Form CMS-2088-17 Community Mental Health Cost (CMHC) Report

DRAFT

FORM CMS-2088-17

4590 (Cont.)

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim
payments made since the beginning of the cost reporting period being deemed as overpayments (42 USC 1395g).

FORM APPROVED
OMB NO. 0938-0037
EXPIRES: 02/28/2020
WORKSHEET S
PARTS I, II & III

COMMUNITY MENTAL HEALTH CENTER COST REPORT
PROVIDER CCN:
PERIOD:
IDENTIFICATION DATA, CERTIFICATION
FROM ___________
AND SETTLEMENT SUMMARY
____________
TO ___________
PART I - COST REPORT STATUS
Provider use only
1. [ ] Electronically filed cost report
Date:
Time:
2. [ ] Manually submitted cost report
3. [ ] If this is an amended report enter the number of times the provider resubmitted this cost report
4 [ ] Medicare Utilization. Enter "F" for full, "L" for low, or "N" for no.
Contractor
5. [ ] Cost Report Status
6. Date Received:_________
10. NPR Date:__________
use only
(1) As Submitted
7. Contractor No.:________
11. Contractor's Vendor Code: ___________
(2) Settled without audit
8. [ ] Initial Report for this Provider CCN
12. [ ] If line 5, column 1 is 4: Enter number of
(3) Settled with audit
9. [ ] Final Report for this Provider CCN
times reopened = 0-9.
(4) Reopened
(5) Amended
PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL,
CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN
THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE
ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually
submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s)
and Number(s)}for the cost reporting period beginning ______________ and ending ______________ and that to the best of my knowledge and belief,
this report and statement are true, correct, complete and prepared from the books and records of the provider in accordance with applicable
instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that
the services identified in this cost report were provided in compliance with such laws and regulations.
______________________________________________
Officer or Administrator of Provider(s)
______________________________________________
Title
______________________________________________
Date
PART III - SETTLEMENT SUMMARY
TITLE XVIII
PART B
1
1 COMMUNITY MENTAL HEALTH CENTER

1

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 0938-0037. The time required to complete this information collection is estimated to average 90 hours
per response including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden
approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where
to submit your documents, please contact 1-800-MEDICARE.
FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4502 THROUGH 4502.3)

Rev. 1

45-303

4590 (Cont.)

FORM CMS-2088-17

COST REPORT IDENTIFICATION DATA

PROVIDER CCN:

PERIOD:
FROM __________
TO ___________

____________

DRAFT
WORKSHEET S-1
PARTS I & II

PART I - IDENTIFICATION DATA
Community Mental Health Center Address:
Provider
CCN
2

1
1
2
3
4

CMHC Name:
Street:
City:
Cost Reporting Period (mm/dd/yyyy)

P.O. Box:
State:
To:

From:

Date
Certified
4

CBSA
3

ZIP Code:

Type of control
(see instructions)
5
1
2
3
4

County:

5 Is this CMHC part of a chain organization as defined in §2150 of CMS Pub. 15-1 that claims home office costs in a
Home Office Cost Statement? Enter "Y for yes or "N" for no in column 1. If yes, enter the chain organization's information below.
6 Name of Chain Organization:

6

7 Street:

P.O. Box:

7

8 City:

State:

5

Home Office CCN:
Zip Code:

8

Medical Malpractice
9 Is this CMHC legally required to carry malpractice insurance? Enter "Y" for yes or "N" for no.
10 If line 9 is "Y", is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.

9
10
Premiums

Paid Losses

Self Insurance

11 Enter total malpractice premiums in column 1, total paid losses in column 2, and total self insurance in column 3
12 Are malpractice premiums and/or paid losses reported in other than the Administrative and General cost center? Enter "Y" for yes or "N" for no. (see instructions)

11
12
Y/N
1

Demonstration Type
2

13 Did this facility participate in any payment demonstration during this cost reporting period? Enter "Y" for yes or "N" for no.
If column 1 is yes, enter the type of demonstration in column 2. If the CMHC participated in more than one demonstration, subscript this line
accordingly.

13

PART II - STATISTICAL DATA
REIMBURSABLE
COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12

Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
TOTAL (sum of lines 1 through 10)
Unduplicated Census

REIMBURSABLE
COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12

Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
TOTAL (sum of lines 1 through 10)
Unduplicated Census

Wkst.
A
23
24
25
26
27
28
29
30
31
32

Wkst.
A
23
24
25
26
27
28
29
30
31
32

Medicare
Patients
1

VISITS
Other
Patients
2

PATIENT DAYS
Total
3

Medicare
4

Other
5

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

Staff
Therapists
7

FTE ON PAYROLL
Social
Physicians
Workers
8
9

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

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4503 THROUGH 4503.2)

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DRAFT
COST REPORT REIMBURSEMENT QUESTIONNAIRE

FORM CMS-2088-17

4590 (Cont.)
PROVIDER CCN:

PERIOD:
FROM _________
TO ___________

___________

PROVIDER ORGANIZATION AND OPERATION
1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period?
Enter "Y" for yes or "N" for no in column 1. If yes, enter the date (mm/dd/yyyy) of the change in column 2.
(see instructions)
2 Has the provider terminated participation in the Medicare Program? Enter "Y" for yes or "N" for no in column 1.
If yes, enter in column 2 the termination date (mm/dd/yyyy); and, enter in column 3, "V" for voluntary or "I"
for involuntary.
3 Is the provider involved in business transactions, including management contracts, with individuals or entities
(e.g., chain home offices, drug or medical supply companies) that were related to the provider or its officers,
medical staff, management personnel, or members of the board of directors through ownership, control, or
family and other similar relationships? Enter "Y" for yes or "N" for no in column 1. (see instructions)

FINANCIAL DATA AND REPORTS
4 Column 1: Were the financial statements prepared by a Certified Public Accountant? Enter "Y" for yes or "N" for no.
Column 2: If yes, enter in column 2: "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy
of financial statements or enter date available (mm/dd/yyyy) in column 3. (see instructions) If no, see instructions.
5 Are the cost report total expenses and total revenues different from those on the filed financial statements? Enter "Y"
for yes or "N" for no in column 1. If yes, submit reconciliation.

Y/N
1

DATE
2

WORKSHEET S-2

V/I
3
1

2

3

Y/N
1

A/C/R
2

4

5

BAD DEBTS
6 Is the provider seeking reimbursement for bad debts? Enter "Y" for yes or "N" for no. If yes, see instructions.
7 If line 6 is yes, did the provider's bad debt collection policy change during the cost reporting period? "Y" for yes or "N" for no. If yes, submit a copy.
8 If line 6 is yes, were patient deductibles and/or co-payments waived? Enter "Y" for yes or "N" for no. If yes, see instructions.

PS&R REPORT DATA
9 Was the cost report prepared using the PS&R report only? Enter "Y" for yes or "N" for no in column 1. If yes, enter in column 2 the
paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions.)
10 Was the cost report prepared using the PS&R report for totals and the provider's records for allocation? Enter "Y" for yes or "N" for no
in column 1. If yes, enter in column 2 the paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions)
11 If line 9 or 10 is yes, were adjustments made to PS&R report data for additional claims that have been billed but are not included on the
PS&R report used to file the cost report? Enter "Y" for yes or "N" for no. If yes, see instructions.
12 If line 9 or 10 is yes, were adjustments made to PS&R report data for corrections of other PS&R report information? Enter "Y" for yes
or "N" for no. If yes, see instructions.
13 If line 9 or 10 is yes, were adjustments made to PS&R report data for Other? Enter "Y" for yes or "N" for no.
If yes, describe the other adjustments:
14 Was the cost report prepared only using the provider's records? Enter "Y" for yes or "N" for no.
If yes, see instructions.

DATE
3

Y/N
6
7
8
Y/N
1

DATE
2
9
10
11
12
13
14

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4504)

Rev. 1

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4590 (Cont.)

FORM CMS-2088-17

DRAFT

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

PROVIDER CCN:

PERIOD:
FROM ___________
TO ___________

___________

COST CENTERS (Omit Cents)

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

0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
1200

23
24
25
26
27
28
29
30
31
32

2300
2400
2500
2600
2700
2800
2900
3000
3100

42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

4200
4300
4400
4500
4600
4700
4800
4900
5000
5100
5200
5300
5400
5500
5600
5700

SALARIES
1

OTHER
2

CONTRACTED
PURCHASED
SERVICES
3

GENERAL SERVICE COST CENTERS
Cap Rel Costs - Bldg & Fixt
Cap Rel Costs - Mvble Equip
Employee Benefits
Administrative & General
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Cafeteria
Central Services & Supplies
Medical Records & Library
Pro Ed & Training (Approved)
Other (specify)
REIMBURSABLE COST CENTERS
Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
NONREIMBURSABLE COST CENTERS
Sheltered Workshops
Recreational Programs
Resident Day Camps
Diagnostic Clinics
Physicians' Private Offices
Fund Raising
Coffee Shops & Canteen
Research
Investment Property
Advertising
Franchise Fees and Other Assessments
Pro Ed & Training (Not Approved)
Meals & Transportation
Activity Therapies
Psychosocial Programs
Vocational Training
Other (specify)
TOTAL (sum of lines 1 through 58)

TOTAL
(col. 1 through col. 3)
4

RECLASS.
(from
Wkst. A-6)
5

RECLASSIFIED
TRIAL BALANCE
(col. 4 ± col. 5)
6

WORKSHEET A

ADJUSTMENTS
(from
Wkst. A-8)
7

NET EXPENSES
FOR ALLOCATION
(col. 6 ± col. 7)
8
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4505)

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DRAFT

FORM CMS-2088-17

RECLASSIFICATIONS

4590 (Cont.)

PROVIDER CCN:

PERIOD:
FROM ___________
TO ___________

___________
EXPLANATION OF RECLASSIFICATION(S)

CODE
(1)
1

COST CENTER
2

INCREASE
LINE NO.
SALARY
3
4

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
100 Total reclassifications (sum of columns 4 and 5 must equal
sum of columns 8 and 9)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A. column 5, line as appropriate.

NON SALARY
5

COST CENTER
6

WORKSHEET A-6

DECREASE
LINE NO.
7

SALARY
8

NON SALARY
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
100

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4506)

Rev. 1

45-307

4590 (Cont.)

FORM CMS-2088-17

ADJUSTMENTS TO EXPENSES

DESCRIPTION (1)
BASIS (2)
1
1 Capital Related Costs - Buildings
and fixtures
2 Capital Related Costs - Movable
Equipment
3 Payments received from
specialists
4 Investment income
(chapter 2)
5 Trade, quantity, and time discounts
(chapter 8)
6 Refunds and rebates of expenses
(chapter 8)
7 Laundry and linen service
8 Cafeteria-employees,
guests, etc.
9 Sale of medical and surgical
supplies to other than patients
10 Sale of workshop products
or services
11 Coffee shops and canteen

A
A

DRAFT

PROVIDER CCN: PERIOD:
WORKSHEET A-8
FROM ___________
____________
TO ___________
EXPENSE CLASSIFICATION ON
WORKSHEET A TO/FROM WHICH
THE AMOUNT IS TO BE ADJUSTED
AMOUNT
COST CENTER
LINE NO.
3
2
4
Capital Related Costs
1
Buildings & Fixtures
1
Capital Related Costs
2
Movable Equipment
2
3

B
4
B

5

B

6
Laundry and Linen Service
Cafeteria

A

7

7
8

9
Central Services and
Supplies

9
10
10
11

12 Vending Machines

12
A

13 Rental of building or office
space to others
14 Sale of scrap, waste,
etc. (Chapter 23)
15 Related organization transactions
(chapter 10)
16 Provider-based physician
adjustment
17 Other (Specify) (3)
50 TOTAL (sum of lines 1 through 49)
(Transfer to Worksheet A, col. 7, line 100.)

13
14
Wkst.
A-8-1
Wkst.
A-8-2

15
16
17
50

(1) Include amounts not already applied against expenses included on Worksheet A, column 4
(2) Basis for adjustment (SEE INSTRUCTIONS).
A. Costs -- if cost, including applicable overhead, can be determined.
B. Amount Received -- if cost cannot be determined.
(3) Additional adjustments may be made on subscripts of this line.
Chapter references are to CMS Pub.15-1

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4507)

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Rev. 1

DRAFT

FORM CMS-2088-17

STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS

4590 (Cont.)

PROVIDER CCN:
___________

PERIOD:
FROM ___________
TO ___________

WORKSHEET A-8-1

PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS
OR CLAIMED HOME OFFICE COSTS:
Amount
Net
Amount
Included
Adjustments
Wkst. A
Allowable
in Wkst. A,
(col. 3 minus
Line No.
Cost Center
Amount
In Cost
column 7
col. 4) *
1
2
3
4
5
6
1
2
3
4
5 TOTALS (Sum of lines 1 through 4) Transfer col. 6, line 5 to Worksheet A-8,
column 2, line 15.

1
2
3
4
5

* The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 7, lines as appropriate.
Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not
been posted to Worksheet A, columns 1, 2 and/or 3, the amount allowable should be indicated in column 4 of this part.
PART II - INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE:
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish
the information requested under Part II of this worksheet.
This information is used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable to services,
facilities and supplies furnished by organizations related to you by common ownership or control, represent reasonable costs as determined
under section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost report is considered
incomplete and not acceptable for purposes of claiming reimbursement under Medicare.

Symbol
(1)
1

Name
2

Percentage
of
Ownership
3

Related Organization(s) and/or Home Office
Percentage
of
Type of
Name
Ownership
Business
4
5
6

1
2
3
4
5

1
2
3
4
5
(1) Use the following symbols to indicate interrelationship to related organizations:
A. Individual has financial interest (stockholder, partner, etc.) in both related
organization and in provider.
B. Corporation, partnership or other organization has financial interest in provider.
C. Provider has financial interest in corporation, partnership, or other organization.
D. Director, officer, administrator or key person of provider or relative of such
person has financial interest in related organization.
E. Individual is director, officer, administrator or key person of provider and
related organization.
F. Director, officer, administrator or key person of related organization or relative
of such person has financial interest in provider.
G. Other (financial or non-financial) specify __________________________________________________

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4508)

Rev. 1

45-309

4590 (Cont.)

DRAFT

FORM CMS-2088-17

PROVIDER-BASED PHYSICIANS ADJUSTMENTS

PROVIDER CCN:
____________

Wkst. A
Line #
1

Cost Center/
Physician
Identifier
2

Total
Remuneration
3

Professional
Component
4

Provider
Component
5

RCE
Amount
6

PERIOD:
FROM ___________
TO ___________
Physician/
Provider
Unadjusted
Component Hours RCE Limit
7
8

WORKSHEET A-8-2

5 Percent of
Unadjusted
RCE Limit
9

1
2
3
4
5
6
7
8
9
10
11
100 TOTAL

Wkst. A
Line #
10

1
2
3
4
5
6
7
8
9
10
11
100

Cost Center/
Physician
Identifier
11

Cost of
Memberships
& Continuing
Education
12

Provider
Component
Share of
col. 12
13

Physician
Cost of
Malpractice
Insurance
14

Provider
Component
Share of
col. 14
15

1
2
3
4
5
6
7
8
9
10
11
100 TOTAL

Adjusted
RCE Limit
16

RCE
Disallowance
17

Adjustment
18
1
2
3
4
5
6
7
8
9
10
11
100

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4509)

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DRAFT

FORM CMS-2088-17

COST ALLOCATION GENERAL SERVICE COSTS

4590 (Cont.) 4590 (Cont.)

PROVIDER CCN:

___________
COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

Net Expenses
(from Wkst. A,
col.8)
0

Capital Related
Buildings &
Movable
Fixtures
Equipment
2
1

Employee
Benefits
3

GENERAL SERVICE COST CENTERS
Cap Rel Costs - Bldg & Fixt
Cap Rel Costs - Mvble Equip
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Cafeteria
Central Services and Supplies
Medical Records and Library
Pro Ed & Training (Approved)(1)
Other (specify)
REIMBURSABLE COST CENTERS
Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
NONREIMBURSABLE COST CENTERS
Sheltered Workshops
Recreational Programs
Resident Day Camps
Diagnostic Clinics
Physicians' Private Office
Fundraising
Coffee Shops &Canteen
Research
Investment Property
Advertising
Franchise Fees & Other Assessments
Pro Ed & Training (Not Approved)(2)
Meals and Transportation
Activity Therapies
Psychosocial Programs
Vocational Training
Other (specify)
TOTAL (sum of line 1 through 58)
(1) Approved Educational Activity
(2) Not an Approved Educational Activity

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)
Rev. 1

PERIOD:
FROM ___________
TO ___________
Subtotal
(cols. 0-3)
3A

WORKSHEET B

Administrative Maintenance
& General
& Repairs
5
4

FORM CMS-2088-17
PROVIDER CCN:

COST ALLOCATION GENERAL SERVICE COSTS

___________
Operation
of
Plant
6

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

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

23
24
25
26
27
28
29
30
31
32

23
24
25
26
27
28
29
30
31
32

42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

Laundry
and Linen
Services
7

Housekeeping
8

Cafeteria
9

Central
Services &
Supplies
10

GENERAL SERVICE COST CENTERS
Cap Rel Costs - Bldg & Fixt
Cap Rel Costs - Mvble Equip
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Cafeteria
Central Services and Supplies
Medical Records and Library
Pro Ed & Training (Approved)(1)
Other (specify)
REIMBURSABLE COST CENTERS
Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
NONREIMBURSABLE COST CENTERS
Sheltered Workshops
Recreational Programs
Resident Day Camps
Diagnostic Clinics
Physicians' Private Office
Fundraising
Coffee Shops &Canteen
Research
Investment Property
Advertising
Franchise Fees & Other Assessments
Pro Ed & Training (Not Approved)(2)
Meals and Transportation
Activity Therapies
Psychosocial Programs
Vocational Training
Other (specify)
TOTAL (sum of line 1 through 58)

DRAFT
PERIOD:
FROM ___________
TO ___________
Medical
Prof.
Records
Education
Library
and Training
11
12

WORKSHEET B

Other
(Specify)
13

Total
14
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

(1) Approved Educational Activity
(2) Not an Approved Educational Activity
FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)
45-31145-312

Rev. 1

DRAFT

4590 (Cont.) 4590 (Cont.)

FORM CMS-2088-17

COST ALLOCATION - STATISTICAL BASIS

PROVIDER CCN:

___________
COST CENTERS
0
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

Capital Related
Buildings &
Movable
Equipment
Fixtures
(Square
(Dollar
Feet)
Value)
2
1

Employee
Benefits
(Gross
Salaries)
3

GENERAL SERVICE COST CENTERS
Cap Rel Costs - Bldg & Fixt
Cap Rel Costs - Mvble Equip
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Cafeteria
Central Services and Supplies
Medical Records and Library
Pro Ed & Training (Approved)(1)
Other (specify)
REIMBURSABLE COST CENTERS
Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
NONREIMBURSABLE COST CENTERS
Sheltered Workshops
Recreational Programs
Resident Day Camps
Diagnostic Clinics
Physicians' Private Office
Fundraising
Coffee Shops &Canteen
Research
Investment Property
Advertising
Franchise Fees & Other Assessments
Pro Ed & Training (Not Approved)(2)
Meals and Transportation
Activity Therapies
Psychosocial Programs
Vocational Training
Other (specify)
TOTAL (sum of line 1 through 58)
(1) Approved Educational Activity
(2) Not an Approved Educational Activity

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)

Rev. 1

PERIOD:
FROM ___________
TO ___________

Reconciliation
4A

WORKSHEET B-1

Administrative Maintenance
& Repairs
& General
(Accum.
(Square
Cost)
Feet)
4
5

FORM CMS-2088-17

COST ALLOCATION - STATISTICAL BASIS

DRAFT

PROVIDER CCN:

___________
Operation
of
Plant
(Square
Feet)
6

COST CENTERS

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

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

23
24
25
26
27
28
29
30
31
32

23
24
25
26
27
28
29
30
31
32

42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

Laundry
and Linen
Services
(Pounds of
Laundry)
7

Housekeeping
(Hrs. of
Service)
8

Cafeteria
(Meals
Served)
9

Central
Services &
Supplies
10

GENERAL SERVICE COST CENTERS
Cap Rel Costs - Bldg & Fixt
Cap Rel Costs - Mvble Equip
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Cafeteria
Central Services and Supplies
Medical Records and Library
Pro Ed & Training (Approved)(1)
Other (specify)
REIMBURSABLE COST CENTERS
Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
NONREIMBURSABLE COST CENTERS
Sheltered Workshops
Recreational Programs
Resident Day Camps
Diagnostic Clinics
Physicians' Private Office
Fundraising
Coffee Shops &Canteen
Research
Investment Property
Advertising
Franchise Fees & Other Assessments
Pro Ed & Training (Not Approved)(2)
Meals and Transportation
Activity Therapies
Psychosocial Programs
Vocational Training
Other (specify)
TOTAL (sum of line 1 through 58)

PERIOD:
FROM ___________
TO ___________
Medical
Records
Prof.Educ.
Library
& Training
(Time
(Assigned
Spent)
Time)
11
12

WORKSHEET B-1

Other
(Specify)
13

Total
14
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

(1) Approved Educational Activity
(2) Not an Approved Educational Activity
FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)

45-313 45-314

Rev.1

DRAFT

FORM CMS-2088-17

APPORTIONMENT OF PATIENT SERVICE COSTS

PROVIDER CCN:

PERIOD:
FROM ___________
TO ___________

___________

REIMBURSABLE COST CENTERS
23
24
25
26
27
28
29
30
31
32
50

From Wkst.
B, col. 14,
Reimbursable
Costs
1

4590 (Cont.)

Total
Charges
2

Ratio of Cost
to Charges
(col. 1 ÷ col. 2)
3

Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
TOTAL (Lines 23 through 32)

WORKSHEET C

Medicare
Charges
4

Medicare
Cost
(col. 3 × col. 4)
5
23
24
25
26
27
28
29
30
31
32
50

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4511)

Rev. 1

45-315

4590 (Cont.)

FORM CMS-2088-17

CALCULATION OF REIMBURSEMENT
SETTLEMENT

PROVIDER CCN:
___________

DRAFT
PERIOD:
FROM __________
TO ___________

WORKSHEET D

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

DESCRIPTION
Gross APC/PPS payments
Outlier payments
Outlier reconciliation amount (transfer from line 54)
Gross reimbursement (sum of lines 1 through 3)
Primary payer payments
Deductibles billed to program patients (do not include coinsurance)
Coinsurance billed to program patients (see instructions)
Subtotal (line 4 minus lines 5, 6, and 7)
Reimbursable bad debts (see instructions)
Adjusted reimbursable bad debts
Reimbursable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (line 8 plus line 10)
Other adjustments (specify) (see instructions)
Other demonstration payment adjustment amount before sequestration
Amount due prior to the sequestration adjustment (see instructions)
Sequestration adjustment (see instructions)
Other demonstration payment adjustment amount after sequestration
Amount due after sequestration adjustment (see instructions)
Interim payments
Tentative settlement (For contractor use only)
Balance due provider/program (line 18 minus lines 19 and 20) (indicate overpayment in brackets)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

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

50
51
52
53
54

TO BE COMPLETED BY CONTRACTOR
Original outlier amount (see instructions)
Outlier reconciliation adjustment amount (see instructions)
The rate used to calculate the Time Value of Money
Time Value of Money (see instructions)
Total (sum of lines 51 and 53)

50
51
52
53
54

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4512

45-316

Rev. 1

DRAFT

FORM CMS-2088-17

ANALYSIS OF PAYMENTS FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES

PROVIDER CCN:

4590 (Cont.)
PERIOD:
FROM ___________
TO ___________

WORKSHEET D-1

DESCRIPTION

PART B
1
mm/dd/yyyy

1
2

3

Total interim payments paid to CMHC
Interim payments payable on individual bills either, submitted or to
be submitted to the contractor, for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
List separately each retroactive lump sum
adjustment amount based on subsequent revision
of the interim rate for the cost reporting period.
Also show date of each payment. If none write
"NONE" or enter a zero. (1)

1
2

Program
to
Provider

Provider
to
Program

4

2
Amount

SUBTOTAL (Sum of lines 3.01-3.49, minus sum
of lines 3.50-3.98)
TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)
(Transfer to Wkst. D, line 19)

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54

.99

3.99
4

.01
.02
.03
.50
.51
.52

5.01
5.02
5.03
5.50
5.51
5.52

.99

5.99

.01

6.01

.02

6.02
7

TO BE COMPLETED BY CONTRACTOR
5

6

7

List separately each tentative settlement payment
after desk review. Also show date of each
payment. If none, write "NONE" or enter
a zero. (1)

SUBTOTAL (Sum of lines 5.01-5.49, minus sum
of lines 5.50-5.98)
Determine net settlement amount (balance due) based
on the cost report (SEE INSTRUCTIONS). (1)

TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)

Program
to
Provider
Provider
to
Program

Program
to
Provider
Provider
to
Program

(1) On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the provider
agrees to the amount of repayment, even though total repayment is not accomplished until a later date.

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4513)

Rev. 1

45-317

DRAFT

FORM CMS-2088-17

STATEMENT OF REVENUES AND EXPENSES

PROVIDER CCN:
____________

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

PERIOD:
FROM ___________
TO ___________

4590 (Cont.)
WORKSHEET F

Total patient revenue
Less: Allowance and discounts on patients' accounts
Net patient revenues (line 1 minus line 2)
Less: Total operating expenses (per Worksheet A, column 4, line 100)
Net income from service to patients (line 3 minus line 4)
OTHER INCOME
Grants, gifts, and income designated by donor for specific expenses
Payments received from specialists
Investment income on unrestricted funds
Trade, quantity, time and other discounts on purchases
Rebates and refunds of expenses
Income from laundry and linen service
Income from cafeteria - employees, guests, etc.
Sale of medical supplies to other than patients
Sale of workshop products or services
Coffee shops and canteen
Vending machines
Rental of building or office space to others
Sale of scrap, waste, etc.
Sale of medical records and abstracts
Other (Specify)
Total other income (sum of lines 6 through 20)
Total (line 5 plus line 21)
OTHER EXPENSES
Fund raising
Gift, coffee shops, and canteen
Investment property
Other (specify)
Total other expenses (sum of lines 23 through 26)
Net income (or loss) for the period (line 22 minus line 27)

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

FORM CMS-2088-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4514.1)

Rev. 1

45-318