Federally Qualified Health Center Cost Report Form

CHAPTER 44
FEDERALLY QUALIFIED HEALTH CENTER COST REPORT
CMS-224-14
TABLE OF CONTENTS
Section
General ................................................................................................................................ 4400
Rounding Standards for Fractional Computations ......................................................... 4400.1
Acronyms and Abbreviations .............................................................................................. 4401
Recommended Sequence for Completing Form CMS-224-14 ............................................ 4402
Sequence of Assembly ......................................................................................................... 4403
Worksheet S - Federally Qualified Health Center Cost Report
Certification and Settlement Summary ............................................................................ 4404
Part I - Cost Report Status ............................................................................................. 4404.1
Part II - Certification ...................................................................................................... 4404.2
Part III - Settlement Summary ....................................................................................... 4404.3
Worksheet S-1 - Federally Qualified Health Center Identification Data ............................. 4405
Part I - Federally Qualified Health Center Identification Data ...................................... 4405.1
Part II - Federally Qualified Health Center Consolidated Cost Report
Participant Identification Data .................................................................................... 4405.2
Worksheet S-2 - Federally Qualified Health Center Reimbursement Questionnaire .......... 4406
Worksheet S-3 - Federally Qualified Health Center Data ................................................... 4407
Part I - Federally Qualified Health Center Statistical Data............................................ 4407.1
Part II - Federally Qualified Health Center Contract Labor and Benefit Cost .............. 4407.2
Part III - Federally Qualified Health Center Employee Data ........................................ 4407.3
Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses.................. 4408
Worksheet A-1 - Reclassifications....................................................................................... 4409
Worksheet A-2 - Adjustments to Expenses ......................................................................... 4410
Worksheet A-2-1 - Statement of Costs of Services from Related Organizations and
Home Office Costs ............................................................................................................ 4411
Part I - Costs Incurred and Adjustments Required as a Result of Transactions
with Related Organizations or Claimed Home Office Costs ...................................... 4411.1
Part II - Interrelationship to Related Organizations and/or Home Office ...................... 4411.2
Worksheet B - Calculation of Federally Qualified Health Center Costs ............................. 4412
Part I - Calculation of Federally Qualified Health Center Cost Per Visit ...................... 4412.1
Part II - Calculation of Direct Graduate Medical Education Costs ............................... 4412.2
Worksheet B-1 - Computation of Pneumococcal and Influenza Vaccine Cost ................... 4413
Worksheet E - Calculation of Reimbursement Settlement .................................................. 4414
Worksheet E-1 - Analysis of Payments to the Federally Qualified Health Center
for Services Rendered ...................................................................................................... 4415
Worksheet F-1 - Statement of Revenue and Expenses ........................................................ 4416
Form CMS-224-14 Worksheets ........................................................................................... 4490
Electronic Reporting Specifications for Form CMS-224-14 ............................................... 4495

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CHAPTER 44
FEDERALLY QUALIFIED HEALTH CENTER COST REPORT
CMS-224-14
TABLE OF CONTENTS

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4400.

FORM CMS-224-14

4400

GENERAL

The Paperwork Reduction Act of 1995 requires that the private sector be informed as to why
information is collected and what the information is used for by the government. In accordance
with §§1815(a) and 1861(v)(1)(A) of the Social Security Act (the Act), providers of medical and
other health services as defined under §1861(s), participating in the Medicare program are required
to submit annual information to achieve settlement of costs for health care services rendered to
Medicare beneficiaries. Federally qualified health centers (FQHCs) are required under
42 CFR 405.2470, to maintain adequate financial and statistical records and provide annual cost
reports as the Secretary determines necessary to administer the program. The data submitted on
the cost reports supports management of Federal programs. The information reported on
Form CMS-224-14, must conform to the requirements and principles set forth in the Provider
Reimbursement Manual, (CMS Pub. 15), as well as those set forth in the Medicare Benefit Policy
Manual, CMS Pub. 100-02, chapter 13, and the Medicare Claims Processing Manual,
CMS Pub. 100-04, chapter 9.
Section 10501(i)(3)(A) of the Affordable Care Act (Pub. L. 111-148 and Pub. L. 111-152) added
§1834(o) of the Act to establish a new system of payment for the costs of FQHC services under
Medicare Part B based on prospectively set rates. The statute requires implementation of the
FQHC prospective payment system (FQHC PPS) for FQHCs with cost reporting periods beginning
on or after October 1, 2014. Form CMS-224-14 must be used by all freestanding FQHCs for cost
reporting periods beginning on or after October 1, 2014. The FQHC cost report must be submitted
to the Medicare administrative contractor (hereafter referred to as contractor) electronically in
accordance with 42 CFR 413.24(f)(4). Cost reports are due on or before the last day of the fifth
month following the close of the period covered by the report. For cost reports ending on a day
other than the last day of the month, cost reports are due 150 days after the last day of the cost
reporting period, in accordance with 42 CFR 413.24(f)(2).
NOTE: This form is to be used by freestanding FQHCs and FQHC’s previously reported as part
of a SNF complex or HHA complex. FQHCs that are part of a hospital healthcare complex must
use the Form CMS-2552.
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 OMB. No. 0938-1298 and the expiration date is
02/28/2022. The time required to complete this information collection is estimated to average 58
hours per response, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. Direct any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form to:
Centers for Medicare and Medicaid Services
Attn: PRA Reports Clearance Officer
7500 Security Boulevard
Mail Stop C4-26-05
Baltimore, Md. 21244-1850
Please do not send applications, claims, payments, medical records or any documentation
containing sensitive information to the PRA Reports Clearance Officer. Please note that any
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correspondence not pertaining to the information collection burden approved under the associated
OMB control number listed on this form wil not be reviewed, forwarded, or retained.
4400.1 Rounding Standards for Fractional Computations.--Throughout the Medicare cost
report, required computations result in the use of fractions. Use the following rounding standards
for such computations:
1.

Round to 2 decimal places:
a. Rates
b. Cost per visit
c. Cost per pneumococcal and influenza vaccine injection

2.

Round to 6 decimal places:
a. Ratios
b. Unit cost multiplier

If a residual exists as a result of computing costs using a fraction, adjust the residual in the largest
amount resulting from the computation. For example, in cost finding, a unit cost multiplier is
applied to the statistics in determining costs. After rounding each computation, the sum of the
allocation may be more or less than the total cost allocated. This residual is adjusted to the largest
amount resulting from the allocation so that the sum of the allocated amounts equals the amount
allocated.
4401.

ACRONYMS AND ABBREVIATIONS

Throughout the Medicare cost report and instructions, a number of acronyms and abbreviations
are used. For your convenience, commonly used acronyms and abbreviations are summarized
below.
A&G
CAP REL
CBSA
CCN
CFR
CMS
ECR
FQHC
HCRIS
HRSA
I&R
MAC
NPR
PCRE
PS&R Report
RCE
THC

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Administrative and General
Capital-Related
Core Based Statistical Area
CMS Certification Number (formerly known as provider number)
Code of Federal Regulations
Centers for Medicare & Medicaid Services
Electronic Cost Report
Federally Qualified Health Center
Healthcare Cost Report Information System
Health Resources and Services Administration
Interns and Residents
Medicare Administrative Contractor
Notice of Program Reimbursement
Primary Care Residency Expansion
Provider Statistical and Reimbursement Report
Reasonable Compensation Equivalency Limit
Teaching Health Center

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FORM CMS-224-14

4402.

RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-224-14

4402

Step
No.

Worksheet

Instructions

1

S, Parts I & II

Read §§4404.1 and 4404.2. Complete Parts I and II.

2

S-1, Part I

Read §4405.1. Complete entire worksheet.

3

S-1, Part II

Read §4405.2. Complete entire worksheet.

4

S-2

Read §4406. Complete entire worksheet if applicable.

5

S-3, Part I

Read §4407.1. Complete entire worksheet.

6

S-3, Part II

Read §4407.2. Complete entire worksheet.

7

S-3, Part III

Read §4407.3. Complete entire worksheet.

8

A

Read §4408. Complete columns 1 through 3.

9

A-1

Read §4409. Complete entire worksheet if applicable.

10

A

Read §4408. Complete columns 4 and 5.

11

A-2-1, Parts I & II

Read §4411.1 and 4411.2. Complete entire worksheet if
applicable.

12

A-2

Read §4410. Complete entire worksheet.

13

A

Read §4408. Complete columns 6 and 7.

14

B, Parts I & II

Read §§4412.1 and 4412.2. Complete entire worksheet.

15

B-1

Read §4413. Complete entire worksheet.

16

E

Read §4414. Complete lines 1 - 17.

17

E-1

Read §4415. Complete entire worksheet.

18

E

Read §4414. Complete lines 18 - 21 as applicable.

19

F-1

Read §4416. Complete entire worksheet.

20

S, Part III

Read §4404.3. Complete Part III.

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SEQUENCE OF ASSEMBLY

The following list of assembly of worksheets is provided so all FQHCs are consistent in the order
of submission of their annual cost report. All FQHCs using Form CMS-224-14 are to adhere to
this sequence. Where worksheets are not completed because they are not applicable, blank
worksheets are not included in the assembly of the cost report.
Worksheet

Part

S

I, II & III

S-1

I & II

S-2
S-3

I, II & III

A
A-1
A-2
A-2-1

I & II

B

I & II

B-1
E
E-1
F-1

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4404.

FORM CMS-224-14

4404.1

WORKSHEET S - FEDERALLY QUALIFIED HEALTH CENTER COST REPORT
CERTIFICATION AND SETTLEMENT SUMMARY

4404.1 Part I - Cost Report Status.--This section is to be completed by the FQHC and contractor
as indicated on the worksheet. If this is a consolidated cost report, the organization must choose a
primary FQHC whose CMS certification number (CCN) must be utilized throughout the entire
cost report.
Lines 1 and 2.--The FQHC must check the appropriate box to indicate on line 1 or 2, whether this
cost report is being filed electronically or manually. For electronic filing, indicate on line 1,
columns 2 and 3 respectively, the date and time corresponding to the creation of the electronic file.
This date and time remains as an identifier for the file by the contractor and is archived accordingly.
Line 2 is only completed by FQHCs filing low utilization cost reports in accordance with
CMS Pub. 15-2, chapter §110 or FQHCs demonstrating financial hardship in accordance with
CMS Pub. 15-2, chapter 1, §133.
Line 3.--If this is an amended cost report, enter the number of times the cost report has been
amended.
Line 4.--Enter an “F” if this is full cost report, an “L” if this is a low Medicare utilization cost
report, or an “N” if this is a no Medicare utilization cost report (“L” requires prior contractor
approval, see CMS Pub. 15-2, chapter 1, §110).
Lines 5 through 12 are for contractor use only:
Line 5.--Enter the Healthcare Cost Report Information System (HCRIS) cost report status code
that corresponds to the filing status of the cost report: 1=As submitted; 2=Settled without audit;
3=Settled with audit; 4=Reopened; or 5=Amended.
Line 6.--Enter the date (mm/dd/yyyy) the accepted cost report was received from the FQHC.
Line 7.--Enter the 5 position contractor number.
Lines 8 and 9.--If this is an initial cost report enter “Y” for yes in the box on line 8. If this is a
final cost report enter “Y” for yes in the box on line 9; if neither, enter “N”. An initial report is
the very first cost report for a particular FQHC CCN. A final cost report is a terminating cost
report for a particular FQHC CCN.
Line 10.--Enter the Notice of Program Reimbursement (NPR) date (mm/dd/yyyy). The NPR date
must be present if the cost report status code is 2, 3 or 4.
Line 11.--Enter the software vendor code of the cost report software used by the contractor to
generate a HCRIS cost report file; use “4” for HFS or “3” for KPMG.
Line 12.--Complete this line only if the cost report status code on line 5 is “4”. If this is a reopened
cost report (response to line 5 cost report status, is “4”), enter the number of times the cost report
has been reopened.
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4404.2 Part II - Certification.--This certification is read, prepared, and signed by an officer or
administrator of the FQHC after the cost report has been completed in its entirety.
Effective for cost reporting periods ending on or after December 31, 2017--(1) A provider that is
required to file an electronic cost report may elect to electronically submit the settlement summary
and certification statement with an electronic signature of the provider's administrator or chief
financial officer. The checkbox for electronic signature and submission immediately follows the
certification statement as set forth in 42 CFR 413.24(f)(4)(iv)(B) and must be checked if electronic
signature and submission is elected. (2) A provider that is required to file an electronic cost report
but does not elect to electronically submit the settlement summary and certification statement with
an electronic signature, must submit a hard copy of the settlement summary and certification
statement with an original signature of the provider's administrator or chief financial officer as set
forth in 42 CFR 413.24(f)(4)(iv)(A) and (B).
4404.3 Part III - Settlement Summary.--Enter the balance due to or due from the Medicare
program. Transfer the amount from Worksheet E, line 20.

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4405.

FORM CMS-224-14
WORKSHEET S-1 - FEDERALLY
IDENTIFICATION DATA

QUALIFIED

4405
HEALTH

CENTER

This worksheet consists of two parts:
Part I - Federally Qualified Health Center Identification Data
Part II - Federally Qualified Health Center Consolidated Cost Report Participant
Identification Data
4405.1 Part I - Federally Qualified Health Center Identification Data.--The information required
on this worksheet is needed to properly identify the FQHC, or in the case of a consolidated cost
report, the primary FQHC. In the case of a consolidated cost report, only the primary FQHC
completes the entire Worksheet S-1, Part I. All other FQHCs filing under a consolidated cost
report must be listed on line 14 and its subscripts and must complete a separate Worksheet S-1,
Part II.
Line 1, columns 1 through 4.--Enter in the appropriate column the site name, CCN, core based
statistical area (CBSA) code (rural CBSA codes are assembled by placing the digits “999” in front
of the two digit state code, e.g., for the state of Maryland the rural CBSA code is 99921), and
certification date.
Line 1, column 5.--Indicate the type of control under which the FQHC operates by entering a
number from the list below:
1
2
3
4
5
6

= Voluntary Nonprofit, Corporation
= Voluntary Nonprofit, Other
= Proprietary, Individual
= Proprietary, Corporation
= Proprietary, Partnership
= Proprietary, Other

7 = Governmental, Federal
8 = Governmental, State
9 = Governmental, County
10 = Governmental, City
11 = Governmental, Other

Line 2.--Enter the FQHC’s street address in column 1 and the post office (P.O.) box in column 2
(if applicable).
Line 3.--Enter the city in column 1, state in column 2, ZIP code in column 3, county in column 4,
and the appropriate designation (“U” for urban or “R” for rural) in column 5. See
CMS Pub. 100-04, chapter 9, §20.6.2 for information regarding urban and rural designations. If
you are uncertain of your designation, contact your contractor.
Line 4.--Enter the inclusive dates covered by this cost report. Enter in column 1, the cost report
beginning date and enter in column 2, the cost report ending date.
Line 5.--Indicate whether this FQHC is owned, leased or controlled by an entity that operates
multiple FQHCs. Enter a “Y” for yes or an “N” for no. If yes, complete lines 6 through 8.
Otherwise, skip to line 9.

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Lines 6 through 8.--Enter the name of the entity that owns, leases or controls the FQHC, the street
address, P.O. box (if applicable), Health Resources Services Administration (HRSA) grant award
number assigned to the organization, city, state, and ZIP code.
Lines 9.--Indicate if this FQHC is part of a chain organization as defined in CMS Pub. 15-1,
chapter 21, §2150 that claimed home office costs in a home office cost statement. Enter “Y” for
yes or “N” for no. If yes, complete lines 10 through 12. Otherwise, skip to line 13.
Lines 10 through 12.--Enter the name of the chain organization, the street address, P.O. box (if
applicable), the home office CCN, city, state, and ZIP code.
Line 13.--Indicate whether this FQHC is filing a consolidated cost report under CMS Pub. 100-02,
chapter 13, §80.2. Enter “Y” for yes or “N” for no, in column 1. If yes, enter in column 2 the date
the FQHC requested approval to file a consolidated cost report, in column 3 the date the contractor
approved the FQHCs request to file a consolidated cost report, and in column 4 the number of
FQHCs included in this consolidated cost report other than the primary FQHC.
Line 14.--If the response to line 13 is yes, list on line 14, beginning with the subscript line 14.01,
each FQHC that is part of this consolidated cost report, excluding the FQHC listed on line 1. Enter
in column 1 the site name, column 2 the CCN, column 3 the CBSA, column 4 the date the FQHC
requested approval to file as part of a consolidated cost report, and column 5 the date the contractor
approved the FQHCs request to file as part of a consolidated cost report. Each FQHC listed on
line 14, beginning with the subscript line 14.01, must complete a separate Worksheet S-1, Part II.
Line 15.--There are 3 types of organizations that are eligible to enroll in Medicare as FQHCs.
Indicate in column 1, the type of organization this FQHC is by entering a number from the list
below. If your response in column 1 is “1” or “3”, enter any or all of the alpha character (s)
associated with the response in column 2. For example if you entered “1” in column 1, enter in
column 2, “A”, “B”, “C” and/or “D.” An organization receiving a grant under §330 of the Public
Health Service (PHS) Act or an outpatient health program/facility can operate as any or all of the
subcategories listed under the respective numeric options presented below.
1) An organization receiving a grant(s) under §330 of the PHS Act:
A) Community Health Centers
B) Migrant and Seasonal Agricultural Workers Health Centers
C) Health Care for the Homeless Health Centers
D) Health Centers for Residents of Public Housing
2) Health Center Program Look-Alikes; Organizations that have been identified by HRSA as
meeting the definition of “Health Center” under §330 of the PHS Act, but not receiving grant
funding under §330; or
3) Outpatient health program/facility operated by:
A) A tribe or tribal organization under the Indian Self-Determination Act
B) An urban Indian organization under title V of the Indian Health Care Improvement
Act
C) Other

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Line 16.--Indicate if your FQHC received a grant under §330 of the PHS Act during this cost
reporting period. If this is a consolidated cost report, did the primary FQHC reported on line 1,
column 2 receive a grant under §330 of the PHS Act during this cost reporting period? Enter “Y”
for yes or “N” for no.
Line 17.--If the response to line 16 is yes, indicate in column 1, the type of grant that was awarded
from the list below. Enter the date of the grant award in column 2 and enter the grant award
number in column 3. If you received more than one grant subscript this line accordingly.
1 = Community Health Center (§330(e), PHS Act)
2 = Migrant and Seasonal Agricultural Workers Health Center (§330(g), PHS Act)
3 = Health Care for the Homeless Health Centers (§330(h), PHS Act)
4 = Health Centers for Residents of Public Housing (§330(i), PHS Act)
5 = Other
Line 18.--Indicate if your FQHC submitted an initial deeming or annual redeeming application for
medical malpractice coverage to HRSA under the Federal Tort Claims Act (FTCA). Enter “Y”
for yes or “N” for no in column 1. If column 1 is yes, enter the effective date of coverage in
column 2.
Line 19.--Does this FQHC carry commercial malpractice coverage? Enter “Y for yes or “No” for
no. Malpractice insurance premiums are money paid by the FQHC to a commercial insurer to
protect the FQHC against potential negligence claims made by their patients/clients.
Line 20.--If line 19 is yes, indicate if your malpractice insurance is a claims-made or occurrence
policy. A claims-made insurance policy covers claims first made (reported or filed) during the
year the policy is in force for any incidents that occur that year or during any previous period
during which the insured was covered under a “claims-made” contract. The occurrence policy
covers an incident occurring while the policy is in force regardless of when the claim arising out
of that incident is filed. Enter 1 if the malpractice insurance is a claims-made policy. Enter 2 if
the malpractice insurance is an occurrence policy.
Line 21.--Enter the total amount of malpractice premiums paid in column 1, enter the total amount
of paid losses in column 2, and enter the total amount of self-insurance paid in column 3.
Malpractice paid losses is money paid by the FQHC to compensate a patient/client for professional
negligence. Malpractice self-insurance is money paid by the FQHC where the FQHC acts as its
own insurance company (either as a sole or part-owner) to financially protect itself against
professional negligence. Often FQHCs will manage their own funds or purchase a policy referred
to as captive insurance, which provides insurance coverage the FQHC needs but could not obtain
economically through the mainstream insurance market.
Line 22.--Indicate if malpractice premiums paid, paid losses, or self-insurance are reported in a
cost center other than the Administrative and General (A&G) cost center. Enter “Y” for yes or
“N” for no. If yes, submit a supporting schedule listing cost centers and amounts.
Line 23.--Is this FQHC involved in training residents in an approved graduate medical education
(GME) program in accordance with 42 CFR 405.2468(f)? Enter “Y” for yes or “N” for no.
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4405.2

Line 24.--Is this FQHC involved in training residents in an unapproved GME program? Enter “Y”
for yes or “N” for no.
Line 25.--Indicate if the FQHC received a Primary Care Residency Expansion (PCRE) grant from
HRSA to train new residents in primary care residency programs. Enter “Y” for yes or “N” for no
in column 1. If yes, enter the number of primary care full time equivalent (FTE) residents your
FQHC trained using PCRE grant funding in column 2, and the total number of visits performed by
such residents in column 3, during this cost reporting period.
Line 26.--Indicate if the FQHC received a Teaching Health Center (THC) development grant
authorized under Part C of title VII of the PHS Act from HRSA for the purpose of establishing
new accredited or expanded primary care residency programs. Enter “Y” for yes or “N” for no in
column 1. If yes, enter the number of FTE residents your FQHC trained using THC funding in
column 2, and the total number of visits performed by such residents in column 3, during this cost
reporting period.
Line 27.--Indicate if you own or lease the building or office space occupied by your FQHC, or if
the building or office space is provided at no cost to the FQHC. Enter a “1” for owned, a “2” for
leased, or a “3” for space provided at no cost in column 1. If you lease the office space, enter the
rent/lease expense for this cost reporting period in column 2. If the building or office space is
provided at no cost to the FQHC, it must be supported by a written agreement with the owner of
record of the building or office space.
Line 28.--Does this FQHC utilize contract labor to provide medical and/or mental health services
to its patients? Enter “Y” for yes or “N” for no.
4405.2 Part II - Federally Qualified Health Center Consolidated Cost Report Participant
Identification Data.--Each FQHC that is included on Worksheet S-1, Part I, line 14, and applicable
subscripts, who is filing as part of a consolidated cost report must complete a separate
Worksheet S-1, Part II in the identical sequence that the consolidated FQHCs are reported on
Worksheet S-1, Part I, line 14 and its subscripts. Do not complete this worksheet for the primary
FQHC reported on Worksheet S-1, Part I, line 1.
Line 1.--Enter the FQHC site name in column 1 and the FQHC certification date in column 2.
Indicate the type of control under which the FQHC operates by entering a number from the list
below in column 3.
1
2
3
4
5
6

= Voluntary Nonprofit, Corporation
= Voluntary Nonprofit, Other
= Proprietary, Individual
= Proprietary, Corporation
= Proprietary, Partnership
= Proprietary, Other

7 = Governmental, Federal
8 = Governmental, State
9 = Governmental, County
10 = Governmental, City
11 = Governmental, Other

Enter the date the FQHC terminated its participation in the Medicare program (if applicable) in
column 4. In column 5, enter a “V” for a voluntary termination or an “I” for an involuntary
termination.
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If the FQHC changed ownership immediately prior to the beginning of the cost reporting period
enter the date of the change of ownership in column 6. Also submit the name and address of the
new owner and a copy of the sales agreement with the cost report.
Line 2.--Enter the FQHC’s street address in column 1 and the P.O. in column 2 (if applicable).
Line 3.--Enter the city in column 1, state in column 2, ZIP code in column 3, county in column 4,
and the appropriate designation (“U” for urban or “R” for rural) in column 5. See
CMS Pub. 100-04, chapter 9, §20.6.2 for information regarding urban and rural designations. If
you are uncertain of your designation, contact your contractor.
Line 4.--There are 3 types of organizations that are eligible to enroll in Medicare as an FQHC. Indicate
in column 1, the type of FQHC organization by entering a number from the list below. If your
response in column 1 is “1” or “3”, enter any or all of the alpha characters associated with the
response in column 2. For example if you entered “1” in column 1, enter in column 2, “A”, “B”,
“C” and/or “D”. An organization receiving a grant under §330 of the PHS Act or an outpatient
health program/facility can operate as any or all of the subcategories listed under the respective numeric
options below.
1) An organization receiving a grant(s) under §330 of the PHS Act:
A) Community Health Centers
B) Migrant and Seasonal Agricultural Workers Health Centers
C) Health Care for the Homeless Health Centers
D) Health Centers for Residents of Public Housing
2) Health Center Program Look-Alikes; Organizations that have been identified by HRSA as
meeting the definition of “Health Center” under §330 of the PHS Act, but not receiving grant
funding under §330; or
3) Outpatient health program/facility operated by:
A) A tribe or tribal organization under the Indian Self-Determination Act
B) An urban Indian organization under title V of the Indian Health Care Improvement Act
C) Other

Line 5.--Indicate if your FQHC received a grant under §330 of the PHS Act during this cost
reporting period? Enter “Y” for yes or “N” for no.
Line 6.--If the response to line 5 is yes, indicate in column 1, the type of grant that was awarded
from the list below. Enter the date of the grant award in column 2 and enter the grant award
number in column 3. If you received more than one grant subscript this line accordingly.
1 = Community Health Center (§330(e), PHS Act)
2 = Migrant and Seasonal Agricultural Workers Health Center (§330(g), PHS Act)
3 = Health Care for the Homeless Health Centers (§330(h), PHS Act)
4 = Health Centers for Residents of Public Housing (§330(i), PHS Act)
5 = Other
Line 7.--Indicate if your FQHC submitted an initial deeming or annual redeeming application for
medical malpractice coverage to HRSA under the FTCA. Enter “Y” for yes or “N” for no in
column 1. If column 1 is yes, enter the effective date of coverage in column 2.
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4405.2 (Cont.)

Line 8.--Does this FQHC carry commercial malpractice coverage? Enter “Y for yes or “N” for
no. Malpractice insurance premiums are money paid by the FQHC to a commercial insurer to
protect the FQHC against potential negligence claims made by their patients/clients.
Line 9.--If line 8 is yes, indicate if your malpractice insurance is a claims-made or occurrence
policy. A claims-made insurance policy covers claims first made (reported or filed) during the
year the policy is in force for any incidents that occur that year or during any previous period
during which the insured was covered under a “claims-made” contract. The occurrence policy
covers an incident occurring while the policy is in force regardless of when the claim arising out
of that incident is filed. Enter 1 if the malpractice insurance is a claims-made policy. Enter 2 if
the malpractice insurance is an occurrence policy.
Line 10.--Enter the total amount of malpractice premiums paid in column 1, enter the total amount
of paid losses in column 2, and enter the total amount of self-insurance paid in column 3.
Malpractice paid losses is money paid by the FQHC to compensate a patient/client for professional
negligence. Malpractice self-insurance is money paid by the FQHC where the FQHC acts as its
own insurance company (either as a sole or part-owner) to financially protect itself against
professional negligence. Often FQHCs will manage their own funds or purchase a policy referred
to as captive insurance, which provides insurance coverage the FQHC needs but could not obtain
economically through the mainstream insurance market.
Line 11.--Is this FQHC 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.
Line 12.--Is this FQHC involved in training residents in an unapproved GME program? Enter “Y”
for yes or “N” for no.
Line 13.--Indicate if the FQHC received PCRE grant funding from HRSA to train new residents
in primary care residency programs. Enter “Y” for yes or “N” for no in column 1. If yes, enter in
column 2 the number of primary care FTE residents your FQHC trained using PCRE grant funding,
and enter in column 3 the total number of visits performed by such residents during this cost
reporting period.
Line 14.--Indicate if the FQHC received a THC development grant authorized under Part C of title
VII of the PHS Act from HRSA for the purpose of establishing new accredited or expanded
primary care residency programs. Enter “Y” for yes or “N” for no in column 1. If yes, enter in
column 2 the number of FTE residents your FQHC trained using THC funding and enter in
column 3 the total number of visits performed by such residents during this cost reporting period.
Line 15.--Indicate whether you own or lease the building or office space occupied by your FQHC,
or if the building or office space is provided at no cost to the FQHC. Enter a “1” for owned, a “2”
for leased, or a “3” for space provided at no cost in column 1. If you lease the office space, enter
the rent/lease expense for this cost reporting period in column 2. If the building or office space is
provided at no cost to the FQHC, it must be supported by a written agreement with the owner of
record of the building or office space.

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Line 16.--Does this FQHC utilize contract labor to provide medical and/or mental health services
to its patients? Enter “Y” for yes or “N” for no.
4406.

WORKSHEET S-2 - FEDERALLY
REIMBURSEMENT QUESTIONNAIRE

QUALIFIED

HEALTH

CENTER

This worksheet collects organizational, financial and statistical information previously reported on
Form CMS-339. Where instructions for this worksheet direct the FQHC to submit
documentation/information, mail or otherwise transmit the requested documentation to the
contractor with submission of the electronic cost report (ECR). The contractor has the right under
§§1815(a) and 1883(e) of the Act to request any missing documentation. When filing a
consolidated cost report, this worksheet applies only to the primary FQHC.
To the degree that the information in the questionnaire constitutes commercial or financial
information which is confidential and/or is of a highly sensitive personal nature, the information
will be protected from release under the Freedom of Information Act. If there is any question
about releasing information, the contractor should consult with the CMS Regional Office.
NOTE: The responses on all lines are “yes” or “no” unless otherwise indicated. When the
instructions require documentation, indicate on the documentation the Worksheet S-2 line number
the documentation supports. Lines 1 through 19 are required to be completed by all FQHCs
reported on Worksheet S-1, Part I, line 1.
Line 1.--Indicate whether the FQHC has changed ownership immediately prior to the beginning
of the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
enter the date the change of ownership occurred in column 2. Also, submit the name and address
of the new owner and a copy of the sales agreement with the cost report.
Line 2.--Indicate whether the FQHC has terminated participation in the Medicare program. Enter
“Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter the date of termination in
column 2, and “V” for voluntary or “I” for involuntary in column 3.
Line 3.--Indicate whether the FQHC is 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 FQHC 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. If column 1 is “Y”, submit a list of the individuals, the
organizations involved, and a description of the transactions with the cost report.
NOTE: A related party transaction occurs when services, facilities, or supplies are furnished to
the provider by organizations related to the provider through common ownership or control. (See
CMS Pub. 15-1, chapter 10 and 42 CFR 413.17.)

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Line 4.--Indicate in column 1 whether the financial statements were prepared by a certified public
accountant; enter “Y” for yes or “N” for no. If column 1 is yes, indicate the type of financial
statements in column 2 by entering “A” for audited, “C” for compiled, or “R” for reviewed. Submit
a complete copy of the financial statements (i.e., the independent public accountant’s opinion, the
statements themselves, and the footnotes) with the cost report. If the financial statements are not
available for submission with the cost report enter the date they will be available in column 3.
Indicate whether the total expenses and total revenues reported on the cost report differ from those
on the filed financial statements? Enter “Y” for yes or “N” for no in column 4. If “Y”, submit a
reconciliation with the cost report.
If column 1 is “N”, submit a copy of the internally prepared financial statements, and written
statements of significant accounting policy and procedure changes affecting Medicare
reimbursement which occurred during the cost reporting period. You may submit the changed
accounting or administrative procedures manual in lieu of written statements.
Line 5.--Indicate whether Intern-Resident costs were claimed on the current cost report. Enter “Y”
for yes or “N” for no in column 1.
Line 6.--Indicate whether Intern-Resident program(s) have been initiated or renewed during the
cost reporting period. Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column
1, submit copies of the certification(s)/program approval(s) with the cost report. (See
42 CFR 413.79(l) for the definition of a new program.)
Line 7.--Indicate whether graduate medical education costs were directly assigned to cost centers
other than the “Allowable GME Costs” on Worksheet A, line 47. Enter “Y” for yes or “N” for no
in column 1. If you answer “Y” in column 1, submit a listing of the cost centers and amounts with
the cost report.
Line 8.--Indicate whether you are seeking reimbursement for bad debts resulting from Medicare
deductible and/or coinsurance amounts which are uncollectible from Medicare beneficiaries. (See
42 CFR 413.89(e) and CMS Pub. 15-1, chapter 3, §§306 - 324 for the criteria for an allowable bad
debt.) Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, submit a
completed Exhibit 1 or internal schedule duplicating the documentation requested on Exhibit 1 to
support the bad debts claimed.
Exhibit 1 requires the following documentation:
Columns 1, 2, 3, 4 - Patient Names, Health Insurance Claim (HIC) Number, and Dates of Service
(From - To).--The documentation required for these columns is derived from the beneficiary’s bill.
Furnish the patient’s name, HIC number and dates of service that correlate to the claimed bad debt.
(See CMS Pub. 15-1, chapter 3, §314 and 42 CFR 413.89.)

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Columns 5 & 6--Indigency/Medicaid Beneficiary.--If the patient included in column 1 has been
deemed indigent, place a check in column 5. If the patient in column 1 has a valid Medicaid
number, include this number in column 6. See the criteria in CMS Pub. 15-1, chapter 3, §§312
and 322 and 42 CFR 413.89 for guidance on the billing requirements for indigent and Medicaid
beneficiaries.
Columns 7 & 8--Date First Bill Sent to Beneficiary & Date Collection Efforts Ceased.--This
information should be obtained from the FQHC’s files and should correlate with the beneficiary
name, HIC number, and dates of service shown in columns 1, 2, 3 and 4 of this exhibit. The date
in column 8 represents the date that the unpaid account is deemed worthless, whereby all collection
efforts, both internal and by an outside entity, ceased and there is no likelihood of recovery of the
unpaid account. (See 42 CFR 413.89(e) and (f), and CMS Pub. 15-1, chapter 3, §§308, 310, and
314.)
Column 9--Medicare Remittance Advice Dates.--Enter in this column the remittance advice dates
that correlate with the beneficiary name, HIC number, and dates of service shown in columns 1,
2, 3 and 4 of this exhibit.
Column 10--Coinsurance/Total Medicare Bad Debts.--Record on each line of this column the
beneficiary’s unpaid coinsurance amount that relates to covered services. Calculate the total bad
debts by summing up the amounts on all lines of column 10. This “total” must agree with the bad
debts claimed on the cost report. Attach additional supporting schedules, if necessary, for bad debt
recoveries.
Line 9.--Indicate whether your bad debt collection policy changed during the cost reporting period.
Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, submit a copy of the
revised bad debt collection policy with the cost report.
Line 10.--Indicate whether patient coinsurance amounts were waived. Enter “Y” for yes or “N”
for no in column 1. If you answer “Y” in column 1, ensure that they are not included on the bad
debt listings (i.e., Exhibit 1 or your internal schedules) submitted with the cost report.
Line 11.--Indicate whether the cost report was prepared using the Provider Statistical &
Reimbursement (PS&R) Report only. Enter “Y” for yes or “N” for no in column 1. If column 1
is “Y” enter the paid through date of the PS&R in column 2. Also, submit a crosswalk between
revenue codes and visits found on the PS&R to the cost center groupings on the cost report. This
crosswalk will reflect a cost center to revenue code match only.

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Line 12.--Indicate whether the cost report was prepared using the PS&R for totals and the FQHC’s
records for allocation. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y” enter the
paid through date of the PS&R used to prepare this cost report in column 2. Also, submit a detailed
crosswalk between revenue codes and visits on the PS&R to the cost center groupings on the cost
report. This crosswalk must show visits by cost center and include which revenue codes were
allocated to each cost center. The total visits on the cost report must match the total visits on the
PS&R (as appropriately adjusted for unpaid claims, etc.) to use this method. Supporting work
papers must accompany this crosswalk to provide sufficient documentation as to the accuracy of
the FQHC’s records.
Line 13.--If you entered “Y” on either line 11 or 12, indicate whether adjustments were made to
the PS&R data for additional claims that have been billed but not included on the PS&R used to
file this cost report. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, include a
schedule which supports any claims not included on the PS&R. This schedule should include
totals consistent with the breakdowns on the PS&R, and should reflect claims that are unprocessed
or unpaid as of the cut-off date of the PS&R used to file the cost report.
Line 14.--If you entered “Y” on either line 11 or 12, column 1, indicate whether adjustments were
made to the PS&R data for corrections of other PS&R information. Enter “Y” for yes or “N” for
no in column 1. If column 1 is “Y”, submit a detailed explanation and documentation which
provides an audit trail from the PS&R to the cost report.
Line 15.--If you entered “Y” on either line 11 or 12, column 1, indicate whether other adjustments
were made to the PS&R data. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
include a description of the other adjustments and documentation which provides an audit trail
from the PS&R to the cost report.
Line 16.--Indicate whether the cost report was prepared using FQHC records only. Enter “Y” for
yes or “N” for no in column 1. If column 1 is “Y”, submit detailed documentation of the system
used to support the data reported on the cost report. If detail documentation was previously
supplied, submit only necessary updated documentation with the cost report.
The minimum requirements are:
•

Internal records supporting program utilization statistics, charges, prevailing rates
and payment information broken into each Medicare bill type in a manner consistent
with the PS&R report.

•

A reconciliation of remittance totals to the provider’s internal records.

•

The name of the system used and system maintainer (vendor or FQHC). If the FQHC
maintained the system, include date of last software update.

NOTE: Additional information may be supplied such as narrative documentation, internal flow
charts, or outside vendor informational material to further describe and validate the reliability of
your system.
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Line 17.--Enter the first name, last name and the title/position held by the cost report preparer in
columns 1, 2, and 3, respectively.
Line 18.--Enter the employer/company name of the cost report preparer.
Line 19.--Enter the telephone number and email address of the cost report preparer in columns 1
and 2, respectively.

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4406 (Cont.)

EXHIBIT 1
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
FQHC Name ____________________
FQHC CCN ______________________
FYE _________________________

Prepared By __________________________________
Date Prepared ________________________________

Dates of Service

Indigency& Medicaid
Beneficiary (Check if
applicable)

Patient Name

HIC. No.

From

To

Yes

Medicaid
Number

1

2

3

4

5

6

Date First
Bill Sent to
Beneficiary

Date
Collection
Efforts Ceased

Medicare
Remittance
Advice Dates

Co-Insurance/
Total Medicare
Bad Debts*

7

8

9

10

*These amounts must not be claimed unless the FQHC bills for these services with the intention of receiving payment.
See instructions for columns 5 and 6 - Indigency/Medicaid Beneficiary, for possible exception.
These amounts must not be claimed if they were included on a previous Medicare bad debt listing or cost report.

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4407.

WORKSHEET S-3 - FEDERALLY QUALIFIED HEALTH CENTER DATA

03-18

This worksheet consists of three parts:
Part I - Federally Qualified Health Center Statistical Data
Part II - Federally Qualified Health Center Contract Labor and Benefit Cost
Part III - Federally Qualified Health Center Employee Data
4407.1 Part I - Federally Qualified Health Center Statistical Data.--This part collects statistical
data regarding the number and types of visits by title, as well as, the number of visits performed
by interns and residents. Only those visits that qualify as a face to face encounter associated with
a beneficiary receiving services under the Medicare fee for service program are included in
column 2. Visits attributable to beneficiaries enrolled in a Medicare Advantage plan must be
included in column 4. For the purposes of the Medicare program, a beneficiary who receives care
at an FQHC can be seen for three types of visits:
•

•
•

Medical Visit - A face to face encounter between an FQHC patient and one of the
following: a physician, physician assistant, nurse practitioner, certified nurse midwife,
visiting registered nurse, visiting licensed practical nurse, registered dietician, or certified
DSMT/MNT educator. The provision of Transitional Care Management (TCM) services
is reported as a medical visit if it is the only medical service provided on that day and it
meets the TCM billing requirements. If it is furnished on the same day as another medical
visit, only one medical visit is reported on the cost report.
Medical Visit for Subsequent Illness or Injury
Mental Health Visit - A face to face encounter between an FQHC patient and one of the
following: a clinical psychologist, clinical social worker, or a physician, physician
assistant, nurse practitioner, certified nurse midwife, visiting registered nurse, or a visiting
licensed practical nurse for mental health services.

All visits performed by interns and residents who are funded by a THC or PCRE grant from HRSA
must be excluded from lines 5 and 6 on this worksheet. Visits performed by an intern or resident
funded by a THC or PCRE grant from HRSA are separately reported on the Worksheet S-1, Parts I
and II.
Column 0.--Use this column to identify the primary FQHC listed on Worksheet S-1, Part I, line 1,
and if you are filing a consolidated cost report, each FQHC listed on Worksheet S-1, Part I, line 14,
beginning with the subscripted line 14.01, in the exact same order.
Columns 1 through 4.--Enter the number of medical visits, mental health visits and visits
performed by interns and residents, if applicable, for each program (title V, title XVIII, and title
XIX) and all other payors. Include dually eligible (Medicare/Medicaid) beneficiaries in column 2.
Column 5.--Enter the sum of the total medical visits, mental health visits and visits performed by
interns and residents included in columns 1 through 4.

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Line 1.--Enter the number of medical visits applicable to columns 1 through 4. Each visit to the
FQHC by the beneficiary counts as a single visit, even in the case where a beneficiary returns to
the FQHC in the same day for a subsequent illness or injury. If you are filing under a consolidated
cost report, line 1 must contain the medical visits exclusively for the primary CCN and you must
subscript line 1 to report the number of medical visits for each additional FQHC included in this
consolidated cost report. Each subscript of line 1, column 0, must contain a corresponding CCN
from Worksheet S-1, Part I, line 14, beginning with subscripted line 14.01, in the exact same order.
Enter the number of medical visits applicable to columns 1 through 4, for each FQHC listed on
line 1 and its subscripts.
Line 2.--Enter the total number of medical visits (sum of line 1 and its subscripts) for each
applicable column.
Line 3.--Enter the number of mental health visits applicable to columns 1 through 4. Each visit to
the FQHC by the beneficiary counts as a single visit, even in the case where a beneficiary returns
to the FQHC in the same day for a subsequent illness or injury. If you are filing under a
consolidated cost report, line 3 must contain the mental health visits exclusively for the primary
CCN and you must subscript line 3 to report the number of mental health visits for each additional
FQHC included in this consolidated cost report. Each subscript of line 3, column 0, must contain
a corresponding CCN from Worksheet S-1, Part I, line 14, beginning with subscripted line 14.01,
in the exact same order. Enter the number of mental health visits applicable to columns 1 through
4, for each FQHC listed on line 3 and its subscripts.
Line 4.--Enter the total number of mental health visits (sum of line 3 and its subscripts) for each
applicable column.
Line 5.--Enter the total number of visits performed by interns and residents not funded by a THC
or PCRE grant from HRSA applicable to columns 1 through 4. If you are filing under a
consolidated cost report, line 5 must contain the visits performed by interns and residents
exclusively for the primary CCN and you must subscript line 5 to report the number of visits
performed by interns and residents for each additional FQHC included in this consolidated cost
report. Visits reported on line 5 and its subscripts, are a subset of the medical and mental health
visits reported on lines 1 and 3 and their subscripts. Each subscript of line 5, column 0, must
contain a corresponding CCN from Worksheet S-1, Part I, line 14, beginning with subscripted
line 14.01, in the exact same order. Enter the number of visits performed by interns and residents
applicable to columns 1 through 4 for each FQHC listed on line 5 and its subscripts.
Line 6.--Enter the total number of visits performed by interns and residents not funded by a THC
or PCRE grant from HRSA (sum of line 5 and its subscripts) for each applicable column.
NOTE: When reporting data for FQHCs reporting under the consolidated cost reporting
provisions, subscript lines 1, 3, and 5 in the identical sequence that the consolidated FQHCs are
reported on Worksheet S-1, Part I, line 14, beginning with subscripted line 14.01.

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04-16

4407.2 Part II - Federally Qualified Health Center Contract Labor and Benefit Cost.--This
section identifies the contract labor and benefit costs relating to direct patient care. See
Worksheet A for the applicable cost center definitions.
DEFINITIONS
Column 1 - Contract Labor Costs.--Enter the amount paid for services furnished under contract,
rather than by employees, for direct patient care and management services for the occupations on
lines 2 through 15. Line 1 is the aggregate of lines 2 through 15. DO NOT include cost for
equipment, supplies, travel expenses, and other miscellaneous or overhead items (non-labor costs).
Column 2 - Benefit Costs.--Enter the amount of employee benefit costs, also referred to as wagerelated costs, for direct patient care services for the occupations listed on lines 2 through 15. Line 1
is the aggregate of lines 2 through 15.
4407.3 Part III - Federally Qualified Health Center Employee Data.--This section identifies data
related to the human resources of the FQHC. The human resources statistics are required for each
of the job categories specified in lines 16 through 29.
Enter the number of hours in your normal work week.
Report in column 1 the FTE employees on the FQHC’s payroll. These are staff for which an
IRS Form W-2 is used.
Report in column 2 the FTE contracted and consultant staff of the FQHC.
Complete staff FTEs for column 1 as follows: Add all hours for which employees were paid and
divide by 2080. Round to two decimal places, e.g., 04447 is rounded to .04. Compute contract
FTE’s for column 2 as follows: Add all hours for which contracted and consultant staff worked
and divide by 2080 hours. If employees are paid for unused vacation, unused sick leave, etc.,
exclude these paid hours from the numerator in the calculations.
Enter the total FTEs in column 3, by adding columns 1 and 2.

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4408

4408. WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE
OF EXPENSES
Worksheet A provides for recording the trial balance of expense accounts from your accounting
books and records. It also provides for the necessary reclassifications and adjustments to certain
accounts. The cost centers listed may not apply to every FQHC using these forms. For example,
a FQHC that does not have an intern and resident program will not complete lines 47 and/or 78.
Complete only those lines that are applicable.
If the cost elements of a cost center are maintained separately on your accounting books, a
reconciliation of costs per the accounting books and records to those on this worksheet must be
maintained and are subject to review by your contractor.
Standard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If
additional or different cost center descriptions are needed, add (subscript) additional lines to the
cost report. Where an added cost center description bears a logical relationship to a standard line
description, the added label must be inserted immediately after the related standard line. The added
line is identified as a numeric subscript of the immediately preceding line. For example, if two
lines are added between lines 7 and 8, identify them as lines 7.01 and 7.02.
Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by health care entities on the Medicare cost reports. Form CMS-224-14 provides for preprinted
cost center descriptions on Worksheet A. In addition, a space is provided for a cost center code.
The preprinted cost center labels are automatically coded by CMS approved cost reporting
software. These cost center descriptions are hereafter referred to as the standard cost centers.
Additionally, nonstandard cost center descriptions have been identified through analysis of
frequently used labels.
This coding methodology allows FQHCs to continue to use labels for cost centers that have
meaning within the individual institution. The four digit cost center codes that are associated with
each FQHC’s label in the ECR file provide standardized meaning for data analysis. FQHCs are
required to compare any added or changed labels to the descriptions offered on the standard or
nonstandard cost center tables. A description of cost center coding and the table of cost center
codes are in §4495, table 5.
Submit the working trial balance for the facility with the cost report. A working trial balance is a
listing of the balances of the accounts in the general ledger to which adjustments are appended in
supplementary columns and used as a basic summary for financial statements.

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COLUMN DESCRIPTIONS
Columns 1 through 3.--The expenses listed in these columns must be in accordance with your
accounting books and records.
Enter on the appropriate lines in columns 1 through 3 the total expenses incurred during the cost
reporting period. These expenses are detailed between salaries (column 1) and other than salaries
(column 2). The sum of columns 1 and 2 must equal column 3.
Column 1.--Salaries are the gross salaries paid to employees before taxes and other items are
withheld. Salaries include paid vacation, holiday, sick, other-paid-time off, severance and bonus
pay. (See CMS Pub. 15-1, chapter 21.) Enter salaries from the FQHC’s accounting books and
records. Do not include costs attributable to contracted labor is this column. Contracted labor is
only reported in column 2.
Column 2.--Enter all costs other than salaries from the FQHC’s accounting books and records.
Column 3.--For each cost center, add the amounts in columns 1 and 2 and enter the total in
column 3.
Column 4.--For each cost center, enter the net amount of reclassifications from Worksheet A-1.
The net total of the entries in column 4 must equal zero on line 100. Show reductions to expenses
as negative numbers.
Column 5.--For each cost center, enter the total of the amount in column 3 plus or minus the
amount in column 4. The total on column 5, line 100 must equal the total on column 3, line 100.
Column 6.--For each cost center, enter the net of any increase and decrease amounts from
Worksheet A-2. The total on Worksheet A, column 6, line 100 must equal Worksheet A-2,
column 2, line 50.
Column 7.--For each cost center, enter the total of the amount in column 5 plus or minus the
amount in column 6.

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LINE DESCRIPTIONS
The Worksheet A segregates the trial balance of expenses into general service cost centers, direct
patient care cost centers, reimbursable pass through costs, other FQHC services, and
nonreimbursable cost centers to facilitate the transfer of costs to the various worksheets.
GENERAL SERVICE COST CENTERS
These cost centers include expenses incurred in operating the FQHC as a whole that are not directly
associated with furnishing patient care such as, but not limited to mortgage, rent, plant operations,
administrative salaries, utilities, telephone, and computer hardware and software costs. General
service cost centers furnish services to other general service cost centers and to reimbursable and
nonreimbursable cost centers in the FQHC.
Lines 1 and 2 - Cap Rel Costs-Bldg & Fix and Cap Rel Costs-Mvble Equip.--These cost centers
include the capital-related costs for buildings and fixtures and the capital-related costs for movable
equipment including depreciation, leases and rentals for the use of facilities and/or equipment,
including electronic health records systems, interest incurred in acquiring land and depreciable
assets used for patient care, insurance on depreciable assets used for patient care, taxes on land or
depreciable assets used for patient care, and software and hardware updates attributable to
electronic health records systems. Do not include in these cost centers costs incurred for the repair
or maintenance of equipment or facilities; amounts specifically included in rentals or lease
payments for repair and/or maintenance agreements; interest expense incurred to borrow working
capital or for any purpose other than the acquisition of land or depreciable assets used for patient
care; general liability insurance or any other form of insurance to provide protection other than the
replacement of depreciable assets; or taxes other than those assessed on the basis of some valuation
of land or depreciable assets used for patient care. However, if no amount of the lease payment is
identified in the lease agreement for maintenance, you are not required to carve out a portion of
the lease payment to represent the maintenance portion. Thus, the entire lease payment is
considered a capital-related cost subject to the provisions of 42 CFR 413.130(b).

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Line 3 - Employee Benefits.--This cost center includes the costs of the employee benefits
department. In addition, this cost center includes the fringe benefits paid to, or on behalf of, an
employee when an FQHC’s accounting system is not designed to accumulate the benefits on a
departmentalized or cost center basis. (See CMS Pub. 15-1, chapter 21, §2144).
Line 4 - Administrative and General (A&G) Services.--A&G includes a wide variety of
administrative costs such as but not limited to cost of fiscal services, legal and accounting services,
facility administrative services (not already included in other general services cost centers),
etcetera.
Line 5 - Plant Operation and Maintenance.--This cost center includes expenses incurred in the
plant operation and maintenance of the FQHC. These costs include the maintenance and service
of utility systems such as heat, light, water, air conditioning and air treatment. This cost center
also includes costs incurred in maintaining the facility and grounds, such as costs of routine
painting, plumbing, mowing, and snow removal.
Line 6 - Janitorial.--This cost center includes the cost of routine janitorial activities such as
mopping, vacuuming, cleaning restrooms, lobbies, waiting areas and otherwise maintaining patient
and non-patient care areas.
Line 7 - Medical Records.--This cost center includes the cost of the medical records department
where patient medical records are maintained. The general library and the medical library are not
included in this cost center but are included in the A&G cost center. None of the costs associated
with electronic health records systems are reported in this cost center.
Line 8 - Subtotal - Administrative Overhead.--Enter the total of lines 1 through 7.
Line 9 - Pharmacy.--This cost center includes only the costs of routine drugs (both prescription
and over the counter), pharmacy supplies, pharmacy personnel, and pharmacy services, provided
incident to an FQHC visit. Drugs and pharmacy supplies that can be traced to individual patients
that are paid separately (outside the FQHC PPS national encounter rate) under Part B, C, or D of
Medicare must be included on line 67 (Drugs Charged to Patients) of this worksheet. Drugs (both
prescription and over the counter), pharmacy supplies, pharmacy personnel and pharmacy services
provided by a retail pharmacy are reported on line 77. Do not include the cost of pneumococcal
and influenza vaccines on this line as these costs are reported on lines 48 and 49, respectively.
Line 10 - Medical Supplies.--This cost center includes the routine cost of supplies used in the
normal course of caring for patients, such as gloves, masks, swabs, or glycerin sticks, and the nonroutine costs of medical supplies that can be traced to individual patients. Do not include the cost
of medical supplies used in administering influenza and pneumococcal vaccines on this line as
these costs are reported on lines 48 and 49, respectively.
Line 11 - Transportation.--This cost center includes the cost of owning or renting vehicles, public
transportation expenses, parking, tolls, or payments to employees for driving their private vehicles
to see patients or for other FQHC business.

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Line 12 - Other General Service (Specify).--Use this line to report the costs of other general service
costs not previously identified on lines 1 through 11. If more than one other general service is
offered, subscript this line. See Table 5 in §4495 for the proper cost center code for this line.
Line 13 - Subtotal - Total Overhead.--Enter the sum of lines 8 and 9 through 12.
Line 14 through 22.--Reserved for future use.
DIRECT CARE COST CENTERS
Line 23 - Physician.--This cost center includes the costs incurred by the FQHC for physicians
providing direct patient care services and general supervisory services, participation in the
establishment of plans of care, supervision of care and services, periodic review and updating of
plans of care, and establishment of governing policies by the governing board. Reclassify the cost
for the portion of time physicians spent on general supervisory services or other FQHC
administrative activities to A&G (line 4). The costs incurred for teaching physicians and interns
and residents must be reported on line 47 or line 48, whichever is applicable. Physician services
provided under an agreement are reported on line 24.
Line 24 - Physician Services Under Agreement.--This cost center includes the costs incurred by
the FQHC for physicians who are providing services under agreement.
Line 25 - Physician Assistant.--This cost center includes the costs incurred by the FQHC for
physician assistants (PA), including the costs for PAs providing physician services.
Line 26 - Nurse Practitioner.--This cost center includes the costs of nursing care provided by nurse
practitioners (NP), including NPs providing physician services.
Line 27 - Visiting Registered Nurse.--This cost center only includes the costs of nursing care
provided by registered nurses (RNs) who perform visiting nurse services in accordance with
CMS Pub. 100-02, chapter 13, §180. Costs associated with RNs who provide services incident to
a physician, PA, NP, certified nurse midwife (CNM), clinical psychologist (CP) or clinical social
worker (CSW) (see CMS Pub. 100-02, chapter 13, §§110, 120 and 140) are included in line 36.
Line 28 - Visiting Licensed Practical Nurse.--This cost center only includes the costs of nursing
care provided by licensed practical nurses (LPNs) who perform visiting nurse services in
accordance with CMS Pub. 100-02, chapter 13, §180. Costs associated with LPNs that provide
services incident to a physician, PA, NP, CNM, CP or CSW (see CMS Pub. 100-02, chapter 13,
§§110, 120 and 140) are included in line 36.
Line 29 - Certified Nurse Midwife.--This cost center includes the costs of nursing care provided
by CNMs.
Line 30 - Clinical Psychologist.--This cost center includes the costs of a CP who holds a doctorate
in psychology and is licensed or certified by the State in which he or she practices, for diagnostic,
assessment, preventative and therapeutic services directed at individuals.

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03-18

Line 31 - Clinical Social Worker.--This cost center includes the costs of a CSW who possesses a
master’s degree or doctorate in social work and meets specified criteria established by regulation.
The CSW must directly examine the patient, or directly review the patient’s medical information,
to provide diagnosis, treatment and consultation.
Line 32 - Laboratory Technician.--This cost center includes the costs of a person who, under the
supervision of a medical technologist or physician, performs microscopic and bacteriologic tests
of human blood, tissue, and fluid for diagnostic and research purposes.
Line 33 - Reg Dietician/Cert DSMT/MNT Educator.--This cost center includes the costs of a
person who is either a registered dietician or nutritionist who meets specified criteria for providing
diabetes self-management training (DSMT) or medical nutrition therapy (MNT) services under the
Program.
Line 34 - Physical Therapist.--This cost center includes the costs of physical or corrective
treatment of bodily or mental conditions by the use of physical, chemical, and other properties of
heat, light, water, electricity, sound massage, and therapeutic exercise by or under the direction of
a registered physical therapist as prescribed by a physician. Physical therapy services may be
provided for purposes of symptom control or to enable the individual to maintain activities of daily
living and basic functional skills.
Line 35 - Occupational Therapist.--This cost center includes the costs of purposeful goal-oriented
activities in the evaluation, diagnosis, and/or treatment of persons whose function is impaired by
physical illness or injury, emotional disorder, congenital or developmental disability, or the aging
process, in order to achieve optimum functioning, to prevent disability, and to maintain health.
Occupational therapy services may be provided for purposes of symptom control or to enable the
individual to maintain activities of daily living and basic functional skills.
Line 36 - Other Allied Health Personnel.--This cost center includes the costs of RNs and LPNs
who provide services incident to a physician, PA, NP, CNM, CP or CSW in accordance with
CMS Pub. 100-02, chapter 13, §§110, 120 or 140 and the costs of other allied health personnel
that provide diagnostic, technical, therapeutic and direct patient care and support services to the
other health professionals they work with and the patients they serve. An example of other allied
health personnel is a medical assistant.
Line 37 - Subtotal Direct Patient Care Services.--Enter the total of lines 23 through 36.
Line 38 through 46.--Reserved for future use.
REIMBURSABLE PASS THROUGH COSTS
Line 47 - Allowable GME Costs.--This cost center includes the costs associated with allowable
direct GME costs set forth in 42 CFR 405.2468(f). These include residents’ salaries and fringe
benefits (including travel and lodging expenses where applicable); the allowable portion of the
teaching physicians’ salaries and fringe benefits that are related to the time spent teaching and
supervising residents (i.e., lecture time, time spent filling out resident evaluations, mentoring, and
program development) subject to the reasonable compensation equivalency limits (RCEs)
(42 CFR 415.70); and overhead costs that are directly assigned to the intern and resident program.
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4408 (Cont.)

This cost center does not include normal operating and capital related costs. If the overhead costs
for the direct GME are not identified and recorded on this line in columns 1 or 2, a reclassification
to this cost center is required. The reclassification must be made on a factual and auditable basis
on Worksheet A-1 (see §2905).
An FQHC must include all allowable direct costs associated with an intern and/or resident program
funded by a THC and/or PCRE grant from HRSA on line 47, only if the program meets the
requirements set forth in 42 CFR 405.2468(f). If the direct costs associated with an intern and/or
resident who is funded by a THC and/or PCRE grant are included in line 47, the FQHC must
reclassify the direct costs associated with the THC and/or PCRE programs funded by HRSA to
line 78, nonallowable GME costs.
A “moonlighting” resident or fellow is a postgraduate medical trainee who is practicing
independently, outside the scope of his or her residency training program and would be treated as
a physician within the scope of the privileges granted by the FQHC. Therefore, costs associated
with a “moonlighting” intern or resident are reported in the physician services cost center, not the
allowable GME cost center.
Line 48 - Pneumococcal Vaccines & Med Supplies.--This cost center includes the cost of the
pneumococcal vaccines and the medical supplies attributable to pneumococcal vaccinations.
Line 49 - Influenza Vaccines & Med Supplies.--This cost center includes the cost of the influenza
vaccines and the medical supplies attributable to influenza vaccinations.
Line 50 - Subtotal - Reimbursable Pass Through Costs.--Enter the total of lines 47 through 49.
Line 51 through 59.--Reserved for future use.
OTHER FQHC SERVICES
Line 60 - Medicare Excluded Services.--This cost center includes the cost of routine dental care,
hearing tests, eye exams, etc. that are excluded from coverage under the Program.
Line 61 - Diagnostic & Screening Lab Tests.--This cost center includes the technical component
of diagnostic and laboratory tests such as electrocardiograms and certain preventative services
authorized by the Medicare statute or the national coverage determination process. (The
professional component is a FQHC service if performed by an FQHC practitioner or furnished
incident to an FQHC service). This does not include venipuncture, which is included in the
pharmacy cost center when furnished by the FQHC.
Line 62 - Radiology - Diagnostic.--This cost center includes the technical component of
radiological diagnostic tests such as x-rays and imaging services.
Line 63 - Prosthetic Devices.--This cost center includes the costs of devices (other than dental)
which replace all or part of an internal body organ (including colostomy bags and supplies directly
related to colostomy care), replacement of such devices, and one pair of conventional eyeglasses
or contact lenses furnished subsequent to each cataract surgery with the insertion of an intraocular
lens.
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Line 64 - Durable Medical Equipment.--This cost center includes the direct costs of durable
medical equipment rented or sold (DME, as defined in 42 CFR 410.38) furnished to an individual
patient and all direct expenses incurred in requisitioning and issuing DME to patients.
Line 65 - Ambulance Services.--Report all ambulance costs on this line for both owned and
operated services and services under arrangement. No subscripting is allowed for this line.
Line 66 - Telehealth.--This cost center includes the cost of telehealth distant-site services as
described in CMS Pub. 100-02, chapter 13, §190.
Line 67 - Drugs Charged to Patients.--This cost center includes only those costs associated with
drugs (both prescription and over the counter), pharmacy supplies, pharmacy personnel and
pharmacy services that can be traced to individual patients that are paid separately (outside the
FQHC PPS national encounter rate) under Medicare Parts B, C, or D.
Line 68 - Chronic Care Management (CCM).--This cost center includes the structured recording
of patient health information, an electronic health care plan addressing all health issues, access to
chronic care management services, managing care transitions, and coordinating and sharing patient
information with practitioners and providers outside the practice. CCM services are reimbursed
as an add-on payment based on the Medicare Physician Fee Schedule (MPFS). See
Federal Register, vol. 80, November 16, 2015, page 71080.
Line 69 - Other (Specify).--Use this line to report the costs of other FQHC services not previously
identified on lines 60 through 68. If more than one other service is offered, subscript this line. See
Table 5 in §4495 for the proper cost center code for this line.
Line 70 - Subtotal Other FQHC Services.--Enter the total of lines 60 through 69.
NONREIMBURSABLE COST CENTERS
Line 71 through 76.--Reserved for future use.
Line 77 - Retail Pharmacy.--This cost center includes only those costs associated with drugs (both
prescription and over the counter), pharmacy supplies, pharmacy personnel and pharmacy services
that are sold through a retail pharmacy.
Line 78 - Nonallowable GME Costs.--This cost center includes the costs associated with an intern
and resident program not approved by Medicare.
Line 79 - Other Nonreimbursable (Specify).--Use this line to record the costs applicable to other
nonreimbursable cost centers not provided for on this worksheet. For example, costs related to a
Medicare Diabetes Prevention Program (MDPP).
Line 80 - Subtotal of Nonreimbursable Cost Centers.--Enter the total of lines 77 through 79.
Line 81 through 99.--Reserved for future use.
Line 100 - Total.--Enter the sum of lines 13, 37, 50, 70 and 80.
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FORM CMS-224-14

4410

4409. WORKSHEET A-1 - RECLASSIFICATIONS
This worksheet provides for the reclassification of certain amounts to effect the proper cost
allocation. The cost centers affected must be specifically identifiable in your accounting records.
Use reclassifications in instances in which the expenses applicable to more than one of the cost
centers listed on Worksheet A are maintained in your accounting books and records in one cost
center.
Column 1.--Identify each reclassification adjustment by assigning an alpha character (e.g., A, B,
C) in column 1. Do not use numeric designations.
Columns 2, 3, and 4.--For each increase reclassification, enter the corresponding cost center
description in column 2, the Worksheet A cost center line number reference in column 3, and
reclassification amount in column 4.
Columns 5, 6, and 7.--For each decrease reclassification, enter the corresponding cost center
description in column 5, the Worksheet A cost center line number reference in column 6, and
reclassification amount in column 7.
4410. WORKSHEET A-2 - ADJUSTMENTS TO EXPENSES
This worksheet provides for adjusting the expenses listed on Worksheet A, column 5. Make these
adjustments, which are required under the Medicare principles of reimbursement, on the basis of
cost, or amount received. Enter the total amount received (revenue) only if the cost (including the
direct cost and all applicable overhead) cannot be determined. However, if total direct and indirect
cost can be determined, enter the cost. Once an adjustment to an expense is made on the basis of
cost, you may not, in future cost reporting periods determine the required adjustment to the expense
on the basis of revenue. Enter the following symbols in column 1 to indicate the basis for
adjustments: “A” for costs and “B” for amount received. Line descriptions indicate the more
common activities which affect allowable costs or result in costs incurred for reasons other than
patient care and, thus, require adjustments.
Types of items to be entered on this worksheet are (1) those needed to adjust expenses incurred,
(2) those items which constitute recovery of expenses through sales, charges, fees, etc., and (3)
those items needed to adjust expenses in accordance with the Medicare principles of
reimbursement. (See CMS Pub. 15-1, §2328.)
If an adjustment to an expense affects more than one cost center, record the adjustment to each
cost center on a separate line on this worksheet.
Columns 2, 3 and 4.--For each adjustment, enter the amount in column 2, enter the Worksheet A
cost center line number reference in column 4, and enter the corresponding cost center description
in column 3.
Lines 1 through 3.--Investment income on restricted and unrestricted funds which are commingled
with other funds must be applied together against, but should not exceed, the total interest expense
included in allowable costs. (See CMS Pub. 15-1, chapter 2.)
Rev. 2

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03-18

Apply the investment income on restricted and unrestricted funds which are commingled with
other funds against the administrative and general, the capital-related - buildings and fixtures, the
capital-related - moveable equipment and any other appropriate cost centers on the basis of the
ratio that interest expense charged to each cost center bears to the total interest expense charged to
all of your cost centers.
Line 7.--Enter the amount from Worksheet A-2-1, column 6, line 5.
Line 10.--Enter the amount which represents the allowable cost of the services furnished by Public
Health Service personnel. Obtain this amount from your contractor.
Lines 11 and 12.--If depreciation expense computed in accordance with Medicare principles of
reimbursement differs from depreciation expenses per your books, enter the difference on lines 11
and/or 12.
Line 13--Enter the RCE adjustment for teaching physicians. RCE limits apply to the portion of
the teaching physician’s salary associated with teaching residents (i.e., lecture time, time spent
filling out resident evaluations, mentoring, and program development, etcetera as these activities
are “direct GME” activities). See CMS Pub. 15-1, chapter 21.
Line 14 through 49.--Enter any additional adjustments required under the Medicare principles of
reimbursement. Label the lines appropriately to indicate the nature of the required adjustments.
Line 50--Enter the sum of lines 1 through 49. Transfer the amounts in column 2 to the appropriate
lines on Worksheet A, column 6.

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4411.

FORM CMS-224-14

4411.2

WORKSHEET A-2-1 - STATEMENT OF COSTS OF SERVICES FROM RELATED
ORGANIZATIONS AND HOME OFFICE COSTS

In accordance with 42 CFR 413.17, costs applicable to services, facilities, and supplies furnished
to the FQHC by organizations related to the FQHC by common ownership or control are includable
in your allowable cost at the cost to the related organization, except for the exceptions outlined in
42 CFR 413.17(d). This worksheet provides for the computation of any needed adjustments to
costs applicable to services, facilities, and supplies furnished to the FQHC by organizations related
to the FQHC or costs associated with a home office. However, such cost must not exceed the
amount a prudent and cost conscious buyer pays for comparable services, facilities, or supplies
that are purchased elsewhere.
4411.1 Part I - Costs Incurred and Adjustments Required as a Result of Transactions with
Related Organizations or Claimed Home Office Costs.--This part of the worksheet provides for
the computation of adjustments needed to properly report costs of services, facilities, and supplies
furnished to the FQHC by related organizations or costs associated with the home office.
Columns 1 and 2.--Enter in column 1 the Worksheet A cost center line number to be adjusted.
Enter the corresponding cost center description in column 2.
Column 3.--Enter the description of the related organization or home office expense.
Column 4.--Enter the allowable costs from the books and/or records of the related organization or
home office. Allowable costs are the actual costs incurred by the related organization or home
office for services, facilities, and/or supplies and exclude any markup, profit or amounts that
otherwise exceed the acquisition cost of such items.
Column 5.--Enter the amount included on Worksheet A for services, facilities, and/or supplies
acquired from related organizations and/or a home office.
Column 6.--Enter the result of column 4 minus column 5.
4411.2 Part II - Interrelationship to Related Organizations and/or Home Office.-- This part of the
worksheet identifies the interrelationship between the FQHC and individuals, partnerships,
corporations, or other organizations having either a related interest to, a common ownership with,
or control over the FQHC as defined in CMS Pub. 15-1, chapter 10. Complete columns 1 through
6 as applicable for each interrelationship.

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Complete only those columns that are pertinent to the type of relationship that exists.
Column 1.--Enter the symbol that represents the interrelationship between the FQHC and the
related organization or home office. Select from the following choices:
Symbol
A
B
C
D
E
F
G

Relationship
Individual has financial interest (stockholder, partner, etc.) in both the
related organization and the provider
Corporation, partnership or other organization has financial interest in
provider
Provider has financial interest in corporation, partnership, or other
organization
Director, officer, administrator or key person of provider or organization
Individual is director, officer, administrator or key person of provider and
related organization
Director, officer, administrator or key person of related organization or
relative of such person has financial interest in provider
Other (financial or non-financial) -- specify

Column 2.--If the symbol entered in column 1 is A, D, E, F, or G, enter the name of the related
individual in column 2.
Column 3.--If the individual reported in column 2, or the organization reported in column 4, has a
financial interest in the FQHC, enter the percent of ownership.
Column 4.--Enter the name of each related corporation, partnership, or other organization.
Column 5.--If the FQHC, or an individual reported in column 2, has a financial interest in the
organization reported in column 4, enter the percent of ownership.
Column 6.--Enter the type of business of the related organization (e.g., medical drugs and/or
supplies, janitorial services).

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4412.

FORM CMS-224-14

4412.1

WORKSHEET B - CALCULATION OF FEDERALLY QUALIFIED HEALTH
CENTER COSTS

Worksheet B consists of two parts. Part I is used to summarize (1) the FQHC medical and mental
health visits furnished by practitioners, including health care staff and physicians under agreement,
and (2) apportion overhead costs to FQHC services to determine the cost per visit for a medical
visit and a mental health visit, by type of practitioner. The cost per visit calculated in Part I is not
used to determine payment under the FQHC PPS, but may be used in future payment analyses.
Part II is used to determine the FQHC’s Medicare reimbursable direct GME costs, where
applicable.
4412.1 Part I - Calculation of Federally Qualified Health Center Cost Per Visit.--The purpose
of Part I is to establish the FQHC medical and mental health Medicare cost per visit.
Column 1.--Enter the total cost for each practitioner from Worksheet A, column 7 as indicated on
the worksheet.
Column 2.--Enter the total medical and mental health visits actually furnished to all patients by
each practitioner during the cost reporting period. Each visit to the FQHC by the beneficiary
counts as a single visit, even in the case where a beneficiary returns to the FQHC in the same day
for a subsequent illness or injury. A beneficiary can have up to three medical visits in a day to
include the initial visit and two subsequent visits for illness or injury.
NOTE: Column 2, line 11 must equal Worksheet S-3, Part I, column 5, sum of lines 2 and 4. For
each line 1 through 10, column 2 must equal the sum of columns 7 and 8.
Column 3.--Use this column to allocate costs associated with other direct care costs, sum of
Worksheet A, column 7, lines 9, 32, and 34 through 36. Calculate the unit cost multiplier (UCM)
related to other direct care costs by dividing the sum of Worksheet A, column 7, lines 9, 32, 34,
35, and 36, by Worksheet B, Part I, column 2, line 11, total medical and mental health visits, and
enter the result on line 12. Calculate the costs for lines 1 through 10 by multiplying the visits on
each corresponding line, column 2, times the UCM on line 12.
Column 4.--Use this column to allocate general service costs, on Worksheet A, column 7, line 13,
minus line 9. Calculate the UCM by dividing Worksheet A, column 7, line 13, minus line 9, by
Worksheet A, column 7, line 100, minus line 13, plus line 9, and enter the result on line 12.
Allocate the general service cost attributable to each practitioner on lines 1 through 10, by
multiplying the UCM times the sum of the amounts in columns 1 and 3, for each corresponding
line.
Column 5.--Enter the sum of columns 1, 3, and 4 for each practitioner.
Column 6.--Calculate the average cost per visit by each practitioner by dividing the total cost in
column 5 by the total visits in column 2. Enter the result in column 6.
Column 7.--Enter the total number of medical visits, included in column 2, provided to all patients
by each practitioner during the cost reporting period.
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Column 8.--Enter the total number of mental health visits, included in column 2, provided to all
patients by each practitioner during the cost reporting period.
Column 9.--Enter the total number of medical visits provided to Medicare beneficiaries by each
practitioner during the cost reporting period.
Column 10.--Enter the total number of mental health visits provided to Medicare beneficiaries by
each practitioner during the cost reporting period.
NOTE: Worksheet S-3, Part I, column 2, line 2, must equal column 9, line 11; and Worksheet
S-3, Part I, column 2, line 4, must equal column 10, line 11.
Column 11.--Calculate the Medicare cost per medical visit by practitioner by multiplying the
average cost per visit in column 6 by the Medicare visits in column 9.
Column 12.--Calculate the Medicare cost per mental health visit by practitioner by multiplying the
average cost per visit in column 6 by the Medicare visits in column 10.
Line 11.--Enter the sum of lines 1 through 10 for the applicable columns.
Line 13, column 6.--Calculate the FQHC average cost per visit by dividing column 5, line 11 by
column 2, line 11.
Line 13, column 11.--Calculate the Medicare average cost per medical visit by dividing column 11,
line 11 by column 9, line 11.
Line 13, column 12.--Calculate the Medicare average cost per mental health visit by dividing
column 12, line 11 by column 10, line 11.
4412.2 Part II - Calculation of Allowable Direct Graduate Medical Education Costs.--The
purpose of Part II is to calculate the allowable cost of direct GME costs that will be reimbursed by
the Medicare program.
Column 1.--Enter the total amount of direct GME cost from Worksheet A, column 7, line 47.
Column 2.--Enter the sum of the total number of medical and mental visits from Worksheet S-3,
Part I, sum of lines 2 and 4, column 5.
Column 3.--Enter the sum of the total number of title XVIII medical and mental visits from
Worksheet S-3, Part I, lines 2 and 4, column 2.
Column 4.--Divide column 3, by column 2. Enter the result in column 4 and round to six decimal
places.
Column 5.--Multiply the amount in column 1 by the result in column 4. Enter the result in
column 5. This is the amount that Medicare will reimburse the FQHC for its direct GME activities
costs.
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4413.

FORM CMS-224-14

4413

WORKSHEET B-1 - COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA
VACCINE COST

The cost and administration of pneumococcal and influenza vaccines to Medicare beneficiaries are
100 percent reimbursable by Medicare. This worksheet provides for the computation of the cost
of the pneumococcal and influenza vaccines.
Line 1.--Enter the health care staff cost from Worksheet A, column 7, sum of lines 23, and 25
through 36, in columns 1 and 2, as applicable. Physician services under agreement are excluded
from this total.
Line 2.--Enter the ratio of the estimated percentage of time involved in administering
pneumococcal and influenza vaccine injections to the total health care staff time. Do not include
physician services under agreement time in this calculation. Obtain the estimated percentage of
time spent from your accounting books and records.
Line 3.--Multiply the amount on line 1 by the amount on line 2 and enter the result.
Line 4.--Enter the cost of pneumococcal and influenza vaccines and the cost of related medical
supplies from Worksheet A column 7, lines 48 and 49, in columns 1 and 2, respectively.
Line 5.--Enter the sum of lines 3 and 4.
Line 6.--Enter the total direct costs of the FQHC from Worksheet A, column 7, line 100, minus
Worksheet A, column 7, line 8.
Line 7.--Enter the administrative overhead of the FQHC from Worksheet A, column 7, line 8.
Line 8.--Divide the amount on line 5 by the amount on line 6 and enter the result.
Line 9.--Multiply the amount on line 7 by the ratio on line 8 and enter the result.
Line 10.--Enter the sum of the amounts on lines 5 and 9.
Line 11.--Enter in columns 1 and 2 respectively, the total number of pneumococcal and influenza
vaccine injections from your records.
Line 12.--Compute the FQHC cost per pneumococcal and influenza vaccine injection by dividing
the costs on line 10 by the number of injections on line 11 and entering the result.
Line 13.--Enter from your records the number of pneumococcal and influenza vaccine injections
administered to Medicare beneficiaries, in columns 1 and 2 respectively.
Line 14.--Enter the Medicare cost per pneumococcal and influenza vaccine injection by
multiplying the cost per vaccine on line 12 by the number of injections administered to Medicare
beneficiaries on line 13.
Line 15.--Enter the total cost of pneumococcal and influenza vaccines and their administration by
entering the sum of the amounts in columns 1 and 2, line 10.
Line 16.--Enter the total Medicare cost of pneumococcal and influenza vaccines and their
administration by entering the sum of the amount in columns 1 and 2, line 14. Transfer this amount
to the Worksheet E, line 3.
Rev. 2

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4414
4414.

FORM CMS-224-14

03-18

WORKSHEET E - CALCULATION OF REIMBURSEMENT SETTLEMENT

This worksheet provides for the reimbursement calculation of FQHC services rendered to program
patients under the FQHC PPS. It also provides for an accumulation of cost reimbursable direct
graduate medical education payments, pneumococcal and influenza vaccine reimbursement, and
Medicare Advantage (MA) supplemental payments.
Line 1.--FQHC services are paid in accordance with the FQHC PPS. Enter the total FQHC PPS
payments paid for FQHC visits rendered during the cost reporting period. Obtain this amount
from the provider statistical and reimbursement (PS&R) report.
Line 2.--Enter the Medicare costs for direct graduate medical education from Worksheet B, Part
II, line 14, column 5.
Line 3.--Enter the Medicare costs for pneumococcal and influenza vaccines and their
administration from Worksheet B-1, line 16.
Line 4.--Medicare advantage supplemental payments are made to an FQHC when the amount paid
by the managed care organization is less than the amount paid under the FQHC PPS on a per visit
basis. Enter the total amount of Medicare advantage supplemental payments from the PS&R,
report type 778. This data is captured for information purposes only and does not impact cost
report settlement.
Line 5.--Enter the sum of lines 1 through 3.
Line 6.--Enter the primary payer amounts from the PS&R.
Line 7.--Enter the result of line 5 minus line 6.
Line 8--Enter the Part B coinsurance.
Line 9--Enter the result of line 7 minus line 8.
Line 10.--Enter Medicare allowable bad debts, reduced by bad debt recoveries. If recoveries
exceed the current year’s bad debts, lines 10 and 11 will be negative.
Line 11.--Multiply the amount (including negative amounts) from line 10 by 65 percent.
Line 12--Enter the gross reimbursable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. These amounts also are included on line 10.
Line 13.--Enter the sum of lines 9 and 11.

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FORM CMS-224-14

4414 (Cont.)

Line 14.--Enter any other adjustments. Provide a description in the space provided.
Line 15.--Enter the result of line 13 plus or minus line 14.
Line 16.--Enter the sequestration adjustment amount as [(2 percent times (total days in the cost
reporting period that occur during the sequestration period beginning on or after April 1, 2013,
divided by total days in the entire cost reporting period, rounded to four decimal places)) times
line 15]. Do not apply the sequestration calculation when gross reimbursement is less than zero.

Line 17.--Enter the result of line 15 minus line 16.
Line 18.--Enter the amount of interim payments from Worksheet E-1, column 2, line 4.
Line 19.--FOR CONTRACTOR USE ONLY.--Enter the tentative settlement amount from Worksheet
E-1, column 2, line 5.99.

Line 20.--Enter the total amount due to/from the program (line 17 minus lines 18 and 19). Transfer
this amount to Worksheet S, Part III, column 1, line 1.
Line 21.--Enter the Medicare reimbursement effect of protested items. Estimate the
reimbursement effect of the non-allowable items by applying a reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See CMS Pub. 15-2, chapter 1, §115.2.) Attach a schedule showing the
supporting details and computations for this line.

Rev. 1

44-39

4415
4415.

FORM CMS-224-14

04-16

WORKSHEET E-1 - ANALYSIS OF PAYMENTS TO THE FEDERALLY
QUALIFIED HEALTH CENTER FOR SERVICES RENDERED

Complete lines 1 through 4 of this worksheet only for Medicare interim payments paid by the
contractor. Do not complete it for purposes of reporting interim payments for titles V or XIX.
The remainder of this worksheet is completed by your contractor. All amounts reported on this
worksheet must be for services rendered during the cost reporting period for which the costs are
included in this cost report.
Line Descriptions
Line 1.--Enter the total Medicare interim payments paid to the FQHC. The amount entered must
reflect the sum of all interim payments paid on individual bills (net of adjustment bills) for services
rendered in this cost reporting period. Do not include MA supplemental payments on this
worksheet. The amount entered must also include amounts withheld from your interim payments
due to an offset against overpayments applicable to the prior cost reporting periods. Do not include
(1) any retroactive lump sum adjustment amounts based on a subsequent revision of the interim
rate, (2) tentative or net settlement amounts, or (3) interim payments payable.
Line 2.--Enter the total Medicare interim payments payable on individual bills. Since the cost in
the cost report is on an accrual basis, this line represents the amount of services rendered in the
cost reporting period but not paid as of the end of the cost reporting period. It does not include
payments reported on line 1.
Line 3.--Enter the amount of each retroactive lump sum adjustment and the applicable date.
Line 4.--Enter the total amount of the interim payments (sum of lines 1, 2, and 3.99). Transfer this
amount to Worksheet E, line 18.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E-1. LINES 5 THROUGH 8
ARE FOR CONTRACTOR USE ONLY. (EXCEPTION: IF WORKSHEET S, PART I, LINE
3 IS GREATER THAN ZERO (AMENDED COST REPORT), THE FQHC MAY COMPLETE
LINES 5 THROUGH 7.)

Line 5.--List separately each tentative settlement payment after the cost report is accepted together
with the date of payment. If the cost report is reopened after the NPR has been issued, report all
settlement payments prior to the current reopening on this line.
Line 6.--Enter the net settlement amount (balance due the FQHC or balance due the program) for
the NPR, or, if this settlement is after a reopening of the NPR, for this reopening. Enter in column 2
the amount from Worksheet E, line 20.
NOTE: On lines 3, 5, and 6, when an FQHC to program amount is due, show the amount and
date on which the FQHC agrees to the amount of repayment even though total repayment is not
accomplished until a later date.
Line 7.--Enter the sum of the amounts on lines 4, 5.99, and 6 in column 2. Enter amounts due the
program as a negative number. The amount in column 2 must equal the amount on Worksheet E,
line 17.
Line 8.--Contractor approving official must verify the accuracy of this worksheet, sign and date.

44-40

Rev. 1

04-16
4416.

FORM CMS-224-14

4416

WORKSHEET F-1 - STATEMENT OF REVENUE AND EXPENSES

This worksheet is prepared from your accounting books and records. It requires the reporting of
total patient revenues (specifically including Medicare, Medicaid and other revenues) for the entire
FQHC and operating expenses for the entire FQHC. Additional worksheets may be submitted if
necessary.
Line 1.--Enter total patient revenue from your accounting books and/or records in columns 1
through 3, by program as indicated. Enter the sum of columns 1 through 3 in column 4.
Line 2.--Enter total patient revenues not received in column 2. This includes:
Provision for Bad Debts,
Contractual Adjustments,
Charity Discounts,
Teaching Allowances,
Policy Discounts,
Administrative Adjustments, and
Other Deductions from Revenue
Line 3.--Enter in column 2, the sum of line 1, column 4 minus line 2, column 2.
Line 4.--Enter in column 2, total operating expenses from Worksheet A, column 3, line 100.
Lines 5 through 9.--Enter any additions to operating expenses in column 1.
Line 10.--Enter in column 2, the sum of lines 5 through 9, column 1.
Lines 11 through 15.--Enter any subtractions to operating expenses in column 1.
Line 16.--Enter in column 2, the sum of lines 11 through 15, column 1.
Line 17.--Enter in column 2, the sum of line 4, column 2, plus line 10, column 2, minus line 16,
column 2.
Line 18.--Enter in column 2, the sum of line 3, column 2, minus line 17, column 2.
Lines 19 through 31.--Enter all other income as specified in column 1.
Line 32.--Enter in column 2, the sum of the amounts on lines 19 through 31, column 1.
Line 33.--Enter in column 2, the sum of line 18, column 2, plus line 32, column 2.

Rev. 1

44-41

4416 (Cont.)

FORM CMS-224-14

04-16

This page is reserved for future use.

44-42

Rev. 1

04-16

FORM CMS-224-14

4490

Form CMS-224-14 Worksheets
The following is a listing of the Form CMS-224-14 worksheets and the page number location.
Changes to worksheets are indicated by redline on this and the subsequent page for this transmittal.
Where only the page number changes, no redlining is indicated.
Worksheets

Page(s)

Wkst. S, Parts I, II & III
Wkst. S-1, Part I
Wkst. S-1, Part II
Wkst. S-2
Wkst. S-3, Part I
Wkst. S-3, Part II & III
Wkst. A
Wkst. A-1
Wkst. A-2
Wkst. A-2-1, Parts I & II
Wkst. B, Parts I & II
Wkst. B-1
Wkst. E
Wkst. E-1
Wkst. F-1

44-103
44-104
44-105
44-106
44-107
44-108
44-109 - 44-110
44-111
44-112
44-113
44-114
44-115
44-116
44-117
44-118

Rev. 1

44-101

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FORM CMS-224-14

04-16

This page is reserved for future use.

44-102

Rev. 1

03-18

FORM CMS-224-14

4495

EXHIBIT 2-ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE OF CONTENTS
Topic

Page(s)

Table 1:

Record Specifications

44-202 - 44-208

Table 2:

Worksheet Indicators

44-209 - 44-210

Table 3:

List of Data Elements With Worksheet, Line, and Column
Designations

44-211 - 44-225

Table 3A:

Worksheets Requiring No Input

44-227

Table 3B:

Table for Worksheet S-1

44-227

Table 3C:

Lines That Cannot Be Subscripted

44-228

Table 4:

Reserved for future use

Table 5:

Cost Center Coding

Table 6:

Edits:

Rev. 2

44-229 - 44-232

Level I Edits

44-233 - 44-240

Level II Edits

44-241 - 44-242

44-201

4495 (Cont.)

FORM CMS-224-14

03-18

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 1 - RECORD SPECIFICATIONS
Table 1 specifies the standard record format required for the four types of records in an electronic cost
reporting (ECR) file. Type 1 records contain information for identifying the provider, for processing the
cost report, and for vendor validation. Type 2 records contain the line and column labels. Type 3 records
contain data necessary to calculate the Federally Qualified Health Center (FQHC) cost report. Table 3
provides specifications for the layout of type 3 records. Type 4 records contain the ECR file encryption
coding, records 1, 1.01, and 1.02.
The medium for transferring ECR files to contractors is CD, flash drive, or the CMS-approved Medicare
Cost Report E-filing (MCREF) portal. [URL: https://mcref.cms.gov]. ECR files must comply with CMS
specifications. Providers must seek approval from their contractor regarding the method of submission to
ensure that the method of transmission is acceptable.
The following are requirements for all records:
1.
2.
3.

All alpha characters must be in upper case.
For micro systems, the end of record indicator must be a carriage return and line feed, in that
sequence.
No record may exceed 60 characters.

Below is an example of a set of type 1 records with a narrative description of their meaning.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
1
1
213975201427420152739A99P00120153202014274
1
4
14:30
Record #1:

This is a cost report file submitted by CCN 213975 for the period from October 1, 2014
(2014274) through September 30, 2015 (2015273). It is filed on Form CMS-224-14. It is
prepared with vendor number A99's PC based system, version number 1. Position 38
changes with each new test case and/or re-approval and is an alpha character. Positions 39
and 40 remain constant for approvals issued after the first test case. This file is prepared
by the FQHC on November 16, 2015 (2015320). The electronic cost report specifications,
dated October 1, 2014 (2014274), were used to prepare this file.
FILE NAMING CONVENTION

Name each cost report ECR file in the following manner:
FQNNNNNN.YYLC, where
1. FQ (FQHC Cost Report) is constant;
2. NNNNNN is the 6 digit CMS Certification Number;
3. YY is the year in which the provider's cost reporting period ends; and
4. L is a character variable (A-Z) to enable separate identification of files from FQHCs with two or
more cost reporting periods ending in the same calendar year.
5. C is the number of times this original cost report is being filed
Name each cost report PI file in the following manner:
PINNNNNN.YYLC, where
1. PI (Print Image) is constant;
2. NNNNNN is the 6 digit CMS Certification Number;
3. YY is the year in which the provider's cost reporting period ends; and
4. L is a character variable (A-Z) to enable separate identification of files from FQHCs with two or
more cost reporting periods ending in the same calendar year.
5. C is the number of times this original cost report is being filed

44-202

Rev. 2

03-18

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 1 Records - Record Number 1
Size

Usage

Loc.

Remarks

1.

Record Type

1

X

1

Constant "1"

2.

For Future Use

10

9

2-11

Alpha numeric

3.

Space

1

X

12

4.

Record Number

1

X

13

5.

Spaces

3

X

14-16

6.

FQHC CCN Number

6

9

17-22

Field must have 6 numeric characters.

7.

Fiscal Year
Beginning Date

7

9

23-29

YYYYDDD - Julian date; first day
covered by this cost report

8.

Fiscal Year
Ending Date

7

9

30-36

YYYYDDD - Julian date; last day
covered by this cost report

9.

MCR Version

1

9

37

Constant "9" (for Form CMS-224-14)

10.

Vendor Code

3

X

38-40

To be supplied upon approval. Refer to
page 44-202.

11.

Vendor Equipment

1

X

41

P = PC; M = Main Frame

12.

Version Number

3

X

42-44

Version of extract software, e.g., 001=1st,
002=2nd, etc. or 101=1st, 102=2nd. The
version number must be incremented by 1
with each recompile and release to
client(s).

13.

Creation Date

7

9

45-51

YYYYDDD - Julian date; date on which
the file was created (extracted from the
cost report)

14.

ECR Spec. Date

7

9

52-58

YYYYDDD - Julian date; date of
electronic cost report specifications used
in producing each file. Valid for cost
reporting periods ending on or after
2017365 (12/31/2017). Prior approvals
2014274 for cost reports beginning on

Constant "1"

or after October 1, 2014

Rev. 2

44-203

4495 (Cont.)

FORM CMS-224-14

03-18

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 1 Records - Record Numbers 2 - 99
Size

Usage

Loc.

Remarks

1.

Record Type

1

9

1

Constant "1"

2.
3.

Spaces

10

X

2-11

#2 - Reserved for future use.

Record Number

2

9

12 - 13

#3 - Vendor information; optional record
for use by vendors. Left justified in
positions 21 through 60.
#4 - The time that the cost report is
created. This is represented in military
time as alpha numeric. Use positions 21
through 25. Example: 2:30PM is
expressed as 14:30.
#5 to #99 - Reserved for future use.

4.

Spaces

7

X

14-20

Spaces (Optional)

5.

ID Information

40

X

21-60

Left justified to position 21.

RECORD NAME: Type 2 Records for Labels
Size

Usage

Loc.

Remarks

1.

Record Type

1

9

1

Constant "2"

2.

Worksheet Indicator

7

X

2-8

Alphanumeric. Refer to Table 2.

3.

Spaces

2

X

9-10

4.

Line Number

3

9

11-13

Numeric

5.

Subline Number

2

9

14-15

Numeric

6.

Column Number

3

X

16-18

Alphanumeric

7.

Sub column Number

2

9

19-20

Numeric

8.

Cost Center Code

4

9

21-24

Numeric. Refer to Table 5 for
appropriate cost center codes.

9.

Labels/Headings
a. Line Labels

36

X

25-60

Alphanumeric, left justified

b. Column Headings
Statistical Basis &
Code

10

X

21-30

Alphanumeric, left justified

The type 2 records contain text which appears on the printed cost report. Of these, there are three groups:
(1) Worksheet A cost center names (labels); (2) column headings for step down entries; and (3) other text
appearing in various places throughout the cost report. The standard cost center labels/descriptions are
listed below.
A Worksheet A cost center label must be furnished for every cost center with cost or charge data anywhere
in the cost report. The line and subline numbers for each label must be the same as the line and subline
numbers of the corresponding cost center on Worksheet A. The columns and subcolumn numbers are
always set to zero.

44-204

Rev. 2

04-16

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 1 - RECORD SPECIFICATIONS
Use the following type 2 cost center descriptions for Worksheet A standard cost center lines.
Line

Description

1
2
3
4
5
6
7
9
10
11
23
24
25
26
27
28
29
30
31
32
33
34
35
36
47
48
49
60
61
62
63
64
65
66
67
68
77
78

CAP REL COSTS-BLDG & FIX
CAP REL COSTS-MVBLE EQUIP
EMPLOYEE BENEFITS
ADMINISTRATIVE & GENERAL SERVICES
PLANT OPERATION & MAINTENANCE
JANITORIAL
MEDICAL RECORDS
PHARMACY
MEDICAL SUPPLIES
TRANSPORTATION
PHYSICIAN
PHYSICIAN SERVICES UNDER AGREEMENT
PHYSICIAN ASSISTANT
NURSE PRACTITIONER
VISITING REGISTERED NURSE
VISITING LICENSED PRACTICAL NURSE
CERTIFIED NURSE MIDWIFE
CLINICAL PSYCHOLOGIST
CLINICAL SOCIAL WORKER
LABORATORY TECHNICIAN
REG DIETICIAN/CERT DSMT/MNT EDUCATOR
PHYSICAL THERAPIST
OCCUPATIONAL THERAPIST
OTHER ALLIED HEALTH PERSONNEL
ALLOWABLE GME COSTS
PNEUMOCOCCAL VACCINES & MED SUPPLIES
INFLUENZA VACCINES & MED SUPPLIES
MEDICARE EXCLUDED SERVICES
DIAGNOSTIC & SCREENING LAB TESTS
RADIOLOGY - DIAGNOSTIC
PROSTHETIC DEVICES
DURABLE MEDICAL EQUIPMENT
AMBULANCE SERVICES
TELEHEALTH
DRUGS CHARGED TO PATIENTS
CHRONIC CARE MANAGEMENT
RETAIL PHARMACY
NONALLOWABLE GME COSTS

Rev. 1

44-205

4495 (Cont.)

FORM CMS-224-14

04-16

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 1 - RECORD SPECIFICATIONS
Examples of type 2 records are below. Either zeros or spaces may be used in the line, subline, column, and
subcolumn number fields (positions 11 through 20). Spaces are preferred. (See first two lines of the
example.)* Refer to Table 5 and 6 for additional cost center code requirements.
Examples:
Worksheet A line labels with embedded cost center codes:
* 2A000000
1
0100CAP REL COSTS-BLDG & FIX
* 2A0000000000200000000200CAP REL COSTS-MVBLE EQUIP
2A000000
4
0400ADMINISTRATIVE & GENERAL
2A000000
10
1000MEDICAL SUPPLIES
2A000000
11
1100TRANSPORTATION
2A000000
26
2600NURSE PRACTITIONER
2A000000
63
6300PROSTHETIC DEVICES

44-206

Rev. 1

04-16

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 3 Records for Non-label Data
Size

Usage

Loc.

Remarks

1.

Record Type

1

9

1

2.

Worksheet Indicator

7

X

2-8

3.

Spaces

2

X

9-10

4.

Line Number

3

9

11-13

Numeric

5.

Subline Number

2

9

14-15

Numeric

6.

Column Number

3

X

16-18

Alphanumeric

7.

Sub column Number

2

9

19-20

Numeric

8.

Field Data
a) Alpha Data

36

X

21-56

Left justified. (Y or N for yes/no answers;
dates must use mm/dd/yyyy format slashes, no hyphens.) Refer to Table 6 for
additional requirements for alpha data.

Spaces

4

X

57-60

Spaces (optional).

16

9

21-36

Right justified. May contain embedded
decimal point. Leading zeroes are
suppressed; trailing zeroes to the right of
the decimal point are not. (See example
below.) Positive values are presumed; no
“+” signs are allowed. Use leading minus
to specify negative values unless the field
is defined as negative on the form.
Express percentages as decimal
equivalents, i.e., 8.75% is expressed as
.087500. All records with zero values are
dropped. Refer to Table 6 for additional
requirements regarding numeric data.

b) Numeric Data

Constant "3"
Alphanumeric. Refer to Table 2.

A sample of type 3 records and a number line for reference are below.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
3A000000
4
1
120502
3A000000
11
1
46347
3A000000
28
2
469
3A000000
62
2
8547

Rev. 1

44-207

4495 (Cont.)

FORM CMS-224-14

04-16

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 1 - RECORD SPECIFICATIONS
The line numbers are numeric. In several places throughout the cost report (see list below), the line numbers
themselves are data. The placement of the line and sub line numbers as data must be uniform.
Worksheet A-1, columns 3 and 6
Worksheet A-2, column 4
Worksheet A-2-1, Part I, column 1
Examples of records (*) with a Worksheet A line number as data and a number line for reference are listed
below. Example of grand total record for Worksheet A-1(**).
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890

*
*

**
**

3A1000C0
3A1000C0
3A1000C0
3A1000C0
3A1000C0
3A1000C0
3A1000C0
3A1000C0
3A100000
3A100000

3
3
3
3
3
3
100
100
100
100

0
1
3
4
6
7
4
7
4
7

RADIOLOGY EXPENSE
C
62.00
41857
32.00
41857
41857
41857
60000
60000

RECORD NAME: TYPE “3” RECORDS
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
3A200000
3A200000
* 3A200000
* 3A210001
3A210001
3A210001
3A210001

9
9
9
1
1
1
1

1
2
4

B
-125
4.00

1
3
4
5

6.00
CLEANING SERVICES
7500
6000

RECORD NAME: TYPE 4 RECORDS
File Encryption and Date and Time Stamp
This type 4 record consists of 3 records: 1, 1.01, and 1.02. These records are created at the point in time in
which the ECR file is created and saved to an electronic medium to ensure the integrity of the file.

44-208

Rev. 1

04-16

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 2 - WORKSHEET INDICATORS
This table contains the worksheet indicators that are used for electronic cost reporting. A worksheet
indicator is provided for only those worksheets for which data are to be provided.
The worksheet indicator consists of seven digits in positions 2 through 8 of the record identifier. The first
two characters of the worksheet indicator (positions 2 and 3 of the record identifier) always show the
worksheet. The third character of the worksheet indicator (position 4 of the record identifier) is used as
part of the worksheet, e.g., A-2-1. The fourth character of the worksheet indicator (position 5 of the record
identifier) is not used. Except for Worksheet A-1 (to handle the reclassification code), the fifth and sixth
characters of the worksheet indicator (positions 6 and 7 of the record identifier) identify worksheets required
by a Federal program (18 = title XVIII, 05 = title V, or 19 = title XIX) or worksheets required for the facility
(00 = Universal). The seventh character of the worksheet indicator (position 8 of the record identifier)
represents the worksheet part.
Worksheets That Apply to the Federally Qualified Health Center Cost Report

Rev. 1

Worksheet

Worksheet
Indicator

S, Part I

S000001

S, Part III

S000003

S-1, Part I

S100001

S-1, Part II

S100012 (c)

S-2

S200000

S-3, Part I

S300001

S-3, Parts II and III

S300002 (a)

A

A000000

A-1

A100?A0 (b)

A-2

A200000

A-2-1, Parts I and II

A210000 (a)

B, Parts I and II

B000000 (a)

B-1

B100000

E

E000000

E-1

E100000

F-1

F100000

44-209

4495 (Cont.)

FORM CMS-224-14

04-16

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 2 - WORKSHEET INDICATORS

FOOTNOTES:
(a) Worksheets With Multiple Parts Using Identical Worksheet Indicator
While this worksheet has several parts, the lines are numbered sequentially. This worksheet
identifier is used with all lines from this worksheet regardless of the worksheet part. This
differs from the Table 3 presentation which still identifies each worksheet and part as they
appear on the printed cost report. This affects Worksheets S-3, Part II & III; A-2-1; and B.
(b) Worksheet A-1
For Worksheet A-1, include in the worksheet identifier the reclassification code as the 5th and
6th digits (6th and 7th of the record). For example, 3A1000A0 or 3A1000B0, 3A1000C0,
3A100AA0, 3A100AB0, or 3A100ZZ0. Additionally, for Worksheet A-1 include in the
worksheet identifier “00” in the 5th and 6th digits (6th and 7th of the record) (3A100000) to
identify grand total reclassification increases and grand total reclassification decreases.
(c) Worksheets S-1, Part II for Consolidated Cost Reports
For Worksheet S-1, Part II, the fifth and sixth digits of the worksheet indicator (positions 6 and
7 of the record) are numeric from 01-99 to accommodate cost reports with one or more
consolidated FQHCs. The number for each additional page of the worksheet is incremented
by 1.

44-210

Rev. 1

04-16

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
INTRODUCTION
This table identifies those data elements necessary to calculate an FQHC cost report. It also
identifies some figures from a completed cost report. These calculated fields (e.g., Worksheet B,
Part I, column 5) are needed to verify the mathematical accuracy of the raw data elements and to
isolate differences between the file submitted by the FQHC and the report produced by the
contractor. Where an adjustment is made, that record must be present in the electronic data file.
For explanations of the adjustment(s) required, refer to the cost report instructions
Table 3 “Usage” column is used to specify the format of each data item as follows:
9
Numeric, greater than or equal to zero.
-9
Numeric, may be either greater than, less than, or equal to zero.
9(x).9(y) Numeric, greater than zero, with x or fewer significant digits to the left of the
decimal point, a decimal point, and exactly y digits to the right of the decimal point.
X
Character.
Consistency in line numbering (and column numbering for general service cost centers) for each
cost center is essential. The sequence of some cost centers does change among worksheets.
Table 3 refers to the data elements needed from a standard cost report. When a standard line is
subscripted, the subscripted lines must be numbered sequentially with the first subline number
displayed as “01” or “1” (with a space preceding the 1) in field locations 14 and 15. It is
unacceptable to format in a series of 10, 20, or to skip sub line numbers (i.e., 01, 03, except for
skipping subline numbers for prior year cost center(s) deleted in the current period or initially
created cost center(s) no longer in existence after cost finding). Exceptions are specified in this
manual. For “Other (specify)” lines, i.e. any other nonstandard cost center lines, all subscripted
lines should be in sequence and consecutively numbered beginning with subscripted line number
“01”. Automated systems should reorder these numbers where provider skips or deletes a line
number in the series.
Drop all records with zero values from the file. Any record absent from a file is treated as if it
were zero.
All numeric values are presumed positive. Leading minus signs may only appear in data with
values less than zero that are specified in Table 3 with a usage of “-9”. Amounts that are within
preprinted parentheses on the worksheets, indicating the reduction of another number, are reported
as positive values.

Rev. 1

44-211

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FORM CMS-224-14

04-16

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description

Line(s)

Column(s)

Field
Size

1
2
3

1
1
1

1
1
1

X
X
9

4

1

1

X

5

1

1

X

6
7
8
9
10

2
2
2
2
3

10
5
1
1
10

X
X
X
X
X

11
12

3
3

1
1

X
9

1

1

11

-9

Usage

WORKSHEET S
Part I: Cost Report Status
Provider Use Only
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.
Contractor Use Only
Cost Report Status
Enter the cost report status code: 1 for as submitted, 2 for
settled without audit, 3 settled with audit, 4 reopened, or
5 amended.
Date received (mm/dd/yyyy)
Contractor Number
Initial report for this Provider CCN
Final report for this Provider CCN
Notice of Program Reimbursement (NPR) date
(mm/dd/yyyy)
Enter contractor’s vendor code (ADR)
If line 5, column 1 is 4: enter the number of times
reopened = 0-9
Part III: Settlement Summary
Balances due provider or program:
title XVIII

44-212

Rev. 1

03-18

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Usage

1
1
1
1
1
2
2
3
3
3
3
3
4
4
5

1
2
3
4
5
1
2
1
2
3
4
5
1
2
1

36
6
5
10
2
36
9
36
2
10
36
1
10
10
1

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

6
7
7
7
8
8
8
9

1
1
2
3
1
2
3
1

36
36
9
20
36
2
10
1

X
X
X
X
X
X
X
X

10
11
11
11
12
12
12

1
1
2
3
1
2
3

36
36
9
6
36
2
10

X
X
X
X
X
X
X

Line(s)
WORKSHEET S-1, PART I

Part I: Federally Qualified Health Center Identification Data
Site Name
Provider CCN (xxxxxx)
CBSA number (xxxxx)
Date Certified (mm/dd/yyyy)
Type of control (see Table 3B)
Street
P.O. Box
City
State
Zip Code
County
Designation (R for Rural or U for Urban)
Cost reporting period beginning date (mm/dd/yyyy)
Cost reporting period ending date (mm/dd/yyyy)
Is this FQHC part of an entity that owns, leases or
controls multiple FQHCs? (Y/N) If yes, enter the
entity’s information below.
Name of Entity
Street
P.O. Box
HRSA Award Number
City
State
Zip Code
Is this FQHC 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? (Y/N) If yes,
enter the chain organization’s information below.
Name of Chain Organization
Street
P.O. Box
Home Office CCN
City
State
Zip Code

Rev. 2

Column(s)

Field
Size

44-213

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FORM CMS-224-14

03-18

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 – LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Usage

13

1

1

X

13
13
13
14.01-14.99
14.01-14.99
14.01-14.99
14.01-14.99
14.01-14.99

2
3
4
1
2
3
4
5

10
10
2
36
6
5
10
10

X
X
9
X
X
X
X
X

15

1

1

X

15

2

4

X

16

1

1

X

17

1

1

X

17

2

10

X

17

3

20

X

18

1

1

X

18

2

10

X

19

1

1

X

20

1

1

X

21

1-3

11

9

Line(s)
WORKSHEET S-1, PART I (Cont.)

Consolidated Cost Report
Is this FQHC filing a consolidated cost report per CMS
Pub. 100-02, chapter 13, §80.2? (Y/N) (see
instructions) If yes, complete line 14, beginning with
line 14.01. If no, leave line 14 blank.
Date Requested (mm/dd/yyyy)
Date Approved (mm/dd/yyyy)
Number of FQHCs
Site Name
FQHC CCN (xxxxxx)
CBSA number (xxxxx)
Date Requested (mm/dd/yyyy)
Date Approved (mm/dd/yyyy)
FQHC Operations
What type of organization is this FQHC? Enter “1”, “2”,
or “3” (see instructions)
If column 1 is “1” or “3”, enter any or all of the applicable
alpha characters in column 2. (see instructions)
Did this FQHC receive a grant under §330 of the PHS Act
during this cost reporting period? If this is a
consolidated cost report, did the FQHC reported on line
1, column 2 receive a grant under §330 of the PHS Act
during this cost reporting period? (Y/N)
If line 16 is “Y” enter the type of HRSA grant that was
awarded in column 1. (see Table 3B) (see instructions)
If line 16 is “Y” enter the date of the grant award in
column 2. (mm/dd/yyyy)
If line 16 is “Y” enter the grant award number in column
3.
Medical Malpractice
Did this FQHC submit an initial deeming or annual
redeeming application for medical malpractice coverage
under the FTCA with HRSA? (Y/N)
If column 1 is “Y” enter the effective date of coverage in
column 2. (mm/dd/yyyy)
Does this FQHC carry commercial malpractice insurance?
(Y/N)
Is the malpractice insurance a claims-made or occurrence
policy? Enter “1” for claims-made or “2” for
occurrence policy.
List malpractice premiums in column1, paid losses in
column 2 and self-insurance in column 3.

44-214

Column(s)

Field
Size

Rev. 2

03-18

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Usage

22

1

1

X

23

1

1

X

24

1

1

X

25

1

1

X

25

2

9

9(3).99

25

3

11

9

26

1

1

X

26

2

9

9(3).99

26

3

11

9

27

1

1

X

27

2

11

9

28

1

1

X

Line(s)
WORKSHEET S-1, PART I (Cont.)

Are malpractice premiums, paid losses, or self-insurance
reported in a cost center other than the Administrative
and General cost center? (Y/N) If yes, submit supporting
schedule listing cost centers and amounts.
Interns and Residents
Is this FQHC involved in training residents in an approved
GME program in accordance with 42 CFR 405.2468(f)?
(Y/N)
Is this FQHC involved in training residents in an
unapproved GME program? (Y/N)
Did this FQHC receive a Primary Care Residency
Expansion (PCRE) grant authorized under Part C of title
VII of the PHS Act from HRSA? (Y/N)
If yes, enter in column 2 the number of primary care FTE
residents that your FQHC trained in this cost reporting
period for which your FQHC received PCRE funding.
(see instructions)
If yes, enter in column 3 the number of visits performed by
such residents during this cost reporting period.
Did this FQHC receive a Teaching Health Center
development grant authorized under Part C of title VII of
the PHS Act from HRSA? (Y/N)
If yes, enter in column 2 the number of FTE residents that
your FQHC trained and received funding through your
THC grant in this cost reporting period. (see instructions)
If yes, enter in column 3 the number of visits performed by
such residents during this cost reporting period.
Capital Related Costs - Ownership/Lease of Building
Do you own or lease the building or office space occupied
by your FQHC or, is the building or office space
provided at no cost to the FQHC? Enter “1” for
owned, “2” for leased or “3” for provided at no cost in
column 1.
If you enter “2” in column 1, enter the amount of rent/lease
expense in column 2.
Contract Labor
Do you use contract labor to provide medical and/or mental
health services to your patients? (Y/N)

Rev. 2

Column(s)

Field
Size

44-215

4495 (Cont.)

FORM CMS-224-14

03-18

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Line(s)
WORKSHEET S-1, PART II

Column(s)

Field
Size

Usage

Part II: Federally Qualified Health Center Consolidated Cost Report Participant Identification Data
Site Name
1
1
36
Date Certified (mm/dd/yyyy)
1
2
10
Type of control (see Table 3B)
1
3
2
Date Decertified (mm/dd/yyyy)
1
4
10
Enter “V” for a voluntary termination or an “I” for an
1
5
1
involuntary termination
Enter date of the change of ownership (mm/dd/yyyy)
1
6
10
(see instructions)
Street
2
1
36
P.O. Box
2
2
9
City
3
1
36
State
3
2
2
Zip Code
3
3
10
County
3
4
36
Designation (“R” for Rural or “U” for Urban)
3
5
1
FQHC Operations
What type of organization is this FQHC? Enter “1”, “2”, or
“3”. (see instructions)
If column 1 is “1” or “3”, enter any or all of the applicable
alpha characters in column 2. (see instructions)
Did this FQHC receive a grant under §330 of the PHS Act
during this cost reporting period? (Y/N)
If line 5 is “Y” enter the type of HRSA grant that was
awarded in column 1. (see Table 3B) (see instructions)
If line 5 is “Y” enter the date of the grant award in
column 2. (mm/dd/yyyy)
If line 5 is “Y” enter the grant award number in column 3.
Medical Malpractice
Did this FQHC submit an initial deeming or annual
redeeming application for medical malpractice coverage
under the FTCA with HRSA? (Y/N)
If column 1 is “Y” enter the effective date of coverage in
column 2. (mm/dd/yyyy)

44-216

X
X
X
X
X
X
X
X
X
X
X
X
X

4

1

1

X

4

2

4

X

5

1

1

X

6

1

1

X

6

2

10

X

6

3

20

X

7

1

1

X

7

2

10

X

Rev. 2

03-18

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Line(s)
Column(s)
WORKSHEET S-1, PART II (Cont.)

Does this FQHC carry commercial malpractice insurance?
(Y/N)
Is the malpractice insurance a claims-made or occurrence
policy? Enter “1” for claims-made or “2” for occurrence
policy.
List malpractice premiums in column1, paid losses in
column 2 and self-insurance in column 3.
Interns and Residents
Is this FQHC involved in training residents in an approved
GME program in accordance with 42 CFR 405.2468(f)?
(Y/N)
Is this FQHC involved in training residents in an
unapproved GME program? (Y/N)
Did this FQHC receive a Primary Care Residency
Expansion (PCRE) grant authorized under Part C of title
VII of the PHS Act from HRSA? (Y/N)
If yes, enter in column 2 the number of primary care FTE
residents that your FQHC trained in this cost reporting
period for which your FQHC received PCRE funding.
(see instructions)
If yes, enter in column 3 the number of visits performed by
such residents during this cost reporting period.
Did this FQHC receive a Teaching Health Center
development grant authorized under Part C of title VII of
the PHS Act from HRSA? (Y/N)
If yes, enter in column 2 the number of FTE residents that
your FQHC trained and received funding through your
THC grant in this cost reporting period. (see instructions)
If yes, enter in column 3 the number of visits performed by
such residents during this cost reporting period.
Capital Related Costs - Ownership/Lease of Building
Do you own or lease the building or office space occupied
by your FQHC or, is the building or office space
provided at no cost to the FQHC? Enter “1” for
owned, “2” for leased, or “3” for provided at no cost in
column 1.
If you enter “2” in column 1, enter the amount of rent/lease
expense in column 2.
Contract Labor
Do you use contract labor to provide medical and/or mental
health services to your patients? (Y/N)

Rev. 2

Field
Size

Usage

8

1

1

X

9

1

1

X

10

1-3

11

9

11

1

1

X

12

1

1

X

13

1

1

X

13

2

9

9(3).99

13

3

11

9

14

1

1

X

14

2

9

9(3).99

14

3

11

9

15

1

1

X

15

2

11

9

16

1

1

X

44-217

4495 (Cont.)

FORM CMS-224-14

03-18

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Usage

1

1

1

X

1

2

10

X

2

1

1

X

2

2

10

X

2

3

1

X

3

1

1

X

4

1

1

X

4

2

1

X

4

3

10

X

4

4

1

X

5

1

1

X

6

1

1

X

7

1

1

X

8
9

1
1

1
1

X
X

10

1

1

X

Line(s)
WORKSHEET S-2

Provider Organization and Operation
Has the FQHC changed ownership immediately prior to the
beginning of the cost reporting period? (Y/N) (see
instructions)
If yes, enter the date of the change in column 2.
(mm/dd/yyyy)
Has the FQHC terminated participation in the Medicare
program? (Y/N)
If yes, enter in column 2 the termination date.
(mm/dd/yyyy)
If yes, enter in column 3 “V” for voluntary or “I” for
involuntary.
Is the FQHC involved in business transactions, including
management contracts, with individuals or entities 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? (Y/N) (see instructions)
Financial Data Reports
Were the financial statements prepared by a certified public
accountant? (Y/N)
If yes, enter in column 2 “A” for audited, “C” for compiled
or “R” for reviewed.
Submit a complete copy of financial statements or enter
date available in column 3. (mm/dd/yyyy)
Are the cost report total expenses and total revenues
different from those on the filed financial statements?
(Y/N)
Approved Educational Activities
Are costs for Intern-Resident programs claimed on the
current cost report? (Y/N)
Was an Intern-Resident program initiated or renewed in the
current cost reporting period? (Y/N) If yes, see
instructions
Are GME costs directly assigned to cost centers other than
Allowable GME Costs on Worksheet A? If yes, see
instructions
Bad Debts
Is the FQHC seeking reimbursement for bad debts? (Y/N)
If line 8 is yes, did the FQHC’s bad debt collection policy
change during the cost reporting period? (Y/N)
If line 8 is yes, were patient coinsurance amounts waived?
(Y/N)

44-218

Column(s)

Field
Size

Rev. 2

03-18

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Usage

11

1

1

X

11

2

10

X

12

1

1

X

12

2

10

X

13

1

1

X

14

1

1

X

15

1

1

X

15
16

0
1

36
1

X
X

17
17
17
18
19
19

1
2
3
1
1
2

36
36
36
36
36
36

X
X
X
X
X
X

Line(s)
WORKSHEET S-2 (Cont.)

PS&R Report Data
Was the cost report prepared using the PS&R Report only?
(Y/N)
If yes, enter in column 2 the paid-through date of the PS&R
Report used to prepare the cost report. (mm/dd/yyyy)
Was the cost report prepared using the PS&R Report for
totals and the FQHC’s records for allocation? (Y/N)
If yes, enter in column 2 the paid-through date of the PS&R
Report. (mm/dd/yyyy)
If line 11 or 12 is yes, were adjustments made to the 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? (Y/N). If yes, see instructions.
If line 11 or 12 is yes, were adjustments made to the PS&R
Report data for corrections of other PS&R Report
information? (Y/N) If yes, see instructions.
If line 11 or 12 is yes, were adjustments made to the PS&R
Report data for Other? (Y/N)
If yes, describe the other adjustments.
Was the cost report prepared using only the FQHC’s
records? (Y/N) If yes, see instructions.
Cost Report Preparer Contact Information
Enter the preparer’s information:
First Name
Last Name
Title
Employer
Telephone Number
Email Address

Rev. 2

Column(s)

Field
Size

44-219

4495 (Cont.)

FORM CMS-224-14

03-18

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Column(s)

Field
Size

Usage

1, 3, 5

0

6

X

1, 3, 5

1

11

9

1, 3, 5

2

11

9

1, 3, 5

3

11

9

1, 3, 5

4

11

9

1
2
1
2

11
11
11
11

-9
-9
-9
-9

16

0

6

99.99

16-29
16-29
16-29

1
2
3

6
6
6

9(3).99
9(3).99
9(3).99

Line(s)
WORKSHEET S-3, PART I

Part I: Federally Qualified Health Center Statistical Data
Use this column only when filing a consolidated cost report
to identify each FQHC listed on Worksheet S-1, Part I,
line 14 and subscripts in the exact same order.
Title V: enter the number of medical visits, mental health
visits, and visits performed by interns/residents.
Title XVIII: enter the number of medical visits, mental
health visits, and visits performed by interns/residents.
Title XIX: enter the number of medical visits, mental health
visits, and visits performed by interns/residents.
Enter the number of medical visits, mental health visits,
and visits performed by interns/residents for all other
patients.

WORKSHEET S-3, PART II and III
Part II: Federally Qualified Health Center Contract Labor and Benefit Cost
Contract Labor Cost:
Total facility’s contract labor
1
Total facility’s benefit cost
1
Personnel specific contract labor cost
2-15
Personnel specific benefit cost
2-15
Part III: Federally Qualified Health Center Employee Data
Number of hours in a normal work week
Number of full-time equivalent employees:
Staff
Contract
Total

44-220

Rev. 2

04-16

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Salaries
Other Costs
Net Expense for Allocation
Total

Column(s)

Field
Size

Usage

1

11

-9

2

11

-9

7

11

-9

1, 2, 7

11

9

1-99
1-99

0
1

36
2

X
X

1-99
1-99

3
4

6
11

99.99
9

1-99
1-99
100#
100#
100#

6
7
4&7
4
7

6
11
11
11
11

99.99
9
9
9
9

0
1
2
4
2

36
1
11
6
11

X
X
-9
99.99
-9

Line(s)
WORKSHEET A
3-7, 9-12, 23-36,
47-49, 60-69, 77-79
1-7, 9-12, 23-36,
47-49, 60-69, 77-79
1-7, 9-12, 23-36,
47-49, 60-69, 77-79
100
WORKSHEET A-1

For each expense reclassification:
Explanation
Code
Increases:
Worksheet A line number
Reclassification amount
Decreases:
Worksheet A line number
Reclassification amount
Total
Total Reclassification Increases
Total Reclassification Decreases

WORKSHEET A-2
Description of adjustment
Basis (A or B)*
Amount*
Worksheet A line number +
Total

14-49
1-6, 8-49
1-6, 8-49
3-6, 8-10, 14-49
50

* These include subscripts of lines 14 through 49, requiring records for columns 1 and 2.
+ Do not include preprinted lines 1, 2, 11, 12, & 13. Include only subscripts of those lines, if activated by
an entry in either of columns 1 or 2.
#
See footnote “b” in “Table 2 - Worksheet Indicators” for appropriate worksheet indicators.

Rev. 1

44-221

4495 (Cont.)

FORM CMS-224-14

04-16

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Line(s)
WORKSHEET A-2-1

Column(s)

Field
Size

Usage

Part I - Costs incurred and adjustments required as a result of transactions with related organizations or
claimed home office costs
Worksheet A line number
1-4
1
6
99.99
Expense item(s)
1-4
3
36
X
Amount allowable in cost
1-4
4
11
-9
Amount included in Worksheet A
1-4
5
11
-9
Net Adjustment(s)
1-4
6
11
-9
Total
5
4-6
11
-9
Part II - Interrelationship to related organizations and/or home office
Type of interrelationship (A through G)
6-10
If type is G, description of relationship must be included.
6-10
Name of individual or partnership with interest in provider
6-10
and related organization
Percent of ownership in provider
6-10
Name of related organization
6-10
Percent of ownership of related organization
6-10
Type of business
6-10

1
0
2

1
36
36

X
X
X

3
4
5
6

6
36
6
36

9(3).99
X
9(3).99
X

2
7
8
9

11
11
11
11

9
9
9
9

10

11

9

WORKSHEET B
Part I - Calculation of Federally Qualified Health Center Cost Per Visit
Total medical and mental health visits by practitioner
1-10
Total medical visits by practitioner
1-10
Total mental health visits by practitioner
1-10
Total XVIII medical visits provided to beneficiaries by
1-10
practitioner
Total XVIII mental health visits provided to beneficiaries
1-10
by practitioner

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FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Description

Column(s)

Field
Size

Usage

2

1&2

8

9.9(6)

11

1&2

11

9

13

1&2

11

9

1

1

11

9

4
6
8
10
12

1
1
1
1
1

11
11
11
11
11

9
9
9
-9
-9

14
14
16
21

0
1
1
1

36
11
11
11

X
-9
9
-9

Line(s)
WORKSHEET B-1

Ratio of pneumococcal and vaccine staff time to total health
care staff time
Total number of pneumococcal and influenza vaccine
injections
Number of pneumococcal and influenza vaccine injections
administered to Medicare beneficiaries
WORKSHEET E
Enter total PPS payments paid for FQHC visits rendered
during the cost reporting period
Medicare advantage supplemental payments
Primary payer payments
Coinsurance billed to program beneficiaries
Allowable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see
instructions)
Other adjustments (specify) (see instructions)
Other adjustments (specify) (see instructions)
Sequestration adjustment (see instructions)
Protested amounts

Rev. 1

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FORM CMS-224-14

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ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Usage

1
2
3.01-3.98

2
2
1

11
11
10

9
9
X

3.01-3.49
3.50-3.98
5.01-5.98

2
2
1

11
11
10

9
9
X

5.01-5.49
5.50-5.98

2
2

11
11

9
9

Line(s)
WORKSHEET E-1

Total interim payments paid to FQHC
Interim payments payable
Date of each retroactive lump sum adjustment
(mm/dd/yyyy)
Amount of each retroactive lump sum adjustment:
Program to Provider
Provider to Program
Date of each tentative settlement payment (mm/dd/yyyy)
Amount of each tentative settlement payment:
Program to Provider
Provider to Program

44-224

Column(s)

Field
Size

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FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS

Description

Line(s)
WORKSHEET F-1

Column(s)

Field
Size

Usage

Gross patient revenue
Less: Allowances and discounts on patients’ accounts
Additions to operating expenses (specify)
Additions to operating expenses (specify)
Subtractions from operating expenses (specify)
Subtractions from operating expenses (specify)

1
2
5-9
5-9
11-15
11-15

1-3
2
0
1
0
1

11
11
36
11
36
11

9
9
X
9
X
9

Other income:
Contributions, donations, bequests, etc.
Income from investments
Purchase discounts
Rebates and refunds of expenses
Sale of medical and nursing supplies to other than patients
Sale of durable medical equipment to other than patients
Sale of drugs to other than patients
Sale of medical records and abstracts
Government appropriations
Other revenues (specify)
Other revenues (specify)

19
20
21
22
23
24
25
26
27
28-31
28-31

1
1
1
1
1
1
1
1
1
0
1

11
11
11
11
11
11
11
11
11
36
11

9
9
9
9
9
9
9
9
9
X
9

Rev. 1

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FORM CMS-224-14

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This page is reserved for future use.

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FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3A - WORKSHEETS REQUIRING NO INPUT
Worksheet B, Part II
TABLE 3B -TABLE TO WORKSHEET S-1, PARTS I AND II
TABLE I: Type of Control
1 = Voluntary, Nonprofit, Corporation
2 = Voluntary Nonprofit, Other
3 = Proprietary, Individual
4 = Proprietary, Corporation
5 = Proprietary, Partnership
6 = Proprietary, Other

7 = Governmental, Federal
8 = Governmental, State
9 = Governmental, County
10 = Governmental, City
11 = Governmental, Other

TABLE II: Types of organizations that can enroll in a FQHC
1) An organization receiving a grant(s) under §330 of the PHS Act :
A = Community Health Center (§330(e), PHS Act)
B = Migrant and Seasonal Agricultural Workers Health Center (§330(g), PHS Act)
C = Health Care for the Homeless Health Centers (§330(h), PHS Act)
D = Health Centers for Residents of Public Housing (§330(i), PHS Act)
2) Health Center Program Look-Alikes; Organizations that have been identified by HRSA
as meeting the definition of Health Center under §330 of the PHS Act, but not receiving grant
funding under §330
3) Outpatient health program/facility operated by:
A = A tribe or tribal organization under the Indian Self-Determination Act
B = An urban Indian organization under title V of the Indian Health Care Improvement Act
C = Other

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FORM CMS-224-14

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ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 3C - LINES THAT CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet S, Part I: ALL
Worksheet S, Part III: ALL
Worksheet S-1, Part I: lines 1-13, 15, 16, and 18-28
Worksheet S-1, Part II: lines 1-5 and 7-16
Worksheet S-2: ALL
Worksheet S-3, Part I: lines 2, 4, and 6
Worksheet S-3, Part II and III: ALL
Worksheet A: lines 1-11, 13, 23-37, 47-50, 60-68, 70, 77, 78, 80, and 100
Worksheet A-1: ALL
Worksheet A-2: lines 1-13, and 50
Worksheet A-2-1 Part I: lines 1-3, and 5
Worksheet A-2-1 Part II: lines 6-9
Worksheet B, Parts I and II: ALL
Worksheet B-1: ALL
Worksheet E: lines 1-13, and 15-21
Worksheet E-1: lines 1, 2, 4, 6, and 7
Worksheet F-1: lines 1-4, 10, 16-27, 32, and 33

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FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 5 - COST CENTER CODING
INSTRUCTIONS FOR PROGRAMMERS
Cost center coding is required because there are thousands of unique cost center names in use by providers.
Many of these names are exclusive to the reporting provider and give no hint as to the actual function being
reported. Using codes to standardize meanings makes practical data analysis possible. The method to
accomplish this must be rigidly controlled to assure accuracy.
For any added cost center names (the preprinted cost center labels must be precoded), the preparer must be
presented with the allowable choices for that line or range of lines from the lists of standard and nonstandard
descriptions. They will then select a description that best matches their added label. The code associated
with the matching description, including increments due to choosing the same description more than once,
will then be appended to the user’s label by the software.
Additional guidelines are:
•
•
•
•
•
•
•

•

Any pre-existing codes for the line must not be allowed to carry over.
All “Other . . .” lines must not be pre-coded.
The order of choice is standard first, followed by specific nonstandard, and lastly, the nonstandard
“Other . . .” cost centers.
When the nonstandard “Other . . .” is chosen, the preparer must be prompted with “Is this the
most appropriate choice?” and offered a chance to answer yes or to select another description.
The cost center coding process must be able to be edited for purposes of making corrections.
A separate list showing the preparer’s added cost center name on the left with the chosen standard
or nonstandard description and code on the right must be printed for review.
The number of times a description can be selected on a given report must be displayed on the
screen next to the description and this number must decrease with each usage to show the
remaining number available. The number of times a description can be selected is shown on the
standard and nonstandard cost center tables.
Standard cost center lines, descriptions, and codes are not to be changed. The acceptable format
for these are displayed in the STANDARD COST CENTER DESCRIPTIONS AND CODES
listed on page 44-231. The proper line number is the first two digits of the cost center code.
Change all “Other” nonstandard lines to the appropriate cost center name.

INSTRUCTIONS FOR PREPARERS
Coding of Cost Center Labels
Cost center coding is a methodology for standardizing the meaning of cost center labels as used by the
FQHC on the Medicare cost report. The use of this coding methodology allows the FQHC to use their
labels for cost centers that have meaning within the institution.
The four digit codes are required and must be associated with each cost center label/description. The codes
provide standardized meaning for data analysis. The preparer must code all added cost center
labels/descriptions. Standard cost center labels/descriptions are automatically coded by CMS approved
cost report software.
Additional cost center descriptions have been identified through analysis of provider labels. The meanings
of these additional descriptions were sufficiently different when compared to the standard labels to warrant
their use. These additional descriptions are hereafter referred to as the nonstandard labels. Included with
the nonstandard descriptions are “Other . . .” designations to provide for situations where no match in
meaning can be found. Refer to Worksheet A, lines 12, 69, and 79. Both the standard and nonstandard
cost center descriptions, along with their cost center codes, are shown on Table 5. The “USE” column on
that table indicates the number of times that a given code can be used on one cost report. Compare your
added cost center labels/descriptions to the standard and nonstandard table and select the appropriate cost
center code. CMS approved software provides an automated process for selecting an appropriate code to
properly match with your added cost center label/description.

Rev. 1

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FORM CMS-224-14

04-16

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 5 - COST CENTER CODING
Additional Guidelines
Categories
You must make your selection from the proper category such as general service description for general
service cost center lines, nonreimbursable descriptions for nonreimbursable cost center lines, etc.
Cost Center Coding and Line Restrictions
Cost center codes may only be used in designated lines in accordance with the classification of the cost
center(s), i.e., lines 1 through 12 may only contain cost center codes within the general service cost center
category of both standard and nonstandard coding. For example, in the general service cost center category
for “Other General Service (specify)” cost, line 12 and subscripts must contain cost center codes of 1200
through 1219 which are identified as nonstandard cost center codes. This logic must hold true for all other
cost center categories, i.e., direct care, reimbursable pass through costs, other FQHC services, and
nonreimbursable cost centers.

44-230

Rev. 1

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FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 5 - COST CENTER CODING
TABLE 5 - STANDARD COST CENTER DESCRIPTIONS AND CODES
CODE

USE

GENERAL SERVICE
COST CENTERS
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits
Administrative & General
Plant Operation &
Maintenance
Janitorial
Medical Records
Pharmacy
Medical Supplies
Transportation

Rev. 1

USE

4700
4800

(01)
(01)

4900

(01)

6000
6100

(01)
(01)

6200
6300
6400
6500
6600
6700
6800

(01)
(01)
(01)
(01)
(01)
(01)
(01)

7700
7800

(01)
(01)

REIMBURSABLE PASS
THROUGH COSTS
0100
0200
0300
0400
0500

(01)
(01)
(01)
(01)
(01)

Allowable GME Costs
Pneumococcal Vaccines & Med
Supplies
Influenza Vaccines & Med
Supplies

0600
0700
0900
1000
1100

(01)
(01)
(01)
(01)
(01)

OTHER FQHC SERVICES

DIRECT CARE COST
CENTERS
Physician
Physician Services Under
Agreement
Physician Assistant
Nurse Practitioner
Visiting Registered Nurse
Visiting Licensed Practical
Nurse
Certified Nurse Midwife
Clinical Psychologist
Clinical Social Worker
Laboratory Technician
Reg Dietician/Cert DSMT/
MNT Educator
Physical Therapist
Occupational Therapist
Other Allied Health
Personnel

CODE

2300
2400

(01)
(01)

2500
2600
2700
2800

(01)
(01)
(01)
(01)

2900
3000
3100
3200
3300

(01)
(01)
(01)
(01)
(01)

3400
3500
3600

(01)
(01)
(01)

Medicare Excluded Services
Diagnostic & Screening Lab
Tests
Radiology-Diagnostic
Prosthetic Devices
Durable Medical Equipment
Ambulance Services
Telehealth
Drugs Charged to Patients
Chronic Care Management
NONREIMBURSABLE
COST CENTERS
Retail Pharmacy
Nonallowable GME Costs

44-231

4495 (Cont.)

FORM CMS-224-14

04-16

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 5 - COST CENTER CODING
TABLE 5 - NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
CODE

USE

1200

(20)

6900

(20)

7900

(20)

GENERAL SERVICE COST CENTERS
Other General Service (specify)
OTHER FQHC SERVICES
Other (specify)
NONREIMBURSABLE COST CENTERS
Other Nonreimbursable (specify)

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FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 6 - EDITS
Medicare cost reports submitted electronically must meet a variety of edits. These include mathematical
accuracy edits, certain minimum file requirements, and other data edits. Any vendor software which
produces an electronic cost report file for Medicare FQHCs must automate all of these edits. Failure to
properly implement these edits may result in the suspension of a vendor's system certification until
corrective action is taken. The vendor’s software should provide meaningful error messages to notify the
FQHC of the cause of every exception. The edit message generated by the vendor systems must contain
the related 4 digit and 1 alpha character, where indicated, reject/edit code specified below. Any file
submitted by a provider containing a Level I edit will be rejected by the contractors. Notification must be
made to CMS for any exceptions.
The edits are applied at two levels. Level I edits (1000 series reject codes) test the format of the data to
identify error conditions that must be corrected or they will result in a cost report rejection. These edits
also test for critical data elements specified in Table 3. Vendor programs must prevent FQHCs from
generating an electronic cost report (ECR) file when the cost report violates any Level I edits. Level II
edits (2000 series edit codes) identify potential inconsistencies and missing data items. These items should
be resolved at the FQHC site and supporting documentation (such as worksheets or data) should be
submitted with the cost report.
The vendor requirements (above) and the edits (below) reduce both contractor processing time and
unnecessary rejections. Vendors must develop their programs to prevent their client FQHCs from
generating an ECR file where Level I edit conditions exist. In addition, ample warnings should be given to
the FQHC where Level II edit conditions are violated.
Level I edit conditions are to be applied against title XVIII services only. However, any
inconsistencies or omissions that would cause a Level I condition for non-title XVIII services must be
resolved prior to acceptance of the cost report. [10/01/2014b]
NOTE: The date in brackets [ ] at the end of each edit indicates the effective date of the edit. A date without
an alpha suffix, such as [10/01/2014], indicates the edit is effective for cost reporting periods ending on or
after the date in brackets. A date followed by a “b,” such as [10/01/2014b], indicates the edit is effective
for cost reporting periods beginning on or after the date in brackets. A date followed by an “s,” such as
[10/01/2014s], indicates the edit is effective for services rendered on or after the date in brackets.
I. Level I Edits (Minimum File Requirements)
Edit

Condition

1000

The first digit of every record must be 1, 2, 3, or 4 (encryption code only). [10/01/2014b]

1005

No record may exceed 60 characters. [10/01/2014b]

1010

All alpha characters must be in upper case, exclusive of the vendor information, type 1 record,
record number 3 and the encryption code, type 4 record, record numbers 1, 1.01, and 1.02.
[10/01/2014b]

1015

The end of the record indicator must be a carriage return and line feed, in that sequence.
[10/01/2014b]

1020

The FQHC provider number (record #1, positions 17-22) must be valid and numeric.
[10/01/2014b]

1025

All calendar format dates must be edited for 10 character format, e.g. 10/01/2014
(MM/DD/YYYY). [10/01/2014b]

Rev. 1

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FORM CMS-224-14

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ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 6 - EDITS
I. Level I Edits (Minimum File Requirements - Cont.)
Edit

Condition

1030

All dates (record #1, positions 23 through 29, 30 through 36, 45 through 51, and 52 through 58)
must be in Julian format and a possible date. [10/01/2014b]

1035

The fiscal year beginning date (record #1, positions 23 through 29) must be less than the fiscal
year ending date (record #1, positions 30 through 36). [10/01/2014b]

1036

The fiscal year ending date (record #1, positions 30 through 36) must be 28 days greater than the
fiscal year beginning date (record #1, positions 23 through 29) and the fiscal year ending date
(record #1, positions 30 through 36) must be less than 458 days greater than the fiscal year
beginning date (record #1, positions 23 through 29). [10/01/2014b]

1040

The vendor code (record #1, positions 38 through 40) must be a valid code. [10/01/2014b]

1045

The type 1 record #1 must be correct and the first record in the file. [10/01/2014b]

1047

The following standard cost centers listed below must be reported on the lines as indicated and
the corresponding cost center codes may only appear on the lines as indicated. No other cost
center codes may be placed on these lines. [10/01/2014b]
Cost Center
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits
Administrative & General Services
Plant Operation & Maintenance
Janitorial
Medical Records
Pharmacy
Medical Supplies
Transportation
Physician
Physician Services Under Agreement
Physician Assistant
Nurse Practitioner
Visiting Registered Nurse
Visiting Licensed Practical Nurse
Certified Nurse Midwife
Clinical Psychologist
Clinical Social Worker
Laboratory Technician
Reg Dietician/Cert DSMT/MNT Educator
Physical Therapist
Occupational Therapy
Other Allied Health Personnel

44-234

Line
1
2
3
4
5
6
7
9
10
11
23
24
25
26
27
28
29
30
31
32
33
34
35
36

Code
0100
0200
0300
0400
0500
0600
0700
0900
1000
1100
2300
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
3500
3600

Rev. 1

03-18

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 6 - EDITS
I. Level I Edits (Minimum File Requirements - Cont.)
Edit

Condition

1047

(Cont.)
Cost Center
Allowable GME Costs
Pneumococcal Vaccines & Med Supplies
Influenza Vaccines & Med Supplies
Medicare Excluded Services
Diagnostic & Screening Lab Tests
Radiology-Diagnostic
Prosthetic Devices
Durable Medical Equipment
Ambulance Services
Telehealth
Drugs Charged to Patients
Chronic Care Management
Retail Pharmacy
Nonallowable GME Costs

Line
47
48
49
60
61
62
63
64
65
66
67
68
77
78

Code
4700
4800
4900
6000
6100
6200
6300
6400
6500
6600
6700
6800
7700
7800

1050

All record identifiers (positions 1 through 20) must be unique. [10/01/2014b]

1055

Only a Y or N is valid for fields that require a yes/no response. [10/01/2014b]

1060

All line, sub line, column, and sub column numbers (positions 11 through 13, 14 through 15,
16 through 18, and 19 through 20, respectively) must be numeric. [10/01/2014b]

1070

Cost center integrity must be maintained throughout the cost report. For subscripted lines, the
relative position must be consistent throughout the cost report. [10/01/2014b]

1075

The cost center code (positions 21-24) (type 2 records) must be a code from Table 5, cost center
coding, and each cost center code must be unique. [10/01/2014b]

1080

Every line used on Worksheet A, must have a corresponding type 2 record. [10/01/2014b]

1085

Fields requiring numeric data (days, costs, etc.) may not contain any alpha characters.
[10/01/2014b]

1090

A numeric field (except unit cost multipliers) cannot exceed more than 11 positions. Unit cost
multipliers cannot exceed 13 positions. . [10/01/2014b]

1095

In all cases where the file includes both a total and the parts which comprise that total, each total
must equal the sum of its parts. [10/01/2014b]

1100

All dates must be possible, e.g., no “00”, no “30” or “31” of February and cannot be greater than
the current date, except for Worksheet S-2, column 3, line 4. [10/01/2014b]

Rev. 2

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FORM CMS-224-14

03-18

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 6 - EDITS
I. Level I Edits (Minimum File Requirements - Cont.)
Edit

Condition

1000S

Worksheet S-1, Part I, lines 1 through 3 must contain: the FQHC site name in column 1, line 1;
the FQHC street address in column 1, line 2; the FQHC city name in column 1, line 3; the FQHC
2-letter state abbreviation in column 2, line 3; the FQHC ZIP code (formatted as XXXXX) or the
FQHC ZIP+4 code (formatted as XXXXX-XXXX) in column 3, line 3; the FQHC county name
in column 4, line 3; and, the FQHC CCN in column 2, line 1. [10/01/2014b]

1001S

If Worksheet S, Part I, line 5, is “5” (amended cost report), then line 3 must be greater than zero.
[10/01/2014b]

1005S

Worksheet S-1, Part I, column 3, line 1 must be completed with a valid five-position
alphanumeric CBSA code. [10/01/2014b]

1010S

The FQHC CCN reported on Worksheet S-1, Part I, column 2, line 1 and column 2, line 14,
beginning with subscripted line 14.01 must be between XX-1000 through XX-1199, or XX-1800
through XX-1989, where XX corresponds to the two digit state code. [10/01/2014b]

1015S

Worksheet S-1, Part I, column 5, line 1 (type of control) must have a value of 1 through 11. (See
Table 3B.) [10/01/2014b]

1020S

Worksheet S-1, Part I, column 5, line 3 must contain an “R” or “U” response. [10/01/2014b]

1025S

The cost reporting period beginning date on Worksheet S-1, Part I, column 1, line 4, must be on
or after October 1, 2014. [10/01/2014b]

1030S

The cost reporting period beginning date on Worksheet S-1, Part I, column 1, line 4, must precede
the cost reporting ending date on Worksheet S-1, Part I, column 2, line 4. [10/01/2014b]

1035S

On Worksheet S-1, Part I, there must be a “Y” or “N” response for:
Column 1: lines 5, 9, 13, 16, 18, 19, 22, 23, 24, 25, 26, and 28. [10/01/2014b]

1040S

If Worksheet S-1, Part I, line 5, is “Y”, then Worksheet S-1, Part I, columns 1, 2, and 3, as
applicable, lines 6 through 8, must be present and valid and vice versa. [10/01/2014b]

1060S

If Worksheet S-1, Part I, line 9, is “Y”, then Worksheet S-1, Part I, columns 1, 2, and 3, as
applicable, lines 10 through 12, must be present and valid and vice versa. Conversely, if
Worksheet S-1, Part I, line 9 is “N”, then Worksheet S-1, Part I, columns 1, 2, and 3, as applicable,
lines 10 through 12 must be blank [10/01/2014b]

1080S

The certification dates for the primary FQHC (Worksheet S-1, Part I, column 4, line 1) and for
each consolidated FQHC entered on Worksheet S-1, Part II, column 2, line 1 must be present and
possible, and must be on or before the cost reporting period beginning date (Worksheet S-1,
Part I, column 1, line 4) and after 01/01/1966. [10/01/2014b]

1100S

If Worksheet S-1, Part I, column 1, line 13 is “Y”, then column 4 must contain a number greater
than or equal to one, for the number of consolidated FQHCs and if Worksheet S-1, Part I,
column 4, line 1, is on or after 10/01/2014, column 2 must contain a date of request, and column 3
must contain the date of approval. If Worksheet S-1, Part I, column 4, line 13 is greater than or
equal to 1, then column 1, must be “Y”. If Worksheet S-1, column 1, line 13 is “N”, then
Worksheet S-1, Part I, line 13, columns 2, 3, and 4 and Worksheet S-1, Part I, line 14 must be
blank and no subscripting. [10/01/2014b]

44-236

Rev. 2

03-18

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 6 - EDITS
I. Level I Edits (Minimum File Requirements - Cont.)
Edit

Condition

1110S

If Worksheet S-1, Part I, column 1, line 13 is “Y”, then line 14, beginning with subscripted line
14.01, for each FQHC must contain: the FQHC site name in column 1, the FQHC CCN in
column 2, and the CBSA code in column 3. If the applicable Worksheet S-1, Part II, column 2,
line 1, is on or after 10/01/2014, then Worksheet S-1, Part I, line 14, beginning with subscripted
line 14.01, must contain the date of request in column 4, and the date of approval in column 5.
If Worksheet S-1, Part I, column 1, line 13 is “N”, line 14, beginning with subscripted line 14.01,
must be blank. [10/01/2010b]

1120S

If Worksheet S-1, Part I, column 1, line 15, is “1” or “3”, then column 2 must have only an A, B,
C, and/or D and vice versa. If Worksheet S-1, Part I, column 1, line 15 is “2”, then column 2
must be blank and vice versa. [10/01/2014b]

1140S

If Worksheet S-1, Part I, column 1, line 16, is “Y”, then line 17 must contain the type of grant
award in column 1 (see Table 3B), the date of the grant award in column 2 (MM/DD/YYYY),
and the grant award number in column 3. If Worksheet S-1, Part I, column 1, line 16 is “N”, then
line 17 must be blank. [10/01/2014b]

1150S

If Worksheet S-1, Part I, column 1, line 18 is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY) and vice versa. If Worksheet S-1, Part I, column 1, line 18 is “N”, then
column 2 must be blank. [10/01/2014b]

1170S

If Worksheet S-1, Part I, line 19 is “Y”, then line 20 must contain a “1” or “2”, and line 21, sum
of columns 1 through 3, must be greater than zero, and vice versa. [10/01/2014b]

1210S

If Worksheet S-1, Part I, column 1, line 25 is “Y”, then columns 2 and 3 must be greater than
zero, and vice versa. If Worksheet S-1, Part I, column 1, line 25 is “N”, then columns 2 and 3
must be blank. [10/01/2014b]

1220S

If Worksheet S-1, Part I, column 1, line 26 is “Y”, then columns 2 and 3 must be greater than
zero and vice versa. If Worksheet S-1, Part I, column 1, line 26 is “N”, then columns 2 and 3
must be blank. [10/01/2014b]

1230S

Worksheet S-1, Part I, column 1, line 27, must contain a response of “1”, “2”, or “3”. If the
response to column 1 is “2”, then column 2 must have an amount greater than zero, and vice
versa. If the response is “1” or “3” then column 2 must be blank. [10/01/2014b]

NOTE: The edits that correspond to Worksheet S-1, Part II are only applied if Worksheet S-1, Part II
is completed for consolidated FQHCs.
1240S

If Worksheet S-1, Part I, any of lines 14.01 through 14.99, has an entry, then the corresponding
Worksheet S-1, Part II, lines 1 through 3 must contain an entry for each FQHC: the FQHC site
name in column 1, line 1; the FQHC street address in column 1, line 2; the FQHC city name in
column 1, line 3; the FQHC 2-letter state abbreviation in column 2, line 3; the FQHC ZIP code
(formatted as XXXXX) or the FQHC ZIP+4 code (formatted as XXXXX-XXXX) in column 3,
line 3; the FQHC county name in column 4, line 3; and an “R” or “U” in column 5 , line 3.
[10/01/2014b]

Rev. 2

44-237

4495 (Cont.)

FORM CMS-224-14

03-18

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 6 - EDITS
I. Level I Edits (Minimum File Requirements - Cont.)
Edit

Condition

1250S

For each consolidated FQHC entered on Worksheet S-1, Part II, column 1, line 1, there must be
a corresponding value of 1 through 11 entered in column 3 for the type of control. (See Table 3B.)
[10/01/2014b]

1280S

Worksheet S-1, Part II, column 5, line 3 must contain an “R” or “U” response. [10/01/2014b]

1290S

If Worksheet S-1, Part II, column 1, line 4, is “1” or “3”, then column 2 must have only an A, B,
C, and/or D and vice versa. If Worksheet S-1, Part II, column 1, line 4 is “2”, then column 2
must be blank and vice versa. [10/01/2014b]

1300S

If Worksheet S-1, Part I, column 1, line 13 is “Y”, for each consolidated FQHC identified on
Worksheet S-1, Part I, column 2, lines 14.01 through 14.99, there must be a “Y” or “N” response
on each applicable Worksheet S-1, Part II for:
Column 1: lines 5, 7, 8, 11, 12, 13, and 14. [10/01/2014b]

1310S

If Worksheet S-1, Part II, column 1, line 5, is “Y”, then line 6 must contain the type of grant
award in column 1 (see Table 3B), the date of the grant award in column 2 (MM/DD/YYYY),
and the grant award number in column 3. If Worksheet S-1, Part II, column 1, line 5 is “N”, then
line 6 must be blank. [10/01/2014b]

1320S

If Worksheet S-1, Part II, column 1, line 7 is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY), and vice versa. [10/01/2014b]

1340S

If Worksheet S-1, Part II, line 8 is “Y”, then line 9 must contain a “1” or “2”, and line 10, sum
of columns 1 through 3, must be greater than zero, and vice versa. [10/01/2014b]

1370S

If Worksheet S-1, Part II, column 1, line 13 is “Y”, then both columns 2 and 3 must be greater
than zero, and vice versa. [10/01/2014b]

1380S

If Worksheet S-1, Part II, column 1, line 14 is “Y”, then both columns 2 and 3 must be greater
than zero, and vice versa. [10/01/2014b]

1390S

Worksheet S-1, Part II, column 1, line 15, must contain a response of “1”, “2”, or “3”. If the
response in column 1 is “2”, then column 2 must have an amount greater than zero, and vice
versa. [10/01/2014b]

1400S

On Worksheet S-2, there must be a “Y” or “N” response for:
Column 1: lines 1 through 8, 11, 12, and 16.
If column 1, line 8, is “Y”, then column 1, lines 9 and 10, must be “Y” or “N”.
If column 1, lines 11 or 12, is “Y”, then column 1, lines 13, 14, and 15 must be “Y” or “N”.
Column 4: line 4. [10/01/2014]

1405S

If Worksheet S-2, column 1, line 1 is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY), and vice versa. [10/01/2014b]

1410S

If Worksheet S-2, column 1, line 2 is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY) and column 3 must contain a “V” or an “I”, and vice versa. [10/01/2014b]

44-238

Rev. 2

03-18

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 6 - EDITS
I. Level I Edits (Minimum File Requirements - Cont.)
Edit

Condition

1420S

If Worksheet S-2, column 1, line 3 is “N”, then Worksheet A-2-1 must not be present.
[10/01/2014b]

1430S

If Worksheet S-2, column 1, line 3 is “Y”, then Worksheet A-2-1, Part I, columns 4 or 5, sum of
lines 1 through 4 must not equal zero, and Worksheet A-2-1, Part II, column 1, any one of lines 6
through 10 must contain one of the alpha characters A, B, C, D, E, F, or G. [10/01/2014b]

1440S

If Worksheet S-2, column 1, line 4 is “Y”, then column 2 must be “A”, “C” or “R”. If
Worksheet S-2, column 1, line 4 is “N”, then column 2 must be blank. [10/01/2014b]

1450S

Worksheet S-3, Part I, columns 1 through 4, lines 1 through 6, and Worksheet S-3, Part III,
columns 1 and 2, lines 16 through 29, must be equal to or greater than zero. [10/01/2014b]

1460S

If Worksheet S-1, Part I, column 2, any of lines 14.01 through 14.99, has an entry, then
Worksheet S-3, Part I, column 0, for lines 1.01 through 1.99, 3.01 through 3.99, and 5.01
through 5.99 must contain a corresponding CCN in the exact same order. [10/01/2010b]

1470S

If Worksheet S-2, column 1, line 11 is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY) and vice versa. [10/01/2014b]

1480S

If Worksheet S-2, column 1, line 12 is “Y”, then column 2 must contain a valid date
(MM/DD/YYYY) and vice versa. [10/01/2014b]

1500S

Worksheet S-3, Part III, column 3, sum of lines 16 through 29, must be greater than zero.
[12/31/2017]

1505S

If Worksheet S-1, Part I, line 23, and/or Worksheet S-1, Part II, line 11 is “Y”, then Worksheet A,
column 1, line 47, must be greater than zero.

1510S

If Worksheet S-1, Part I, line 24, and/or Worksheet S-1, Part II, line 12 is “Y”, then Worksheet A,
column 3, line 78, must be greater than zero. [12/31/2017]

1515S

If Worksheet S-1, Part I, lines 23 or 24, and/or Worksheet S-1, Part II, lines 11 or 12, are “Y”,
then Worksheet S-3, Part III, line 29, column 3 must be greater than zero. [12/31/2017]

1520S

If Worksheet S-1, Part 1, line 28, and/or Worksheet S-1, Part II, line 16 is “Y”, then
Worksheet S-3, Part II, sum of columns 1 and 2, lines 1 through 15, and Worksheet S-3, Part III,
column 2, sum of lines 16 through 29, must greater than zero. [12/31/2017]

1000A

Worksheet A, columns 1, 2, and 7, line 100, must be greater than zero. [10/01/2014b]

1060A

For each amount on Worksheet A, column 7, lines 23 through 31, and line 33 that are greater
than zero, the corresponding total visits on Worksheet B, Part I, column 2, lines 1 through 10
must also be greater than zero, and vice versa. [10/01/2014b]

Rev. 2

44-239

4495 (Cont.)

FORM CMS-224-14

03-18

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 6 - EDITS
I. Level I Edits (Minimum File Requirements - Cont.)
Edit

Condition

1120A

For reclassifications reported on Worksheet A-1, all increases (column 4) must equal all
decreases (column 7). [10/01/2014b]

1130A

For each line on Worksheet A-1, when an entry is present in column 4, there must be an entry in
columns 1 and 3, and if an entry is present in column 7, then there must be an entry in columns 1
and 6. All entries in column 1 must be upper case alpha characters. [10/01/2014b]

1140A

Worksheet A-1, column 0 must have an explanation present on the first line for each
reclassification code. [10/01/2014b]

1200A

For Worksheet A-2 adjustments on lines 3 through 6 and 8 through 10, if column 2 has an amount,
then column 1 must be either “A” or “B”, and column 4 for that line must have an entry, and if
lines 14 through 49, column 2 have entries, then columns 0, 1, and 4, for the corresponding line
must have entries. [10/01/2014b]

1210A

For Worksheet A-2 adjustments on lines 1, 2, 11, 12, and 13, if column 2 has an entry, then
column 1 of the corresponding lines must be either “A” or “B”. [10/01/2014b]

1220A

Worksheet A-2-1, Part I, columns 1 and 3, must have an entry when there is an amount in
column 4 or 5 for each of lines 1 through 4. [10/01/2014b]

1230A

On a line specific basis, if Worksheet A, column 1, lines 23, and 25 through 36, is greater than
zero, then the corresponding line (lines 16 through 28) on Worksheet S-3, Part III, column 1,
must be greater than zero. [12/31/2017]

1000B

Worksheet B, Part I, columns 1 through 12, lines 1 through 10, all amounts must be greater than
or equal to zero. [10/01/2014b]

1010B

Worksheet B, Part I, column 2, lines 1 through 10 must be equal to the sum of columns 7 and 8,
lines 1 through 10, for each line. [10/01/2014b]

1020B

Worksheet B, Part I, column 2, line 11 must be equal to Worksheet S-3, Part I, column 5, sum of
lines 2 and 4. [10/01/2014b]

1030B

Worksheet B, Part I, column 9, line 11 must be equal to Worksheet S-3, Part I, column 2, line 2.
[10/01/2014b]

1040B

Worksheet B, Part I, column 10, line 11 must be equal to Worksheet S-3, Part I, column 2, line 4.
[10/01/2014b]

1050B

If Worksheet B-1, columns 1 or 2, line 13, are greater than zero, then Worksheet S-3, Part I,
column 2, sum of lines 2 and 4, must be greater than zero. [12/31/2017]

1000E

If Worksheet E, column 1, line 1, is greater than zero, then Worksheet E-1, column 2, line 4, must
be greater than zero, and Worksheet S-3, Part I, column 2, sum of lines 2 and 4, must be greater
than zero. [12/31/2017]

44-240

Rev. 2

04-16

FORM CMS-224-14

4495 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 6 - EDITS
II. Level II Edits (Potential Rejection Errors)
These conditions are usually, but not always, incorrect. These edit errors should be cleared when possible
through the cost report. When corrections on the cost report are not feasible, provide additional information
in schedules, notes, or any other manner as may be required by your contractor. Failure to clear these errors
in a timely fashion, as determined by your contractor, may be grounds for withholding of payments.
Edit

Condition

2000

All type 3 records with numeric fields and a positive usage must have values greater than zero
(supporting documentation may be required for negative amounts). [10/01/2014b]

2005

Only elements set forth in Table 3, with subscripts as appropriate, are required in the file.
[10/01/2014b]

2010

The cost center code (positions 21 through 24 in type 2 records) must be a code from Table 5,
Cost Center Coding, and each cost center code must be unique. [10/01/2014b]

2025

Only nonstandard cost center codes within a cost center category may be placed on lines 12, 69,
and 79, and subscripts. [10/01/2014b]

Rev. 1

44-241

4495 (Cont.)

FORM CMS-224-14

04-16

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-224-14
TABLE 6 - EDITS
II.

Level II Edits (Potential Rejection Errors - Cont.)

Edit

Condition

2220S

Worksheet S-2, lines 17 through 19, all columns must be completed. [10/01/2014b]

2000F

Net income or loss on Worksheet F-1, column 2, line 33 should not equal zero. [10/01/2014b]

NOTE: CMS reserves the right to require additional edits to correct deficiencies that become evident
after processing the data commences and, as needed, to meet user requirements.

44-242

Rev. 1