Form CMS-2088-17 Form CMS-2088-17

01-21

FORM CMS-2088-17

4590 (Cont.)

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 as overpayments (42 USC 1395g).
COMMUNITY MENTAL HEALTH CENTER COST REPORT
IDENTIFICATION DATA, CERTIFICATION
AND SETTLEMENT SUMMARY

PROVIDER CCN:
____________________

PERIOD:
FROM _______________
TO _______________

PART I - COST REPORT STATUS
Provider use
1. [ ] Electronically prepared cost report
Date:
only
2. [ ] Manually prepared 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.
Contractor
5. [ ] Cost Report Status
6. Date Received:_________
use only
(1) As Submitted
7. Contractor No.:________
(2) Settled without audit
8. [ ] Initial Report for this Provider CCN
(3) Settled with audit
9. [ ] Final Report for this Provider CCN
(4) Reopened
(5) Amended

FORM APPROVED
OMB NO. 0938-0037
EXPIRES: 05/31/2021
WORKSHEET S
PARTS I, II & III

Time:

10. NPR Date:__________
11. Contractor's Vendor Code: ___________
12. [ ] If line 5, column 1 is 4: Enter number of
times reopened = 0-9.

PART II - CERTIFICATION BY A CHIEF FINANCIAL OFFICER OR ADMINISTRATOR
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.
SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR
1
1

CHECKBOX
2

ELECTRONIC
SIGNATURE STATEMENT
I have read and agree with the above certification
statement. I certify that I intend my electronic
signature on this certification be the legally binding
equivalent of my original signature.

2 Signatory Printed Name
3 Signatory Title
4 Signature date

1

2
3
4

PART III - SETTLEMENT SUMMARY
TITLE XVIII
1
1 COMMUNITY MENTAL HEALTH CENTER
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 0938-0037. The time required to complete this information collection is estimated to average 90 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 comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports 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 1-800MEDICARE.
FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4502 THROUGH 4502.3)

Rev. 2

45-303

4590 (Cont.)

FORM CMS-2088-17

COMMUNITY MENTAL HEALTH CENTER IDENTIFICATION DATA

01-21

PROVIDER CCN:
____________________

PERIOD:
FROM _______________
TO _______________

WORKSHEET S-1
PARTS I & II

PART I - IDENTIFICATION DATA
PROVIDER
CCN
2

DATE
CERTIFIED
4

CBSA
3

TYPE OF CONTROL
(SEE INSTRUCTIONS)
5

1
1 Site Name:
2 Street:
P O Box:
3 City:
State:
ZIP Code:
County:
4 Cost Reporting Period (mm/dd/yyyy)
From:
To:
5 Is this CMHC part of a HO/CO as defined in §2150 of CMS Pub. 15-1 that claims HO/CO costs in a home office cost statement?
Enter "Y for yes or "N" for no in column 1. If yes, enter the HO/CO information below.
6 Name of HO/CO:
7 Street:
P O Box:
HO/CO CCN:
8 City:
State:
ZIP Code:
Medical Malpractice
9 Is this CMHC legally required to carry malpractice insurance? Enter "Y" for yes or "N" for no.
10 If line 9 is "Y", is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.

1
2
3
4
5
6
7
8
9
10

PREMIUMS
1

PAID LOSSES
2

SELF
INSURANCE
3

11 Enter total malpractice premiums in col. 1, total paid losses in col. 2, and total self insurance in col. 3
12 Are malpractice premiums and/or paid losses reported in other than the A&G cost center? Enter "Y" for yes or "N" for no. (see instructions)
Miscellaneous

11
12

Y/N
1

DEMONSTRATION TYPE
2

13

Did this facility participate in any payment demonstration during this cost reporting period? Enter "Y" for yes or "N" for no.
If column 1 is yes, enter the type of demonstration in column 2. If the CMHC participated in more than one demonstration,
subscript this line accordingly.
14 Are there any costs included in Worksheet A that resulted from transactions with related organizations as defined in
CMS Pub. 15-1, chapter 10? If yes, complete Worksheet A-8-1.

13

14

PART II - STATISTICAL DATA
REIMBURSABLE
COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12

Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
TOTAL (sum of lines 1 through 10)
Unduplicated Census

REIMBURSABLE
COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12

Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
TOTAL (sum of lines 1 through 10)
Unduplicated Census

WKST
A
23
24
25
26
27
28
29
30
31
32

WKST
A
23
24
25
26
27
28
29
30
31
32

MEDICARE
PATIENTS
1

VISITS
OTHER
PATIENTS
2

TOTAL
3

MEDICARE
4

PATIENT DAYS
OTHER
5

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

STAFF
THERAPISTS
7

FTES ON PAYROLL
SOCIAL
PHYSICIANS
WORKERS
8
9

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

FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4503 THROUGH 4503.2)

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FORM CMS-2088-17

COST REPORT REIMBURSEMENT QUESTIONNAIRE

PROVIDER CCN:
____________________

PROVIDER ORGANIZATION AND OPERATION
1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period?
Enter "Y" for yes or "N" for no in column 1. If yes, enter the date (mm/dd/yyyy) of the change in column 2.
(see instructions)
2 Has the provider terminated participation in the Medicare Program? Enter "Y" for yes or "N" for no in
column 1. If yes, enter in column 2 the termination date (mm/dd/yyyy); and, enter in column 3,
"V" for voluntary or "I" for involuntary.
3 Is the provider involved in business transactions, including management contracts, with individuals or entities
(e.g., chain home offices, drug or medical supply companies) 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? Enter "Y" for yes or "N" for no in column 1. (see instructions)

FINANCIAL DATA AND REPORTS
4 Column 1: Were the financial statements prepared by a Certified Public Accountant? Enter "Y" for yes or
"N" for no.
Column 2: If yes, enter in col. 2: "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit
complete copy of financial statements or enter date available (mm/dd/yyyy) in column 3. (see
instructions) If no, see instructions.
5 Are the cost report total expenses and total revenues different from those on the filed financial statements?
Enter "Y" for yes or "N" for no in column 1. If yes, submit reconciliation.

4590 (Cont.)
PERIOD:
FROM _______________
TO _______________

Y/N
1

WORKSHEET S-2

DATE
2

1

2

3

Y/N
1

A/C/R
2

5

PS&R REPORT DATA
9 Was the cost report prepared using the PS&R report only? Enter "Y" for yes or "N" for no in column 1. If yes, enter in
column 2 the paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions)
10 Was the cost report prepared using the PS&R report for totals and the provider's records for allocation? Enter "Y" for yes or
"N" for no in col. 1.
If yes, enter in col. 2 the paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions)
11 If line 9 or 10 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? Enter "Y" for yes or "N" for no. If yes, see instructions.
12 If line 9 or 10 is yes, were adjustments made to PS&R report data for corrections of other PS&R report information? Enter "Y"
for yes or "N" for no. If yes, see instructions.
13 If line 9 or 10 is yes, were adjustments made to PS&R report data for Other? Enter "Y" for yes or "N" for no.
If yes, describe the other adjustments:
14 Was the cost report prepared only using the provider's records? Enter "Y" for yes or "N" for no.
If yes, see instructions.

Last name:

DATE
3
4

BAD DEBTS
6 Is the provider seeking reimbursement for bad debts? Enter "Y" for yes or "N" for no. If yes, see instructions.
7 If line 6 is yes, did the provider's bad debt collection policy change during the cost reporting period? "Y" for yes or "N" for no. If yes, submit a copy.
8 If line 6 is yes, were patient deductibles and/or co-payments waived? Enter "Y" for yes or "N" for no. If yes, see instructions.

COST REPORT PREPARER CONTACT INFORMATION
15 First name:
16 Employer:
17 Phone number:

V/I
3

Title:
E-mail Address:

Y/N
1

Y/N
6
7
8
DATE
2
9
10

11
12
13
14

15
16
17

FORM CMS-2088-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4504)

Rev. 2

45-305

4590 (Cont.)

FORM CMS-2088-17

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

01-21

PROVIDER CCN:
____________________

COST CENTERS (Omit Cents)

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

0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
1200

23
24
25
26
27
28
29
30
31
32

2300
2400
2500
2600
2700
2800
2900
3000
3100

42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

4200
4300
4400
4500
4600
4700
4800
4900
5000
5100
5200
5300
5400
5500
5600
5700

SALARIES
1

OTHER
2

CONTRACTED
PURCHASED
SERVICES
3

GENERAL SERVICE COST CENTERS
Cap Rel Costs - Bldgs & Fixt
Cap Rel Costs - Mvble Equip
Employee Benefits
Administrative & General
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Cafeteria
Central Services & Supply
Medical Records & Library
Pro Ed & Training (Approved)
Other (specify)
REIMBURSABLE COST CENTERS
Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
NONREIMBURSABLE COST CENTERS
Sheltered Workshops
Recreational Programs
Resident Day Camps
Diagnostic Clinics
Physicians' Private Offices
Fund Raising
Coffee Shops & Canteen
Research
Investment Property
Advertising
Franchise Fees & Other Assessments
Pro Ed & Training (Not Approved)
Meals & Transportation
Activity Therapies
Psychosocial Programs
Vocational Training
Other (specify)
TOTAL (sum of lines 1 through 58)

TOTAL
(sum of col. 1
through col. 3)
4

RECLASSIFICATIONS
5

PERIOD:
FROM _______________
TO _______________

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

WORKSHEET A

ADJUSTMENTS
7

NET EXPENSES
FOR
ALLOCATION
(col. 6 ± col. 7)
8
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100

FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4505)

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FORM CMS-2088-17

RECLASSIFICATIONS

4590 (Cont.)

PROVIDER CCN:
____________________

EXPLANATION OF RECLASSIFICATION(S)

CODE
1

(1)

COST CENTER
2

INCREASE
(2)
LINE NO.
SALARY
3
4

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
36
37
38
39
40

100

NON SALARY
5

(2)

PERIOD:
FROM _______________
TO _______________

COST CENTER
6

WORKSHEET A

DECREASE
LINE NO.
SALARY (2)
7
8

NON SALARY
9

(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
36
37
38
39
40

Total reclassifications (sum of columns 4 and 5
must equal sum of columns 8 and 9)
A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2)
Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A. column 5, line as appropriate.

100

(1)

FORM CMS-2088-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4506)

Rev. 2

45-307

4590 (Cont.)

FORM CMS-2088-17

ADJUSTMENTS TO EXPENSES

PROVIDER CCN:
____________________

DESCRIPTION

(1)

1

Capital Related Costs - Buildings
& fixtures
2 Capital Related Costs - Movable
Equipment
3 Payments received from
specialists
4 Investment income
(chapter 2)
5 Trade, quantity, and time discounts
(chapter 8)
6 Refunds and rebates of expenses
(chapter 8)
7 Laundry and linen service
8 Cafeteria-employees,
guests, etc.
9 Sale of medical and surgical
supplies to other than patients
10 Sale of workshop products
or services
11 Coffee shops and canteen
12

Vending Machines

13

Rental of building or office
space to others
Sale of scrap, waste,
etc. (chapter 23)
Related organization transactions
(chapter 10)
Provider-based physician
adjustment
(3)
Other adjustments (specify)

14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

50

BASIS
1
A

(2)

AMOUNT
2

A

01-21
PERIOD:
FROM _______________
TO _______________

WORKSHEET A-8

EXPENSE CLASSIFICATION ON
WORKSHEET A TO/FROM WHICH
THE AMOUNT IS TO BE ADJUSTED
COST CENTER
LINE NO.
3
4
Capital Related Costs
1
Buildings & Fixtures
Capital Related Costs
2
Movable Equipment

B

1
2
3
4

B

5

B

6

A

Laundry and Linen Service
Cafeteria

7
9

7
8

Central Services and
Supplies

10

9
10
11

A

12
13
14

Wkst.
A-8-1
Wkst.
A-8-2

TOTAL (sum of lines 1 through 49)
(Transfer to Worksheet A, col. 7, line 100.)
(1)

Include amounts not already applied against expenses included on Worksheet A, column 4

(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 17 thru 49 and subscripts thereof.

15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

50

Chapter references are to CMS Pub.15-1

FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4507)

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FORM CMS-2088-17

STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS

PROVIDER CCN:
____________________

4590 (Cont.)
PERIOD:
FROM _______________
TO _______________

WORKSHEET A-8-1

PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS
OR CLAIMED HOME OFFICE COSTS
AMOUNT
AMOUNT
INCLUDED
WKST A
ALLOWABLE
IN WKST A,
LINE NO.
COST CENTER
EXPENSE ITEMS
IN COST
COL 6
1
2
3
4
5
1
2
3
4
5 TOTALS (sum of lines 1 through 4) Transfer col. 6, line 5, to Worksheet A-8,
col. 2, line 15.

NET
ADJUSTMENTS
(COL 4 MINUS
COL 5) *
6
1
2
3
4
5

* The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 7, 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, 2 and/or 3, the amount allowable should be
indicated in column 4 of this part.

PART II - INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish the information requested under Part II of this
worksheet.
This information is used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable to services, facilities and supplies
furnished by organizations related to you by common ownership or control, represent reasonable costs as determined under section 1861 of the Social Security Act. If you
do not provide all or any part of the requested information, the cost report is considered incomplete and not acceptable for purposes of claiming reimbursement under Medicare.

SYMBOL
(1)

1

NAME
2

PERCENT
OF
OWNERSHIP
3

RELATED ORGANIZATIONS AND/OR HO/CO
PERCENT
OF
NAME
OWNERSHIP
TYPE OF 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 provider.
B. Corporation, partnership or other organization has financial interest in provider.
C. Provider has financial interest in corporation, partnership, or other organization.
D. Director, officer, administrator or key person of provider or relative of such
person has financial interest in related organization.
E. Individual is director, officer, administrator or key person of provider and
related organization.
F. Director, officer, administrator or key person of related organization or relative
of such person has financial interest in provider.
G. Other (financial or non-financial) specify __________________________________________________

FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4508)

Rev. 2

45-309

4590 (Cont.)

FORM CMS-2088-17

PROVIDER-BASED PHYSICIANS ADJUSTMENTS

01-21

PROVIDER CCN:
____________________

WKST A
LINE NO.
1

COST CENTER/
PHYSICIAN IDENTIFIER
2

TOTAL
REMUNERATION
3

PROFESSIONAL
COMPONENT
4

PROVIDER
COMPONENT
5

RCE
AMOUNTS
6

PERIOD:
FROM _______________
TO _______________

PHYSICIAN/
PROVIDER
COMPONENT
HOURS
7

WORKSHEET A-8-2

UNADJUSTED
RCE LIMIT
8

5 PERCENT OF
UNADJUSTED
RCE LIMIT
9

1
2
3
4
5
6
7
8
9
10

1
2
3
4
5
6
7
8
9
10

100

TOTAL

WKST A
LINE NO.
10

100

COST CENTER/
PHYSICIAN IDENTIFIER
11

COST OF
MEMBERSHIPS
& CONTINUING
EDUCATION
12

PROVIDER
COMPONENT
SHARE OF
COLUMN 12
13

1
2
3
4
5
6
7
8
9
10

100

PHYSICIAN
COST OF
MALPRACTICE
INSURANCE
14

PROVIDER
COMPONENT
SHARE OF
COLUMN 14
15

ADJUSTED
RCE LIMIT
16

RCE
DISALLOWANCE
17

ADJUSTMENT
18
1
2
3
4
5
6
7
8
9
10

TOTAL

100

FORM CMS-2088-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4509)

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FORM CMS-2088-17

COST ALLOCATION GENERAL SERVICE COSTS

4590 (Cont.)

PROVIDER CCN:
____________________

COST CENTERS

1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
99
100

NET EXPENSES
FROM WKST A
COL 8
0

CAPITAL RELATED
BLDGS &
MOVABLE
FIXTURES
EQUIPMENT
1
2

GENERAL SERVICE COST CENTERS
Cap Rel Costs - Bldgs & Fixt
Cap Rel Costs - Mvble Equip
Employee Benefits
Administrative & General
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Cafeteria
Central Services & Supply
Medical Records & Library
(1)
Pro Ed & Training (Approved)
Other (specify)
REIMBURSABLE COST CENTERS
Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
NONREIMBURSABLE COST CENTERS
Sheltered Workshops
Recreational Programs
Resident Day Camps
Diagnostic Clinics
Physicians' Private Offices
Fundraising
Coffee Shops &Canteen
Research
Investment Property
Advertising
Franchise Fees & Other Assessments
(2)
Pro Ed & Training (Not Approved)
Meals & Transportation
Activity Therapies
Psychosocial Programs
Vocational Training
Other (specify)
Negative Cost Centers
TOTAL (sum of lines 1 through 99)
(1)
Approved Educational Activity (2) Not an Approved Educational Activity

EMPLOYEE
BENEFITS
3

SUBTOTAL
(SUM OF COLS
0 THROUGH 3)
3A

PERIOD:
FROM _______________
TO _______________

ADMINISTRATIVE &
GENERAL
4

WORKSHEET B

MAINTENANCE &
REPAIRS
5

OPRATION
OF PLANT
6
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
99
100

FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)

Rev. 2

45-311

4590 (Cont.)

FORM CMS-2088-17

COST ALLOCATION GENERAL SERVICE COSTS

01-21

PROVIDER CCN:
____________________

COST CENTERS

1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
99
100

LAUNDRY
& LINEN
7

HOUSEKEEPING
8

CAFETERIA
9

GENERAL SERVICE COST CENTERS
Cap Rel Costs - Bldgs & Fixt
Cap Rel Costs - Mvble Equip
Employee Benefits
Administrative & General
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Cafeteria
Central Services & Supply
Medical Records & Library
(1)
Pro Ed & Training (Approved)
Other (specify)
REIMBURSABLE COST CENTERS
Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
NONREIMBURSABLE COST CENTERS
Sheltered Workshops
Recreational Programs
Resident Day Camps
Diagnostic Clinics
Physicians' Private Offices
Fundraising
Coffee Shops &Canteen
Research
Investment Property
Advertising
Franchise Fees & Other Assessments
(2)
Pro Ed & Training (Not Approved)
Meals & Transportation
Activity Therapies
Psychosocial Programs
Vocational Training
Other (specify)
Negative Cost Centers
TOTAL (sum of lines 1 through 99)
(1)
Approved Educational Activity (2) Not an Approved Educational Activity

CENTRAL
SERVICE &
SUPPLY
10

MEDICAL
RECORDS &
LIBRARY
11

PERIOD:
FROM _______________
TO _______________

PROF
EDUCATION
& TRAINING
12

WORKSHEET B

OTHER
(SPECIFY)
13

TOTAL
14
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
99
100

FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)

45-312

Rev. 2

2

01-21

FORM CMS-2088-17

COST ALLOCATION - STATISTICAL BASIS

4590 (Cont.)

PROVIDER CCN:
____________________

COST CENTERS

CAPITAL RELATED
BLDGS &
MOVABLE
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

GENERAL SERVICE COST CENTERS
Cap Rel Costs - Bldgs & Fixt
Cap Rel Costs - Mvble Equip
Employee Benefits
Administrative & General
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Cafeteria
Central Services & Supply
Medical Records & Library
Pro Ed & Training (Approved)(1)
Other (specify)
REIMBURSABLE COST CENTERS
23 Drugs & Biologicals
24 Occupational Therapy
25 Behavioral Health Treatment/Services
26 Individual Therapy
27 Group Therapy
28 Activity Therapy
29 Family Therapy
30 Psychiatric Testing
31 Education Training
32 Other (specify)
NONREIMBURSABLE COST CENTERS
42 Sheltered Workshops
43 Recreational Programs
44 Resident Day Camps
45 Diagnostic Clinics
46 Physicians' Private Offices
47 Fundraising
48 Coffee Shops &Canteen
49 Research
50 Investment Property
51 Advertising
52 Franchise Fees & Other Assessments
53 Pro Ed & Training (Not Approved)(2)
54 Meals & Transportation
55 Activity Therapies
56 Psychosocial Programs
57 Vocational Training
58 Other (specify)
100 Negative Cost Center
101 Cost to be Allocated
102 Unit Cost Multiplier
(1) Approved Educational Activity
(2) Not an Approved Educational Activity
FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)
1
2
3
4
5
6
7
8
9
10
11
12
13

EMPLOYEE
BENEFITS
(GROSS
SALARIES)
3

RECONCILIATION
4A

PERIOD:
FROM _______________
TO _______________

ADMINISTRATIVE &
GENERAL
(ACCUM
COST)
4

WORKSHEET B-1

MAINTENANCE &
REPAIRS
(SQUARE
FEET)
5

OPRATION
OF PLANT
(SQUARE
FEET)
6
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100
101
102

Rev. 2

45-313

4590 (Cont.)

FORM CMS-2088-17

COST ALLOCATION - STATISTICAL BASIS

01-21

PROVIDER CCN:
____________________

COST CENTERS

LAUNDRY
& LINEN
(POUNDS OF
LAUNDRY)
7

HOUSEKEEPING
(HOURS OF
SERVICE)
8

CAFETERIA
(MEALS
SERVED)
9

GENERAL SERVICE COST CEN
Cap Rel Costs - Bldgs & Fixt
Cap Rel Costs - Mvble Equip
Employee Benefits
Administrative & General
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Cafeteria
Central Services & Supply
Medical Records & Library
Pro Ed & Training (Approved)(1)
Other (specify)
REIMBURSABLE COST CENTERS
23 Drugs & Biologicals
24 Occupational Therapy
25 Behavioral Health Treatment/Services
26 Individual Therapy
27 Group Therapy
28 Activity Therapy
29 Family Therapy
30 Psychiatric Testing
31 Education Training
32 Other (specify)
NONREIMBURSABLE COST CENTERS
42 Sheltered Workshops
43 Recreational Programs
44 Resident Day Camps
45 Diagnostic Clinics
46 Physicians' Private Offices
47 Fundraising
48 Coffee Shops &Canteen
49 Research
50 Investment Property
51 Advertising
52 Franchise Fees & Other Assessments
53 Pro Ed & Training (Not Approved)(2)
54 Meals & Transportation
55 Activity Therapies
56 Psychosocial Programs
57 Vocational Training
58 Other (specify)
100 Negative Cost Center
101 Cost to be Allocated
102 Unit Cost Multiplier
(1) Approved Educational Activity
(2) Not an Approved Educational Activity
FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)
1
2
3
4
5
6
7
8
9
10
11
12
13

CENTRAL
SERVICE &
SUPPLY
(COSTED
REQUIS)
10

MEDICAL
RECORDS &
LIBRARY
(TIME
SPENT)
11

PERIOD:
FROM _______________
TO _______________

PROF
EDUCATION
& TRAINING
(ASSIGNED
TIME)
12

WORKSHEET B-1

OTHER
(SPECIFY)
13

TOTAL
14
1
2
3
4
5
6
7
8
9
10
11
12
13
23
24
25
26
27
28
29
30
31
32
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
100
101
102

45-314

Rev. 2

05-18

FORM CMS-2088-17

APPORTIONMENT OF PATIENT SERVICE COSTS

PROVIDER CCN:
____________________

REIMBURSABLE COST CENTERS

23
24
25
26
27
28
29
30
31
32
50

FROM
WKST B,
COL. 14,
REIMBURSABLE
COSTS
1

TOTAL
CHARGES
2

4590 (Cont.)
PERIOD:
FROM _______________
TO _______________

RATIO
OF COST
TO CHARGES
(COL 1 ÷ COL. 2)
3

Drugs & Biologicals
Occupational Therapy
Behavioral Health Treatment/Services
Individual Therapy
Group Therapy
Activity Therapy
Family Therapy
Psychiatric Testing
Education Training
Other (specify)
TOTAL (lines 23 through 32)

WORKSHEET C

MEDICARE
CHARGES
4

MEDICARE
COST
(COL 3 X COL 4)
5
23
24
25
26
27
28
29
30
31
32
50

FORM CMS-2088-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4511)

Rev. 1

45-315

4590 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT

FORM CMS-2088-17
PROVIDER CCN:
____________________

05-18
PERIOD:
FROM _______________
TO _______________

WORKSHEET D

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

DESCRIPTION
Gross APC/PPS payments
Outlier payments
Outlier reconciliation amount (transfer from line 54)
Gross reimbursement (sum of lines 1 through 3)
Primary payer payments
Deductibles billed to program patients (do not include coinsurance)
Coinsurance billed to program patients (see instructions)
Subtotal (line 4 minus lines 5, 6, and 7)
Reimbursable bad debts (see instructions)
Adjusted reimbursable bad debts
Reimbursable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (line 8 plus line 10)
Other adjustments (specify) (see instructions)
Other demonstration payment adjustment amount before sequestration
Amount due prior to the sequestration adjustment (see instructions)
Sequestration adjustment (see instructions)
Other demonstration payment adjustment amount after sequestration
Amount due after sequestration adjustment (see instructions)
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 18 minus lines 19 and 20) (indicate overpayment in brackets)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

50
51
52
53
54

TO BE COMPLETED BY CONTRACTOR
Original outlier amount (see instructions)
Outlier reconciliation adjustment amount (see instructions)
The rate used to calculate the Time Value of Money
Time Value of Money (see instructions)
Total (sum of lines 51 and 53)

50
51
52
53
54

FORM CMS-2088-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4512

45-316

Rev. 1

01-21

FORM CMS-2088-17

ANALYSIS OF PAYMENTS FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES

4590 (Cont.)

PROVIDER CCN:

PERIOD:
FROM _______________
TO _______________

____________________

MM/DD/YYYY
1
1 Total interim payments paid to CMHC
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)

5

6

PART B
AMOUNT
2
1
2

Program
to
Provider

Provider
to
Program

4

WORKSHEET D-1

SUBTOTAL (sum of lines 3.01 through 3.49, minus sum of lines 3.50 through 3.98)
TOTAL INTERIM PAYMENTS (sum of lines 1, 2 and 3.99) (Transfer to Wkst. D, line 19)
TO BE COMPLETED BY CONTRACTOR
List separately each tentative settlement payment
after desk review. Also show date of each
payment. If none, write "NONE" or enter
a zero. (1)

Program
to
Provider
Provider
to
Program

SUBTOTAL (sum of lines 5.01 through 5.49, minus sum of lines 5.50 through 5.98)
Determine net settlement amount (balance due) based
(1)
on the cost report (see instructions)

Program
to
Provider
Provider
to
Program

.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

5.01
5.02
5.03
5.50
5.51
5.52
5.99

.01

6.01

.02

6.02

7 TOTAL MEDICARE PROGRAM LIABILITY (see instructions)

7
1

8

Name of
Contractor
(1)

2
Contractor
Number

3
NPR Date
(MM/DD/YYYY)

8

On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the provider
agrees to the amount of repayment, even though total repayment is not accomplished until a later date.

FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4513)

Rev. 2

45-317

01-21

FORM CMS-2088-17

STATEMENT OF REVENUES AND EXPENSES

PROVIDER CCN:
____________________

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20.50
21
22
23
24
25
26
27
28

4590 (Cont.)
PERIOD:
FROM _______________
TO _______________

DESCRIPTION
Total patient revenue
Less: Allowance and discounts on patients' accounts
Net patient revenues (line 1 minus line 2)
Less: Total operating expenses (per Worksheet A, column 4, line 100)
Net income from service to patients (line 3 minus line 4)
OTHER INCOME
Grants, gifts, and income designated by donor for specific expenses
Payments received from specialists
Investment income on unrestricted funds
Trade, quantity, time and other discounts on purchases
Rebates and refunds of expenses
Income from laundry and linen service
Income from cafeteria - employees, guests, etc.
Sale of medical supplies to other than patients
Sale of workshop products or services
Coffee shops and canteen
Vending machines
Rental of building or office space to others
Sale of scrap, waste, etc.
Sale of medical records and abstracts
Other (Specify)
COVID-19 PHE funding
Total other income (sum of lines 6 through 20)
Total (line 5 plus line 21)
OTHER EXPENSES
Fund raising
Gift, coffee shops, and canteen
Investment property
Other (specify)
Total other expenses (sum of lines 23 through 26)
Net income (or loss) for the period (line 22 minus line 27)

WORKSHEET F

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20.50
21
22
23
24
25
26
27
28

FORM CMS-2088-17 (01-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4514.1)

Rev. 2

45-318