CMS-224-14 FQHC Cost Report Form

03-18

FORM CMS-224-14

4490

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

FEDERALLY QUALIFIED HEALTH CENTER COST REPORT
CERTIFICATION AND SETTLEMENT SUMMARY

CCN:
___________

PERIOD:
FROM: ___________
TO: ___________

FORM APPROVED
OMB NO. 0938-1298
EXPIRES 2-28-2022
WORKSHEET S
PARTS I, II & III

PART I - COST REPORT STATUS
Provider use only

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

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

1

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1298. The time required to complete this information collection is estimated 58 hours per response, including the time to review instructions, search existing resources, gather the
data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under
the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,
please contact 1-800-MEDICARE.

FORM CMS-224-14 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4404.1 - 4404.3)

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FORM CMS-224-14

03-18

FEDERALLY QUALIFIED HEALTH CENTER IDENTIFICATION DATA

CCN:
______________

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET S-1
PART I

PART I - FEDERALLY QUALIFIED HEALTH CENTER IDENTIFICATION DATA
Provider
CCN
2

1
1
2
3
4
5
6
7
8
9

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

P.O. Box:
State:
From:

Zip Code:
To:

County:

Is this FQHC part of an entity that owns, leases or controls multiple FQHCs? Enter "Y" for yes or "N" for no. If yes, enter the entity's information
below.
Name of Entity:
Street:
P.O. Box:
City:
State:
Zip Code:
Is this FQHC part of a chain organization as defined in §2150 of CMS Pub. 15-1 that claims home office costs in a

Home Office Cost Statement? Enter "Y for yes or "N" for no in column 1. If yes, enter the chain organization's information below.
10 Name of Chain Organization:
11 Street:
P.O. Box:
12 City:
State:
Zip Code:

CBSA
3

Date
Certified
4

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

Designation - Enter "R" for rural or "U" for urban:

6
7
8
9

HRSA Award Number:

10
11
12

Home Office CCN:

Consolidated Cost Report
13 Is this FQHC filing a consolidated cost report per CMS Pub. 100-04, chapter 9, §30.8? Enter "Y" for yes or "N" for no in column 1.

1
Y/N

If column 1 is yes, complete columns 2 through 4, and line 14, beginning with subscripted line 14.01. If column 1 is no, leave line 14 blank. (see instructions)
Site Name
CCN
1
2
14 List of Consolidated Providers
14.01
FQHC Operations
15 What type of organization is this FQHC? If you operate as more than one sub-type of an organization enter only the applicable alpha characters in column 2. (see instructions)
16 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? Enter "Y" for yes or "N" for no. (complete line 17)
17 If the response to line 16 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). 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.
Medical Malpractice
18 Did this FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA? Enter "Y" for yes or "N" for no in column 1. If column 1 is yes, enter the

2
Date Requested

3
Date Approved

4
Number of FQHCs

CBSA
3

Date Requested
4

Date Approved
5

13

14
14.01
1

2

3
15
16
17

effective date of coverage in column 2.
19 Does this FQHC carry commercial malpractice insurance? Enter "Y" for yes or "N" for no.
20 Is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.

18
19
20
Premiums

21 List amounts of malpractice premiums, paid losses or self-insurance in the applicable columns.
22 Are malpractice premiums, paid losses or self-insurance reported in a cost center other than the Administrative and General cost center? Enter "Y" for yes or "N" for no. (see instructions)
Interns and Residents
23 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.
24 Is this FQHC involved in training residents in an unapproved GME program? Enter "Y" for yes or "N" for no.
25 Did this FQHC receive a Primary Care Residency Expansion (PCRE) grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for no in column 1.
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 and
in column 3, enter the total number of visits performed by residents funded by the PCRE grant in this cost reporting period. (see instructions)
26 Did this FQHC receive a Teaching Health Center development grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for no in column 1.
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 and
in column 3, enter the total number of visits performed by residents funded by the THC grant in this cost reporting period. (see instructions)
Capital Related Costs - Ownership/Lease of Building
27 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 space provided at no cost in column 1. If you entered "2" in column 1, enter the amount of rent/lease expense in column 2.
Contract Labor Cost
28 Do you use contract labor to provide medical and/or mental health services to your patients? Enter "Y" for yes or "N" for no in column 1.

Paid Losses

Self Insurance
21
22
23
24
25

26

27

28

FORM CMS-224-14 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4405.1 )
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4490 (Cont.)

FORM CMS-224-14

FEDERALLY QUALIFIED HEALTH CENTER IDENTIFICATION DATA

CCN: ___________
CENTER CCN: __________

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET S-1
PART II

PART II - FEDERALLY QUALIFIED HEALTH CENTER CONSOLIDATED COST REPORT PARTICIPANT IDENTIFICATION DATA
Date
Certified
2

Type of control
(see instructions)
3

Date
Decertified
4

V/I
Decertification
5

1
1 Site Name:
2 Street:
P.O. Box:
3 City:
State:
Zip Code:
County:
Designation - Enter "R" for rural or "U" for urban:
FQHC Operations
1
4 What type of organization is this FQHC? If you operate as more than one sub-type of an organization enter only the applicable alpha
characters in column 2. (see instructions)
5 Did this FQHC receive a grant under §330 of the PHS Act during this cost reporting period? Enter "Y" for yes or "N" for no. If yes, complete line 6.
6 If the response to line 5 is yes, indicate in column 1, the type of HRSA grant that was awarded (see instructions). 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.
Medical Malpractice
7 Did this FQHC submit an initial deeming or annual redeeming application for medical malpractice coverage under the FTCA with HRSA? Enter "Y" for yes or "N" for no in

Date of
CHOW
6
1
2
3

2

3
4
5
6

column 1. If column 1 is yes, enter the effective date of coverage in column 2.
8 Does this FQHC carry commercial malpractice insurance? Enter "Y" for yes or "N" for no.
9 Is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.

7
8
9
Premiums

10 List amounts of malpractice premiums, paid losses or self-insurance in the applicable columns.
Interns and Residents
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.
12 Is this FQHC involved in training residents in an unapproved GME program? Enter "Y" for yes or "N" for no.
13 Did this FQHC receive a Primary Care Residency Expansion (PCRE) grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for
no in column 1. 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 and in column 3, enter the total number of visits performed by residents funded by the PCRE grant in this cost reporting period. (see instuctions)
14 Did this FQHC receive a Teaching Health Center development grant authorized under Part C of Title VII of the PHS Act from HRSA? Enter "Y" for yes or "N" for no
in column 1. 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 and in column 3, enter the total number of visits performed by residents funded by the THC grant in this cost reporting period. (see instructions)
Capital Related Costs - Ownership/Lease of Building
15 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 space provided at no cost in column 1. If you entered "2" in column 1 enter the amount
of rent/lease expense in column 2.
Contract Labor Costs
16 Do you use contract labor to provide medical and/or mental health services to your patients? Enter "Y" for yes or "N" for no in column 1.

Paid Losses

Self Insurance
10
11
12
13

14

15

16

FORM CMS-224-14 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4405.2)

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FORM CMS-224-14

FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT
QUESTIONNAIRE

CCN:
___________

03-18
PERIOD:
FROM: ___________
TO: ___________

WORKSHEET S-2

General Instruction: Enter Y for all YES responses. Enter N for all NO responses.
Enter all dates in the mm/dd/yyyy format.
COMPLETED BY ALL FQHCs
Y/N
1

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

Date
2

1
2
3

Y/N
1

Type
2

Date
3

Y/N
1

Y/N
1
8
9
10
Y/N
1

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

Date
2
11
12
13
14
15
16

Title:
E-mail Address:

Y/N
2
5
6
7

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

Last name:

Y/N
4
4

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

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

V/I
3

17
18
19

FORM CMS-224-14 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4406)

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FORM CMS-224-14
CCN:

FEDERALLY QUALIFIED HEALTH CENTER DATA

___________
PART I - FEDERALLY QUALIFIED HEALTH CENTER STATISTICAL DATA

CENTER
CCN
0
1
2
3
4
5
6

Title V
1

4490 (Cont.)
PERIOD:
FROM: __________
TO: ___________

Title
XVIII
2

Title
XIX
3

Other
4

WORKSHEET S-3
PART I

Total
All
Patients
5

Medical Visits
Total Medical Visits
Mental Health Visits
Total Mental Health Visits
Number of Visits Performed by Interns and Residents
Total Number of Visits Performed by
Interns and Residents

1
2
3
4
5
6

FORM CMS-224-14 (04-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4407.1)

Rev. 2

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FORM CMS-224-14
CCN:

03-18

PERIOD:
FROM: __________
TO: ___________
___________
PART II - FEDERALLY QUALIFIED HEALTH CENTER CONTRACT LABOR AND BENEFIT COST
Contract
Labor
1
1 Total facility contract labor and benefit cost
2 Physician
3 Physician Assistant
4 Nurse Practitioner
5 Visiting Registered Nurse
6 Visiting Licensed Practical Nurse
7 Certified Nurse Midwife
8 Clinical Psychologist
9 Clinical Social Worker
10 Laboratory Technician
11 Reg Dietician/Cert DSMT/MNT Educator
12 Physical Therapist
13 Occupational Therapist
14 Other Allied Health Personnel
15 Interns & Residents
FEDERALLY QUALIFIED HEALTH CENTER DATA

WORKSHEET S-3
PART II & III

Benefit
Cost
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

PART III - FEDERALLY QUALIFIED HEALTH CENTER EMPLOYEE DATA
Enter the number of hours in
your normal work week ________
16
17
18
19
20
21
22
23
24
25
26
27
28
29

Physician
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
Interns & Residents

Number of Employees
(Full Time Equivalent)
Staff
Contract
Total
1
2
3
16
17
18
19
20
21
22
23
24
25
26
27
28
29

FORM CMS-224-14 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4407.2 & 4407.3)

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FORM CMS-224-14

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

4490 (Cont.)

CCN:

PERIOD:
FROM:
TO:

___________

COST CENTER DESCRIPTIONS
(omit cents)

SALARIES
1

OTHER
2

TOTAL
(col. 1 + col. 2)
3

GENERAL SERVICE COST CENTERS
1 0100 Cap Rel Costs-Bldg and Fix
2 0200 Cap Rel Costs-Mvble Equip
3 0300 Employee Benefits
4 0400 Administrative & General Services
5 0500 Plant Operation & Maintenance
6 0600 Janitorial
7 0700 Medical Records
8
Subtotal - Administrative Overhead
9 0900 Pharmacy
10 1000 Medical Supplies
11 1100 Transportation
12 1200 Other General Service (specify)
13
Subtotal - Total Overhead
DIRECT CARE COST CENTERS
23 2300 Physician
24 2400 Physician Services Under Agreement
25 2500 Physician Assistant
26 2600 Nurse Practitioner
27 2700 Visiting Registered Nurse
28 2800 Visiting Licensed Practical Nurse
29 2900 Certified Nurse Midwife
30 3000 Clinical Psychologist
31 3100 Clinical Social Worker
32 3200 Laboratory Technician
33 3300 Reg Dietician/Cert DSMT/MNT Educator
34 3400 Physical Therapist
35 3500 Occupational Therapist
36 3600 Other Allied Health Personnel
37
Subtotal - Direct Patient Care Services

RECLASSIFICATIONS
4

RECLASSIFIED
TRIAL BALANCE
(col. 3 ± col. 4)
ADJUSTMENTS
5
6

WORKSHEET A
NET
EXPENSES FOR
ALLOCATION
(col. 5 ± col. 6)
7
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37

FORM CMS-224-14 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4408)

Rev. 2

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FORM CMS-224-14

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

03-18
PERIOD:
FROM ____________
TO ____________

CCN:
____________

COST CENTER DESCRIPTIONS
(omit cents)

SALARIES
1

OTHER
2

TOTAL
(col. 1 + col. 2)
3

REIMBURSABLE PASS THROUGH COSTS
47 4700 Allowable GME Costs
48 4800 Pneumococcal Vaccines & Med Supplies
49 4900 Influenza Vaccines & Med Supplies
50
Subtotal - Reimbursable Pass through Costs
OTHER FQHC SERVICES
60 6000 Medicare Excluded Services
61 6100 Diagnostic & Screening Lab Tests
62 6200 Radiology - Diagnostic
63 6300 Prosthetic Devices
64 6400 Durable Medical Equipment
65 6500 Ambulance Services
66 6600 Telehealth
67 6700 Drugs Charged to Patients
68 6800 Chronic Care Management
69 6900 Other (Specify)
70
Subtotal - Other FQHC Services
NONREIMBURSABLE COST CENTERS
77 7700 Retail Pharmacy
78 7800 Nonallowable GME Costs
79 7900 Other Nonreimbursable (Specify)
80
Subtotal - Non-Reimbursable Costs
100
TOTAL (sum of lines 13, 37, 50, 70 and 80)

RECLASSIFICATIONS
4

RECLASSIFIED
TRIAL BALANCE
ADJUSTMENTS
(col. 3 ± col. 4)
5
6

WORKSHEET A

NET
EXPENSES FOR
ALLOCATION
(col. 5 ± col. 6)
7
47
48
49
50
60
61
62
63
64
65
66
67
68
69
70
77
78
79
80
100

FORM CMS-224-14 (04-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4408)

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FORM CMS-224-14

RECLASSIFICATIONS

4490 (Cont.)
CCN:

___________
INCREASES
EXPLANATION OF RECLASSIFICATION(S)

CODE
(1)
1

COST CENTER
2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100 Total reclassifications
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
Transfer the amounts in columns 4 and 7 to Worksheet A, column 4, lines as appropriate.

LINE #
3

AMOUNT
4

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET A-1

DECREASES
COST CENTER
5

LINE #
6

AMOUNT
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100

FORM CMS-224-14 (04-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4409)

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FORM CMS-224-14

ADJUSTMENTS TO EXPENSES

08-16

CCN:

PERIOD:
FROM: ___________
TO: ___________

___________

DESCRIPTION (1)
BASIS/CODE
(2)
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
50

Investment income - buildings and fixtures (chapter 2)
Investment income - movable equipment (chapter 2)
Investment income - other (chapter 2)
Trade, quantity, and time discounts (chapter 8)
Refunds and rebates of expenses (chapter 8)
Rental of building or office space to others (chapter 8)
Related organization transactions (chapter 10)
Sale of drugs to other than patients
Vending machines
Practitioner assigned by Public Health Service
Depreciation - buildings and fixtures
Depreciation - movable equipment
RCE adjustment to teaching physicians' cost
Other adjustments (specify) (3)
TOTAL (sum of lines 1 thru 49)

AMOUNT
2

WORKSHEET A-2

EXPENSE CLASSIFICATION ON
WORKSHEET A TO/FROM WHICH
THE AMOUNT IS TO BE ADJUSTED
COST CENTER
LINE #
3
4
Buildings and Fixtures
1
Movable Equipment
2

Wkst A-2-1

Buildings and Fixtures
Movable Equipment
Allowable GME Costs

1
2
47

1
2
3
4
5
6
7
8
9
10
11
12
13
14
50

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

FORM CMS-224-14 (04-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4410)

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FORM CMS-224-14

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

4490 (Cont.)

CCN:
___________

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET A-2-1

PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS
OR CLAIMED HOME OFFICE COSTS
Amount
Net
Amount of
included in
Adjustments
Allowable
Wkst. A
(col. 4 minus
Line No.
Cost Center
Expense Items
Cost
column 5
col. 5) *
1
2
3
4
5
6
1
1
2
2
3
3
4
4
5 TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet
5
A-2, column 2, line 7.
* The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as appropriate.
Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not
been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.
PART II - INTERRELATIONSHIP TO RELATED ORGANIZATIONS AND/OR HOME OFFICE
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish
the information requested under Part B of this worksheet.
This information is used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable to services,
facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs as determined under
section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost report is considered incomplete and
not acceptable for purposes of claiming reimbursement under Title XVIII.

Symbol
(1)
1

Name
2

Percentage
of
Ownership
3

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

6
7
8
9
10

6
7
8
9
10
(1) Use the following symbols to indicate interrelationship to related organizations:
A. Individual has financial interest (stockholder, partner, etc.) in both related
organization and in FQHC.
B. Corporation, partnership, or other organization has financial interest in FQHC.
C. FQHC has financial interest in corporation, partnership, or other organization.
D. Director, officer, administrator, or key person of FQHC or relative of such
person has financial interest in related organization.
E. Individual is director, officer, administrator, or key person of FQHC and
related organization.
F. Director, officer, administrator, or key person of related organization or relative
of such person has financial interest in FQHC.
G. Other (financial or non-financial) specify __________________________________________________

FORM CMS-224-14 (04-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4411.1 - 4411.2)

Rev. 2

44-113

FORM CMS-224-14

4490 (Cont.)

03-18

CALCULATION OF FEDERALLY QUALIFIED HEALTH CENTER COSTS

CCN:

PERIOD:
FROM: ___________
TO: ___________

___________

WORKSHEET B
PARTS I & II

PART I - CALCULATION OF FEDERALLY QUALIFIED HEALTH CENTER COST PER VISIT
Total Visits

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

Positions
Physician
Physician Services Under Agreement
Physician Assistant
Nurse Practitioner
Visiting Registered Nurse
Visiting Licensed Practical Nurse
Certified Nurse Midwife
Clinical Psychologist
Clinical Social Worker
Reg Dietician/Cert DSMT/MNT Educator
Totals
Unit Cost Multiplier
Total Cost Per Visit

From Wkst.
A, col. 7,
line:
23
24
25
26
27
28
29
30
31
33

Other Direct
Direct Cost
Total Medical Care Costs &
by
& Mental Health Pharmacy Costs
(see
Practitioner
Visits
instructions)
from Wkst. A by Practitioner
1
2
3

General
Service Cost
(see
instructions)
4

Total Costs
by
Practitioner
5

Average
Cost Per Visit
by Practitioner
6

Medical Visits
by Practitioner
7

Mental
Health Visits
by Practitioner
8

Title XVIII Visits

Medical Visits
by Practitioner
9

Mental
Health Visits
by Practitioner
10

Title XVIII Costs

Medical Cost
by Practitioner
11

Mental
Health Cost
by Practitioner
12
1
2
3
4
5
6
7
8
9
10
11
12
13

PART II - CALCULATION OF ALLOWABLE DIRECT GRADUATE MEDICAL EDUCATION COSTS
Total
Cost
(from Wkst.
A col. 7,
line 47)
1
14 Allowable GME Costs

Total
Visits
2

Title XVIII
Visits
3

Ratio of
Title XVIII
Visits to
Total Visits
4

Allowable
Title XVIII
Direct
GME Costs
5
14

FORM CMS-214-14 (03-2018) INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4412.1 - 4412.2)

44-114

Rev. 2

03-18
COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA
VACCINE COST

FORM CMS-224-14

4490 (Cont.)
CCN:
____________

PERIOD:
WORKSHEET B-1
FROM: ____________
TO: ____________
PNEUMOCOCCAL
1

1 Health care staff cost (from Worksheet A, column 7, sum of lines 23, and 25 through 36)
2 Ratio of pneumococcal and influenza vaccine staff time to total
health care staff time
3 Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)
4 Vaccines and related medical supplies cost (from Worksheet A, column 7, lines 48 and 49, respectively)
5 Direct cost of pneumococcal and influenza vaccine (line 3 + line 4)
6 Total direct cost of the FQHC (from Worksheet A, column 7, line 100, minus Worksheet A, column 7, line 8)
7 Total administrative overhead (from Worksheet A, column 7, line 8)
8 Ratio of pneumococcal and influenza vaccine direct cost to total direct
cost (line 5 / line 6)
9 Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)
10 Total cost of pneumococcal and influenza vaccine and their
administration (sum of lines 5 and 9)
11 Total number of pneumococcal and influenza vaccine injections
(from your records)
12 Cost per pneumococcal and influenza vaccine injection (line 10 / line 11)
13 Number of pneumococcal and influenza vaccine injections administered
to Medicare beneficiaries
14 Cost of pneumococcal and influenza vaccines and their
administration costs furnished to Medicare beneficiaries (line 12 x line 13)
15 Total cost of pneumococcal and influenza vaccines and their administration costs (sum of columns
1 and 2, line 10)
16 Total Medicare cost of pneumococcal and influenza vaccines and their administration costs (sum
of columns 1 and 2, line 14) (transfer this amount to Worksheet E, line 3)

INFLUENZA
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

FORM CMS-224-14 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4413)

Rev. 2

44-115

4490 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT

FORM CMS-224-14

03-18
CCN:
___________

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

PERIOD:
FROM: ___________
TO: ___________

FQHC PPS Amount
Direct graduate medical education payments (from Worksheet B, Part II, line 14, column 5)
Medicare cost of pneumococcal and influenza vaccine and their administration (From Worksheet B-1, line 16)
Medicare advantage supplemental payments (for information only)
Total (sum of amounts on lines 1 through 3)
Primary payer payments
Total amount payable for program beneficiaries (line 5 minus line 6)
Coinsurance billed to program beneficiaries
Net Medicare reimbursement excluding bad debts (line 7 minus line 8)
Allowable bad debts (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (line 9 plus line 11)
Other adjustments (specify) (see instructions)
Amount due FQHC prior to the sequestration adjustment (see instructions)
Sequestration adjustment (see instructions)
Amount due FQHC after sequestration adjustment (see instructions)
Interim payments
Tentative settlement (for contractor use only)
Balance due FQHC/program (line 17 minus lines 18 and 19)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

WORKSHEET E

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

FORM CMS-224-14 (04-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4414)

44-116

Rev. 2

03-18

FORM CMS-224-14

ANALYSIS OF PAYMENTS TO THE FEDERALLY QUALIFIED HEALTH CENTER FOR SERVICES RENDERED

4490 (Cont.)
CCN:

PERIOD:
FROM:
TO:

Description

Part B
mm/dd/yyyy
1

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

Program to
Provider

Program to
Provider
Provider to
Program

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

Amount
2
1
2

Provider to
Program
Subtotal (sum of lines 3.01- 3.49 minus sum of lines 3.50-3.98)
4 Total interim payments (sum of lines 1, 2, and 3.99)
(transfer to Wkst. E, line 18)
TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative settlement
payment after desk review. Also show
date of each payment.
If none, write "NONE" or enter a zero. (1)

WORKSHEET E-1

Program to provider
Provider to program
Date:

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

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

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

5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8

(1) On lines 3, 5, and 6, where an amount is due FQHC to program, 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.

FORM CMS-224-14 (04-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4415)

Rev. 2

44-117

4490 (Cont.)
STATEMENT OF

FORM CMS-224-14

03-18

CCN:

PERIOD

REVENUE AND EXPENSES

WORKSHEET F-1

From: ___________
___________

To: ___________

Title XVIII

Title XIX

Medicare

Medicaid

Other

Total

1

2

3

4

1

Gross patient revenues

1

2

Less: Allowances and discounts on patients' accounts

2

3

Net patient revenues (Line 1 minus line 2)

3

4

Operating expenses (From Worksheet A, column 3, line 100)

4

5

Additions to operating expenses (specify)

5

1

2

6

6

7

7

8

8

9

9

10

Total additions (sum of lines 5 through 9)

10

11

Subtractions from operating expenses (specify)

11

12

12

13

13

14

14

15

15

16

Total subtractions (sum of lines 11 through 15)

16

17

Total operating expenses (sum of line 4, plus line 10, minus line 16)

17

18

Net income from service to patients (line 3 minus line 17)

18

Other income:
19

Contributions, donations, bequests, etc.

19

20

Income from investments

20

21

Purchase discounts

21

22

Rebates and refunds of expenses

22

23

Sale of Medical and Nursing Supplies to other than patients

23

24

Sale of durable medical equipment to other than patients

24

25

Sale of drugs to other than patients

25

26

Sale of medical records and abstracts

26

27

Government Appropriations

27

28

Other revenues (specify)

28

29

29

30

30

31

31

32

Total Other Income (sum of lines 19 through 31)

32

33

Net Income or Loss for the period (line 18 plus line 32)

33

FORM CMS-224-14 (03-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4416)

44-118

Rev. 2