CMS-216-94 Data and Certification Statement

Organ Procurement Organization/Histocompatibility Laboratory Cost Report (CMS-216-94)

R6P233f_AC030817.xls

Organ Procurement Organization/Histcompatibility Laboratory Statement of Reimbursable Costs, Manual Instructions (CMS-216-94)

OMB: 0938-0102

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Sheet 1: ws-S^

06-15


Form CMS-216-94

3390(Cont.)
This report is required by law (42 USC 1395g) and 42CFR 413.20 and 413.24.




FORM APPROVED
Failure to report can result in all payments made during the reporting period




OMB NO. 0938-0102
being deemed overpayments (42 USC 1395g).




Expires: 09/30/2020
ORGAN PROCUREMENT ORGANIZATION


Provider CCN: PERIOD: WORKSHEET
HISTOCOMPATIBILITY LABORATORY GENERAL


_______________ FROM:_______ S
DATA AND CERTIFICATION STATEMENT



TO:__________

Contractor Use Only:








[ ] Audited Date Received ________________
[ ] Initial [ ] Re-opened


[ ] Desk Reviewed Contractor No. ______________
[ ] Final

PART I - GENERAL






Check

[ ] Electronic filed cost report

Date:
applicable box

[ ] Manually submitted cost report

Time:
1 Name:

Provider CCN:

1
1.01 Street:


P.O. Box:
1.01
1.02 City:
State:
Zip Code:
1.02
2 Name:

Provider CCN:

2
2.01 Street:


P.O. Box:
2.01
2.02 City:
State:
Zip Code:
2.02
3 Reporting Period: From To




3










Type of Control
Type of Provider




(see instructions)
(see instructions) Participation Date

1 2 3 4
4





4
PART II-CERTIFICATION BY OFFICER OR ADMINISTRATOR OF FACILITY






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. FUTHERMORE, IF SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED






OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE






ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATION ACTION, FINES AND/OR IMPRISONMENT MAY RESULT














CERTIFICATION BY OFFICER, ADMINISTRATOR OR DIRECTOR OF ORGANIZATION/LABORATORY
I HEREBY CERTIFY that I have read the above cerification 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 CCN(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 OPO/LAB 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, Administrator or Director




______________________________________________






Title




______________________________________________






Date








PART III - SETTLEMENT SUMMARY











TITLE XVIII





Organ Acquisition Tissue Typing





1 2








1 OPO/LAB




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 0938-0102. The time required to complete






this information collection is estimated to average 45 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: Centers for Medicare and Medicaid Services, 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-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2,






SECTIONS 3302, 3302.1 and 3302.2)














Rev. 6





33-303

Sheet 2: ws-S1^

3390 (Cont.)


Form CMS 216-94

06-15
ORGAN PROCUREMENT ORGANIZATION/


Provider CCN: PERIOD:


HISTOCOMPATIBILITY LABORATORY


___________________ FROM_______________
WORKSHEET S-1
IDENTIFICATION DATA



TO________________


PART I-OPO STATISTICS





1 2 3





Local Imported Total (Columns 1 & 2)
1 Total number of kidneys retrieved (viable and nonviable)





1
2 Total number of kidneys included in line 1 that were nonviable.





2
3 Net number of kidneys for which payment should





3

have been received (line 1 minus line 2).











USA Foreign Country Total
4 Total number of kidneys included in line 3, column 3 that





4

were exported out of local retrieval areas











Military VA Total
5 Total number of kidneys sent to military or VA





5

hospitals that were included in line 3,column 3.

Number



6 Amount received for kidneys listed in line 5.

Amount Received


6






Number of Kidneys Amount Received
7 Was payment received for kidneys furnished to foreign countries and included





7

on line 4,column 2. Enter "Y" for yes or "N" for no. If yes, enter the total number







of kidneys and amount received in columns 2 and 3, respectively.
















Total number of organs/tissue other than kidneys retrieved and administratively processed. In the amount received column enter







the total amount of payment received for each type of organ.







Organ Total Nonviable Amount Received
8 Cornea





8
8.01 Liver





8.01
8.02 Pancreas





8.02
8.03 Pancreas Islet





8.03
8.04 Heart





8.04
8.05 Heart Valves





8.05
8.06 Heart/Lung





8.06
8.07 Bone





8.07
8.08 Skin





8.08
8.09 Lung





8.09
8.10 Other





8.10
9 Total





9
PART II-LAB STATISTICS







1 Total number of tests performed- all laboratory.





1
2 Total number of tests performed-tissue typing laboratory.





2
3 Total number of pre-transplant tests performed for kidney transplantation that are included in line 2.





3

Tissue typing pre-transplant tests performed for kidney transplant:








Test Name Number of Tests
4






4
4.01






4.01
4.02






4.02
4.03






4.03
4.04






4.04
4.05






4.05
4.06






4.06
4.07






4.07
4.08






4.08
4.09






4.09
4.10






4.10
5 Total Tests





5
PART III-Full Time Equivalent Employees (FTEs)







Number of full-time equivalent employees








Administrative OPO Histo-Lab

1 2 3 4 5 6
1 Medical Director
Medical Director
Lab Director
1
1.01 Exec. Director
Procurement Coordinator
Technicians
1.01
1.02 Clerical
Preservation Technicians
Tissue Typing Tech.
1.02
1.03 Other
Other
Other
1.03









2 Total FTEs





2



























FORM CMS 216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2 SECTIONS 3303, 3303.1, 3303.2 and 3303.3)

























33-304






Rev. 6

Sheet 3: ws-A^

06-15

Form CMS-216-94





3390 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL

Provider CCN:
REPORTING PERIOD

WORKSHEET A

BALANCE OF EXPENSES

_________________
FROM:_______________________









TO:____________________










RECLASS. RECLASSIFIED ADJUSTMENTS NET COST






TO EXPENSES TRIAL BALANCE TO COST FOR COST


COST CENTERS (OMIT CENTS)
TOTAL (FROM (COL.3 (FROM ALLOCATION



SALARIES OTHER (Cols. 1 & 2) WKST.A-4) +/- COL.4) (WKST. A-5) (COL.5+/-COL.6)



1 2 3 4 5 6 7

GENERAL SERVICE COST CENTERS







1 0100 Capital Costs--Buildings and Fixtures






1
2 0200 Capital Costs--Movable Equipment






2
3 0300 Employee Benefits






3
4 0400 Administrative and General-Cols. 1-3-From W/S-A-1






4
5 0500 Operation and Maintenance of Plant






5
6 0600 Housekeeping






6
7 0700 Medical Supplies






7
8 0800 Other Overhead (Specify)






8


ORGAN ACQUISITION OVERHEAD







9 0900 Procurement Coordinators






9
10 1000 Professional Education






10
11 1100 Public Education






11
12 1200 Other Acquisition (Specify)






12


REIMBURSABLE COST CENTERS







13 1300 Kidney Acquisition(From W/S A-2 Cols. 1-3,line 23)






13
14 1400 Tissue Typing Laboratory (Cols. 1-3,From W/S-A-3, Line 11)






14


NON-REIMBURSABLE COST CENTERS







15 1500 Liver Acquisitions (W/S-A-2, Col. 1-3, Line 23)






15
16 1600 Heart Acquisitions (W/S-A-2, Col.1-3, Line 23)






16
17 1700 Pancreas Acquisitions (W/S-A-2, Col.1-3, Line 23)






17
18 1800 Lung Acquisitions (W/S-A-2, Col. 1-3, line 23)






18
19 1900 Other Acquisitions (W/S-A-2, Col. 1-3, line 23)






19
20 2000 Other Acquisitions (W/S-A-2, Col. 1-3)






20
21 2100 Research






21
22 2200 Blood Bank






22
23 2300 Laboratory-Non-Tissue Typing






23
24 2400 Dialysis Units






24
25 2500 Other Non-Reimbursable (Specify)






25
26
Total Expenses (sum of lines 1-25), Transfer Column 7 to W/S-B






26


line 1, or W/S-C, as per instructions


















FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3304)




















Rev. 6








33-305

Sheet 4: ws-A-1^

3390 (Cont.)
Form CMS-216-94

06-15
ADMINISTRATIVE AND GENERAL EXPENSES
Provider CCN: REPORTING WORKSHEET A-1


PERIOD:




FROM___________




TO______________








COST CENTER SALARIES OTHER TOTAL


1 2 3
1 Medical Director


1
2 Executive Director


2
3 Home Office/Central Administration


3
4 Data Processing


4
5 Accounting-Legal-Audit


5
6 Rent and Lease Expense


6
7 Office Supplies


7
8 Telephone


8
9 Travel-Meetings and Seminars


9
10 Insurance


10
11 Employee Professional Education


11
12 Public Relations


12
13 Interest Expense


13
14 Taxes


14
15 Office Salaries


15
16 Other Administrative and General:


16
17



17
18



18
19



19
20 Total Administrative and General


20

sum of lines 1-19




Transfer line 20 columns 1-3 to




Worksheet A, line 4, columns 1-3















FORM CMS 216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,




SECTION 3305)










33-306



Rev. 6

Sheet 5: ws-A-2

06-15
Form CMS-216-94

3390 (Cont.)
ORGAN ACQUISITION COST
Provider CCN: REPORTING WORKSHEET A-2


PERIOD:




FROM___________




TO______________

Check One:




[ ] Kidney [ ] Liver [ ] Heart [ ] Pancreas [ ] Lung [ ] Other ___________





COST CENTER SALARIES OTHER TOTAL


1 2 3

Organ Acquisition Costs




Amounts Paid To Excision Hospitals



1 Operating Room


1
2 Anesthesiology


2
3 Respiratory Therapy


3
4 Intensive Care Unit


4
5 Medical Supplies


5
6 Pharmacy


6
7 Electroencephalography


7
8 Hospital Laboratory


8
9 Other Excision Hospital Cost (specify)


9
10 Subtotal-Excision Hospital Cost (sum of lines 1-9)


10

Other Acquisitions Costs



11 Computer Registry


11
12 Donor Evaluation


12
13 Surgeon Fee


13
14 Organ Preservation


14
15 Donor Tissue Typing


15
16 Recipient Crossmatch


16
17 Imported Organ Cost


17
18 Transportation of Organs


18
19 Tissue Typing Lab-Under Agreement


19
20 Anesthesiologist Professional Fees


20
21 Other Acquisition Costs (specify)


21
22 Subtotal-Other Acquisition Cost (sum of lines 11-21)


22
23 Total-Organ Acquisition Cost


23

(sum of lines 10 and 22)




Transfer line 23 columns 1 and 2 to W/S A.




(see instructions)















FORM CMS 216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,




SECTION 3306)










Rev. 6



33-307

Sheet 6: ws-A-3

3390 (Cont.)
Form CMS-216-94

06-15
TISSUE TYPING LABORATORY COSTS
Provider CCN: REPORTING WORKSHEET A-3


PERIOD:




FROM___________




TO______________








COST CENTER SALARIES OTHER TOTAL


1 2 3
1 Laboratory Director


1
2 Tissue Typing Technologist


2
3 Sera Procurement


3
4 Equipment Maintenance


4
5 Other Tissue Typing Cost (Specify)


5
6



6
7



7
8



8
9



9
10



10
11 Total -Tissue Typing Cost


11

(sum of lines 1-10)




Transfer line 11 columns 1-3 to




Worksheet A, Line 14, columns 1-3





































































FORM CMS 216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,




SECTION 3307)










33-308



Rev. 6

Sheet 7: ws-A-4

06-15

Form CMS-216-94



3390 (Cont.)
RECLASSIFICATIONS
Provider CCN:

REPORTING PERIOD:
WORKSHEET A-4



_______________________

FROM:___________________








TO:____________________





CODE INCREASE

DECREASE





COST LINE
COST LINE


EXPLANATION OF RECLASSIFICATION ENTRY (1) CENTER NO. AMOUNT (2) CENTER NO. AMOUNT (2)


1 2 3 4 5 6 7
1







1
2







2
3







3
4







4
5







5
6







6
7







7
8







8
9







9
10







10
11







11
12







12
13







13
14







14
15







15
16







16
17







17
18







18
19







19
20







20
21







21
22







22
23







23
24







24
25







25
26







26
27







27
28







28
29







29
30







30
31







31
32







32
33







33
34







34
35







35
36 TOTAL RECLASSIFICATIONS (Sum of Column 4






36

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 to Worksheet A, Column 4, line as appropriate.








FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3308)








Rev. 6







33-309

Sheet 8: ws-A-5

3390 (Cont.)


Form CMS-216-94



06-15
ADJUSTMENTS TO EXPENSES
Provider CCN:

REPORTING PERIOD:
WORKSHEET A-5



___________________

FROM:_____________








TO:____________





Basis for
Expense Classification on Worksheet A





Adjust-
from which amount is to be deducted




Description (1) ment
or to which the amount is to be added





(2) Amount Cost Center

Ln No.


1 2 3

4
1 Purchase Discounts






1
2 Rebates and Refunds






2
3 Home Office Costs






3
4 Adjustments resulting from transactions From




4

with related organizations (Chapter 10) Supp. W/S








A-5-1





5 Income received from the procurement






5

of organs other than kidneys. (3)







6 Vending Machines






6
7 Rental or Lease Income






7
8 Organs Sold for Research






8
9 Public Relations-Not related to






9

Organ Procurement







10 Income received from Professional






10

Education







11 Sale of Supplies






11
12 Interest Income applied to interest exp.






12
13 Capital Costs -Buildings & Fixtures






13
14 Capital Costs -Movable Equipment






14
15







15
16







16
17 Total -Transfer to W/S. A, Column 6,






17

Line as Appropriate


















(1) Description-all line 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) Only the income from organs such as Cornea, Skin, Heart Valves, Bone, and Pancreas Islet may be offset.








All solid organs such as Kidneys, Hearts, Livers, Lung, and Pancreas must go through cost finding on W/S B


























































FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS








PUB 15-2, SECTION 3309)

















33-310







Rev. 6

Sheet 9: ws-A-6^

06-15

Form CMS-216-94



3390 (Cont.)
CAPITAL EXPENDITURES AND
Provider CCN:
REPORTING PERIOD

WORKSHEET
DEPRECIATION RECONCILIATION

FROM:__________________

A-6




TO:_____________________



Part I - Analysis of Changes in
Beginning Acquisitions
Ending
Capital Asset Balances During Cost
Balance Purchase Donations Total Disposals Balance
Reporting Period
1 2 3 4 5 6
1 Land





1
2 Land Improvements





2
3 Building and Fixtures





3
4 Fixed Equipment





4
5 Movable Equipment





5
6 Auto,Truck, Van





6
7 Other (Specify)





7
8 Total





8


















Part II - Analysis of Changes

Beginning

Ending
In Accumulated Depreciation

Balance Additions Deletions Balance
Description

1 2 3 4
1 Land





1
2 Land Improvements





2
3 Buildings and Fixtures





3
4 Building Improvements





4
5 Fixed Equipment





5
6 Movable Equipment





6
7 Auto,Truck, Van





7
8 Other (Specify)





8
9 Total





9


















Part III - Depreciation Reported In Cost Statement







1 Straight Line





1
2 Declining Balance





2
3 Sum of Years Digits





3
4 Depreciation reported on W/S -A column 7. (Total- Sum of 1, 2 and 3)





4






1 2
5 Is depreciation funded? Enter "Y" for yes or "N" for no in column 1. If yes,





5

enter in column 2 the balance in fund at the end of the period.






6 Was there a gain or loss on the sale of assets during the cost reporting





6

period? (See CMS Pub-15-1, Section 132)















FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2







SECTION 3310)
















Rev.6






33-311

Sheet 10: ws-B^

3390 (Cont.)



Form CMS-216-94



06-15
COST ALLOCATION-GENERAL SERVICE COSTS



Provider CCN:

REPORTING PERIOD

WORKSHEET B








FROM____________________












TO_______________________






NET CAPITAL-











COST BUILDING,











FOR OPERATION CAPITAL EMPLOYEE MEDICAL

ORGAN SUBTOTAL ADMIN. TOTAL


ALLOCATION OF PLANT COSTS BENEFITS SUPPLIES OTHER
ACQUISITION (COLS.1-8) & EXPENSES


(FROM AND MOVABLE



COSTS
GENERAL

COST CENTER
WKST. A, HOUSE EQUIPMENT










COL.7) KEEPING











1 2 3 4 5 6 7 8 9 10 11
1 COSTS TO BE ALLOCATED
( ) ( ) ( ) ( ) ( )


( )
1
2 Organ Acquisitions






( ) -0-

2

REIMBURSABLE












COST CENTERS











3 Kidney Acquisitions (1)










3
4 Tissue Typing Laboratory(2)










4

NONREIMBURSABLE












COST CENTERS











5 Liver Acquisitions










5
6 Heart Acquisitions










6
7 Pancreas Acquisitions










7
8 Lung Acquisitions










8
9 Other Acquisitions










9
10 Research










10
11 Blood Bank










11
12 Laboratory-Non-Tissue Typing










12
13 Dialysis Units










13
14












15











14
16 Totals Expenses
-0- -0- -0- -0- -0-
-0-
-0-
16
(1) Transfer amount on line 3, column 11 to Worksheet C, line 4, Part I












(2) Transfer amount on line 4, column 11 to Worksheet C, line 4, Part II






















































FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3311)


























33-312











Rev. 6

Sheet 11: ws-B-1^

06-15



Form CMS-216-94




3390 (Cont.)
COST ALLOCATION-STATISTICAL BASIS



Provider CCN:

REPORTING PERIOD:

WORKSHEET B-1






___________________

FROM________________












TO_______________







CAPITAL












BUILDING










COST CENTERS
OPERATION CAPITAL



ORGAN

ADMINISTRATION



OF PLANT COSTS EMPLOYEE MEDICAL OTHER
ACQUISITION

&



AND MOVABLE BENEFITS SUPPLIES

COSTS
RECONCILIATION GENERAL



HOUSE- EQUIPMENT



(NUMBER






KEEPING (DOLLAR (ADJUSTED (COSTED

OF

(ACCUMULATED



(SQ. FEET) VALUE) SALARIES) REQUISITIONS)

ORGANS)

COSTS)



2 3 4 5 6 7 8 9 10A 10
1 COSTS TO BE ALLOCATED










1
2 Organ Acquisition Costs










2

REIMBURSABLE COST CENTERS











3 Kidney Acquisitions










3
4 Tissue Typing Laboratory










4

NONREIMBURSABLE COST CENTERS











5 Liver Acquisitions










5
6 Heart Acquisitions










6
7 Pancreas Acquisitions










7
8 Lung Acquisitions










8
9 Other Organ Acquisitions










9
10 Research










10
11 Blood Bank










11
12 Laboratory-Non-Tissue Typing










12
13 Dialysis Units










13
14











14
15












16 Total (lines 2-15)










16
17 COSTS TO BE ALLOCATED PER W/S B










17
18 UNIT COST MULTIPLIER (line 17/line 16)










18














FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3311)


























Rev. 6











33-313

Sheet 12: ws-C^

06-15
Form CMS-216-94

3390 (Cont.)
COMPUTATION OF MEDICARE COST
Provider CCN: REPORTING PERIOD WORKSHEET C


FROM_____________




TO________________


Part I - KIDNEY ACQUISITION



1 Total Number of Viable Kidneys Procured (W/S S-1, Part 1, line 3, col. 3)


1
2 Total Number of Medicare Kidneys (see instructions)


2
3 Ratio of Medicare Kidneys to Total Kidneys (line 2 / line 1)


3
4 Total Cost Applicable to Kidney Acquisition (see instructions)


4
5 Total Medicare Kidney Acquisition Costs (line 3 x line 4) (1)


5
(1) Transfer amount on line 5 to Worksheet D, Column 1, Line 1











Part II - TISSUE TYPING LABORATORY



1 Gross Charges - Tissue Typing Laboratory-All Tests


1
2 Gross Charges - Tissue Typing Laboratory-Kidney Transplant Related Tests Only (2)


2
3 Ratio of Kidney Transplant Charges to Total Charges (line 2 / line 1)


3
4 Total Cost Applicable to Tissue Typing Lab. (see instructions)


4
5 Reimbursable Kidney Transplant Related Costs (line 3 x line 4) (3)


5
(2) If the cost report is a partial year under the program, show only the kidney related revenue earned since




the participation date.




(3) Transfer amount on line 5 to Worksheet D, Column 2, Line 1.






































































Form CMS-216-94 (06-2015) (INSTRUCTION FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, Section 3312)
















33-314



Rev. 6

Sheet 13: ws-D

06-15
Form CMS-216-94
3390 (Cont.)
CALCULATION OF REIMBURSEMENT
Provider CCN: REPORTING PERIOD WORKSHEET D
SETTLEMENT
FROM_____________




TO________________




1 2



Kidney Acquisition Tissue Typing Lab
1 Medicare Reimbursable Cost-Kidney Acquisition-


1

W/S-C, Part I, line 5




Tissue Typing-Laboratory W/S-C, Part II, line 5



2 Total Revenue Received for Lab Services Furnished to


2

Foreign Countries, Military and VA Hospitals



3 Total Reimbursable Cost to OPO/HL (line 1 - line 2)


3
4 Total Payments Received and Receivable from OPOs


4

and Transplant Hospitals for Kidneys Furnished or




Laboratory Services Provided for Kidney Transplantation




(From Your Records)



5 Subtotal (line 3 - line 4)


5
6 Sequestration Adjustment (see instructions)


6
7 Interim Payments


7
8 Net Balance Due to/from the OPO/LAB (Medicare Program)


8

(line 5 - (line 6 + line 7)























































































Form CMS-216-94 (06-2015) (INSTRUCTION FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, Section 3313)
















Rev. 6



33-315

Sheet 14: ws-E

3390 (Cont.)
Form CMS 216-94
06-15


Provider CCN:
PERIOD:

BALANCE SHEET

FROM _____________________
WORKSHEET



TO ________________________
E











Liabilities and Fund


Assets General
Balance
General

(Omit cents) Fund
(Omit Cents)
Fund


1


1

CURRENT ASSETS

CURRENT LIABILITIES

1 Cash
34 Accounts payable

2 Temporary investments
35 Salaries, wages & fees payable

3 Notes receivable
36 Payroll taxes payable

4 Accounts receivable
37 Notes & loans payable (Short term)

5 Other receivables
38 Advanced blood deposits

6 Less: allowances for uncollectible ( ) 39



notes and accounts receivable
40 Due to other funds

7 Inventory
41


8 Prepaid expenses
42 TOTAL CURRENT LIABILITIES

9 Other current assets

(sum of lines 34 - 41)

10 Due from other funds

LONG TERM LIABILITIES

11 TOTAL CURRENT ASSETS
43 Mortgage payable


(sum of lines 1 - 10)
44 Notes payable


FIXED ASSETS
45 Unsecured loans

12 Land
46


13 Land improvements




14 Less: Accumulated depreciation ( ) 47


15 Buildings
48


16 Less: Accumulated depreciation ( ) 49 TOTAL LONG TERM LIABILITIES

17 Leasehold improvements

(sum of lines 43 - 48)

18 Less: Accumulated depreciation ( ) 50 TOTAL LIABILITIES

19 Fixed equipment

(sum of lines 42 and 49)

20 Less: Accumulated depreciation ( )
CAPITAL ACCOUNTS

21 Automobiles and trucks
51 General fund balance

22 Less: Accumulated depreciation ( ) 52 Specific purpose fund balance

23 Major movable equipment
53 Donor created - endowment fund

24 Less: Accumulated depreciation ( )
balance - restricted

25 Minor equipment nondepreciable
54 Donor created - endowment fund

26 Other fixed assets

balance - unrestricted

27 TOTAL FIXED ASSETS
55 Governing board created - endowment


(Sum of lines 12 - 26)

fund balance


OTHER ASSETS
56 Plant fund balance - invested in plant

28 Investments
57 Plant fund balance - reserve for

29 Deposits on leases

plant improvement, replacement and

30 Due from owners/officers

expansion

31

58 TOTAL FUND BALANCE

32 TOTAL OTHER ASSETS

(sum of lines 51 thru 57)


(sum of lines 28 - 31)
59 TOTAL LIABILITIES AND

33 TOTAL ASSETS

FUND BALANCE


(sum of lines 11, 27 and 32)

(sum of lines 50 and 58)


( ) = contra amount




FORM CMS -216-94 ( 06-2015 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN





CMS PUB. 15-2, SECTION 3314 )












33-316




Rev. 6

Sheet 15: ws-E-1

06-15
Form CMS-216-94

3390 (Cont.)
STATEMENT OF OPERATING EXPENSES
Provider CCN: REPORTING PERIOD WORKSHEET E-1
AND REVENUES
FROM_____________




TO________________

PART I
OPO BLOOD BANK/LAB TOTAL
REVENUES




1 Whole Blood and Components


1
2 Processing Fees


2
3 Other Blood Products and Services


3
4 Tissue Typing Services


4
5 Other Laboratory Services


5
6 Other Patient Service Fees:


6
7



7
8



8
9



9
10 Kidney Procurement Revenue


10
11 Other Organ Procurement Revenue


11
12 Total Revenue for Services Provided


12
PART II




EXPENSES




1 Operating Expenses (W/S A, column 3, line 26)


1
2 Add (Specify)


2
3



3
4



4
5



5
6 Total Additions


6
7 Deduct (Specify)


7
8

( )
8
9

( )
9
10

( )
10
11 Total Deductions

( ) 11
12 Total Operating Expenses (sum of lines 1 and 6 minus 11)


12

Transfer to Worksheet E-2 Line 4















Form CMS 216-94 (06-2015) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2




Section 3315)










Rev. 6



33-317

Sheet 16: ws-E-2

3390 (Cont.)
Form CMS-216-94

06-15
STATEMENT OF REVENUES
Provider CCN: REPORTING PERIOD WORKSHEET E-2
AND EXPENSES
FROM_____________




TO________________

1 Total Revenues for Services Provided (W/S E-1, Part I, Line 12)


1
2 Less: Allowances for Discounts on Services

( ) 2
3 Net Revenue for Services Provided


3
4 Less: Total Operating Expenses (W/S E-1, Part II Line 12)

( ) 4
5 Net Income From Services


5
6 Other Income:


6
7 Contributions


7
8 Income From Investments


8
9 Purchase Discounts


9
10 Rebates and Refunds of Expenses


10
11 Parking Lot Receipts


11
12 Vending Machine Receipts


12
13 Rental or Lease Income


13
14 Income From Sales of Supplies


14
15 Federal Research Grants (Specify)


15
16 Federal Research Grants (Specify)


16
17 Federal Research Grants (Specify)


17
18 Other Research Grants (Specify)


18
19 Other Research Grants (Specify)


19
20 Other (Specify)


20
21 Other (Specify)


21
22 Other (Specify)


22
23 Other (Specify)


23
24 Total Other Income (sum of lines 6-23)


24
25 Total (line 5 plus line 24)


25
26 Other Expenses(Specify)


26
27 Other Expenses(Specify)


27
28 Total Other Expenses (sum of lines 26 & 27)

( ) 28
29 Net Income (or Loss) for the Period (line 25 minus line 28)


29












Form CMS 216-94 (06-2015) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2




Section 3316)










33-318



Rev. 6

Sheet 17: sup ws-A-5-1

06-15



Form CMS-216-94




3390 (Cont.)
STATEMENT OF COSTS OF SERVICES


Provider CCN:


REPORTING PERIOD:



SUPPLEMENTAL
FROM RELATED ORGANIZATIONS





FROM__________________



WORKSHEET
AND HOME OFFICE COSTS






TO_________________



A-5-1
A. Are there any costs included on Worksheet A which resulted from transactions with related organizations as













defined in the Provider Reimbursement Manual, Part 1, Chapter 10?













[ ] Yes [ ] No (If "Yes", complete Parts II and III )











B. Costs incurred and adjustments required as a result of transactions with related organizations or claimed home office costs






















AMOUNT OF

NET
LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COLUMN 6







ALLOWABLE


ADJUSTMENT










COST

(COL.4 MINUS

LINE NO. COST CENTER EXPENSES ITEMS


AMOUNT




COL. 5)

1 2
3

4

5

6
1












1
2












2
3












3
4












4
5 TOTALS (sum of lines 1-4) Transfer col.6, line 1-4 to Wkst. A,col.6 as appropriate)











5

(Transfer col.6, line 5 to Wkst. A-5, col.2, line 4, Adjustment to Expenses)












C. Interrelationship of facility 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 the provider to furnish the information requested on Part C of this worksheet.




























This information will be 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 the facility by













common ownership or control, represent reasonable costs as determined under section 1861(v) (1) (a) of the Social













Security Act. If the provider does 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.






































RELATED ORGANIZATION (S) and/or Home Office (S) AND/ OR HOME OFFICE





Percentage



Percentage






SYMBOL
of




of


Type of

(1) Name Ownership

Name
Ownership



Business

1 2 3


4
5


6
1












1
2












2
3












3
4












4
















(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 facility;













B. Corporation, partnership, or other organization has financial interest in the facility;













C. Facility has financial interest in corporation, partnership, or other organization(s);













D. Director, officer, administrator, or key person of the facility or relative of such person has financial interest













in related organization;













E. Individual is director, officer, administrator, or key person of the facility and related organization;













F. Director, officer, administrator, or key person of related organization or relative of such person has













financial interest in the facility;













G. Other (financial or non-financial) specify _____________________________


























FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, Section 3317)













Rev. 6












33-319
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AuthorHCFA Software Control
Last Modified ByAMELIA CITERONE
File Modified2017-03-08
File Created2001-07-11

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