	0	0	0
	16	DED+CO on claims processed by MACs		0	0		0	0	0	0	0
	17	Other - Medicare Bad Debts...…		0	0		0	0	0	0	0
	18	Other - Blood Deductible.....…		0	0		0	0	0	0	0
	19	Part B Cost Not Subj to Coins.		0	0		0	0	0	0	0
	20	Non-Allowable Costs		0	0		0	0	0	0	0
	21	Other - (Specify)...…….......…		0	0		0	0	0	0	0
	22	Other - (Specify)...…….......…		0	0		0	0	0	0	0
	23	Other - (Specify)...…….......…		0	0		0	0	0	0	0
				___________	___________		___________	___________	___________	___________	___________
	24	Subtotal (Sum of Lines 1 thru 23)...........…		0	0		0	0	0	0	0

	25	Plan Administration....................................
	26	Special Administrative Costs............…
				___________	___________		___________	___________
	27	Subtotal (Sum of 25 and 26) ...................						0
				___________	___________		___________	___________	___________	___________	___________
		Total (Sum of Lines 24 & 27)....................		0	0		0	0	0	0	0

	28	Administrative & General Costs..........................................
				___________	___________		___________	___________	___________	___________	___________
	29	TOTAL STATS (Sum of 24 & 27)...........		0	0		0	0	0	0	0
				===========	============		============	=============	=============	=============	============
											Col 5 - (1+2+3+4)
	30	COSTS TO BE ALLOCATED.....................							0		0
		(Input here)

	31	UNIT COST MULTIPLIER..........................................		0.000000	0.000000		0.00000	0.000000			0.000000
		(Line 30 / Line 29)

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

Sheet 8: Worksheet J

		SUMMARY OF PROVIDER COSTS							WORKSHEET J

									PAGE 1
		Name of Plan:	0
		Plan #:	H-xxxx		PERIOD FROM:	12/30/99
					TO:	12/30/99


			1	2	3	4		5
					PART A			PART B
PROVIDERS			PROVIDER	REIMBURSABLE	DEDUCTIBLE +	REIMBURSABLE		DEDUCTIBLE
			NUMBER	PART A	COINSURANCE	PART B

	1	Medicare Memb Mos (WS D, Pt II, Sec E, Ln 3)		0	0	0		0
				=========	=========	=========		=========
	2	Hospitals
	3	__________________________________	____________	0	0	0		0
	4	__________________________________	____________	0	0	0		0
	5	__________________________________	____________	0	0	0		0
	6	__________________________________	____________	0	0	0		0
	7	__________________________________	____________	0	0	0		0
	8	__________________________________	____________	0	0	0		0
	9		____________	0	0	0		0
	10	__________________________________	____________	0	0	0		0
	11	__________________________________	____________	0	0	0		0
	12	__________________________________	____________	0	0	0		0
	13	__________________________________	____________	0	0	0		0
	14	__________________________________	____________	0	0	0		0
	15	__________________________________	____________	0	0	0		0
	16	__________________________________	____________	0	0	0		0
	17	__________________________________	____________	0	0	0		0
	18	__________________________________	____________	0	0	0		0
	19	__________________________________	____________	0	0	0		0
	20	__________________________________	____________	0	0	0		0
	21	__________________________________	____________	0	0	0		0
	22	__________________________________	____________	0	0	0		0
	23	__________________________________	____________	0	0	0		0
	24	__________________________________	____________	0	0	0		0
	25	__________________________________	____________	0	0	0		0
	26	__________________________________	____________	0	0	0		0
	27	__________________________________	____________	0	0	0		0
	28	__________________________________	____________	0	0	0		0
	29	__________________________________	____________	0	0	0		0
	30	__________________________________	____________	0	0	0		0
	31	__________________________________	____________	0	0	0		0
	32	__________________________________	____________	0	0	0		0
	33	__________________________________	____________	0	0	0		0
	34	__________________________________	____________	0	0	0		0
	35	__________________________________	____________	0	0	0		0
	36	__________________________________	____________	0	0	0		0
	37	__________________________________	____________	0	0	0		0
	38	__________________________________	____________	0	0	0		0
	39	__________________________________	____________	0	0	0		0
	40	__________________________________	____________	0	0	0		0
	41	__________________________________	____________	0	0	0		0
	42	__________________________________	____________	0	0	0		0
	43	__________________________________	____________	0	0	0		0
	44	__________________________________	____________	0	0	0		0
	45	__________________________________	____________		0	0		0
	46	__________________________________	____________	0	0	0		0
	47	__________________________________	____________	0	0	0		0
	48	Total Hospital ………………………………………………………………………………………		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							WORKSHEET J
									(Continued)
									PAGE 2
		Name of Plan:	0
		Plan #:	H-xxxx		PERIOD FROM:	12/30/99
					TO:	12/30/99


			1	2	3	4		5
					PART A			PART B
		PROVIDERS	PROVIDER	REIMBURSABLE	DEDUCTIBLE+	REIMBURSABLE		DEDUCTIBLE
			NUMBER	PART A	COINSURANCE	PART B

	51	Skilled Nursing Facilities:
	52	__________________________________	____________	0	0	0		0
	53	__________________________________	____________	0	0	0		0
	54	__________________________________	____________	0	0	0		0
	55	__________________________________	____________	0	0	0		0
	56	__________________________________	____________	0	0	0		0
	57	__________________________________	____________	0	0	0		0
	58	__________________________________	____________	0	0	0		0
	59	__________________________________	____________	0	0	0		0
	60	__________________________________	____________	0	0	0		0
	61	__________________________________	____________	0	0	0		0
	62	Total (Sum of Lines 52 thru 61)………………………………………………………………		0	0	0		0
				=========	=========	=========		=========
	63	Cost PMPM (Line 62 / Line 1)......................................................................		0.0000	0.0000	0.0000		0.0000

	64	Enter on Wkst, Col, Line.................................................................................		M, 2, 2	M, 2, 2&8	M, 3, 2		M, 3, 2

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

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

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

	78	Other Providers (Specify Type):
	79	__________________________________	____________	0	0	0		0
	80	__________________________________	____________	0	0	0		0
	81	__________________________________	____________	0	0	0		0
	82	__________________________________	____________	0	0	0		0
	83	__________________________________	____________	0	0	0		0
	84	__________________________________	____________	0	0	0		0
	85	__________________________________	____________	0	0	0		0
	86	__________________________________	____________	0	0	0		0
	87	__________________________________	____________	0	0	0		0
	88	__________________________________	____________	0	0	0		0
	89	__________________________________	____________	0	0	0		0
				_____________	_____________	_____________		_____________
	90	Total (Sum Lines 79 thru 89)..........................................................................		0	0	0		0
				=========	=========	=========		========
	91	Cost PMPM (Line 90 / Line 1)......................................................................		0.0000	0.0000	0.0000		0.0000

	92	Enter on Wkst, Col, Line................................................................................		M, 2, 4	M, 2, 4&8	M, 3, 4		M, 3, 4


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

Sheet 9: Worksheet K

	SUMMARY APPORTIONMENT OF NON-PROVIDER COSTS						Worksheet K


	Name of Plan:	0
	Plan #:	H-xxxx		PERIOD FROM:	12/30/99
				TO:	12/30/99


		1	2	3	4	5	6	7
				COVERED PRIM	SUBPART E	RATIO	TOTAL COSTS	MEDICARE
	COST CENTERS	STATISTIC	TOTAL	MED ENROLLEE	LIMITS IF	Col 3 or Col	(Fr Wkst E	COSTS
		USED	STATISTICS	STATISTICS	APPLICABLE	4 / Col 2	Col 6)	Col 5 X Col 6

1	Clinics (furnished directly).............................................	___________	0	0		0.0000		0
2	Physician Groups:
3	Fee For Service………………………………………………	___________	0	0	0	0.0000	0	0
4	Capitation…………………………………………………………	___________	0	0	0	0.0000	0	0
5	Other………………………………………………………………..	___________	0	0	0	0.0000	0	0	0
6	Individual Physicians:								0
7	Fee For Service………………………………………………	___________	0	0	0	0.0000	0	0	0
8	Capitation…………………………………………………………	___________	0	0	0	0.0000	0	0	0
9	Other………………………………………………………………..	___________	0	0	0	0.0000	0	0	0
10	Certified Labs:								0
11	Fee For Service………………………………………………	___________	0	0	0	0.0000	0	0	0
12	Capitation…………………………………………………………	___________	0	0	0	0.0000	0	0	0
13	Other………………………………………………………………..	___________	0	0	0	0.0000	0	0	0
14	X-Ray Units:								0
15	Fee For Service………………………………………………	___________	0	0	0	0.0000	0	0	0
16	Capitation…………………………………………………………	___________	0	0	0	0.0000	0	0	0
17	Other………………………………………………………………..	___________	0	0	0	0.0000	0	0	0
18	ESRD Facilities................................................................	___________	0	0	0	0.0000	0	0	0
19	_________________________________	___________	0	0	0	0.0000	0	0	0
20	Durable Medical Equipment.........................................	___________	0	0	0	0.0000	0	0	0
21	Ambulance..........................................................................	___________	0	0	0	0.0000	0	0	0
22	Emergency-Urgently Needed Svcs............................	___________	0	0	0	0.0000	0	0	0
23	_________________________________	___________	0	0	0	0.0000	0	0
24	Mental Health Svcs	___________	0	0	0	0.0000	0	0	0
25	_________________________________	___________	0	0	0	0.0000	0	0	Err:508
26	_________________________________	___________	0	0	0	0.0000	0	0	Err:508
27	_________________________________	___________	0	0	0	0.0000	0	0	Err:508
28	_________________________________	___________	0	0	0	0.0000	0	0	Err:508
29	_________________________________	___________	0	0	0	0.0000	0	0	Err:508
30	_________________________________	___________	0	0	0	0.0000	0	0	Err:508
31	_________________________________	___________	0	0	0	0.0000	0	0	Err:508
32	_________________________________	___________	0	0	0	0.0000	0	0	Err:508
33	_________________________________	___________	0	0	0	0.0000	0	0	Err:508
34	_________________________________	___________	0	0	0	0.0000	0	0	Err:508

35	Total (Sum Lines 1 thru 34).............................................................................							0	Err:508
								=========
36	Member Months - Part B (W/S D, Part II, Pg 2, Pt E, Col 2, Line 1)..........................................................................................................							0
								=========
37	Cost PMPM (Line 35 / Line 36)..............................................................…..							0.0000

38	Enter on Worksheet, Col, Line..................................................................….							M, 3, 5

	FORM CMS 276-16
	(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2313)

Sheet 10: Worksheet L

	SUMMARY OF MISCELLANEOUS ITEMS							WORKSHEET L


	Name of Plan:	0
	Plan #:	H-xxxx		PERIOD FROM:	12/30/99
				TO:	12/30/99


			1	2	3	4	5	6

	DESCRIPTION		MEDICARE	MEDICARE	TOTAL	NON-	TOTAL	ENTER ON
			PART A	PART B	Col 1+Col 2	MEDICARE	Col 2+Col 4	WKST LINE

1	Member Months (Wkst D, Pt II, Pg 2, Pt E, Col 1 and 2, Ln 1)		0	0			0
2
3	Plan Administration (Wkst E, Col 6, Ln 25)................................................						0
4	Cost PMPM (Line 3 / Line 1)..........................................................................		0.0000	0.0000			0.0000	M 6
5
6	Special Admin Costs (Wkst E, Col 6, Ln 26)............................................			0
7	Cost PMPM (Line 6 / Line 1)..........................................................................			0.0000				M 14
8
9	Allowable Medicare Bad Debts (Wkst E, Col 6, Line 17).....................				0
10	Cost PMPM (Line 9 / Line 1)..........................................................................		0.0000	0.0000	0.0000			M 15
11
12	Part B Blood Deductible (Wkst E, Col 6, Line 18).....................			0	0
13	Cost PMPM (Line 12 / Line 1).........................................................................			0.0000	0.0000			M 10
14
15	Third Party Insurer Revenue (see Instructions)......................................				0
16	Cost PMPM (Line 15 / Line 1)........................................................................		0.0000	0.0000	0.0000			M 18
17
18	Pt B DED on claims processed by MACs (Wkst E, Col 6, Ln 16)......			0	0
19	Cost PMPM (Line 18 / Line 1).........................................................................			0.0000	0.0000			M 5a
20
21	Part B Cost Not Subject to Coinsurance (Wkst E, Col 6, Ln 19)…..……………………………….			0	0
22	Cost PMPM (Line 21 / Line 1)………………………………………………………..			0.0000	0.0000			M 16

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

Sheet 11: Worksheet M

	SETTLEMENT SHEET	Name of Plan:		PERIOD FROM:	12/30/99	WORKSHEET M
		Plan #: H-xxxx		TO:	12/30/99


	DESCRIPTION		FROM	MEDICARE	MEDICARE		TOTAL
			WKST	PART A	PART B		Col 2 + Col 3
			1	2	3		4
1	Hospital Costs………………………………………………………………………………………………………….........		J	0.0000	0.0000		0.0000
2	Skilled Nursing Facility Costs………………………………………………………………………………………..		J	0.0000	0.0000		0.0000
3	Home Health Agency Costs………………………………………………………………………………………….		J	0.0000	0.0000		0.0000
4	Other Provider's Costs ………………………………………………………………………………………………….		J	0.0000	0.0000		0.0000
5	Nonprovider Costs………………………………………………………………………………………………………….		K		0.0000		0.0000
5a	DED on claims processed by MACs……………………...……………..…………………………………………………..		L		0.0000		0.0000
6	Plan Administration Costs…………………………………………………………………………………………….		L	0.0000	0.0000		0.0000
				___________	___________
7	Totals (Sum Lines 1 - 6)………………………………………………………………………………………………….			0.0000	0.0000		0.0000

8	Part A Deductible and Coinsurance…………………………………………………………………………….		J	0			0.0000
9	Part B Standard Deductible……………………………………………………………………………………………				0.0000		0.0000
10	Part B Blood Deductible…………………………………………………………………………………………………		L		0.0000		0.0000
				___________	___________
11	Line 7 Minus (The Sum of Lines 8 - 10)………………………………………………………………………….			0.0000	0.0000		0.0000

12	20% of (Col 3 Line 11 minus Col 3 Line 3)…………………………………………………………………….				0.0000		0.0000
				___________	___________
13	Reimbursable Costs (Line 11 Minus Line 12)……………………………………………………………….			0.0000	0.0000		0.0000
14	Special Administrative Costs……………………………………………………………………………………….		L		0.0000		0.0000
15	Medicare Bad Debts……………………………………………………………………………………………………….		L	0.0000	0.0000		0.0000
16	Part B Cost Not Subject to Coinsurance……………………………………………………………………………………………………….		L	0.0000	0.0000		0.0000
17	Total (Sum Lines 13 thru 16)…………………………………………………………………………………………….			0.0000	0.0000		0.0000
18	Less: Third Party Insurer Revenue………………………………………………………………………………..		L	0.0000	0.0000		0.0000
				___________	___________
19	Medicare Costs (Line 17 minus Line 18)……………………………………………………………………….			0.0000	0.0000		0.0000
20	Medicare Primary Member Months…………………………………………………………………………….		D	0	0
				___________	___________
21	Reimbursable Costs (Line 19 X Line 20)……………………………………………………………………….			0	0		0
22	Interim Payments (by) to CMS…………………………………………………………………………………….
							___________
23	Balance (Line 21 plus Line 22)…………………………………………………………………………………….						0
	Adjustments:
24	____________________________________________
25	____________________________________________
26	____________________________________________
27	____________________________________________
28	____________________________________________
29	____________________________________________

30	Balance Due Plan (CMS) (Line 23 + or - Lines 24-29).....……………………………………….						0
							=========

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

Sheet 12: Worksheet N

MEDICARE PREMIUM RECONCILIATION						WORKSHEET N

		Name of Plan:	0	Period From:	12/30/99
		Plan Number:	H-xxxx	To:	12/30/99

Under and Over Collection of Medicare Premiums - Current Year
					Member	Cost Per
Premium Determinations Covered by this Part				Totals	Months	Member Month	Line
				1	2	3
0	Total Medicare Member Months			XXXXXXXXXXXX	0	XXXXXXXXXXXX	0

1	Total Premiums/Dues collected during the period			-	XXXXXXXXXXXX	-	1
2	Total Copayments collected during the period			-	XXXXXXXXXXXX	-	2
					XXXXXXXXXXXX
3	Total Collections (Line 1 plus Line 2)			-	XXXXXXXXXXXX	-	3
					XXXXXXXXXXXX
4	Less: Accounts Receivable for premiums/dues and copayments (beg of period)			-	XXXXXXXXXXXX	-	4
					XXXXXXXXXXXX
5	Net Collections for period (Line 3 minus Line 4)			-	XXXXXXXXXXXX	-	5
6	Add: Accounts Receivable for premiums/dues and copayments (end of period)			-	XXXXXXXXXXXX	-	6
					XXXXXXXXXXXX
7	Net Collections and Amounts to be Collected (Line 5 plus Line 6)			-	XXXXXXXXXXXX	-	7


8	Total Medicare Deductible and Coinsurance from Cost Report:						8
	a. Deductible and copayments (Worksheet M, Col 2 + 3 , Sum lines 8 thru 10)			XXXXXXXXXXXX	XXXXXXXXXXXX	0.0000	8a
	b. Part B Coinsurance (Worksheet M, Col 3, Line 12)			XXXXXXXXXXXX	XXXXXXXXXXXX	0.0000	8b
	c. CO on claims processed by MACs (Worksheet G, Col 2, Line 23/Col 2, Ln 0)			XXXXXXXXXXXX	XXXXXXXXXXXX	#DIV/0!	8c

	d. Total (Sum of Lines 8a thru 8c)			XXXXXXXXXXXX	XXXXXXXXXXXX	#DIV/0!	8d
9a	(Over)/Involuntary Under collection from prior period (Worksheet N, Line 11/12b, respectively) NotePrior Period = Current Period -2 Years			XXXXXXXXXXXX	-	XXXXXXXXXXXX	9
9b	Prior Period Member Months (Worksheet N, Line 0)			XXXXXXXXXXXX	-	XXXXXXXXXXXX
9c	Gross (over)/under collections from prior period			0	XXXXXXXXXXXX	XXXXXXXXXXXX
9d	Adjusted (over)/under collection from the prior period			XXXXXXXXXXXX	XXXXXXXXXXXX	#DIV/0!
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
12	Budgeted Voluntary under collection for the period (Worksheet B, Line 8)			XXXXXXXXXXXX	XXXXXXXXXXXX	0.0000	12
12a	Actual Voluntary under collection - No recoupment			XXXXXXXXXXXX	XXXXXXXXXXXX	#DIV/0!	12a
12b	Involuntary Under collection - may recoup during subsequent period			XXXXXXXXXXXX	XXXXXXXXXXXX	#DIV/0!	12b

FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2316)

Sheet 13: Special Administration Costs

Special Administration Costs	Amount
Accretion/Deletion Cost
Certification Cost
Special Studies
Other (Specify)
Total Special Administration Cost	0

Sheet 14: Subpart E Limits

	SUBPART E LIMITS

	Name of Plan:	0	Period From:	0
	Plan #:	H-xxxx	To:	0

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


			COMPARABLE
	COST CENTERS		CARRIER
			PAYMENTS

1	Physician Groups:
2	Fee For Service………………………………………………
3	Capitation…………………………………………………………
4	Other………………………………………………………………..
5	Individual Physicians:
6	Fee For Service………………………………………………
7	Capitation…………………………………………………………
8	Other………………………………………………………………..
9	Certified Labs:
10	Fee For Service………………………………………………
11	Capitation…………………………………………………………
12	Other………………………………………………………………..
13	X-Ray Units:
14	Fee For Service………………………………………………
13	Capitation…………………………………………………………
14	Other………………………………………………………………..
15	ESRD Facilities................................................................
16	_________________________________
17	Durable Medical Equipment.........................................
18	Ambulance..........................................................................
19	Emergency-Urgently Needed Svcs............................
20
21	Mental Health Svcs
22	_________________________________
23	_________________________________
24	_________________________________
25	_________________________________
26	_________________________________
27	_________________________________
28	_________________________________
29	_________________________________
30	_________________________________
31	_________________________________





































































































































































































































































































































































































































































































































































































































































































































































































































































































































					Yes
					No

Sheet 15: H-part C, Supplemental

	STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS					WORKSHEET H
		Name of Plan:	0	PERIOD FROM:	12/30/99
		Plan #:	H-xxxx	TO:	12/30/99

C.	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.

				----------RELATED ORGANIZATION(S)--------
	SYMBOL (2)	NAME OF INDIVIDUAL	OWNERSHIP OF PLAN	ORGANIZATION	OWNERSHIP	TYPE OF
				NAME	%	BUSINESS
	1	2	3	4	5	6

21	_	________________________________	_______________________________	______________	0.00%	_____________
22	_	________________________________	_______________________________	______________	0.00%	_____________
23	_	________________________________	_______________________________	______________	0.00%	_____________
24	_	________________________________	_______________________________	______________	0.00%	_____________
25	_	________________________________	_______________________________	______________	0.00%	_____________
26	_	________________________________	_______________________________	______________	0.00%	_____________
27	_	________________________________	_______________________________	______________	0.00%	_____________
28	_	________________________________	_______________________________	______________	0.00%	_____________
29	_	________________________________	_______________________________	______________	0.00%	_____________
30	_	________________________________	_______________________________	______________	0.00%	_____________
31	_	________________________________	_______________________________	______________	0.00%	_____________
32	_	________________________________	_______________________________	______________	0.00%	_____________
33	_	________________________________	_______________________________	______________	0.00%	_____________
34	_	________________________________	_______________________________	______________	0.00%	_____________
35	_	________________________________	_______________________________	______________	0.00%	_____________
36	_	________________________________	_______________________________	______________	0.00%	_____________
37	_	________________________________	_______________________________	______________	0.00%	_____________
38	_	________________________________	_______________________________	______________	0.00%	_____________
39	_	________________________________	_______________________________	______________	0.00%	_____________
40	_	________________________________	_______________________________	______________	0.00%	_____________
41	_	________________________________	_______________________________	______________	0.00%	_____________
42	_	________________________________	_______________________________	______________	0.00%	_____________
43	_	________________________________	_______________________________	______________	0.00%	_____________
44	_	________________________________	_______________________________	______________	0.00%	_____________
45	_	________________________________	_______________________________	______________	0.00%	_____________
46	_	________________________________	_______________________________	______________	0.00%	_____________
47	_	________________________________	_______________________________	______________	0.00%	_____________
48	_	________________________________	_______________________________	______________	0.00%	_____________
49	_	________________________________	_______________________________	______________	0.00%	_____________
50	_	________________________________	_______________________________	______________	0.00%	_____________
51	_	________________________________	_______________________________	______________	0.00%	_____________
52	_	________________________________	_______________________________	______________	0.00%	_____________
53	_	________________________________	_______________________________	______________	0.00%	_____________
54	_	________________________________	_______________________________	______________	0.00%	_____________
55	_	________________________________	_______________________________	______________	0.00%	_____________
56	_	________________________________	_______________________________	______________	0.00%	_____________
57	_	________________________________	_______________________________	______________	0.00%	_____________
58	_	________________________________	_______________________________	______________	0.00%	_____________
59	_	________________________________	_______________________________	______________	0.00%	_____________
60	_	________________________________	_______________________________	______________	0.00%	_____________
61	_	________________________________	_______________________________	______________	0.00%	_____________
62	_	________________________________	_______________________________	______________	0.00%	_____________
63	_	________________________________	_______________________________	______________	0.00%	_____________
64	_	________________________________	_______________________________	______________	0.00%	_____________
65	_	________________________________	_______________________________	______________	0.00%	_____________
66	_	________________________________	_______________________________	______________	0.00%	_____________
67	_	________________________________	_______________________________	______________	0.00%	_____________
68	_	________________________________	_______________________________	______________	0.00%	_____________
69	_	________________________________	_______________________________	______________	0.00%	_____________

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

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

Sheet 16: I-Supplemental Descriptions

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
		ALLOWABLE	ALLOCATION	TOTALS
	COST CENTER	COST	(WKST I,
		(Col 1 thru 3)	Part I)	(Col 4 + Col 5)	Explanation
		4	5	6

1	Inpatient Hospitals ……………….	0	0	0
2	Outpatient Hospitals …………….	0	0	0
3	Skilled Nursing Facilities.......….…	0	0	0
4	Home Health Agencies........….….	0	0	0
5	Clinics..........……….........….......…	0	0	0
6	Physician Groups.......................…	0	0	0
7	Individual Physicians.....…...….…	0	0	0
8	Certified Labs..................…......…	0	0	0
9	X-Ray Units....................……....…	0	0	0
10	ESRD Facilities.........................…	0	0	0
11	Durable Medical Equipment.......…	0	0	0
12	Ambulance...............……….......…	0	0	0
13	Pharmacy (Outpatient).......…...…	0	0	0
13a	Pharmacy-Medicare Covered Rx	0	0	0
14	Emergency-Urgent Needed Svcs..	0	0	0
15	Mental Health Services....….……	0	0	0
16	DED+CO on claims processed by MACs	0	0	0
17	Other - Medicare Bad Debts...…	0	0	0
18	Other - Blood Deductible.....…	0	0	0
19	Part B Cost Not Subj to Coins.	0	0	0
20	Non-Allowable Costs	0	0	0
21	Other - (Specify)...…….......…	0	0	0
22	Other - (Specify)...…….......…	0	0	0
23	Other - (Specify)...…….......…	0	0	0
		_____________	_____________	___________
24	Subtotal (Sum Lines 1-23).................................................................................................	0	0	0

25	Plan Administration..............…..…	0	0	0
26	Special Admin Costs................…	0	0	0
		_____________	_____________	___________
27	Subtotal: (Sum Lns 25+26)...................................................................................................................................	0	0	0

28	Admin & General Costs...…......…	0	0	0
		_____________	_____________	___________

29	Total Program Costs (24+27+28)......................................................................................................................	0	0	0
		=========	=========	=========

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