Crosswalk

Form CMS-222-17 RURAL HEALTH CLINIC COST REPORT APPLICATION
FORMS AND INSTRUCTIONS
The Form CMS-222-17, Rural Health Clinic (RHC) cost report replaces the RHC existing cost reporting Form CMS-222-92. The new forms are
effective for cost reporting periods beginning on or after October 1, 2017. There were only minor changes to the cost report including:
1. Added Worksheets S-1, Parts I & II; S-2; S-3; and C-1.
The overall burden to RHCs is estimated at 55 hours compared to the existing burden associated with the CMS-222-92 of 50 hours.
Issue
#

Instructions
Page #

1. 46-3 - 46-5

Form Section
Page #

Old Package
Form
CMS-222-92

New Package
Form
CMS-222-17

4600 4602
46-303 4603 4603.3

Worksheet S,
Parts I and II

Worksheet S,
Parts I, II, and III

3. 46-7 - 46-9

46-304 4604 4604.1

Worksheet S,
Part I

Worksheet S-1,
Part I

4. 46-10 - 46-11

46-305 4604.2

Worksheet S, Part
III

Worksheet S-1,
Part II

5. 46-12 - 46-17

46-306 4605

6. 46-18 - 46-19

46-307 4606

Worksheet S, Part
I

Worksheet S-3

7. 46-20 - 46-24

46-308 4607
& 46309

Worksheet A

Worksheet A

2. 46-6 - 46-7

Worksheet S-2

Reason for the Change/ Application of the instructions Burden
and accompanying worksheets
Effect
General Instructions

N/A

Modified Worksheet S to conform to other cost reports
and reference this page as the certification and settlement
summary page.
This worksheet incorporates data previously included on
the Worksheet S, Part I and added questions regarding
malpractice insurance.
This worksheet incorporates some data previously
included on the Worksheet S, Part III and added questions
regarding malpractice insurance.
This worksheet incorporates the Form CMS-339, Provider
Reimbursement Questionnaire into the official cost report
and eliminates the requirement to file a separate form.
This worksheet collects the number of medical and mental
health visits by payer, and visits performed by interns and
residents formerly collected on Worksheet S, Part I.
Added additional cost centers.

N/A

Increase

Increase

Increase

Increase

N/A

8. 46-25

46-310

4608

Worksheet A-1,

Worksheet A-6,

9. 46-25 - 46-26

46-311

4609

Worksheet A-2

Worksheet A-8

10. 46-27 - 46-28

46-312

Worksheet A-2-1

Worksheet A-8-1

11. 46-28 - 46-30

46-313

12. 46-31 - 46-34

46-314

4610 4610.2
4611 4611.2
4612 4612.2

Worksheet B,
Parts I & II
Worksheet C,
Parts I & II

Worksheet B,
Parts I & II
Worksheet C,
Part I & II

13. 46-35

46-315

4613

14. 46-36

46-316

4614

Supplemental
Worksheet B-1

Worksheet C-1

Renamed worksheet to be consistent with other cost
report packages.
Renamed worksheet to be consistent with other cost
report packages and added additional line descriptions.
Renamed worksheet to be consistent with other cost
report packages.
Added a category for certified nurse midwife, subject to
productivity standards.
Minimal changes made to this worksheet, added a few
new lines to reflect demonstration payment adjustment
amounts before and after sequestration and a line for
protested amounts.
This is a new interim payment worksheet.

Worksheet B-1

No change to this worksheet.

N/A
N/A
N/A
N/A
N/A

Increase
N/A