CMS-222-17 Rural Health Clinic Cost Report

DRAFT

FORM CMS-222-17

4690

This report is required by law (42 USC. 1395g: CFR 413.20(b)). Failure to report can result
in all payments made during the reporting period being deemed overpayments (42 USC 1395g).
RURAL HEALTH CLINIC COST REPORT
CERTIFICATION AND SETTLEMENT SUMMARY

CCN:

PERIOD:
FROM: __________
TO: __________

___________
PART I - COST REPORT STATUS
Provider use only

1. [ ]
2. [ ]
3. [ ]
4. [ ]
Contractor
5. [ ] Cost Report Status
use only
(1) As Submitted
(2) Settled without audit
(3) Settled with audit
(4) Reopened
(5) Amended
PART II - CERTIFICATION

FORM APPROVED
OMB NO: 0938-0107
EXPIRATION DATE 09/30/2020
WORKSHEET S
PARTS I, II & III

Date:
Time:
Electronically filed cost report
Manually submitted cost report
If this is an amended report enter the number of times the provider resubmitted this cost report.
Medicare Utilization. Enter "F" for full, "L" for low, or "N" for no utilization .
6. Date Received:_________
10. NPR Date:___________
7. Contractor No.:________
11. Contractors Vendor Code: ____________
8. [ ] Initial Report for this Provider CCN
12. [ ] If line 5, column 1 is 4: Enter the number of
times reopened = 0-9.
9. [ ] Final Report for this Provider CCN

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL
AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS
REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL,
CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually
submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s)
and Number(s)}for the cost reporting period beginning ______________ and ending ______________ and that to the best of my knowledge and belief,
this report and statement are true, correct, complete and prepared from the books and records of the provider in accordance with applicable
instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that
the services identified in this cost report were provided in compliance with such laws and regulations.
(Signed)
Officer or Administrator of Provider(s)
Title
Date

PART III - SETTLEMENT SUMMARY
TITLE XVIII
1
1 RHC
The above amount represents "due to" or "due from" the Medicare program.

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 0938-0107. The time required to complete this information collection is estimated
55 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications,
claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE.

FORM CMS-222-17 (DATE) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4603 THROUGH 4603.3)

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FORM CMS-222-17

RURAL HEALTH CLINIC IDENTIFICATION DATA

DRAFT
CCN:
______________

PERIOD:
FROM: ____________
TO: _____________

WORKSHEET S-1
PART I

PART I - RURAL HEALTH CLINIC IDENTIFICATION DATA

1
2
3
4

1
Site Name:
Street:
City:
Cost Reporting Period (mm/dd/yyyy) From:

Provider
CCN
2
P.O. Box:
State:
To:

CBSA
3

Zip Code:

Date
Certified
4

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

County:

5 Is this RHC part of an entity that owns, leases or controls multiple RHCs? Enter "Y" for yes or "N" for no.
If yes, enter the entity's information below.
6 Name of Entity:
7 Street:
8 City:

P.O. Box:
State:

5

6
7
8

HRSA Award Number:
Zip Code:

9 Is this RHC part of a chain organization as defined in §2150 of CMS Pub. 15, Part 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.
10 Name of Chain Organization:
11 Street:
12 City:

P.O. Box:
State:

Consolidated Cost Report
13 Is this RHC filing a consolidated cost report per CMS Pub. 100-02, chapter 13,
§80.2? Enter "Y" for yes or "N" for no in column 1. If column 1 is yes,
complete columns 2 through 4, and line 14, beginning with subscripted line
14.01. If column 1 is no, leave line 14 blank. (see instructions)
Site Name
1

Y/N
1

9

10
11
12

Home Office CCN:
Zip Code:
Date Requested
2

Date Approved
3

Number of RHCs
4
13

CCN
2

CBSA
3

Date Requested
4

Date Approved
5

14 List of Consolidated Poviders
14.01
Medical Malpractice
15 Does this RHC carry commercial malpractice insurance? Enter "Y" for yes or "N" for no.
16 If line 15 is yes, is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.
Premiums
Paid Losses
Self Insurance
17 List amounts of malpractice premiums, paid losses or self-insurance in the applicable columns.
18 Are malpractice premiums, paid losses or self-insurance reported in a cost center other than the Malpractice Premiums cost center?
Enter "Y" for yes or "N" for no. (see instructions)
Miscellaneous
19 Is this RHC and/or any consolidated RHCs involved in training residents in an approved GME program in accordance with 42 CFR 405.2468(f)?
Enter "Y" for yes or "N" for no. (see instructions)
20 Have you received an approval for an exception to the productivity standard?
21 Does the facility operate as other than a RHC? Enter "Y" for yes or "N" for no.
22 If line 21 is "Y", specify type of operation. (i.e. physicians office, independent laboratory, etc.)
23 Identify days and hours by listing the time the facility operates as a RHC next to the applicable day.
Hours of Operation
From
To
Days
1
2
23.01 Sunday
23.02 Monday
23.03 Tuesday
23.04 Wednesday
23.05 Thursday
23.06 Friday
23.07 Saturday
24 Identify days and hours by listing the time the facility operates as other than a RHC next to the applicable day.
Hours of Operation
From
To
Days
1
2
24.01 Sunday
24.02 Monday
24.03 Tuesday
24.04 Wednesday
24.05 Thursday
24.06 Friday
24.07 Saturday
Y/N
1
25 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.
26 Are there any costs included in Worksheet A that resulted from transactions with related organizations as defined in
CMS Pub. 15-1, chapter 10? If yes, complete A-8-1.

14
14.01
15
16
17
18

19
20
21
22
23

23.01
23.02
23.03
23.04
23.05
23.06
23.07
24

24.01
24.02
24.03
24.04
24.05
24.06
24.07

Demonstration Type
2
25
26

FORM CMS-222-17 (DATE) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4604.1)

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4690 (Cont.)

FORM CMS-222-17

RURAL HEALTH CLINIC IDENTIFICATION DATA

CCN: ___________

PERIOD:
FROM: ____________
TO: _____________

CENTER CCN: __________
PART I - RURAL HEALTH CLINIC CONSOLIDATED COST REPORT IDENTIFICATION DATA

1

Date Certified
2

Type of control
(see instructions)
3

1 Site Name:
2 Street:
P.O. Box:
3 City:
State:
Zip Code:
Medical Malpractice
4 Does this RHC carry commercial malpractice insurance? Enter "Y" for yes or "N" for no.
5 If line 4 is yes, is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.

Date
Decertified
4

WORKSHEET S-1
PART II

V/I Decertification
5

Date of
CHOW
6
1
2
3

County:

4
5
Premiums

Paid Losses

Self Insurance

6 List amounts of malpractice premiums, paid losses or self-insurance in the applicable columns.
Miscellaneous
7 Does the facility operate as other than a RHC? Enter "Y" for yes or "N" for no.
8 If line 7 is "Y", specify type of operation. (i.e. physicians office, independent laboratory, etc.)
9 Identify days and hours by listing the time the facility operates as a RHC next to the applicable day.

6
7
8
9
Hours of Operation

9.01
9.02
9.03
9.04
9.05
9.06
9.07
10

Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Identify days and hours by listing the time the facility operates as other than a RHC next to the applicable day.

From
1

To
2
9.01
9.02
9.03
9.04
9.05
9.06
9.07
10
Hours of Operation

10.01
10.02
10.03
10.04
10.05
10.06
10.07

Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

From
1

To
2
10.01
10.02
10.03
10.04
10.05
10.06
10.07

FORM CMS-222-17 (DATE) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4604.2)

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FORM CMS-222-17

RURAL HEALTH CLINIC REIMBURSEMENT
QUESTIONNAIRE

CCN:
___________

DRAFT
PERIOD:
FROM: ___________
TO: ___________

WORKSHEET S-2

COMPLETED BY ALL RHCs
Y/N
1

Provider Organization and Operation
1 Has the RHC changed ownership immediately prior to the beginning of the cost reporting period?
If yes, enter the date of the change in column 2. (see instructions)
2 Has the RHC terminated participation in the Medicare program? If yes, enter in column 2 the date
of termination and in column 3, "V" for voluntary or "I" for involuntary. (see instructions)
3 Is the RHC involved in business transactions, including management contracts, with individuals or entities
(e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers, medical
staff, management personnel, or members of the board of directors through ownership, control, or family and
other similar relationships? (see instructions)
Financial Data and Reports
4 Column 1: Were the financial statements prepared by a Certified Public Accountant? Enter Y or N. If
N, see instructions.
Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter
date available in column 3. (mm/dd/yyyy).
Column 4: Are the cost report total expenses and total revenus different from those on the field financial statements?
If yes, submit reconciliation.

Date
2

1
2
3

Y/N
1

Type
2

Date
3

Y/N
1

Y/N
1
8
9
10
Y/N
1

PS&R Report Data
11 Was the cost report prepared using the PS&R Report only? If column 1 is yes, enter the
paid-through date of the PS&R Report used in column 2. (see instructions)
12 Was the cost report prepared using the PS&R Report for totals and the RHCs records for allocation?
If column 1 is yes, enter the paid-through date in column 2. (see instructions)
13 If line 11or 12 is yes, were adjustments made to PS&R Report data for additional claims that have been
billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions.
14 If line 11 or 12 is yes, were adjustments made to PS&R Report data for corrections of other
PS&R Report information? If yes, see instructions.
15 If line 11 or 12 is yes, were adjustments made to PS&R Report data for Other?
________________________________________
Describe the other adjustments:
16 Was the cost report prepared only using the RHC's records? If yes, see instructions.

Date
2
11
12
13
14
15
16

Title:
E-mail Address:

Y/N
2
5
6
7

Bad Debts
8 Is the RHC seeking reimbursement for bad debts? If yes, see instructions.
9 If line 8 is yes, did the RHC's bad debt collection policy change during this cost reporting period? If yes, submit copy.
10 If line 8 is yes, were patient coinsurance amounts waived? If yes, see instructions.

Last name:

Y/N
4
4

Approved Educational Activities
5 Are costs for Intern-Resident programs claimed on the current cost report?
6 Was an Intern-Resident program initiated or renewed in the current cost reporting period? If yes, see instructions.
7 Are GME costs directly assigned to cost centers other than Allowable GME Costs on Worksheet A?
If yes, see instructions.

Cost Report Preparer Contact Information
17 First name:
18 Employer:
19 Phone number:

V/I
3

17
18
19

FORM CMS-222-17 (DATE) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4605)

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4690 (Cont.)

FORM CMS-222-17
CCN:

RURAL HEALTH CLINIC DATA

PERIOD:
FROM: __________
TO: ___________

___________

WORKSHEET S-3

RURAL HEALTH CLINIC STATISTICAL DATA

CENTER
CCN
0

Title V
1

Title
XVIII
2

Title
XIX
3

1
2
3
4
5
6

Medical Visits
Total Medical Visits
Mental Health Visits
Total Mental Health Visits
Number of Visits Performed by Interns and Residents
Total Number of Visits Performed by Interns
and Residents
7 Total Visits (sum of lines 2 and 4)

Other
4

Total
All
Patients
5
1
2
3
4
5
6
7

FORM CMS-224-17 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4606)

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FORM CMS-222-17

4690 (Cont.)

RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES

CCN:
____________

COST CENTER

SALARIES
1

OTHER
2

FACILITY HEALTH CARE STAFF COSTS
1 0100 Physician
2 0200 Physician Assistant
3 0300 Nurse Practitioner
4 0400 Certified Nurse Midwife
5 0500 Registered Nurse
6 0600 Licensed Practical Nurse
7 0700 Clinical Psychologist
8 0800 Clinical Social Worker
9 0900 Laboratory Technician
10 1000 Other (specify)
14
Subtotal-Facility Health Care Staff Costs (sum of lines 1 through 10)
COSTS UNDER AGREEMENT
15 1500 Physician Services Under Agreement
16 1600 Physician Supervision Under Agreement
17
Subtotal Under Agreement (sum of lines 15 and 16)
OTHER HEALTH CARE COSTS
25 2500 Medical Supplies
26 2600 Transportation (Health Care Staff)
27 2700 Depreciation-Medical Equipment
28 2800 Malpractice Premiums
29 2900 Allowable GME Costs
30 3000 Pneumococcal Vaccines & Med Supplies
31 3100 Influenza Vaccines & Med Supplies
32 3200 Other (specify)
38
Subtotal-Other Health Care Costs (sum of lines 25 through 32)
39
Total Cost of Services (Other Than
Overhead And Other RHC Services)
(sum of lines 14, 17, and 38)
FACILITY OVERHEAD-FACILITY COST
40 4000 Rent
41 4100 Insurance
42 4200 Interest On Mortgage Or Loans
43 4300 Utilities
44 4400 Depreciation-Buildings And Fixtures
45 4500 Depreciation-Movable Equipment
46 4600 Housekeeping And Maintenance
47 4700 Property Tax
48 4800 Other (specify)
59
Subtotal-Facility Costs (sum of lines 40 through 48)

TOTAL
3

RECLASSIFICATIONS
4

PERIOD:
FROM: ____________
TO: ____________
RECLASSIFIED
TRIAL BALANCE
5

WORKSHEET A

ADJUSTMENTS
6

NET
EXPENSES FOR
ALLOCATION
7
1
2
3
4
5
6
7
8
9
10
14
15
16
17
25
26
27
28
29
30
31
32
38
39

40
41
42
43
44
45
46
47
48
59

FORM CMS-222-17 (DATE) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4607)

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FORM CMS-222-17

DRAFT

RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES

CCN:
____________

COST CENTER
SALARIES
1

OTHER
2

TOTAL
(col. 1 + col. 2)
3

FACILITY OVERHEAD-ADMINISTRATIVE COSTS
60 6000 Office Salaries
61 6100 Depreciation-Office Equipment
62 6200 Office Supplies
63 6300 Legal
64 6400 Accounting
65 6500 Insurance
66 6600 Telephone
67 6700 Fringe Benefits And Payroll Taxes
68 6800 Other (specify)
73
Subtotal-Administrative Cost (sum of lines 60 through 68)
74
Total Overhead (sum of lines 59 and 73)
COST OTHER THAN RHC SERVICES
75 7500 Pharmacy
76 7600 Dental
77 7700 Optometry
78 7800 Non-allowable GME Pass Through Costs
79 7900 Telehealth
80 8000 Chronic Care Management
81 8100 Other (specify)
86
Subtotal-Cost Other Than RHC (sum of lines 75 through 81)
NON-REIMBURSABLE COSTS
87 8700
88 8800
89 8900
90
Subtotal Non-Reimbursable Costs (sum of lines 87 through 89)
100
TOTAL COSTS (sum of lines 39, 74, 86, and 90)

RECLASSIFICATIONS
4

PERIOD:
FROM: ____________
TO: ____________
RECLASSIFIED
TRIAL BALANCE
(col. 3 ± col. 4)
5

WORKSHEET A

ADJUSTMENTS
6

NET
EXPENSES FOR
ALLOCATION
(col. 5 ± col. 6)
7
60
61
62
63
64
65
66
67
68
73
74
75
76
77
78
79
80
81
86
87
88
89
90
100

FORM CMS-222-17 (DATE) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4607)

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FORM CMS-222-17

RECLASSIFICATIONS

CCN:

EXPLANATION OF ENTRY

____________
CODE
COST
(1)
CENTER
1
2

PERIOD:
FROM: __________
TO: ___________
INCREASES
LINE
NO.
AMOUNT (2)
3
4

1
2
3
4
5
6
7
8
9
10
11
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100 TOTAL RECLASSIFICATIONS (Sum of Column 4
must equal sum of Column 7)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer the amounts in columns 4 and 7 to Worksheet A, column 4, lines as appropriate.

4690 (Cont.)
WORKSHEET A-6

COST
CENTER
5

DECREASES
LINE
NO.
AMOUNT (2)
6
7
1
2
3
4
5
6
7
8
9
10
11
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100

FORM CMS-222-17 (DATE) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4608)

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FORM CMS-222-17

ADJUSTMENTS TO EXPENSES

CCN:

DRAFT
PERIOD:

WORKSHEET A-8

FROM: ___________
____________

TO: ___________
EXPENSE CLASSIFICATION ON WORKSHEET A
TO/FROM WHICH THE AMOUNT IS TO BE

BASIS/
DESCRIPTION (1)

CODE (2)
1

ADJUSTED
AMOUNT
2

COST CENTER
3

LINE #
4

1

Investment income- buildings and fixtures (chapter 2)

Buildings and Fixtures

44

1

2

Investment income- movable equipment (chapter 2)

Movable Equipment

45

2

3

Investment income- other (chapter 2)

3

4

Trade, quantity and time discounts (chapter 8)

4

5

Refunds and rebates of expenses (chapter 8)

5

6

Rental of building or office space to others (chapter 8)

7

Related organization transactions (chapter 10)

8

Sale of drugs to other than patients

9

Vending machines

10

6

Wkst A-8-1

7
8
9

Practitioner assigned by Public Health Service

10

11

Depreciation - buildings and fixtures

Buildings and Fixtures

44

11

12

Depreciation - movable equipment

Movable Equipment

45

12

13

RCE adjustment to teaching physician's cost

Allowable GME Costs

29

14

Other adjustments (Specify)(3)

50 TOTAL (sum of lines 1 through 49)

13
14
50

(1) Description - all chapter references in this column pertain to CMS Pub. 15-1.
(2) Basis for adjustment (see instructions)
A. Costs - if cost, including applicable overhead, can be determined.
B. Amount Received - if cost cannot be determined.
(3) Additional adjustments may be made on lines 14 through 49 and subscripts thereof.

FORM CMS-222-17 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4609)

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FORM CMS-222-17

STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS AND
HOME OFFICE COSTS

CCN:
____________

PERIOD:
FROM: ____________
TO: ____________

PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED
ORGANIZATIONS OR CLAIMED HOME OFFICE COSTS
Amount of
Allowable
Line No.
Cost Center
Cost
Expense Items
1
2
4
3
1
2
3
4
5 TOTALS (sum of lines 1-4) Transfer col. 6, line 5 to Wkst. A-8 , column 2, line 7.)

DRAFT
WORKSHEET A-8-1

Amount included
in Wkst. A,
col. 5
5

Net Adjustments
(col. 4 minus
col. 5) *
6
1
2
3
4
5

* The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as appropriate.
Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not
been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.
PART II - INTERRELATIONSHIP TO RELATED ORGANIZATIONS AND/OR HOME OFFICE
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires the
provider to furnish the information requested on 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 Title XVIII.

Symbol
(1)
1

Name
2

Percentage
of
Ownership
3

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

6
7
8
9
10

Type of
Business
6
6
7
8
9
10

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

FORM CMS-222-17 (DATE) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4610 THROUGH 4610.2)

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FORM CMS-222-17

VISITS AND OVERHEAD COST FOR RHC SERVICES

4690 (Cont.)
PERIOD:
FROM: ____________
TO: ____________

CCN:
____________

WORKSHEET B
PARTS I & II

PART I - VISITS AND PRODUCTIVITY

Positions

Number of
FTE
Personnel
1

Total
Visits
2

Productivity
Standard (1)
3

1

Physicians

4200

2

Physician Assistants

2100

3

Nurse Practitioner

2100

4

Certified Nurse Midwife

2100

5

Subtotal (sum of lines 1 through 4)

Minimum
Visits
(col. 1 x col. 3)
4

Greater of
Col. 2 or
Col. 4
5
1
2
3

5
6

6 Registered Nurse

6

7 Licensed Practical Nurse
8

Clinical Psychologist

9

Clinical Social Worker

8
9
10

10 Total Staff

11

11 Physician Services Under Agreement
(1) Productivity standards established by CMS are: 4200 visits for each physician and 2100 visits for each nonphysician
practitioner. If an exception to the productivity standard has been granted (Wkst. S-1, Part I, line 20, equals "Y"), input
in col. 3, lines 1 through 4, the productivity standards derived by the contractor.
PART II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO RHC SERVICES
Amount
12

Cost of RHC services - excluding overhead and allowable GME costs

12

(Worksheet A, column 7, line 39, minus Worksheet A, column 7, line 29)
13

Cost of other than RHC - excluding overhead (Worksheet A, column 7, sum of lines 86 and 90)

13

14

Cost of all services - excluding overhead - (sum of lines 12 and 13)

14

15

Ratio of RHC (line 12 divided by line 14)

15

16

Total overhead - (Worksheet A, column 7, line 74)

16

17

Overhead applicable to RHC services (line 15 times line 16) (see instructions)

17

18

Total allowable cost of RHC services (sum of lines 12 and 17)

18

FORM CMS-222-17 (DATE) INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4611 THROUGH 4611.2)

Rev. 1

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4690 ( Cont.)

FORM CMS-222-17

COMPUTATION OF
PNEUMOCOCCAL AND INFLUENZA
VACCINE COST

CCN:
___________

DRAFT

PERIOD:
FROM: ___________
TO: ___________
PNEUMOCOCCAL
1

WORKSHEET B-1

INFLUENZA
2

1 Health care staff cost (from Worksheet A, column 7, line 14)

1

2 Ratio of pneumococcal and influenza vaccine staff time to total health care staff time

2

3 Pneumococcal and influenza vaccine health care staff cost (line 1 multiplied by line 2)

3

4 Vaccines and related medical supplies cost
(from Worksheet A, column 7, lines 30 and 31, respectively)
5 Direct cost of pneumococcal and influenza vaccine (sum of lines 3 and 4)

4

6 Total direct cost of the facility (from Worksheet A, column 7, line 39)

6

7 Total facility overhead (from Worksheet A, column 7, line 74)

7

8 Ratio of pneumococcal and influenza vaccine direct cost to total direct cost
(line 5 divided by line 6)
9 Overhead cost - pneumococcal and influenza vaccine (line 7 multiplied by line 8)

8

5

9

10 Total pneumococcal and influenza vaccine cost and administration (sum of lines 5 and 9)

10

11 Total number of pneumococcal and influenza vaccine injections (from provider records)

11

12 Cost per pneumococcal and influenza vaccine injection (line 10 divided by line 11)

12

13 Number of pneumococcal and influenza vaccine injections administered
to Medicare beneficiaries
14 Medicare cost of pneumococcal and influenza vaccine and administration
(line 12 multiplied by line 13)
15 Total cost of pneumococcal and influenza vaccine and administration
(sum of columns 1 and 2, line 10 ) Transfer to Worksheet C, Part I, line 2
16 Total Medicare cost of pneumococcal and influenza vaccine and administration
(sum of columns 1 and 2, line 14) Transfer to Worksheet C, Part II, line 23

13
14
15
16

FORM CMS-222-17 (DATE) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB 15-2, SECTION 4612)

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Rev. 1

4690 (Cont. )

FORM CMS-222-17

DETERMINATION OF MEDICARE
PAYMENT

CCN:
____________

DRAFT

PERIOD:
FROM: ____________
TO: ___________

WORKSHEET C
PARTS I & II

PART I- DETERMINATION OF RATE FOR RHC SERVICES
1 Total allowable costs (Worksheet B, Part II, line 18)

AMOUNT
1

2 Cost of pneumococcal and influenza vaccine and administration (from Worksheet B-1, line 15)

2

3 Total allowable cost excluding pneumococcal and influenza vaccine (line 1 minus line 2)

3

4 Greater of minimum visits or actual visits by health care staff (from Worksheet B, Part I, column 5, line 10)

4

5 Physicians visits under agreements (from Worksheet B, Part I, column 5, line 11)

5

6 Total adjusted visits (line 4 plus line 5)

6

7 Adjusted cost per visit (line 3 divided by line 6)

7
Calculation of Limit (1)
Payment Limit
Payment Limit
Period 1
Period 2

8 Maximum rate per visit (see instructions)

8

9 Rate for Medicare covered visits (lessor of line 7 or line 8)

9

PART II - DETERMINATION OF TOTAL PAYMENT

Payment Limit
Period 1

Payment Limit
Period 2

10

Medicare covered visits excluding mental health services (from contractor records)

10

11

Medicare cost excluding costs for mental health services (line 9 multiplied by line 10)

11

12

Medicare covered visits for mental health services (from contractor records)

12

13

Medicare covered cost for mental health services (line 9 multiplied by line 12)

13

14

Total Medicare cost (line 11 plus line 13 )

14

15

Less: beneficiary deductible (see instructions)

15

16

Net Medicare cost excluding pneumococcal and influenza vaccine and administration
(line 14 minus line 15)
Total Medicare charges (see instructions)

16

17
18

Total Medicare preventive charges (see instructions)

18

19

Total Medicare preventive costs ((line 18 divided by line 17) times line 14)

19

20

Total Medicare non-preventive costs ((line 16 minus line 19) times 80 percent)

20

Net Medicare cost (line 19 plus 20) (see instructions)

21

22

Graduate medical education pass through cost (see instructions)

22

23

Medicare cost of pneumococcal and influenza vaccine and administration (from Worksheet B-1, line 16)

23

21

17

.

.

24 Net Medicare reimbursement excluding bad debts (sum of lines 21 through 23)

24

25 Allowable bad debts (see instructions)

25
`

26 Adjusted reimbursable bad debts (see instructions)

26

27 Allowable bad debts for dual eligible beneficiaries (see instructions)

27

28 Subtotal (line 24 plus line 26)

28

29 Other demonstration payment adjustment amount before sequestration

29

30 Other adjustments (specify) (see instructions)

30

31 Amount due RHC prior to sequestration adjustment (line 28 minus lines 29 and 30)

31

32 Sequestration adjustment (see instructions)

32

33 Other demonstration payment adjustment amount after sequestration

33

34 Amount due RHC after sequestration adjustment (line 31 minus lines 32 and 33)

34

35 Interim payments

35

36 Tentative settlement (for contractor use only)

36

37 Balance due RHC/program (line 34 minus lines 35 and 36)

37

38 Protested amounts (nonallowable cost report items) in accordance with 42 CFR 413.24(j)(2)(i)

38

(1) Lines 8 through 16: Fiscal year providers use columns 1 and 2 (and column 3, if applicable); calendar year providers with one rate in effect for the entire
cost reporting period use column 2 only.
FORM CMS-222-17 (DATE) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4613 THROUGH 4613.2)

Rev. 1

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DRAFT
FORM CMS-222-17
ANALYSIS OF PAYMENTS TO THE RURAL HEALTH CLINIC FOR SERVICES RENDERED

CCN:

PERIOD:
FROM: ____________
TO: ___________

4490 (Cont.)
WORKSHEET C-1

___________
Description

Part B
mm/dd/yyyy
1

1 Total interim payments paid to RHC
2 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
3 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
Subtotal (sum of lines 3.01- 3.49 minus sum of lines 3.50-3.98)
4 Total interim payments (sum of lines 1, 2, and 3.99)
(transfer to Wkst. C, Part II, line 35)
TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative settlement
payment after desk review. Also show
date of each payment.
If none, write "NONE" or enter a zero. (1)

Program to
Provider

Provider to
Program
Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50-5.98)
6 Determine net settlement amount (balance
due) based on the cost report (1)
7 Total Medicare program liability (see instructions)
8 Contractor approving official signature:

Amount
2

Program to provider
Provider to program
Date:

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4

.01
.02
.03
.50
.51
.52
.99
.01
.02

5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8

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

FORM CMS-222-17 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4614)
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