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pdfCHAPTER 46
INDEPENDENT RURAL HEALTH CLINIC
COST REPORT
FORM CMS-222-17
Section
General ........................................................................................................................4600
Rounding Standards for Fractional Computations ......................................................4600.1
Recommended Sequence for Completing Form CMS-222-17 ..........................................4601
Acronyms and Abbreviations ..........................................................................................4602
Worksheet S - Rural Health Clinic Cost Report Certification and Settlement
Summary ....................................................................................................................4603
Part I - Cost Report Status ....................................................................................4603.1
Part II - Certification by a Chief Financial Officer or Administrator........................4603.2
Part III - Settlement Summary...............................................................................4603.3
Worksheet S-1 - Rural Health Clinic Identification Data .................................................4604
Part I - Rural Health Clinic Identification Data .....................................................4604.1
Part II - Rural Health Clinic Consolidated Cost Report
Identification Data ............................................................................................4604.2
Worksheet S-2 - Rural Health Clinic Reimbursement Questionnaire ................................4605
Worksheet S-3 - Rural Health Clinic Statistical Data ......................................................4606
Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses .................4607
Worksheet A-6 - Reclassification................................................................. .....................4608
Worksheet A-8 - Adjustments to Expenses.................................................. .....................4609
Worksheet A-8-1 - Statement of Costs of Services from Related
Organizations and Home Office Costs .........................................................................4610
Part I - Costs Incurred and Adjustments Required as a Result of
Transactions with Related Organizations or Claimed Home Office Costs............4610.1
Part II - Interrelationship to Related Organizations and/or Home Office.................4610.2
Worksheet B - Visits and Overhead Cost for RHC Services ............................................4611
Part I - Visits and Productivity ..............................................................................4611.1
Part II - Determination of Total Allowable Cost Applicable to RHC Services.........4611.2
Worksheet B-1 - Computation of Vaccine Cost...............................................................4612
Worksheet C - Determination of Medicare Payment........................................................4613
Part I - Determination of Rate for RHC Services ...................................................4613.1
Part II - Determination of Total Payment ..............................................................4613.2
Worksheet C-1 - Analysis of Payments to the Rural Health Clinic
for Services Rendered .................................................................................................4614
Exhibit 1-Form CMS-222-17 Worksheets.......................................................................4690
Electronic Cost Reporting Specifications for Form CMS-222-17 .....................................4695
Rev. 2
46-1
This page is reserved for future use.
46-2
Rev. 2
04-21
4600.
FORM CMS-222-17
4600
GENERAL
The Paperwork Reduction Act of 1995 establishes the requirement that the private sector be
informed why information is collected and how it will be used 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 healthcare 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. Rural health clinics (RHCs) must file cost reports in
accordance with 42 CFR 413.24(f). The data submitted on the cost reports supports management
of federal programs. The information reported on Form CMS-222-17, must conform to the
requirements and principles set forth in the Provider Reimbursement Manual, CMS Pub. 15-1, 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.
These forms must be used by all independent rural health clinics (RHC) for cost reporting periods
beginning on or after October 1, 2017, and ending on or after September 30, 2018. These forms
are required for determining Medicare payment for RHC services under 42 CFR 405, Subpart X.
An RHC must complete all applicable items on the worksheets. For its initial reporting period, the
facility completes these worksheets with estimates of costs and visits and other information
required by the reports. The contractor uses the estimates to determine an interim rate of payment
for the facility. Following the end of the facility’s reporting period, the facility is required to
submit its worksheets using data based on its actual experience for the reporting period. This
information is used by the contractor for determining the total Medicare payment due the RHC for
services furnished Medicare beneficiaries.
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 0938-0107. The expiration date of this information
collection instrument is XXXX XX, 2024. The time required to complete this information
collection is estimated to average 55 hours per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions
for improving this form, please write to:
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Attn: PRA 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 1-800-MEDICARE.
Rev. 2
46-3
4600.1
FORM CMS-222-17
04-21
4600.1 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 for pneumococcal vaccine
2.
Round to 6 decimal places:
a. Ratios
b. Limit adjustments
4601. RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-222-17
Step
No.
Worksheet
Instructions
1
S, Part I
Read §4603.1. Complete Part I.
2
S-1, Part I
Read §4604.1. Complete entire worksheet.
3
S-1, Part II
Read §4604.2. Complete entire worksheet.
4
S-2
Read §4605. Complete entire worksheet if applicable.
5
S-3
Read §4606. Complete entire worksheet.
6
A
Read §4607. Complete columns 1 through 3, lines 1 through
100.
7
A-6
Read §4608. Complete entire worksheet if applicable.
8
A
Read §4607. Complete columns 4 and 5, lines 1 through 100.
9
A-8-1, Parts I & II
Read §4610 through 4610.2.
applicable.
10
A-8
Read §4609. Complete entire worksheet.
11
A
Read §4607. Complete columns 6 and 7, lines 1 through 100.
12
B, Parts I & II
Read §§4611 through 4611.2. Complete entire worksheet.
13
B-1
Read §4612. Complete if applicable.
14
C, Parts I & II
Read §§4613 through 4613.2. Complete lines 1 through 34.
15
C-1
Read §4614. Complete lines 1 through 4.
16
C, Part II
Read §§4613 through 4613.2. Complete lines 35 through 38.
17
S, Parts II & III
Read §4603.3. Complete Parts II & III.
46-4
Complete entire worksheet if
Rev. 2
04-21
FORM CMS-222-17
4602
4602. 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.
ACA
CBSA
CCN
CCM
CFR
CMS
CNM
COL
CP
CSW
ECR
FR
FTE
GME
HCRIS
HRSA
LPN
MBI
MPFS
NP
NPR
PA
PCRE
RCE
RN
TCM
THC
Rev. 2
-
Affordable Care Act
Core Based Statistical Areas
CMS Certification Number
Chronic Care Management
Code of Federal Regulations
Centers for Medicare & Medicaid Services
Certified Nurse Midwife
Column
Clinical Psychologist
Clinical Social Worker
Electronic Cost Report
Federal Register
Full Time Equivalents
Graduate Medical Education
Healthcare Cost Report Information System
Health Resources and Services Administration
Licensed Practical Nurse
Medicare Beneficiary Identifier
Medicare Physician Fee Schedule
Nurse Practitioner
Notice of Program Reimbursement
Physician Assistant
Primary Care Residency Expansion
Reasonable Compensation Equivalency limits
Registered Nurse
Transitional Care Management
Teaching Health Center
46-5
4603
FORM CMS-222-17
04-21
4603. WORKSHEET S - RURAL HEALTH CLINIC COST REPORT CERTIFICATION
AND SETTLEMENT SUMMARY
4603.1 Part I - Cost Report Status.--This section is to be completed by the RHC and contractor
as indicated on the worksheet. If this is a consolidated cost report, the organization must choose a
primary RHC whose CMS certification number (CCN) must be utilized throughout the entire cost
report.
Lines 1 and 2.--The provider must check the appropriate box to indicate on line 1 or 2, whether
this cost report is prepared electronically or manually. Only RHCs submitting manually prepared
cost reports, 1) reporting low Medicare utilization in accordance with CMS Pub. 15-2, chapter 1,
§110, or 2) after demonstrating financial hardship in accordance with §133, may select line 2,
manually prepared. For electronically prepared cost reports, indicate on line 1, columns 2 and 3
respectively, the date and time corresponding to the creation of the electronic file. The date and
time remains as an identifier for the file by the contractor and is archived accordingly.
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 a full cost report or 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 RHC.
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 RHC CCN. A final cost report is a terminating cost report
for a particular RHC 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 MCRIF32 or “3” for HFS CompuMax.
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.
46-6
Rev. 2
04-21
FORM CMS-222-17
4604.1
4603.2 Part II - Certification by a Chief Financial Officer or Administrator.--After the cost
report is completed, an administrator or the Chief Financial Officer completes this certification
section to comply with the regulations set forth in 42 CFR 413.24(f)(4)(iv)(A) and (B).
Line 1.--The signatory (administrator or Chief Financial Officer) must:
• when signing electronically through the ECR software, sign in column 1 as provided in
42 CFR 413.24(f)(4)(iv)(C)(1); and in column 2, enter “Y” (for yes) to check the
electronic signature checkbox to transmit the cost report electronically with an electronic
signature; or
• when signing outside the ECR software, sign in column 1 as provided in
42 CFR 413.24(f)(4)(iv)(C)(1); and enter a check mark in column 2, to check the
electronic signature checkbox to submit the cost report with an electronic signature; or
• sign in column 1 as provided in 42 CFR 413.24(f)(4)(iv)(C)(2); and make no entry in
column 2 to submit the cost report with an original signature.
Lines 2, 3, and 4.--Enter the signatory name, the signatory title, and the date signed on lines 2, 3,
and 4, respectively.
4603.3 Part III - Settlement Summary.--Enter the balance due to or due from the Medicare
program. Transfer the amount from Worksheet C, Part II, line 37.
4604. WORKSHEET S-1 - RURAL HEALTH CLINIC IDENTIFICATION DATA
This worksheet consists of two parts:
Part I - Rural Health Clinic Identification Data
Part II - Rural Health Clinic Consolidated Cost Report Participant Identification Data
4604.1 Part I - Rural Health Clinic Identification Data.--The information required on this
worksheet is needed to properly identify the RHC, or in the case of a consolidated cost report, the
primary RHC. In the case of a consolidated cost report, only the primary RHC completes the entire
Worksheet S-1, Part I. All other RHCs filing under a consolidated cost report must be listed on
subscripts of line 14 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 RHC operates by entering a number
from the list below:
1
2
3
4
5
6
Rev. 2
= Voluntary Nonprofit, Corporation
= Voluntary Nonprofit, Other
= Proprietary, Individual
= Proprietary, Corporation
= Proprietary, Partnership
= Proprietary, Other
7 = Governmental,
8 = Governmental,
9 = Governmental,
10 = Governmental,
11 = Governmental,
Federal
State
County
City
Other
46-7
4604.1 (Cont.)
FORM CMS-222-17
04-21
Line 2.--Enter the RHC’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, and county in column
4.
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 RHC is owned, leased or controlled by an entity that operates
multiple RHCs. Enter a “Y” for yes or an “N” for no. If yes, complete lines 6 through 8.
Otherwise, skip to line 9.
Lines 6 through 8.--Enter the name of the entity that owns, leases or controls the RHC, the street
address, P.O. box (if applicable), city, state, and ZIP code.
Line 9.--Is this RHC 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.--Is this RHC 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 RHC requested
approval to file a consolidated cost report, in column 3 the date the contractor approved the RHC’s
request to file a consolidated cost report, and in column 4 the number of RHCs included in this
consolidated cost report other than the primary RHC.
Line 14.--If the response to line 13, column 1 is yes, list on line 14, beginning with the subscript
line 14.01, each RHC that is part of this consolidated cost report, excluding the RHC listed on line
1. Enter in column 1 the site name, column 2 the CCN, column 3 the CBSA, column 4 the date
the RHC requested approval to file as part of a consolidated cost report, and column 5 the date the
contractor approved the RHCs request to file as part of a consolidated cost report. Each RHC
listed on line 14, beginning with the subscript line 14.01, must complete a separate Worksheet S-1,
Part II.
Line 15.--Indicate if your RHC carries commercial malpractice coverage. Enter “Y” for yes or
“No” for no. Malpractice insurance premiums are money paid by the RHC to a commercial insurer
to protect the RHC against potential negligence claims made by their patients/clients.
46-8
Rev. 2
04-21
FORM CMS-222-17
4604.1 (Cont.)
Line 16.--If line 15 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 17.--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 RHC to compensate a patient/client for professional
negligence. Malpractice self-insurance is money paid by the RHC where the RHC acts as its own
insurance company (either as a sole or part-owner) to financially protect itself against professional
negligence. Often RHCs will manage their own funds or purchase a policy referred to as captive
insurance, which provides insurance coverage the RHC needs but could not obtain economically
through the mainstream insurance market.
Line 18.--Indicate if malpractice premiums paid, paid losses, or self-insurance are reported in a
cost center other than the Malpractice Premiums cost center, Worksheet A, line 28. Enter “Y” for
yes or “N” for no. If yes, submit a supporting schedule listing cost centers and amounts.
Line 19.--Is this RHC and/or any consolidated RHCs 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.
Line 20.--Have you received an approval for an exception to the productivity standard? Enter “Y”
for yes and “N” for no.
Line 21.--Does the facility operate as other than a RHC? Enter “Y” for yes or “N” for no.
Line 22.--If line 21 is yes, enter the type of operation (i.e., laboratory or physicians services).
Line 23.--Enter on lines 23.01 through 23.07 the hours of operation (from/to) based on a 24 hour
clock next to the appropriate day that the facility is available to provide RHC services. For
example 8:00 am is 0800 and 5:30 pm is 1730.
Line 24.--If line 23 is yes, enter on lines 24.01 through 24.07 the hours of operation (from/to) next
to the appropriate day that the facility is available to provide other than RHC services.
Line 25.--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 RHC participated in more than one demonstration, subscript this line for column
2, as applicable.
Line 26.--Are there any related organization costs claimed as defined in CMS Pub. 15-1 chapter
10? Enter “Y” for yes or “N” for no. If yes, complete worksheet A-8-1.
Rev. 2
46-9
4604.2
FORM CMS-222-17
04-21
4604.2 Part II - Rural Health Clinic Consolidated Cost Report Identification Data.-Each RHC
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 RHCs are reported on Worksheet S-1, Part I, line 14 and its
subscripts. Do not complete this worksheet for the primary RHC reported on Worksheet S-1, Part
I, line 1.
Line 1.--Enter the RHC site name in column 1 and the RHC certification date in column 2. Indicate
the type of control under which the RHC 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,
8 = Governmental,
9 = Governmental,
10 = Governmental,
11 = Governmental,
Federal
State
County
City
Other
Enter the date the RHC 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.
If the RHC 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 RHC’s street address in column 1 and the 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, and county in column
4.
Line 4.--Indicate if your RHC carries commercial malpractice coverage. Enter “Y” for yes or “N”
for no. Malpractice insurance premiums are money paid by the RHC to a commercial insurer to
protect the RHC against potential negligence claims made by their patients/clients.
46-10
Rev. 2
05-18
FORM CMS-222-17
4604.2 (Cont.)
Line 5.--If line 4 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 6.--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 RHC to compensate a patient/client for professional
negligence. Malpractice self-insurance is money paid by the RHC where the RHC acts as its own
insurance company (either as a sole or part-owner) to financially protect itself against professional
negligence. Often RHCs will manage their own funds or purchase a policy referred to as captive
insurance, which provides insurance coverage the RHC needs but could not obtain economically
through the mainstream insurance market.
Line 7.--Does the facility operate as other than a RHC? Enter “Y” for yes or “N” for no.
Line 8.--If line 7 is yes, enter the type of operation (i.e., laboratory or physicians services).
Line 9.--Enter on lines 9.01 through 9.07 the hours of operation (from/to) based on a 24 hour clock
next to the appropriate day that the facility is available to provide RHC services. For example
8:00 am is 0800 and 5:30 pm is 1730.
Line 10.--If 7 is yes, enter on lines 10.01 through 10.07 the hours of operation (from/to) next to
the appropriate day that the facility is available to provide other than RHC services.
Rev. 1
46-11
4605
FORM CMS-222-17
05-18
4605. WORKSHEET S-2 - RURAL HEALTH CLINIC REIMBURSEMENT
QUESTIONNAIRE
This worksheet collects organizational, financial and statistical information previously reported on
Form CMS-339.
Where instructions for this worksheet direct the RHC 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 RHC.
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 RHCs reported
on Worksheet S-1, Part I, line 1.
Line 1.--Indicate whether the RHC 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 RHC 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 RHC 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 RHC 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 Pub.
15-1, chapter 10 and 42 CFR 413.17.)
46-12
Rev. 1
05-18
FORM CMS-222-17
4605 (Cont.)
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 29. 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, at a minimum, the documentation requested
on Exhibit 1 to support the bad debts claimed.
Rev. 1
46-13
4605 (Cont.)
FORM CMS-222-17
05-18
Exhibit 1 requires the following documentation:
Columns 1, 2, 3, 4 - Patient Names, Medicare Beneficiary Identifier (MBI) 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, MBI 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.)
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 RHC’s files and should correlate with the beneficiary
name, MBI 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, MBI 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.--If line 8 is yes, 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.--If line 8 is yes, 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.
46-14
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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.
Line 12.--Indicate whether the cost report was prepared using the PS&R for totals and the RHC’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 RHCs 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 RHC 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 detailed documentation was previously
supplied, submit only necessary updated documentation with the cost report.
Rev. 1
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05-18
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 RHC). If the RHC
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.
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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FORM CMS-222-17
4605 (Cont.)
EXHIBIT 1
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
RHC Name ____________________
RHC CCN ______________________
FYE _________________________
Patient Name
1
MBI. No.
2
Prepared By __________________________________
Date Prepared ________________________________
Dates of Service
Indigency& Medicaid
Beneficiary (Check if applicable)
From
To
Yes
Medicaid
Number
3
4
5
6
Date First
Bill Sent to
Beneficiary
Date Collection
Efforts Ceased
Medicare
Remittance
Advice Dates
Co-Insurance/
T otal Medicare
Bad Debts*
7
8
9
10
*These amounts must not be claimed unless the RHC 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.
Rev. 1
46-17
4606
FORM CMS-222-17
05-18
4606. WORKSHEET S-3 - RURAL HEALTH CLINIC STATISTICAL DATA
This worksheet 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 RHC can be seen for three types of visits:
•
•
•
Medical Visit - A face to face encounter between an RHC patient and one of the following :
a physician, physician assistant, nurse practitioner, certified nurse midwife, registered
nurse, or licensed practical nurse. 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 RHC patient and one the of the
following: a clinical psychologist, clinical social worker, or a physician, physician
assistant, nurse practitioner, certified nurse midwife, registered nurse, or a licensed
practical nurse for mental health services.
All visits performed by interns and residents who are funded by a Teaching Health Center (THC)
or Primary Care Residency Expansion (PCRE) grant from HRSA must be included in column 4
(other), lines 1 through 4, as applicable, on this worksheet.
Column 0.--Use this column to identify the primary RHC listed on Worksheet S-1, Part I, line 1,
and if you are filing a consolidated cost report, each RHC listed on Worksheet S-1, Part I, line 14,
beginning with the subscripted line 14.01, in the exact same order.
Columns 1 through 3.--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). Intern and resident visits are a subset of the medical or mental health visits. Include dually
eligible (Medicare/Medicaid) beneficiaries in column 2.
Column 4.--Enter the number of medical visits, mental health visits, and visits performed by
interns and residents, for all other payors by adding visits in columns 1 through 3 and subtracting
from total visits reported in column 5.
Column 5.--Enter the total medical visits, mental health visits, and visits performed by interns and
residents, for the entire facility. The total in this column will be used to compute all other payors
in column 4.
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Line 1.--Enter the number of medical visits applicable to columns 1 through 3, and 5. Each visit
to the RHC by the beneficiary counts as a single visit, even in the case where a beneficiary returns
to the RHC 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 RHC 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 3, and 5, for each RHC 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 3, and 5. Each
visit to the RHC by the beneficiary counts as a single visit, even in the case where a beneficiary
returns to the RHC 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
RHC 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
3, and 5, for each RHC 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 applicable to columns
1 through 3, and 5. 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 RHC
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 3, and 5 for each RHC listed
on line 5 and its subscripts.
Line 6.--Enter the total number of visits performed by interns and residents (sum of line 5 and its
subscripts) for each applicable column.
Line 7.--Enter the total number of medical and mental health visits (sum of lines 2 and 4).
NOTE: When reporting data for RHCs reporting under the consolidated cost reporting provisions,
subscript lines 1, 3, and 5 in the identical sequence that the consolidated RHCs are reported on
Worksheet S-1, Part I, line 14, beginning with subscripted line 14.01.
Rev. 1
46-19
4607
FORM CMS-222-17
05-18
4607. WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES
Use Worksheet A to record the trial balance of expense accounts from your accounting books and
records. The worksheet also provides for the necessary reclassifications and adjustments to certain
accounts. All cost centers listed do not apply to all RHCs using this worksheet. For example, an
RHC that does not have an intern and resident program will not complete lines 29 and/or 78. In
addition to those lines listed, the worksheet also provides blank lines for other RHC cost centers.
Complete only those lines that are applicable.
If the cost elements of a cost center are maintained separately on your 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 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. Added cost centers
must be appropriately coded. Identify the added line as a numeric subscript of the immediately
preceding line. That is, if two lines are added between lines 25 and 26, identify them as lines 25.01
and 25.02.
Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by health care providers on the Medicare cost reports. The Form CMS-222-17 provides for
preprinted cost center descriptions that may apply to RHC services 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, hereafter referred to as the standard cost centers.
One additional cost center description with general meaning has been identified. This additional
description will hereafter be referred to as a nonstandard label with an “Other...” designation to
provide for situations where no match in meaning to the standard cost centers can be found. Refer
to Worksheet A, line 10. Additionally, nonstandard cost center descriptions have been identified
through analysis of frequently used labels.
The use of this coding methodology allows providers 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 RHC’s label in their electronic file provide standardized meaning for data analysis.
RHCs are required to compare any added or changed label 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 §4695, Table 5 of the electronic reporting specifications.
Also, submit the working trial balance of 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 is used as a basic summary for financial statements.
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
reporting period. Detail the expenses as salaries (column 1) and other than salaries (column 2).
The sum of columns 1 and 2 must equal column 3. Record any needed reclassification and
adjustments in columns 4 and 6, as appropriate.
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4607 (Cont.)
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 RHC’s accounting books and
records. Do not include costs attributable to contracted labor in this column. Contracted labor is
only reported in column 2.
Column 2.--Enter all costs other than salaries from the RHC’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-6.
The net total of the entries in column 4 must equal zero on line 100. Show reductions to expenses
as negative numbers.
Column 5.--Adjust the amounts entered in column 3 by the amounts in column 4 (increase or
decrease) and extend the net balances to column 5. The total of column 5, line 100, must equal
the total of column 3, line 100.
Column 6.--Enter on the appropriate lines the amounts of any adjustments to expenses indicated
on Worksheet A-8, column 2. The total on Worksheet A, column 6, line 100, must equal the
amount on Worksheet A-8, column 2, line 50.
Column 7.--Adjust the amounts in column 5 by the amounts in column 6 (increases or decreases)
and extend the net balances to column 7.
Transfer the amounts in column 7 to the appropriate lines on Worksheet B and Worksheet B-1.
Line Descriptions
Line 1 - Physician.--This cost center includes the costs incurred by the RHC 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. The costs incurred
for teaching physicians and interns and residents must be reported on line 29. Physician services
provided under an agreement are reported on line 15.
Line 2 - Physician Assistant.--This cost center includes the costs incurred by the RHC for physician
assistants (PA), including the costs for PAs providing physician services.
Rev. 1
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05-18
Line 3 - Nurse Practitioner.--This cost center includes the costs of nursing care provided by nurse
practitioners (NP), including NPs providing physician services.
Line 4 -- Certified Nurse Midwife.--This cost center includes the costs of services provided by a
Certified Nurse Midwife (CNM).
Line 5 - Registered Nurse.--This cost center only includes the costs of nursing care provided by
registered nurses (RNs) who perform nurse services in accordance with CMS Pub. 100-02, chapter
13, §190.
Line 6 - 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, §190.
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FORM CMS-222-17
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This page is reserved for future use.
Rev. 1
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FORM CMS-222-17
05-18
Line 7 - Clinical Psychologist.--This cost center includes the costs of a clinical psychologist (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.
Line 8 - Clinical Social Worker.--This cost center includes the costs of a clinical social worker
(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 9 - 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 10.--Enter costs for all other health care staff not entered on lines 1 through 9.
Line 14.--Enter the sum of the amounts on lines 1 through 10.
Lines 11 through 13.--Reserved for future use.
Line 15 - Physician Services Under Agreement.--This cost center includes the costs incurred by
the RHC for physicians services that are provided on a short term or irregular basis under
agreements.
Line 16 - Physician Supervision Under Agreement.--This cost center includes the costs incurred
by the RHC for physician supervision services under agreement.
Line 17.--Enter the sum of the amounts on lines 15 and 16.
Lines 18 through 24.--Reserved for future use.
Line 25 - 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.
Line 26 - Transportation (Health Care Staff).--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 RHC business.
Line 27 - Depreciation-Medical Equipment.--Enter the medical equipment depreciation expense.
Line 28 - Malpractice Premiums.--Enter the malpractice premiums expense for the cost reporting
period.
Line 29 - Allowable GME Costs.--Enter the total allowable interns and residents 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
46-24
Rev. 1
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FORM CMS-222-17
4607 (Cont.)
reasonable compensation equivalency limits (RCEs) (42 CFR 415.70); and overhead costs that are
directly assigned to the intern and resident program. 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-6 (see
§4608).
Additionally, an RHC 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 29, 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 29, the RHC 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 RHC. Therefore, costs associated with
a “moonlighting” intern or resident are reported in the physician services cost center, not the
allowable GME cost center.
Line 30 - Pneumococcal Vaccines & Med Supplies.--This cost center includes the cost of the
pneumococcal vaccines and the medical supplies attributable to pneumococcal vaccinations.
Line 31 - Influenza Vaccines & Med Supplies.--This cost center includes the cost of the influenza
vaccines and the medical supplies attributable to influenza vaccinations.
Line 31.10 - COVID-19 Vaccines & Med Supplies.--Enter the cost of COVID 19 vaccines and the
medical supplies attributable to COVID-19 vaccinations, authorized and furnished for use during
the COVID-19 public health emergency (PHE). Do not report the cost of COVID-19 vaccines
provided by the government free of charge.
Line 31.11 - Monoclonal Antibody Products.--Enter the cost of monoclonal antibody products for
treatment of COVID-19, authorized and furnished for use during the COVID-19 PHE. Do not report
the cost of monoclonal antibody products for treatment of COVID-19 provided by the government
free of charge.
Line 32.--Enter the expenses of other health care costs not entered on lines 25 through 31.
Line 38.--Enter the sum of the amounts on lines 25 through 32.
Line 39.--Enter the sum of the amounts on lines 14, 17, and 38. Transfer the total amount in column
7 to Worksheet B, Part II, line 12 reduced by the amount on line 29, column 7.
Lines 33 through 37.--Reserved for future use.
Lines 40 through 48.--Enter the overhead expenses related to the facility.
Line 59.--Enter the sum of the amounts on lines 40 through 48.
Lines 49 through 58.--Reserved for future use.
Lines 60 through 68.--Enter the expenses related to the administration and management of the RHC.
Rev. 2
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Lines 69 through 72.--Reserved for future use.
Line 73.--Enter the sum of the amount on lines 60 through 68.
Line 74.--Enter the sum of lines 59 and 73. Transfer the total amount in column 7 to Worksheet B,
Part II, line 16.
Line 75 - 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 RHC visit.
Line 76 - Dental.--Enter the cost incurred for dental services rendered (excluding overhead).
Line 77 - Optometry.--Enter the cost incurred for optometry services rendered (excluding overhead).
Line 78 - Nonallowable GME Pass Through Costs.--This cost center includes the costs associated
with an intern and resident program not approved by Medicare.
Line 79 - Telehealth.--This cost center includes the cost of telehealth distant-site services as
described in CMS Pub. 100-02, chapter 13, §200.
Line 80 - Chronic Care Management.--This cost center includes the cost related to the structured
recording of patient health information, an electronic health care plan addressing all health issues,
access to chronic care management (CCM) 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
80 FR 71080 (November 16, 2015).
Line 81.--Enter the cost applicable to services other than RHC services (excluding overhead) not
entered on lines 75 through 80.
Lines 82 through 85.--Reserved for future use.
Line 86.--Enter the sum of the amounts on lines 75 through 81.
Line 87 through 89.--Enter other cost of services that are not reimbursable under Medicare.
Line 90.--Enter the sum of the amounts on lines 87 through 89.
Lines 91 through 99.--Reserved for future use.
Line 100.--This is the total cost of the facility. It is the sum of the amounts on lines 39, 74, 86, and
90.
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4609
4608. WORKSHEET A-6 - 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. For example, if a physician performs administrative duties, the appropriate portion of his/her
compensation, payroll taxes and fringe benefits must be reclassified from “Facility Health Care Staff
Cost” to “Facility Overhead”, line 60 for the office salaries and line 67 for the benefits and taxes.
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.
4609. WORKSHEET A-8 - 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, chapter 23, §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.
Line Descriptions
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.)
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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 capitalrelated - 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-8-1, 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 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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FORM CMS-222-17
4610.2
4610. WORKSHEET A-8-1 - 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 RHC by organizations related to the RHC 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 RHC by organizations related to the
RHC 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.
4610.1 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 RHC 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 item.
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.
4610.2 Part II - Interrelationship to Related Organizations and/or Home Office.--This part of the
worksheet identifies the interrelationship between the RHC and individuals, partnerships,
corporations, or other organizations having either a related interest to, a common ownership with,
or control over the RHC as defined in CMS Pub. 15-1, chapter 10. Complete columns 1 through 6
as applicable for each interrelationship.
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 RHC and the related
organization or home office. Select from the following choices:
Rev. 1
46-29
4610.2 (Cont.)
Symbol
A
B
C
D
E
F
G
FORM CMS-222-17
05-18
Relationship
Individual has financial interest (stockholder, partner, etc.) in both the related
organization and in 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 RHC, enter the percent of ownership.
Column 4.--Enter the name of each related corporation, partnership, or other organization.
Column 5.--If the RHC, 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).
46-30
Rev. 1
05-18
FORM CMS-222-17
4611.1
4611. WORKSHEET B - VISITS AND OVERHEAD COST FOR RHC SERVICES
Worksheet B is used by the RHC to summarize (1) the visits furnished by your health care staff and
by physicians under agreements with you, and (2) the overhead costs incurred by you which apply
to RHC services.
4611.1 Part I - Visits and Productivity.--Use Part I to summarize the number of facility visits
furnished by the health care staff and to calculate the number of visits to be used in the rate
determination. Productivity standards established by CMS are applied as a guideline that reflects
the total combined services of the staff. Apply a level of 4200 visits for each physician and a level
of 2100 visits for each nonphysician practitioner. (See CMS Pub. 100-02, chapter 13, §80.4)
Lines 1 through 11 (and applicable subscripts) of Part I list the types of practitioners (positions)
for whom facility visits must be counted and reported.
Line 1--Enter the number of full time equivalents (FTEs) and total visits furnished to facility patients
by staff physicians working at the facility on a regular ongoing basis. Also include on this line,
physician data (FTEs and visits) for services furnished to facility patients by staff physicians
working under contractual agreement with you on a regular ongoing basis in the RHC facility. These
physicians are subject to productivity standards.
Column 1.--Record the number of all FTE personnel in each of the applicable staff positions in the
facility practice.
Column 2.--Record the total visits actually furnished to all patients by all personnel in each of the
applicable staff positions in the reporting period. Count visits in accordance with instructions in 42
CFR 405.2463(a) defining a visit.
Column 3.--Productivity standards established by CMS are guidelines that reflect the total combined
services of the staff. Apply a level of 4200 visits for each physician and 2100 visits for each
nonphysician practitioner. However, if you were granted an exception to the productivity standards
(answered yes to question 22 of Worksheet S-1, Part I), enter on lines 1 through 3 the number of
productivity visits approved by the contractor.
Contractors have the authority to waive productivity guidelines in cases where you have
demonstrated reasonable justification for not meeting the standard. In such cases, the contractor
may set any number of visits as reasonable (not just actual visits) if an exception is granted. For
example, if the guideline is 4200 visits and you furnished only 1000 visits, the contractor may permit
2500 visits to be used in the calculation.
Column 4.--This is the minimum number of facility visits the personnel in each staff position are
expected to furnish. Enter the product of column 1 and column 3.
Column 5.--Enter the greater of the visits from column 2 or column 4. Contractors have the authority
to waive the productivity guideline in cases where you have demonstrated reasonable justification
for not meeting the standard. In such cases, the contractor could set any number of visits as
reasonable (not just your actual visits) if an exception is granted. For example, if the guideline
number is 4200 visits and you have only furnished 1000 visits, the contractor need not accept the
1000 visits but could permit 2500 visits to be used in the calculation.
Line 5.--Enter the total of lines 1 through 4.
Rev. 1
46-31
4611.2
FORM CMS-222-17
05-18
Line 10.--Enter the total of lines 5 through 9.
Line 11.--Enter the number of visits furnished to facility patients by physicians under agreement
with you who do not furnish services to patients on a regular ongoing basis in the RHC facility.
Physician’s services under agreements with you are (1) all medical services performed at your site
by a nonstaff physician who is not the owner or an employee of the facility, and (2) medical services
performed at a location other than your site by such a physician for which the physician is
compensated by you. While all physician services at your site are included in RHC services,
physician services furnished in other locations by physicians who are not on your full time staff are
paid to you only if your agreement with the physician provides for compensation for such services.
4611.2 Part II - Determination of Total Allowable Cost Applicable to RHC Services.--Use Part II
to determine the amount of overhead cost applicable to RHC services.
Line 12.--Enter the cost of RHC services (excluding overhead and allowable GME costs) from
Worksheet A, column 7, line 39, less the amount on Worksheet A, column 7, line 29.
Line 13.--Enter the cost of services (other than RHC services) excluding overhead from Worksheet
A, column 7, sum of lines 86 and 90.
Line 14.--Enter the cost of all services (excluding overhead), determined as the sum of lines 12 and
13.
Line 15.--Enter the percentage of RHC services. This percentage is determined by dividing the
amount on line 12 (the cost of RHC services) by the amount on line 14 (the cost of all services,
excluding overhead).
Line 16.--Enter the total overhead costs incurred from Worksheet A, column 7, line 74. It is the
sum of facility costs and administrative overhead costs.
Line 17.--Enter the overhead amount applicable to RHC services. Multiply the ratio on line 15 (the
percentage of RHC services) by the amount on line 16 (total overhead).
Line 18.--Enter the total allowable cost of RHC services. Enter the sum of line 12 (cost of RHC
services other than overhead services) and line 17 (overhead services applicable to RHC services).
46-32
Rev. 1
04-21
FORM CMS-222-17
4612
4612. WORKSHEET B-1 - COMPUTATION OF 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. Additionally, in accordance with §3713 of the
Coronavirus Aid, Relief, and Economic Security (CARES) Act, during the COVID-19 public health
emergency (PHE), this worksheet computes the cost of COVID-19 vaccines and monoclonal
antibody products for treatment of COVID-19 and their administration to Medicare and Medicare
Advantage (MA) enrollees for calendar years 2020 and 2021.
Report the applicable data in columns 1, 2, 2.01, and 2.02, for pneumococcal vaccines, influenza
vaccines, COVID-19 vaccines, and monoclonal antibody products for treatment of COVID-19,
authorized for use during the COVID-19 PHE. The data entered in all columns (1, 2, 2.01, and 2.02)
for lines 4, 11, 13, and 13.01 are mutually exclusive. That is, the injection/infusion costs, the total
number of injections/infusions administered, and the total number of Medicare/MA covered
injections/infusions must only be represented one time in the appropriate column.
Line 1.--Enter the health care staff cost from Worksheet A, column 7, line 14.
Line 2.--Enter the ratio of the estimated percentage of time involved in administering
injections/infusions, including the time involved in administering COVID-19 vaccines and
monoclonal antibodies for treatment of COVID-19, to the total health care staff time. Do not include
physician service 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 injections/infusions and the cost of related medical supplies from
Worksheet A, column 7, lines 30, 31, 31.10, and 31.11, in columns 1, 2, 2.01, and 2.02, respectively.
Line 5.--Enter the sum of lines 3 and 4.
Line 6.--Enter the amount of total direct cost of the facility from Worksheet A, column 7, line 39.
Line 7.--Enter the amount from Worksheet A, column 7, line 74.
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 amount 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, 2, 2.01, and 2.02, respectively, the total number of injections/infus ions
from your records.
Line 12.--Enter the cost per injection/infusion by dividing the amount on line 10 by the number on
line 11 and entering the result.
Line 13.--Enter from your records the number of injections/infusions administered to Medicare
beneficiaries, in columns 1, 2, 2.01, and 2.02, respectively.
Line 13.01.--Enter from your records the number of COVID-19 injections/infusions administered
to MA enrollees, in columns 2.01 and 2.02, respectively.
Rev. 2
46-33
4613
FORM CMS-222-17
04-21
Line 14--Enter the Medicare cost of injections/infusions by multiplying the amount on line 12 by
the sum of the amount on lines 13 and 13.01, as applicable.
Line 15--Enter the total cost of injections/infusions and their administration by entering the sum
of the amounts in columns 1, 2, 2.01, and 2.02, line 10. Transfer this amount to Worksheet C, Part
I, line 2.
Line 16--Enter the Medicare cost of injections/infusions and their administration by entering the
sum of the amount in columns 1, 2, 2.01, and 2.02, line 14. Transfer the result to Worksheet C,
Part II, line 23.
4613. WORKSHEET C - DETERMINATION OF MEDICARE PAYMENT
Use this worksheet to determine the interim all inclusive rate of payment and the total Medicare
payment reimbursement calculation for RHC services rendered to program patients for the
reporting period.
4613.1 Part I - Determination of Rate for RHC Services.--Use Part I to calculate the cost per visit
for RHC services and to apply the screening guideline established by CMS on your health care
staff productivity.
Line 1.--Enter the total allowable cost from Worksheet B, Part II, line 18.
Line 2.--Enter the total cost of injections/infusions from Worksheet B-1, line 15.
Line 3.--Subtract the amount on line 2 from the amount on line 1 and enter the result.
Line 4.--Enter the greater of the minimum or actual visits by the health care staff from
Worksheet B, Part I, column 5, line 10.
Line 5.--Enter the visits made by physicians under agreement from Worksheet B, Part I, column 5,
line 11.
Line 6.--Enter the total adjusted visits (sum of lines 4 and 5).
Line 7.--Enter the adjusted cost per visit. This is determined by dividing the amount on line 3 by
the visits on line 6.
Lines 8 through 16.--Complete columns 1 and 2 for lines 8 through 16 to identify costs and visits
affected by different payment limits during a cost reporting period. The payment limits are updated
every January 1. However, the possibility exists that payment limits may also be updated other
than on January 1. Complete columns 1 and 2 (and if applicable complete column 3 for lines 8
through 16, if the cost reporting period overlaps 3 payment limit periods as may be the case when
implementing §130 of the Consolidated Appropriations Act of 2021 (see CR 12185, dated
March 16, 2021, or subsequent applicable CRs)). If only one payment limit is applicable during
the cost reporting period (calendar year reporting period), complete column 2 only.
46-34
Rev. 2
DRAFT
FORM CMS-222-17
4613.2
Line 8.--Enter the per visit payment limit. Obtain this amount from your contractor.
Line 9.--Enter the lesser of the amount on line 7 or line 8.
4613.2 Part II - Determination of Total Payment.--Use Part II to determine the total Medicare
payment due you for covered RHC services furnished to Medicare beneficiaries during the reporting
period.
Line 10.--Enter the number of Medicare covered visits excluding mental health services. Obtain
this from your contractor records. This visit count (sum of columns 1, 2, and 3) must equal the visits
on Worksheet S-3, column 2, line 2.
Line 11.--Enter the subtotal of Medicare cost. This cost is determined by multiplying the rate per
visit on line 9 by the number of visits on line 10 (the total number of covered Medicare beneficiary
visits excluding mental health services for RHC services during the reporting period).
Line 12.--Enter the number of Medicare covered visits for mental health services. Obtain this from
your contractor records. This visit count (sum of columns 1, 2, and 3) must equal the visits on
Worksheet S-3, column 2, line 4.
Line 13.--Enter the Medicare covered cost for mental health services by multiplying the rate per
visit on line 9 by the number of visits on line 12.
Line 14.--Enter the total Medicare cost. This is equal to the sum of the amounts on lines 11 and 13.
Line 15.--Enter the Medicare beneficiary’s deductible amount. RHCs obtain this amount from the
PS&R report.
Line 16.--Enter the net Medicare cost excluding injections/infusions and their administration.
Determine by subtracting the amount on line 15 from the amount on line 14.
NOTE: Section 4104 of ACA eliminates coinsurance and deductible for preventive services. RHCs
must provide detailed healthcare common procedure coding system (HCPCS) coding for preventive
services to ensure coinsurance and deductible are not applied. Providers must maintain this
documentation in order to apply the appropriate reductions on lines 19 and 20.
Line 17.--Enter the total Medicare charges from the contractor’s records (PS&R report).
Line 18.--Enter the total Medicare preventive charges from the provider’s records or the PS&R
report.
Line 19.--Enter the total Medicare preventive costs ((line 18 divided by line 17) times line 14, sum
of columns 1, 2, and 3)).
Line 20.--Enter the total program non-preventive costs ((line 16, sum of columns 1, 2, and 3, minus
line 19) times 80 percent)).
Line 21.--Enter the sum of lines 19 and 20.
Rev.
46-35
4613.2 (Cont.)
FORM CMS-222-17
DRAFT
Line 22.--Enter the total allowable GME pass-through costs determined by dividing Medicare visits
(sum of Worksheet C, Part II, columns 1 and 2, lines 10 and 12) by the total visits (from Worksheet
C, Part I, line 6) and multiply that result by (the sum of the total allowable GME cost reported on
Worksheet A, column 7, line 29). NOTE: If Worksheet S-1, Part I, line 19, column 1 is “N”, GME
pass-through costs on this line must be zero.
Line 23.--Enter the Medicare cost of injections/infusions and their administration from Worksheet
B-1, line 16.
Line 24.--Enter the primary payer amounts from the PS&R.
Line 25.--Enter the sum of lines 21, 22, and 23, minus line 24.
Line 26.--Enter Medicare allowable bad debts, reduced by bad debt recoveries. If recoveries exceed
the current year’s bad debts, lines 26 and 27 will be negative.
Line 27.--Multiply the amount (including negative amounts) from line 26 by 65 percent.
Line 28.--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 26.
Line 29.--Enter the sum of lines 25 and 27.
Line 30.--Enter all demonstration payment adjustment amounts before sequestration.
Line 31.--Enter any other adjustment. If the other adjustment is an addition to costs, enter the
amount as a negative. Specify the adjustment in the space provided.
Line 32.--Enter the result of line 29 minus lines 30 and 31.
Line 33.--Enter the sequestration adjustment amount as [(2 percent times (total days in the cost
reporting period that occur during the sequestration period divided by total days in the entire cost
reporting period, rounded to four decimal places)) times line 32]. Do not apply the sequestration
calculation when gross reimbursement is less than zero. Note: In accordance with §3709 of the
CARES Act, as amended by §102 of the Consolidated Appropriations Act, 2021, and §1 of
Public Law 117-7, do not apply the sequestration adjustment to the period of May 1, 2020, through
December 31, 2021.
Line 34.--Enter all demonstration payment adjustment amounts after sequestration.
Line 35.--Enter the result of line 32 minus lines 33 and 34.
Line 36.--Enter the amount of interim payments from Worksheet C-1, column 2, line 4.
Line 37.--FOR CONTRACTOR USE ONLY.--Enter the tentative settlement amount from Worksheet
C-1, column 2, line 5.99.
46-36
Rev.
04-21
FORM CMS-222-17
4613.2 (Cont.)
Line 38.--Enter the total amount due to/from the program (line 35 minus lines 36 and 37). Transfer
this amount to Worksheet S, Part III, column 1, line 1.
Line 39.--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 42 CFR 413.24(j)(2)(i)). Attach a schedule showing the supporting details and
computations for this line.
Rev. 2
46-37
4614
FORM CMS-222-17
04-21
4614. WORKSHEET C-1 - ANALYSIS OF PAYMENTS TO THE RURAL HEALTH CLINIC
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 RHC. 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 C, Part II, line 36.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET C-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 RHC 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 RHC 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 C, Part II, line 37.
NOTE: On lines 3, 5, and 6, when an RHC to program amount is due, show the amount and date
on which the RHC 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 C,
Part II, line 35.
Line 8.--Enter the contractor’s name, the contractor number, and NPR date in columns 0, 1, and 2,
respectively.
46-38
Rev. 2
05-18
FORM CMS-222-17
4690
EXHIBIT 1 - Form CMS-222-17
The following is a listing of the Form CMS-222-17 worksheets and the page number location.
Rev. 1
Worksheets
Page(s)
Wkst. S, Part I
Wkst. S-1, Part I
Wkst. S-1, Part II
Wkst. S-2
Wkst. S-3
Wkst. A
Wkst. A-6
Wkst. A-8
Wkst. A-8-1
Wkst. B, Parts I & II
Wkst. B-1
Wkst. C, Parts I & II
Wkst. C-1
46-303
46-304
46-305
46-306
46-307
46-308 - 46-309
46-310
46-311
46-312
46-313
46-314
46-315
46-316
46-301
4690
FORM CMS-222-17
05-18
This page is reserved for future use.
46-302
Rev. 1
05-18
FORM CMS-222-17
4695
EXHIBIT 2-ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE OF CONTENTS
Topic
Page(s)
Table 1:
Record Specifications
46-503 - 46-509
Table 2:
Worksheet Indicators
46-510 - 46-511
Table 3:
46-512 - 46-526
Table 3A:
List of Data Elements With Worksheet, Line, and
Column Designations
Worksheets Requiring No Input
Table 3B:
Table to Worksheet S-1, Parts I and II
46-527
Table 3C:
Lines that Cannot be Subscripted
46-527
Table 5:
Cost Center Coding
Table 6:
Edits:
Rev. 1
46-527
46-528 - 46-532
Level 1 Edits
46-533 - 46-540
Level 2 Edits
46-540
46-501
4695 (Cont.)
FORM CMS-222-17
05-18
This page is reserved for future use.
46-502
Rev. 1
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 1 - RECORD SPECIFICATIONS
Table 1 specifies the standard record format to be used for electronic cost reporting. Each
electronic cost report submission (file) has three types of records. The first group (type one
records) contains information for identifying, processing, and resolving problems. The text used
throughout the cost report for variable line labels (e.g., Worksheet A) is included in the type two
records. Refer to Table 5 for cost center coding. The data detailed in Table 3 are identified as
type three records. The encryption coding at the end of the file, records 1, 1.01, and 1.02, are type
4 records.
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 should seek approval from their contractors 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
213975201727420182734A99P00120190152018273
1
2
14:30
Record #1:
This is a cost report file submitted by Provider 213975 for the period from October
1, 2017 (2017274) through September 30, 2018 (2018273). It is filed on FORM CMS-222-17. It
is prepared with vendor number A99's PC based system, version number 1. Position 38 changes
with each new test case and/or approval and is alpha. Positions 39 and 40 remain constant for
approvals issued after the first test case. This file is prepared by the independent rural health clinic
facility on January 15, 2019 (2018015). The electronic cost report specification dated September
30, 2018 (2018273) is used to prepare this file.
FILE NAMING CONVENTION
Name each cost report ECR file in the following manner:
RHNNNNNN.YYLC, where
1. RH (Rural Health Clinic 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 independent
RHC facility 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 RHCs 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
Rev. 2
46-503
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
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.
NPI
10
9
2-11
Numeric only
3.
Spaces
1
X
12
4.
Record Number
1
X
13
5.
Spaces
3
X
14-16
6.
RHC Provider
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 “4” (for FORM
CMS-222-17)
10.
Vendor Code
3
X
38-40
To be supplied upon approval. Refer
to page 46-503.
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 2021090 (03/31/2021). Prior
approval 2018273.
46-504
Constant “1”
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
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.
Spaces
10
X
2-11
3.
Record Number
2
9
12-13
#2 - Cost report iteration identifier is
222-17 in positions 21 through 26.
#3 - Vendor information; optional
record for use by vendors. Left
justified in positions 21 through 60.
#4 - The time that the ECR file is
created. This is represented in military
time as alpha numeric. Use positions
21-25. Example 2:30 PM 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.
Wkst. 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.
Cost Center Code
4
9
21-24
9.
Labels/Headings
Numeric. Refer to Table 5 for
appropriate cost center codes.
a. Line Labels
36
X
25-60
Alphanumeric, left justified
b. Column Headings
Statistical Basis
& Code
10
X
21-30
Alphanumeric, left justified
Alphanumeric. Refer to Table 2.
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.
Rev. 2
46-505
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 2 Records for Labels (Cont.)
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.
Use the following type 2 cost center descriptions for Worksheet A standard cost center lines.
Line
Description
1
2
3
4
5
6
7
8
9
15
16
25
26
27
28
29
30
31
31.10
31.11
40
41
42
43
44
45
46
47
60
61
62
63
64
65
66
67
75
76
77
78
79
80
PHYSICIAN
PHYSICIAN ASSISTANT
NURSE PRACTITIONER
CERTIFIED NURSE MIDWIFE
REGISTERED NURSE
LICENSED PRACTICAL NURSE
CLINICAL PSYCHOLOGIST
CLINICAL SOCIAL WORKER
LABORATORY TECHNICIAN
PHYSICIAN SERVICES UNDER AGREEMENT
PHYSICIAN SUPERVISION UNDER AGREEMNT
MEDICAL SUPPLIES
TRANSPORTATION (HEALTH CARE STAFF)
DEPRECIATION-MEDICAL EQUIPMENT
MALPRACTICE PREMIUMS
ALLOWABLE GME COSTS
PNEUMOCOCCAL VACCINES & MED SUPPLIES
INFLUENZA VACCINES & MED SUPPLIES
COVID-19 VACCINES & MED SUPPLIES
MONOCLONAL ANTIBODY PRODUCTS
RENT
INSURANCE
INTEREST ON MORTGAGE OR LOANS
UTILITIES
DEPRECIATION-BUILDINGS AND FIXTURES
DEPRECIATION-MOVABLE EQUIPMENT
HOUSEKEEPING AND MAINTENANCE
PROPERTY TAX
OFFICE SALARIES
DEPRECIATION-OFFICE EQUIPMENT
OFFICE SUPPLIES
LEGAL
ACCOUNTING
INSURANCE
TELEPHONE
FRINGE BENEFITS AND PAYROLL TAXES
PHARMACY
DENTAL
OPTOMETRY
NON-ALLOWABLE GME PASS THROUGH COSTS
TELEHEALTH
CHRONIC CARE MANAGEMENT
46-506
Rev. 2
05-18
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 1 - RECORD SPECIFICATIONS
Examples of type 2 records are below. Either zeros or spaces may be used in the line, subline,
column, and sub column number fields (positions 11through 20). However, spaces are preferred.
Refer to Table 5 and 6 for additional cost center code requirements.
Examples:
Worksheet A line labels with embedded cost center codes:
2A000000
1
0100PHYSICIAN
2A0000000000200000000200PHYSICIAN ASSISTANT
2A000000
9
0900LABORATORY TECHNICIAN
2A000000
25
2500MEDICAL SUPPLIES
2A000000
27
2700DEPRECIATION-MEDICAL EQUIPMENT
2A000000
40
4000RENT
Rev. 1
46-507
4695 (Cont.)
FORM CMS-222-17
05-18
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 3 Records for Non Label Data
Size
Usage
Loc.
Remarks
1.
Record Type
1
9
1
2.
Wkst. 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
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.
4
X
57-60
Spaces (optional).
16
9
21-36
Right justified. May contain
embedded decimal point. Leading
zeros are suppressed; trailing zeros 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.
a. Alpha 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
5
1
20502
3A000000
8
1
46347
3A000000 17
2
98469
46-508
Rev. 1
05-18
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
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 subline numbers as data must
be uniform.
Worksheet A-6, columns 3 and 6
Worksheet A-8, column 4
Worksheet A-8-1, Part I, column 1
RECORD NAME: TYPE “3” RECORDS
Examples of records (*) with a Worksheet A line number as data are below.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
3A600010
3A600010
*3A600010
3A600010
*3A600010
3A600010
1
1
1
1
1
1
0
1
3
4
6
7
NON-RHC PHYSICIAN COMPENSATION
AA
87.00
121656
1.00
121656
3A800000
3A800000
*3A800000
5
5
5
1
2
4
B
*3A810002
3A810002
3A810002
3A810002
1
1
1
1
1
3
4
5
17.00
LATEX GLOVES
32
280
-1993
25.00
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 which the ECR file has been completed and saved to disk, CD, or flash drive to insure the
integrity of the file.
Rev. 1
46-509
4695 (Cont.)
FORM CMS-222-17
05-18
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 2 - WORKSHEET INDICATORS
This table contains the worksheet indicators that are used for electronic cost reporting.
worksheet indicator is provided for only those worksheets for which data are to be provided.
A
The worksheet indicator consists of seven digits in positions 2 through 8 of the record identifier.
The first two digits of the worksheet indicator (positions 2 and 3 of the record identifier) always
show the worksheet. The third digit of the worksheet indicator (position 4 of the record identifier)
is used to identify the part of the worksheet, e.g., worksheet A-8-1. The fourth character of the
worksheet indicator (position 5 of the record identifier) is not used. For Worksheet A-6, the fifth
and sixth digits of the worksheet indicator (positions 6 and 7 of the record identifier) identify the
reclassification code. The seventh character of the worksheet indicator (position 8 of the record
identifier) represents the worksheet or worksheet part.
Worksheets That Apply to the Rural Health Clinic Cost Report
Worksheet
S, Part I
S, Part II
S, Part III
S-1, Part I
S-1, Part II
S-2
S-3
A
A-6
A-8
A-8-1, Parts I & II
B, Parts I & II
B-1
C, Parts I & II
C-1
46-510
Worksheet Indicator
S000001
S000002
S000003
S100001
S100002
S200000
S300000
A000000
A600??0
A800000
A810001
B000001
B100000
C000001
C100000
(a)
(c)
(b)
(b)
(b)
Rev. 1
05-18
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 2 - WORKSHEET INDICATORS
FOOTNOTES:
(a) Worksheet S-1, Part II for Consolidated Cost Reports
The fifth and sixth digits of the worksheet indicator (positions 6 and 7 of the record) are
numeric from 01-99 to accommodate reports with one or more consolidated RHCs. For reports
that do not need additional worksheets, the default is 01. For reports that do need additional
worksheets, the first page is numbered 01. The number for each additional page of the
worksheet is incremented by 1.
(b) Worksheets with Multiple Parts Using Identical Worksheet Indicator
Although some worksheets have multiple parts, the lines are numbered sequentially. In these
instances, the same 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 A-8-1,
B, and C.
(c) Worksheet A-6
For Worksheet A-6, include in the worksheet identifier the reclassification code as the 5th and
6th digits (6th and 7th of the record). For example, 3A6000A0 or 3A6000B0, 3A6000C0,
3A600AA0, 3A600AB0, or 3A600ZZ0. Additionally, for Worksheet A-6 include in the
worksheet identifier “00” in the 5th and 6th digits (6th and 7th of the record) (3A600000) to
identify grand total reclassification increases and grand total reclassification decreases.
Rev. 1
46-511
4695 (Cont.)
FORM CMS-222-17
05-18
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
This table identifies the collection of all data elements from all worksheets in a rural health clinic
cost report. This includes data elements necessary to calculate a rural health clinic cost report,
informational data, and calculated data. Calculated fields (e.g., Worksheet A, column 7) are used
to verify the mathematical accuracy of the raw data elements and to isolate differences between
the file submitted by the independent rural health clinic and the report produced by the Medicare
contractor. Where an adjustment is made, that record must be present in the electronic data file.
For explanations of the adjustments 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 5. It is
unacceptable to format in a series of 10, 20, or skip subline 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., Worksheet settlement series and 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 providers skip or delete a line 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.
46-512
Rev. 1
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Line(s)
Column(s)
Field
Size
Usage
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
36
X
1
2
1
X
Signature date (mm/dd/yyyy)
2
3
4
1
1
1
36
36
10
X
X
X
Part III - Settlement Summary
Balances due provider or program:
title XVIII
1
1
11
-9
WORKSHEET S
Part I - Cost Report Status
Provider Use Only
Electronically prepared cost report
Manually prepared 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 utilization.
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 II - Certification by a Chief Financial Officer or
Administrator
Signature of chief financial officer or administrator
Checkbox (enter “Y” if electronic signature;
otherwise, leave blank)
Printed Name
Title
Rev. 2
46-513
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S-1, PART I (Cont.)
Site Name
Provider CCN
CBSA
Date Certified
Type of Control
Street
P.O. Box
City
State
Zip Code
County
Cost reporting period beginning date
(MM/DD/YYYY)
Cost reporting period ending date
(MM/DD/YYYY)
Is this RHC part of an entity that owns,
leases or controls multiple RHCs? (Y/N).
If yes, enter the entity’s information
below.
Name of Entity
Street
P.O. Box
City
State
Zip Code
Is this RHC 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? (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
46-514
Line(s)
Column(s)
Field
Size
Usage
1
1
1
1
1
2
2
3
3
3
3
4
1
2
3
4
5
1
2
1
2
3
4
1
36
6
5
10
2
36
9
36
2
10
36
10
X
X
X
X
X
X
X
X
X
X
X
X
4
2
10
X
5
1
1
X
6
7
7
8
8
8
9
1
1
2
1
2
3
1
36
36
9
36
2
10
1
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
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S-1, PART I (Cont.)
Consolidated Cost Report
Is this RHC filing a consolidated cost report
per CMS Pub. 100-02, Chapter 13, §80.2?
(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, and subscripted lines blank.
Date Requested
Date Approved
Number of RHCs
List of Consolidated Providers
CCN
CBSA
Date Requested
Date Approved
Medical Malpractice
Does this RHC carry commercial malpractice
insurance? (Y/N)
If line 15 is yes, is the malpractice insurance a
claims made or occurrence policy? Enter
“1” for claims made or “2” for occurrence
policy.
List amounts of malpractice premiums in
column 1, paid losses in column 2, or self
insurance in column 3.
Are malpractice premiums, paid losses, or self
insurance reported in a cost center other
than the malpractice premiums cost center?
(Y/N)
Miscellaneous
Is this RHC and/or any consolidated RHCs
involved in training residents in an
approved GME program in accordance with
42 CFR 405.2468(f)? (Y/N)
Rev. 2
Line(s)
Column(s)
Field
Size
Usage
13
1
1
X
13
13
13
14.0114.50
14.0114.50
14.0114.50
14.0114.50
14.0114.50
2
3
4
10
10
2
X
X
9
1
36
X
2
6
X
3
5
X
4
10
X
5
10
X
15
1
1
X
16
1
1
X
17
1-3
11
9
18
1
1
X
19
1
1
X
46-515
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S-1, PART I (Cont.)
Have you received an approval for an
exception to the productivity standard?
(Y/N)
Does the facility operate as other than a
RHC? (Y/N)
If line 21 is “Y”, specify type of operation.
Identify days and hours by listing the time
the facility operates as a RHC next to the
applicable day. *
Sunday through Saturday
Identify days and hours by listing the time
the facility operates as other than a RHC
next to the applicable day. *
Sunday through Saturday
Did this facility participate in any payment
demonstration during this cost reporting
period? (Y/N)
If line 25, column 1 is yes, enter the type of
demonstration in column 2. If the RHC
participated in more than one
demonstration, subscript this line
accordingly, starting with line 25.
Are there any costs included in Worksheet
A that resulted from transactions with
related organizations as defined in CMS
Pub. 15-1, chapter 10? (Y/N) If yes,
complete A-8-1.
WORKSHEET S-1, PART II
Site Name
Date Certified
Type of Control
Date Decertified
V/I Decertification
Date of CHOW
Street
P.O. Box
City
State
Zip Code
County
46-516
Line(s)
Column(s)
Field
Size
Usage
20
1
1
X
21
1
1
X
22
1
36
X
23.0123.07
1, 2
4
X
24.0124.07
25
1, 2
4
X
1
1
X
25
2
36
X
26
1
1
X
Line(s)
Column(s)
Field
Size
Usage
1
1
1
1
1
1
2
2
3
3
3
3
1
2
3
4
5
6
1
2
1
2
3
4
36
10
2
10
1
10
36
9
36
2
10
36
X
X
X
X
X
X
X
X
X
X
X
X
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S-1, PART II (Cont.)
Medical Malpractice
Does this RHC carry commercial malpractice
insurance? (Y/N)
If line 4 is yes, is the malpractice insurance a
claims-made or occurrence policy? Enter
“1” for claims-made or “2” for occurrence
policy.
List amounts of malpractice premiums in
column 1, paid losses in column 2, or self
insurance in column 3.
Miscellaneous
Does the facility operate as other than a RHC?
Enter “Y” for yes and “N” for no.
If line 7 is “Y”, specify type of operation (i.e.
physician’s office, independent laboratory
etc.)
Identify days and hours by listing the time the
facility operates as a RHC next to the
applicable day. *
Sunday through Saturday
Identify days and hours by listing the time the
facility operates as other than a RHC next to
the applicable day. *
Sunday through Saturday
Line(s)
Column(s)
Field
Size
Usage
4
1
1
X
5
1
1
X
6
1-3
11
9
7
1
1
X
8
1
36
X
9.019.07
1, 2
4
X
10.0110.07
1, 2
4
X
* Enter the time based on a 24 hour clock. For example 8:30 am is 0830 and 5:00 pm is 1700.
Rev. 2
46-517
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S-2
Provider Organization and Operation
Has the RHC changed ownership immediately prior to
the beginning of the cost reporting period? (Y/N)
If yes, enter the date of the change in column 2.
(mm/dd/yyyy)
Has the RHC terminated participation in the Medicare
program? (Y/N)
If yes, enter in column 2 the date of termination.
(mm/dd/yyyy)
If yes, enter in column 3 “V” for voluntary or “I” for
involuntary.
Is the RHC 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)
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)
Are GME costs directly assigned to cost centers other
than Allowable GME Costs on Worksheet A? (Y/N)
46-518
Line(s)
Column(s)
Field
Size
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
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET S-2 (Cont.)
Bad Debts
Is the RHC seeking reimbursement for bad debts?
(Y/N)
If line 8 is yes, did the RHC’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)
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 RHC’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 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 line 11 or 12 is yes, describe the other adjustments.
If line 11 or 12 is yes, were adjustments made to the
PS&R Report data for Other? (Y/N)
Was the cost report prepared only using the RHC’s
records? (Y/N)
Cost Report Preparer Contact Information
Enter the preparer’s information:
First Name
Last Name
Title
Employer
Phone Number
Email Address
Rev. 2
Line(s)
Column(s)
Field
Size
Usage
8
1
1
X
9
1
1
X
10
1
1
X
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
15
0
1
36
1
X
X
16
1
1
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
46-519
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Line(s)
Column(s)
Field
Size
Usage
1, 3, 5
0
6
X
1-6
1
11
9
1-6
2
11
9
1-6
3
11
9
1-6
4
11
9
1-6
7
5
1-5
11
11
9
9
Line(s)
Column(s)
Usage
1-10, 15-16, 2532, 40-48, 60-68,
75-81, 87-89
1-10, 15-16, 2532, 40-48, 60-68,
75-81, 87-89
1-10, 15-16, 2532, 40-48, 60-68,
75-81, 87-89
1-10, 15-16, 2532, 40-48, 60-68,
75-81, 87-89
1-10, 15-16, 2532, 40-48, 60-68,
75-81, 87-89
1-10, 15-16, 2532, 40-48, 60-68,
75-81, 87-89
1
Field
Size
11
2
11
-9
3
11
-9
4
11
-9
5
11
-9
6
11
-9
WORKSHEET S-3
Rural Health Clinic Statistical Data
Use this column only when filing a consolidated cost
report to identify each RHC 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.
Total All Patients
Total Visits
WORKSHEET A
Salaries
Other Costs
Total
Reclassifications
Reclassified Trial Balance
Adjustments
46-520
-9
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET A (Cont.)
Line(s)
Net Expenses For Allocation
1-10, 15-16, 2532, 40-48, 60-68,
75-81, 87-89
14, 17, 38, 59,
73, 86, 90
39
74
100
Subtotal
Total Cost of Services
Total Overhead
Total Costs
Rev. 2
Column(s)
Field
Size
Usage
7
11
-9
1-7
11
-9
1-7
1-7
1-7
11
11
11
-9
-9
9
46-521
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET A-6
For each expense reclassification:
Explanation
Code
Increases:
Worksheet A cost center
Worksheet A line number
Reclassification amount
Decreases:
Worksheet A cost center
Worksheet A line number
Reclassification amount
Total
Total Reclassification Increases
Total Reclassification Decreases
WORKSHEET A-8
Description of adjustment
Basis (A or B) *
Amount *
Cost Center
Worksheet A line number +
Total
Line(s)
Column(s)
Field
Size
Usage
1-99
1-99
0
1
36
2
X
X
1-99
1-99
1-99
2
3
4
36
5
11
X
99.99
9
1-99
1-99
1-99
100#
100#
100#
5
6
7
4&7
4
7
36
5
11
11
11
11
X
99.99
9
9
9
9
Line(s)
Column(s)
Field
Size
Usage
14-49
1-6, 8-49
1-49
3-6, 8-10, 14-49
3-6, 8-10, 14-49
50
0
1
2
3
4
2
36
1
9
36
5
11
X
X
-9
X
99.99
-9
* 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 “c” in “Table 2 - Worksheet Indicators” for appropriate worksheet indicators.
46-522
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET A-8-1
Line(s)
Column(s)
Field
Size
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
5
Cost center
1-4
2
36
Expense item(s)
1-4
3
36
Amount of allowable cost
1-4
4
11
1-4
5
11
Amount included in Worksheet A
1-4
6
11
Net Adjustments
5
4-6
11
Total
Usage
99.99
X
X
-9
-9
-9
-9
Part II - For each related organization
Type of interrelationship (A through G)
If type is G, description of relationship must
be included
Name of individual or partnership with
interest in provider and related
organization
Percentage of ownership in provider
Name of related individual or organization
Percentage of ownership of provider
Type of business
WORKSHEET B, PART I
6-10
6-10
1
0
1
36
X
X
6-10
2
36
X
6-10
6-10
6-10
6-10
3
4
5
6
6
36
6
36
9 (3).99
X
9(3).99
X
Line(s)
Column(s)
Field
Size
Usage
1-10
1-11
1-4
1-5
5-11
1
2
3
4
5
6
11
11
11
11
9(3).99
9
9
9
9
Line(s)
Column(s)
Field
Size
Usage
12
1
11
9
13
1
11
9
14
1
11
9
Position by department:
Number of FTE personnel
Total Visits
Productivity Standard
Minimum Visits
Greater of columns 2 or 4
WORKSHEET B, PART II
Cost of RHC service - excluding overhead
and allowable GME costs
Cost of other than RHC - excluding overhead
Cost of all services - excluding overhead
Rev. 2
46-523
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
WORKSHEET B, PART II
Ratio of RHC
Total Overhead
Overhead applicable to RHC Services
Total allowable cost of RHC services
WORKSHEET B-1
Line(s)
Column(s)
Field
Size
Usage
15
16
17
18
1
1
1
1
8
11
11
11
9.9(6)
9
9
9
Column(s)
Field
Size
Usage
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
11
9
8
9.9(6)
11
9
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
1, 2, 2.01,
2.02
2.01 & 2.02
11
9
11
9
11
9
11
9
8
9.9(6)
11
9
11
9
11
9
6
9(3).99
11
9
11
9
11
9
15
1, 2, 2.01,
2.02
1
11
9
16
1
11
9
Line(s)
Health care staff cost
1
Ratio of injection/infusion staff time to total
health care staff time
Injection/infusion health care staff cost
2
Injection/infusions and related medical
supplies cost
Direct cost of injections/infusions
4
Total direct cost of the facility
6
Total facility overhead
7
Ratio of injection/infusion direct cost to
total direct cost
Overhead cost - injections/infusions
8
Total injection/infusion cost and
administration
Total number of injections
10
Cost per injection/infusion
12
Number of injections/infusions administered
to Medicare beneficiaries
Number of COVID-19 injections/infusions
administered to MA enrollees
Medicare cost of vaccine/infusion and
administration
Total cost of injections/infusions and
administration
Total Medicare cost of injections/infusions
and administration
13
46-524
3
5
9
11
13.01
14
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Field
WORKSHEET C, PART I
Line(s) Column(s)
Size
Usage
Total allowable costs
Cost of injections/infusions and administration
Total allowable cost excluding
injections/infusions
Greater of minimum visits or actual visits by
health care staff
Physicians visits under agreements
Total adjusted visits
Adjusted cost per visit
Maximum rate per visit
Rate for Medicare covered visits
WORKSHEET C, PART II
Medicare covered visits excluding mental
health services
Medicare costs excluding costs for mental
health services
Medicare covered visits for mental health
services
Medicare covered cost for mental health
services
Total Medicare cost
Less: beneficiary deductible
Net Medicare cost excluding
injections/infusions and administration
Total Medicare charges
Total Medicare preventive charges
Total Medicare preventive costs
Total Medicare non-preventive costs
Net Medicare cost
Graduate medical education pass through cost
Medicare cost of injections/infusions and
administration
Primary payer payments
Net Medicare reimbursement excluding bad
debts
Allowable bad debts
Adjusted reimbursable bad debts
Rev. 2
1
2
3
1
1
1
11
11
11
9
9
9
4
1
11
9
5
6
7
8
9
1
1
1
1-3
1-3
11
11
6
6
6
9
9
9(3).99
9(3).99
9(3).99
Line(s)
Column(s)
Field
Size
Usage
10
1-3
11
9
11
1-3
11
9
12
1-3
11
9
13
1-3
11
9
14
15
16
1-3
1-3
1-3
11
11
11
9
9
9
17
18
19
20
21
22
23
1
1
1
1
1
1
1
11
11
11
11
11
11
11
9
9
9
9
9
9
9
24
25
1
1
11
11
9
9
26
27
1
1
11
11
9
9
46-525
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
Field
WORKSHEET C, PART II (Cont.)
Line(s) Column(s)
Size
Usage
Allowable bad debts for dual eligible
28
1
11
9
beneficiaries
Subtotal
29
1
11
9
Other demonstration payment adjustment
30
1
11
-9
amount before sequestration
Other adjustments (specify)
31
1
11
-9
Amount due RHC prior to sequestration
32
1
11
9
adjustment
Sequestration adjustment
33
1
11
9
Other demonstration payment adjustment
34
1
11
-9
amount after sequestration
Amount due RHC after sequestration
35
1
11
9
adjustment
Interim payments
36
1
11
-9
Tentative Settlement
37
1
11
-9
Balance due RHC/program
38
1
11
-9
Protested amounts
39
1
11
-9
Field
WORKSHEET C-1
Line(s) Column(s)
Size
Usage
Total interim payments paid to RHC
1
2
11
9
Interim payments payable
2
2
11
9
Date of each retroactive lump sum adjustment
3.01-3.98
1
10
X
(mm/dd/yyyy)
Amount of each retroactive lump sum
adjustment:
Program to provider
3.01-3.49
2
11
9
Provider to Program
3.50-3.98
2
11
9
Subtotal
3.99
2
11
9
Total interim payments
4
2
11
9
Date of the tentative payment from Program to 5.01-5.98
1
10
X
Provider (mm/dd/yyyy)
Amount of tentative payment:
Program to provider
5.01-5.49
2
11
9
Provider to Program
5.50-5.98
2
11
9
Subtotal
5.99
2
11
9
Date of the net settlement amount
6.01-6.02
1
10
X
(mm/dd/yyyy)
Net settlement amount Program to provider
6.01
2
11
9
Net settlement amount provider to Program
6.02
2
11
9
Total Medicare program liability
7
2
11
9
Enter name of the Contractor
8
0
36
X
Enter Contractor’s number
8
1
5
X
Enter the date of the NPR (mm/dd/yyyy)
8
2
10
X
46-526
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 3A - WORKSHEETS REQUIRING NO INPUT
All Worksheets require input
TABLE 3B - TABLE TO WORKSHEET S-1, PARTS I AND II
Type of Control:
1 = Voluntary Nonprofit, Corporation
2 = Voluntary Nonprofit, Other
3 = Proprietary, Individual
4 = Proprietary, Corporation
5 = Proprietary, Partnership
6 = Proprietary, Other
7 = Government, Federal
8 = Government, State
9 = Government, County
10 = Government, City
11 = Government, Other
TABLE 3C - LINES THAT CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Rev. 2
S, Part I: All
S, Part II: All
S, Part III: All
S-1, Part I: lines 1-13, 15-24, and 26
S-1, Part II: lines 1-10
S-2: ALL
S-3: lines 2, 4, 6, and 7
A: lines 1-9, 14, 15-17, 25-31, 38-47, 59-67, 73-80, 86, 90, and 100
A-6: lines 1-99, and 100
A-8: lines 1-13, and 50
A-8-1, Part I: lines 1-3, and 5
A-8-1, Part II: line 6-9
B-Part I: All
B-Part II: All
B-1: All
C, Part I: All
C, Part II: lines 10-30, and 32-39
C-1: lines 1, 2, 4, and 6-8
46-527
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
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 peculiar 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 pre-coded), 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 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 46-530. 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.
46-528
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 5 - COST CENTER CODING
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 RHC on the Medicare cost report. The use of this coding methodology allows the RHC 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 10,
32, 48, 68, and 81. 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.
Categories
Additional Guidelines
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 10 may only contain cost center codes within the facility health
care staff costs category of both standard and nonstandard coding. For example, in the facility
health care staff costs category for “Other (specify)” cost, line 10 and subscripts must contain cost
center codes of 1000 through 1019 which are identified as nonstandard cost center codes. This
logic must hold true for all other cost center categories, i.e., other health care costs, other than
RHC services, and nonreimbursable cost centers.
Rev. 2
46-529
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 5 - STANDARD COST CENTER DESCRIPTIONS AND CODES
CODE
USE
0100
0200
0300
0400
0500
0600
0700
0800
0900
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
1500
1600
(01)
(01)
Medical Supplies
Transportation (Health Care Staff)
Depreciation-Medical Equipment
Malpractice Premiums
Allowable GME Costs
Pneumococcal Vaccines & Med Supplies
Influenza Vaccines & Med Supplies
COVID-19 Vaccines & Med Supplies
Monoclonal Antibody Products
2500
2600
2700
2800
2900
3000
3100
3110
3111
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
FACILITY OVERHEAD-FACILITY COST
Rent
Insurance
Interest on Mortgage or Loans
Utilities
Depreciation-Building and Fixtures
Depreciation-Equipment
Housekeeping and Maintenance
Property Tax
4000
4100
4200
4300
4400
4500
4600
4700
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
FACILITY HEALTH CARE STAFF COSTS
Physician
Physician Assistant
Nurse Practitioner
Certified Nurse Midwife
Registered Nurse
Licensed Practical Nurse
Clinical Psychologist
Clinical Social Worker
Laboratory Technician
COSTS UNDER AGREEMENT
Physician Services Under Agreement
Physician Supervision Under Agreemnt
OTHER HEALTH CARE COSTS
46-530
Rev. 2
05-18
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 5 - STANDARD COST CENTER DESCRIPTIONS AND CODES
FACILITY OVERHEAD-ADMINISTRATIVE COSTS
Office Salaries
Depreciation-Office Equipment
Office Supplies
Legal
Accounting
Insurance
Telephone
Fringe Benefits and Payroll Taxes
CODE
USE
6000
6100
6200
6300
6400
6500
6600
6700
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
7500
7600
7700
7800
7900
8000
(01)
(01)
(01)
(01)
(01)
(01)
COSTS OTHER THAN RHC SERVICES
Pharmacy
Dental
Optometry
Non-allowable GME Pass Through Costs
Telehealth
Chronic Care Management
Rev. 1
46-531
4695 (Cont.)
FORM CMS-222-17
05-18
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 5 - NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
FACILITY HEALTH CARE STAFF COSTS
Other Facility Health Care Staff Costs (specify)
CODE
USE
1000
(20)
3200
(20)
4800
(20)
6800
(20)
8100
(20)
8700
8800
8900
(20)
(20)
(20)
OTHER HEALTH CARE COSTS
Other Health Care Costs (specify)
FACILITY OVERHEAD-FACILITY COSTS
Other Facility Overhead-Facility Costs (specify)
FACILITY OVERHEAD-ADMINISTRATIVE COSTS
Other Facility Overhead-Administrative Costs (specify)
COSTS OTHER THAN RHC SERVICES
Other Than RHC Service Costs (specify)
NON-REIMBURSABLE COSTS
Other Non-reimbursable Costs (specify)
Other Non-reimbursable Costs (specify)
Other Non-reimbursable Costs (specify)
46-532
Rev. 1
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
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 RHCs 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 RHC 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 1
edit will be rejected by the contractors. Notification must be made to CMS for any exceptions.
The edits are applied at two levels. Level 1 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
RHCs from generating an electronic cost report (ECR) file when the cost report violates any Level
1 edits. Level 2 edits (2000 series edit codes) identify potential inconsistencies and missing data
items. These items should be resolved at the RHC 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 RHCs from
generating an ECR file where Level 1 edit conditions exist. In addition, ample warnings should
be given to the RHC where Level 2 edit conditions are violated.
Level 1 edit conditions are to be applied against title XVIII services only. However, any
inconsistencies or omissions that would cause a Level 1 condition for non-title XVIII services
must be resolved prior to acceptance of the cost report. [09/30/2018]
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 [09/30/2018], 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 [09/30/2018b] ,
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 [09/30/2018s], indicates the edit is effective for services
rendered on or after the date in brackets.
I.
Level 1 Edits (Minimum File Requirements)
Edit
Condition
1000
The first digit of every record must be either 1, 2, 3, or 4 (encryption code only).
[09/30/2018]
1005
No record may exceed 60 characters. [09/30/2018]
1010
All alpha characters must be in upper case. This is exclusive of the encryption code, type
4 record, record numbers 1, 1.01, and 1.02. [09/30/2018]
1015
For micro systems, the end of record indicator must be a carriage return and line feed, in
that sequence. [09/30/2018]
1020
The RHC facility provider number (record #1, positions 17 through 22) must be valid and
numeric (issued by the applicable certifying agency and falls within the specified range).
[09/30/2018]
Rev. 2
46-533
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 6 - EDITS
Edit
Condition
1025
All calendar format dates must be edited for 10 character format, e.g., 01/01/2017
(MM/DD/YYYY). [09/30/2018]
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 legitimate. [09/30/2018]
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). [09/30/2018]
1036
The fiscal year ending date (record #1, positions 30 through 36) must be 30 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). [09/30/2018]
1040
The vendor code (record #1, positions 38 through 40) must be a valid code. [09/30/2018]
1045
The type 1 record #1 must be correct and the first record in the file. [09/30/2018]
1050
All record identifiers (positions 1 through 20) must be unique. [09/30/2018]
1055
Only a Y or N is valid for fields which require a Yes/No response. [09/30/2018]
1065
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. [09/30/2018]
1067
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. [09/30/2018]
1070
The 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 or subscripts of these lines, unless indicated
herein. [09/30/2018]
Cost Center
Line
Code
Physician
1
0100
Physician Assistant
2
0200
Nurse Practitioner
3
0300
Certified Nurse Midwife
4
0400
Registered Nurse
5
0500
Licensed Practical Nurse
6
0600
Clinical Psychologist
7
0700
Clinical Social Worker
8
0800
Laboratory Technician
9
0900
Physician Services Under Agreement
15
1500
Physician Supervision Under Agreemnt
16
1600
Medical Supplies
25
2500
46-534
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 6 - EDITS
Edit
Condition
Cost Center
Transportation (Health Care Staff)
Depreciation-Medical Equipment
Malpractice Premiums
Allowable GME Costs
Pneumococcal Vaccine & Med Supplies
Influenza Vaccines & Med Supplies
COVID-19 Vaccines & Med Supplies
Monoclonal Antibody Products
Rent
Insurance
Interest on Mortgage or Loans
Utilities
Depreciation-Buildings and Fixtures
Depreciation-Movable Equipment
Housekeeping and Maintenance
Property Tax
Office Salaries
Depreciation- Office Equipment
Office Supplies
Legal
Accounting
Insurance
Telephone
Fringe Benefits and Payroll Taxes
Pharmacy
Dental
Optometry
Non-allowable GME Pass Through Costs
Telehealth
Chronic Care Management
Line
26
27
28
29
30
31
31.10
31.11
40
41
42
43
44
45
46
47
60
61
62
63
64
65
66
67
75
76
77
78
79
80
Code
2600
2700
2800
2900
3000
3100
3110
3111
4000
4100
4200
4300
4400
4500
4600
4700
6000
6100
6200
6300
6400
6500
6600
6700
7500
7600
7700
7800
7900
8000
1075
Cost center integrity must be maintained throughout the cost report. For subscripted lines,
the relative position must be consistent throughout the cost report. [09/30/2018]
1080
Every line used on Worksheet A, there must be a corresponding type 2 record. [09/30/2018]
1085
Fields requiring numeric data (days, costs, FTEs, etc.) may not contain any alpha character.
[09/30/2018]
1090
A numeric field cannot exceed more than 11 positions. [09/30/2018]
1095
In all cases where the file includes both a total and the parts that comprise that total, each
total must equal the sum of its parts. [09/30/2018]
Rev. 2
46-535
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 6 - EDITS
Edit
Condition
1100
All dates must be possible, e.g., no “00”, no “30”, or “31” of February. [09/30/2018]
1000S The RHC facility name, address, provider number, and certification date (Worksheet S-1,
Part I, line 1, column 1(name); line 2, column 1 (street address); line 3, columns 1 (city), 2
(State), 3 (ZIP code formatted as XXXXX or as XXXXX-XXXX), and line 1, column 4
(certification date), respectively) must be present and valid. [09/30/2018]
1001S If Worksheet S, Part I, line 5, is “5” (amended cost report), then line 3 must be greater than
zero. [09/30/2018]
1002S Worksheet S-1, Part I, column 3, line 1, must be completed with a valid five-position
alphanumeric CBSA code. [09/30/2018]
1005S The cost report beginning date (Worksheet S-1, Part I, column 1, line 4) must be on or after
October 1, 2017, and the cost report ending date (Worksheet S-1, Part I, column 2, line 4)
must be on or after September 30, 2018. [09/30/2018]
1010S The type of control (Worksheet S-1, Part I, column 5, line 1) must have a value of 1 through
11. (See Table 3B.) [09/30/2018]
1020S The cost report period beginning date (Worksheet S-1, Part I, column 1, line 4) must
precede the cost report ending date (Worksheet S-1, Part I, column 2, line 4). [09/30/2018]
1030S The RHC 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-3800 through XX-3974, or
XX-8900 through XX-8999, where XX corresponds to the two digit state code.
[09/30/2018]
1035S On Worksheet S-1, Part I, there must be a “Y” or “N” response for:
Column 1: lines 5, 9, 13, 15, 18, 19, 21, 25, and 26. [09/30/2018]
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. Conversely, if
Worksheet S-1, Part I, line 5, is “N”, then Worksheet S-1, Part I, columns 1, 2, and 3, as
applicable, lines 6 through 8 must be blank. [09/30/2018]
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. [09/30/2018]
1065S On Worksheet S-1, Part I, there must be an entry on at least one of the subscripted lines
23.02 through 23.06, in columns 1 and 2. If Worksheet S-1, Part I, column 1, line 21, is
“Y”, then there must be an entry on at least one of the subscripted lines 24.01 through
24.07, in columns 1 and 2, and vice versa. [09/30/2018]
46-536
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 6 - EDITS
Edit
Condition
1070S If Worksheet S-1, Part I, line 19, is “Y”, then Worksheet A, column 7, line 29, must be
greater than zero, and vice versa. [09/30/2018]
NOTE: The edits that correspond to Worksheet S-1, Part II, are only applied if Worksheet S-1,
Part II, is completed for consolidated RHCs.
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 1, for the number of consolidated RHCs and if Worksheet S-1, Part
I, column 4, line 1, is on or after 10/01/2017, column 2, line 13, must contain a date of
request, and column 3, line 13, 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. [09/30/2018]
1110S If Worksheet S-1, Part I, column 1, line 13, is “Y”, then line 14, beginning with subscripted
line 14.01, for each RHC must contain: the RHC site name in column 1, the RHC 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 10/01/2017, 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. [09/30/2018]
1170S If Worksheet S-1, Part I, line 15, is “Y”, then line 16 must contain a “1” or “2”, and line
17, sum of columns 1 through 3, must be greater than zero, and vice versa. [09/30/2018]
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
RHC: the RHC site name in column 1, line 1; the RHC street address in column 1, line 2;
the RHC city name in column 1, line 3; the RHC ZIP code (formatted as XXXXX) or the
RHC ZIP+4 code (formatted as XXXXX-XXXX) in column 3, line 3. [09/30/2018]
1245S If Worksheet S-1, Part I, line 21, is “Y”, then line 22 must be present, and vice versa.
[09/30/2018]
1246S If Worksheet S-1, Part I, column 1, line 25, is “Y”, then column 2 must be present, and
vice versa. [09/30/2018]
1250S For each consolidated RHC 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.) [09/30/2018]
1300S If Worksheet S-1, Part I, column 1, line 13, is “Y”, for each consolidated RHC 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 4 & 7. [09/30/2018]
Rev. 2
46-537
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 6 - EDITS
Edit
Condition
1305S If Worksheet S-1, Part I, column 1, line 13 is “Y”, then
must be an entry on at least one of the subscripted lines
and 2, and vice versa. If Worksheet S-1, Part II, column
be an entry on at least one of the subscripted lines 10.01
2, and vice versa. [09/30/2018]
on Worksheet S-1, Part II, there
9.02 through 9.06, in columns 1
1, line 7, is “Y”, then there must
through 10.07, in columns 1 and
1340S If Worksheet S-1, Part II, line 4, is “Y”, then line 5 must contain a “1” or “2”, and line 6,
sum of columns 1 through 3, must be greater than zero, and vice versa. [09/30/2018]
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. [09/30/2018]
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. [09/30/2018]
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. [09/30/2018]
1420S If Worksheet S-2, column 1, line 3, is “N”, then Worksheet A-8-1 must not be present.
[09/30/2018]
1430S If Worksheet S-2, column 1, line 3, is “Y”, then Worksheet A-8-1, Part I, columns 4 or 5,
sum of lines 1 through 4 must not equal zero, and Worksheet A-8-1, 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.
[09/30/2018]
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. [09/30/2018]
1450S Worksheet S-3, columns 1 through 4, lines 1 through 6, must be equal to or greater than
zero. [09/30/2018]
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. [09/30/2018]
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. [09/30/2018]
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. [09/30/2018]
46-538
Rev. 2
04-21
FORM CMS-222-17
4695 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 6 - EDITS
Edit
Condition
1490S Total Medicare medical visits on Worksheet S-3, line 2, column 2, must equal the total
Medicare medical visits on Worksheet C, Part II, line 10, sum of columns 1 and 2; and total
Medicare mental health visits on Worksheet S-3, line 4, column 2, must equal the total
Medicare mental health visits on Worksheet C, Part II, line 12, sum of columns 1 and 2.
[10/31/2018]
1000A All amounts reported on Worksheet A, columns 1, 2, and 7, line 100, must be greater than
zero. [09/30/2018]
1020A For reclassifications reported on Worksheet A-6, the sum of all increases (column 4) must
equal the sum of all decreases (column 7). [09/30/2018]
1025A For each line on Worksheet A-6, 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.
[09/30/2018]
1032A Worksheet A-6, column 0, must have an explanation present on the first line for each
reclassification code. [09/30/2018]
1040A For Worksheet A-8 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. [09/30/2018]
1042A For Worksheet A-8 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”. [09/30/2018]
1045A Worksheet A-8-1, 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. [09/30/2018]
1060A For each amount on Worksheet A, column 7, lines 1, 2, 3, 4, 5, 6, 7, and 8, if the amount
is greater than zero, then the corresponding FTEs and total visits on worksheet B, Part I,
columns 1 and 2, must also be greater than zero and vice versa. [09/30/2018]
1065A If the amount on Worksheet A, column 7, line 15 (Physician Services Under Agreement),
is greater than zero, then the corresponding total visits on worksheet B, Part I, column 2,
line 11, must also be greater than zero and vice versa. [09/30/2018]
1000B Total visits on Worksheet B, Part I (column 2, sum of lines 10 and 11), must be greater
than or equal to the sum of the total Medicare covered visits on Worksheet C, Part II, lines
10 and 12, columns 1 and 2. [09/30/2018]
Rev. 2
46-539
4695 (Cont.)
FORM CMS-222-17
04-21
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-17
TABLE 6 - EDITS
Edit
Condition
1050B If Worksheet B-1, columns 1, 2, 2.01, or 2.02, line 13, are greater than zero, then Worksheet
S-3, column 2, line 7, must be greater than zero. [09/30/2018]
1055B If Worksheet B-1, columns 2.01 or 2.02, line 13.01, are greater than zero, then Worksheet
S-3, column 4, line 7, must be greater than zero. [01/01/2020s through 12/31/2021s]
1000C Worksheet C, Part II, line 18, must be less than or equal to line 17. [09/30/2018].
1010C If any of the following is greater than zero, then they all must be greater than zero:
Worksheet S-3, column 2, sum of lines 2 and 4; Worksheet C, column 1, line 1; and
Worksheet C-1, column 2, line 4. [09/30/2018]
II. Level 2 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, note form, 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 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). [09/30/2018]
2005
All elements set forth in Table 3, with subscripts as appropriate, are required in the file.
[09/30/2018]
2015
Standard cost center lines, descriptions, and codes should not be changed. (See Table 5.)
This edit applies to the standard line only and not subscripts of that code. [09/30/2018]
2020
All standard cost center codes must be entered on the designated standard cost center line
and subscripts thereof as indicated in Table 5. [09/30/2018]
2025
Only nonstandard cost center codes within a cost center category may be placed on lines
10, 32, 48, 68, and 81, and subscripts. [09/30/2018]
2000S The amount due the provider or program (Worksheet S, Part III, column 1, line 1) must
not equal zero. [09/30/2018]
2020S Worksheet S-2, lines 17 through 19, all columns, must be completed. [09/30/2018]
NOTE:
46-540
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.
Rev. 2
| File Type | application/pdf |
| File Modified | 2021-09-23 |
| File Created | 2021-09-23 |