CMS-222-17 Rural Health Clinic Cost Report

Independent Rural Health Clinic Cost Report (CMS-222-17)

R2P246f.xlsx

OMB: 0938-0107

Document [xlsx]
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Overview

S, Part I, II, III
S-1, Part I
S-1, Part II
S-2
S-3
A
A-6
A-8
A-8-1
B-Part I &II
B-1
C-Part I & II
C-1


Sheet 1: S, Part I, II, III

DRAFT



FORM CMS-222-17

4690
This report is required by law (42 USC. 1395g: CFR 413.20(b)). Failure to report can result






FORM APPROVED
in all payments made during the reporting period being deemed overpayments (42 USC 1395g).






OMB NO: 0938-0107








EXPIRATION DATE XX/XX/XXXX
RURAL HEALTH CLINIC COST REPORT




CCN: PERIOD: WORKSHEET S
CERTIFICATION AND SETTLEMENT SUMMARY





FROM: __________ PARTS I, II & III






___________ TO: __________

PART I - COST REPORT STATUS








Provider use only

1. [ ] Electronically prepared cost report

Date: Time:



2. [ ] Manually prepared cost report







3. [ ] If this is an amended report enter the number of times the provider resubmitted this cost report.







4. [ ] Medicare Utilization. Enter "F" for full, "L" for low, or "N" for no utilization .




Contractor
5. [ ] Cost Report Status

6. Date Received:_________
10. NPR Date:___________

use only
(1) As Submitted

7. Contractor No.:________
11. Contractors Vendor Code: ____________



(2) Settled without audit

8. [ ] Initial Report for this Provider CCN
12. [ ] If line 5, column 1 is 4: Enter the number of



(3) Settled with audit

9. [ ] Final Report for this Provider CCN
times reopened = 0-9.



(4) Reopened








(5) Amended






PART II - CERTIFICATION BY A CHIEF FINANCIAL OFFICER OR ADMINISTRATOR


















MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL








AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS








REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL,








CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.



















CERTIFICATION BY CHIEF FINANCIAL OFFICER OR ADMINISTRATOR OF PROVIDER(S)


















I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually








submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s)








and Number(s)}for the cost reporting period beginning ______________ and ending ______________ and that to the best of my knowledge and belief,








this report and statement are true, correct, complete and prepared from the books and records of the provider in accordance with applicable








instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that








the services identified in this cost report were provided in compliance with such laws and regulations.




























SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR



CHECKBOX ELECTRONIC

1 2 SIGNATURE STATEMENT
1





I have read and agree with the above certification statement.
1







I certify that I intend my electronic signature on this certification be the legally binding equivalent of my original signature.







certification be the legally binding equivalent of my original







signature.

2 Signatory Printed Name






2
3 Signatory Title






3
4 Signature date






4


















































PART III - SETTLEMENT SUMMARY


























TITLE XVIII








1
1 RHC






1
The above amount represents "due to" or "due from" the Medicare program.










































































































































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 time required to complete this information collection is estimated








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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:








CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications,








claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any








correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed,








forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE.


































































































FORM CMS-222-17 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4603 THROUGH 4603.3)


















Rev.







46-303

Sheet 2: S-1, Part I

4690 (Cont.)

FORM CMS-222-17



DRAFT
RURAL HEALTH CLINIC IDENTIFICATION DATA


CCN: PERIOD:
WORKSHEET S-1





FROM: ____________
PART I




______________ TO: _____________


PART I - RURAL HEALTH CLINIC IDENTIFICATION DATA










Provider
Date Type of control



CCN CBSA Certified (see instructions)


1
2 3 4 5
1 Site Name:





1
2 Street:

P.O. Box:


2
3 City:

State: Zip Code: County:
3
4 Cost Reporting Period (mm/dd/yyyy)
From: To:


4









5 Is this RHC part of an entity that owns, leases or controls multiple RHCs? Enter "Y" for yes or "N" for no.





5

If yes, enter the entity's information below.















6 Name of Entity:





6
7 Street:

P.O. Box:


7
8 City:

State: Zip Code:

8









9 Is this RHC part of a chain organization as defined in §2150 of CMS Pub. 15, Part 1 that claims home office costs in a





9

Home Office Cost Statement? Enter "Y" for yes or "N" for no in column 1. If yes, enter the chain organization's information below.















10 Name of Chain Organization:





10
11 Street:

P.O. Box: Home Office CCN:

11
12 City:

State: Zip Code:

12













Y/N Date Requested Date Approved Number of RHCs
Consolidated Cost Report


1 2 3 4
13 Is this RHC filing a consolidated cost report per CMS Pub. 100-02, chapter 13,





13

§80.2? Enter "Y" for yes or "N" for no in column 1. If column 1 is yes,







complete columns 2 through 4, and line 14, beginning with subscripted line







14.01. If column 1 is no, leave line 14 blank. (see instructions)
















Site Name CCN CBSA Date Requested Date Approved

1 2 3 4 5
14 List of Consolidated Providers





14
14.01






14.01
Medical Malpractice



15 Does this RHC carry commercial malpractice insurance? Enter "Y" for yes or "N" for no.





15
16 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.





16





Premiums Paid Losses Self Insurance
17 List amounts of malpractice premiums, paid losses or self-insurance in the applicable columns.





17
18 Are malpractice premiums, paid losses or self-insurance reported in a cost center other than the Malpractice Premiums cost center?





18

Enter "Y" for yes or "N" for no. (see instructions)






Miscellaneous



19 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)?





19

Enter "Y" for yes or "N" for no. (see instructions)






20 Have you received an approval for an exception to the productivity standard?





20
21 Does the facility operate as other than a RHC? Enter "Y" for yes or "N" for no.





21
22 If line 21 is "Y", specify type of operation. (i.e. physicians office, independent laboratory, etc.)





22
23 Identify days and hours by listing the time the facility operates as a RHC next to the applicable day.





23






Hours of Operation






From To

Days



1 2
23.01 Sunday





23.01
23.02 Monday





23.02
23.03 Tuesday





23.03
23.04 Wednesday





23.04
23.05 Thursday





23.05
23.06 Friday





23.06
23.07 Saturday





23.07
24 Identify days and hours by listing the time the facility operates as other than a RHC next to the applicable day.





24






Hours of Operation






From To

Days



1 2
24.01 Sunday





24.01
24.02 Monday





24.02
24.03 Tuesday





24.03
24.04 Wednesday





24.04
24.05 Thursday





24.05
24.06 Friday





24.06
24.07 Saturday





24.07















Y/N Demonstration Type






1 2
25 Did this facility participate in any payment demonstration during this cost reporting period? Enter "Y" for yes or "N" for no.





25

If column 1 is yes, enter the type of demonstration in column 2.






26 Are there any costs included in Worksheet A that resulted from transactions with related organizations as defined in





26

CMS Pub. 15-1, chapter 10? If yes, complete A-8-1.















FORM CMS-222-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4604.1)
















46-304






Rev.

Sheet 3: S-1, Part II

05-18


FORM CMS-222-17



4690 (Cont.)
RURAL HEALTH CLINIC IDENTIFICATION DATA


CCN: ___________
PERIOD:
WORKSHEET S-1






FROM: ____________
PART II




CENTER CCN: __________
TO: _____________


PART II - RURAL HEALTH CLINIC CONSOLIDATED COST REPORT IDENTIFICATION DATA












Type of control Date
Date of



Date Certified (see instructions) Decertified V/I Decertification CHOW


1
2 3 4 5 6
1 Site Name:






1
2 Street:

P.O. Box:



2
3 City:

State: Zip Code: County:

3
Medical Malpractice

1
4 Does this RHC carry commercial malpractice insurance? Enter "Y" for yes or "N" for no.






4
5 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.






5






Premiums Paid Losses Self Insurance






1 2 3
6 List amounts of malpractice premiums, paid losses or self-insurance in the applicable columns.






6
Miscellaneous



7 Does the facility operate as other than a RHC? Enter "Y" for yes or "N" for no.






7
8 If line 7 is "Y", specify type of operation. (i.e. physicians office, independent laboratory, etc.)






8
9 Identify days and hours by listing the time the facility operates as a RHC next to the applicable day.






9







Hours of Operation







From To

Days




1 2
9.01 Sunday






9.01
9.02 Monday






9.02
9.03 Tuesday






9.03
9.04 Wednesday






9.04
9.05 Thursday






9.05
9.06 Friday






9.06
9.07 Saturday






9.07
10 Identify days and hours by listing the time the facility operates as other than a RHC next to the applicable day.






10







Hours of Operation







From To

Days




1 2
10.01 Sunday






10.01
10.02 Monday






10.02
10.03 Tuesday






10.03
10.04 Wednesday






10.04
10.05 Thursday






10.05
10.06 Friday






10.06
10.07 Saturday






10.07




















FORM CMS-222-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4604.2)




























































































































































































































































































































































































































































































































Rev. 1







46-305

Sheet 4: S-2

4690 (Cont.)

FORM CMS-222-17


05-18
RURAL HEALTH CLINIC REIMBURSEMENT


CCN: PERIOD:
WORKSHEET S-2

QUESTIONNAIRE



FROM: ___________







___________ TO: ___________























COMPLETED BY ALL RHCs














Y/N Date V/I
Provider Organization and Operation




1 2 3
1 Has the RHC changed ownership immediately prior to the beginning of the cost reporting period?






1

If yes, enter the date of the change in column 2. (see instructions)







2 Has the RHC terminated participation in the Medicare program? If yes, enter in column 2 the date






2

of termination and in column 3, "V" for voluntary or "I" for involuntary. (see instructions)







3 Is the RHC involved in business transactions, including management contracts, with individuals or entities






3

(e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers, medical








staff, management personnel, or members of the board of directors through ownership, control, or family and








other similar relationships? (see instructions)






















Y/N Type Date Y/N
Financial Data and Reports



1 2 3 4
4 Column 1: Were the financial statements prepared by a Certified Public Accountant? Enter Y or N. If






4

N, see instructions.








Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter








date available in column 3. (mm/dd/yyyy).








Column 4: Are the cost report total expenses and total revenues different from those on the field financial statements?








If yes, submit reconciliation.
























Y/N Y/N
Approved Educational Activities





1 2
5 Are costs for Intern-Resident programs claimed on the current cost report?






5
6 Was an Intern-Resident program initiated or renewed in the current cost reporting period? If yes, see instructions.






6
7 Are GME costs directly assigned to cost centers other than Allowable GME Costs on Worksheet A?






7

If yes, see instructions.

























Y/N
Bad Debts






1
8 Is the RHC seeking reimbursement for bad debts? If yes, see instructions.






8
9 If line 8 is yes, did the RHC's bad debt collection policy change during this cost reporting period? If yes, submit copy.






9
10 If line 8 is yes, were patient coinsurance amounts waived? If yes, see instructions.






10















Y/N Date
PS&R Report Data





1 2
11 Was the cost report prepared using the PS&R Report only? If column 1 is yes, enter the






11

paid-through date of the PS&R Report used in column 2. (see instructions)







12 Was the cost report prepared using the PS&R Report for totals and the RHCs records for allocation?






12

If column 1 is yes, enter the paid-through date in column 2. (see instructions)







13 If line 11or 12 is yes, were adjustments made to PS&R Report data for additional claims that have been






13

billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions.







14 If line 11 or 12 is yes, were adjustments made to PS&R Report data for corrections of other






14

PS&R Report information? If yes, see instructions.







15 If line 11 or 12 is yes, were adjustments made to PS&R Report data for Other?






15

Describe the other adjustments:
________________________________________





16 Was the cost report prepared only using the RHC's records? If yes, see instructions.






16










Cost Report Preparer Contact Information








17 First name:
Last name:

Title:

17
18 Employer:






18
19 Phone number:

E-mail Address:



19












































































































































































































































































































FORM CMS-222-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4605)


















46-306







Rev. 1

Sheet 5: S-3

04-21
FORM CMS-222-17




4690 (Cont.)
RURAL HEALTH CLINIC DATA

CCN:
PERIOD:
WORKSHEET S-3





FROM: __________





___________
TO: ___________


RURAL HEALTH CLINIC STATISTICAL DATA























Total


CENTER
Title Title
All


CCN Title V XVIII XIX Other Patients


0 1 2 3 4 5
1 Medical Visits





1
2 Total Medical Visits





2
3 Mental Health Visits





3
4 Total Mental Health Visits





4
5 Number of Visits Performed by Interns and Residents





5
6 Total Number of Visits Performed by Interns





6

and Residents






7 Total Visits (sum of lines 2 and 4)





7

































































































































































































































































































































































































































































































































FORM CMS-222-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4606)
















Rev. 2






46-307

















































































































































































































































































































































































































































































































































































































































































































































Sheet 6: A

4690 (Cont.)

FORM CMS-222-17



04-21
RECLASSIFICATION AND ADJUSTMENT OF TRIAL




CCN: PERIOD:
WORKSHEET A
BALANCE OF EXPENSES





FROM: ____________








____________ TO: ____________











NET






RECLASSIFI- RECLASSIFIED
EXPENSES FOR


COST CENTER SALARIES OTHER TOTAL CATIONS TRIAL BALANCE ADJUSTMENTS ALLOCATION



1 2 3 4 5 6 7
FACILITY HEALTH CARE STAFF COSTS









1 0100 Physician






1
2 0200 Physician Assistant






2
3 0300 Nurse Practitioner






3
4 0400 Certified Nurse Midwife






4
5 0500 Registered Nurse






5
6 0600 Licensed Practical Nurse






6
7 0700 Clinical Psychologist






7
8 0800 Clinical Social Worker






8
9 0900 Laboratory Technician






9
10 1000 Other (specify)






10
14
Subtotal-Facility Health Care Staff Costs (sum of lines 1 through 10)






14
COSTS UNDER AGREEMENT









15 1500 Physician Services Under Agreement






15
16 1600 Physician Supervision Under Agreement






16
17
Subtotal Under Agreement (sum of lines 15 and 16)






17
OTHER HEALTH CARE COSTS








25 2500 Medical Supplies






25
26 2600 Transportation (Health Care Staff)






26
27 2700 Depreciation-Medical Equipment






27
28 2800 Malpractice Premiums






28
29 2900 Allowable GME Costs






29
30 3000 Pneumococcal Vaccines & Med Supplies






30
31 3100 Influenza Vaccine & Med Supplies






31
31.10 3110 COVID-19 Vaccine & Med Supplies






31.10
31.11 3111 Monoclonal Antibody Products






31.11
32 3200 Other (specify)






32
38
Subtotal-Other Health Care Costs (sum of lines 25 through 32)






38
39
Total Cost of Services (Other Than






39


Overhead And Other RHC Services)








(sum of lines 14, 17, and 38)






FACILITY OVERHEAD-FACILITY COST








40 4000 Rent






40
41 4100 Insurance






41
42 4200 Interest On Mortgage Or Loans






42
43 4300 Utilities






43
44 4400 Depreciation-Buildings And Fixtures






44
45 4500 Depreciation-Movable Equipment






45
46 4600 Housekeeping And Maintenance






46
47 4700 Property Tax






47
48 4800 Other (specify)






48
59
Subtotal-Facility Costs (sum of lines 40 through 48)






59







































































































































































































































FORM CMS-222-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4607)




















46-308








Rev. 2
05-18

FORM CMS-222-17



4690 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL




CCN: PERIOD:
WORKSHEET A
BALANCE OF EXPENSES





FROM: ____________








____________ TO: ____________











NET







RECLASSIFIED
EXPENSES FOR


COST CENTER

TOTAL RECLASSIFI- TRIAL BALANCE
ALLOCATION



SALARIES OTHER (col. 1 + col. 2) CATIONS (col. 3 ± col. 4) ADJUSTMENTS (col. 5 ± col. 6)



1 2 3 4 5 6 7
FACILITY OVERHEAD-ADMINISTRATIVE COSTS








60 6000 Office Salaries






60
61 6100 Depreciation-Office Equipment






61
62 6200 Office Supplies






62
63 6300 Legal






63
64 6400 Accounting






64
65 6500 Insurance






65
66 6600 Telephone






66
67 6700 Fringe Benefits And Payroll Taxes






67
68 6800 Other (specify)






68
73
Subtotal-Administrative Cost (sum of lines 60 through 68)






73
74
Total Overhead (sum of lines 59 and 73)






74
COST OTHER THAN RHC SERVICES








75 7500 Pharmacy






75
76 7600 Dental






76
77 7700 Optometry






77
78 7800 Non-allowable GME Pass Through Costs






78
79 7900 Telehealth






79
80 8000 Chronic Care Management






80
81 8100 Other (specify)






81
86
Subtotal-Cost Other Than RHC (sum of lines 75 through 81)






86
NON-REIMBURSABLE COSTS








87 8700







87
88 8800







88
89 8900







89
90
Subtotal Non-Reimbursable Costs (sum of lines 87 through 89)






90
100
TOTAL COSTS (sum of lines 39, 74, 86, and 90)






100











































































































































































































































































































































































FORM CMS-222-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4607)




















Rev. 1








46-309

Sheet 7: A-6

4690 (Cont.)

FORM CMS-222-17




05-18
RECLASSIFICATIONS
CCN:

PERIOD:
WORKSHEET A-6






FROM: __________





____________

TO: ___________





CODE INCREASES

DECREASES





COST LINE
COST LINE


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


1 2 3 4 5 6 7
1







1
2







2
3







3
4







4
5







5
6







6
7







7
8







8
9







9
10







10
11







11
14







14
15







15
16







16
17







17
18







18
19







19
20







20
21







21
22







22
23







23
24







24
25







25
26







26
27







27
28







28
29







29
30







30
31







31
32







32
33







33
34







34
35







35
100 TOTAL RECLASSIFICATIONS (Sum of Column 4






100

must equal sum of Column 7)







(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.








(2) Transfer the amounts in columns 4 and 7 to Worksheet A, column 4, lines as appropriate.




































































FORM CMS-222-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4608)


















46-310







Rev. 1

Sheet 8: A-8

05-18
FORM CMS-222-17




4690 (Cont.)
ADJUSTMENTS TO EXPENSES
CCN:
PERIOD:
WORKSHEET A-8





FROM: ___________





____________
TO: ___________







EXPENSE CLASSIFICATION ON WORKSHEET A




TO/FROM WHICH THE AMOUNT IS TO BE


BASIS/
ADJUSTED

DESCRIPTION (1) CODE (2) AMOUNT COST CENTER LINE #


1 2 3

4
1 Investment income- buildings and fixtures (chapter 2)

Buildings and Fixtures

44 1
2 Investment income- movable equipment (chapter 2)

Movable Equipment

45 2
3 Investment income- other (chapter 2)





3
4 Trade, quantity and time discounts (chapter 8)





4
5 Refunds and rebates of expenses (chapter 8)





5
6 Rental of building or office space to others (chapter 8)





6
7 Related organization transactions (chapter 10) Wkst A-8-1




7
8 Sale of drugs to other than patients





8
9 Vending machines





9
10 Practitioner assigned by Public Health Service





10
11 Depreciation - buildings and fixtures

Buildings and Fixtures

44 11
12 Depreciation - movable equipment

Movable Equipment

45 12
13 RCE adjustment to teaching physician's cost

Allowable GME Costs

29 13
14 Other adjustments (Specify)(3)





14
50 TOTAL (sum of lines 1 through 49)





50









(1) Description - all chapter references in this column pertain to CMS Pub. 15-1.







(2) Basis for adjustment (see instructions)







A. Costs - if cost, including applicable overhead, can be determined.







B. Amount Received - if cost cannot be determined.







(3) Additional adjustments may be made on lines 14 through 49 and subscripts thereof.






























































































































































































































































































FORM CMS-222-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4609)
















Rev. 1






46-311

Sheet 9: A-8-1

4690 (Cont.)


FORM CMS-222-17
05-18
STATEMENT OF COSTS OF SERVICES


CCN: PERIOD:
WORKSHEET A-8-1
FROM RELATED ORGANIZATIONS AND



FROM: ____________


HOME OFFICE COSTS


____________ TO: ____________











PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED







ORGANIZATIONS OR CLAIMED HOME OFFICE COSTS












Amount of Amount included Net Adjustments





Allowable in Wkst. A, (col. 4 minus

Line No. Cost Center Expense Items Cost col. 5 col. 5) *

1 2 3 4 5 6
1






1
2






2
3






3
4






4
5 TOTALS (sum of lines 1-4) Transfer col. 6, line 5 to Wkst. A-8 , column 2, line 7.)





5


















* The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as appropriate.







Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not







been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.
















PART II - INTERRELATIONSHIP TO RELATED ORGANIZATIONS AND/OR HOME OFFICE







The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires the







provider to furnish the information requested on Part II of this worksheet.
















This information is used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable to services,







facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs as determined under







section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost report is considered incomplete and







not acceptable for purposes of claiming reimbursement under Title XVIII.






























Related Organization(s) and/or Home Office





Percentage

Percentage


Symbol
of

of Type of

(1) Name Ownership Name Ownership Business

1 2 3 4 5 6
6





6
7






7
8






8
9






9
10






10










(1) Use the following symbols to indicate interrelationship to related organizations:

















A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in the RHC;







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







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







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







in related organization;







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







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







financial interest in the RHC;







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





































































































































































































































































































FORM CMS-222-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4610 THROUGH 4610.2)
















46-312






Rev. 1

Sheet 10: B-Part I &II

04-21
FORM CMS-222-17


4690 (Cont.)


VISITS AND OVERHEAD COST FOR RHC SERVICES
CCN:
PERIOD:
WORKSHEET B







FROM: ____________
PARTS I & II





____________
TO: ____________
















PART I - VISITS AND PRODUCTIVITY











Number of

Minimum Greater of





FTE Total Productivity Visits Col. 2 or





Personnel Visits Standard (1) (col. 1 x col. 3) Col. 4




Positions 1 2 3 4 5



1 Physicians

4200

1


2 Physician Assistants

2100

2


3 Nurse Practitioner

2100

3


4 Certified Nurse Midwife

2100

4


5 Subtotal (sum of lines 1 through 4)




5


6 Registered Nurse




6


7 Licensed Practical Nurse




7


8 Clinical Psychologist




8


9 Clinical Social Worker




9


10 Total Staff




10


11 Physician Services Under Agreement




11



(1) Productivity standards established by CMS are: 4200 visits for each physician and 2100 visits for each nonphysician









practitioner. If an exception to the productivity standard has been granted (Wkst. S-1, Part I, line 20, equals "Y"), input









in col. 3, lines 1 through 4, the productivity standards derived by the contractor.



















PART II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO RHC SERVICES














Amount



12 Cost of RHC services - excluding overhead and allowable GME costs




12



(Worksheet A, column 7, line 39, minus Worksheet A, column 7, line 29)








13 Cost of other than RHC - excluding overhead (Worksheet A, column 7, sum of lines 86 and 90)




13


14 Cost of all services - excluding overhead - (sum of lines 12 and 13)




14


15 Ratio of RHC (line 12 divided by line 14)




15


16 Total overhead - (Worksheet A, column 7, line 74)




16

17 Overhead applicable to RHC services (line 15 times line 16) (see instructions)




17


18 Total allowable cost of RHC services (sum of lines 12 and 17)




18






















































































































































































































































































































FORM CMS-222-17 (05-2018) INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4611 THROUGH 4611.2)




















Rev. 2





46-313



Sheet 11: B-1

4690 (Cont.)
FORM CMS-222-17


04-21
COMPUTATION OF VACCINE COST
CCN: PERIOD:
WORKSHEET B-1



FROM: ___________




___________ TO: ___________














MONOCLONAL


PNEUMOCOCCAL INFLUENZA COVID-19 ANTIBODY


VACCINES VACCINES VACCINES PRODUCTS


1 2 2.01 2.02
1 Health care staff cost (from Worksheet A, column 7, line 14)



1







2 Ratio of injection/infusion staff time to total health care



2

staff time




3 Injection/infusion health care staff cost (line 1 multiplied



3

by line 2)




4 Injections/infusions and related medical supplies cost



4

(from Worksheet A, column 7, lines 30, 31, 31.10, and





31.11, respectively)




5 Direct cost of injections/infusions



5

(sum of lines 3 and 4)




6 Total direct cost of the RHC (from Worksheet A,



6

column 7, line 39)




7 Total facility overhead (from Worksheet A,



7

column 7, line 74)




8 Ratio of injection/infusion direct cost to total direct cost



8

(line 5 divided by line 6)




9 Overhead cost - injections/infusions (line 7 multiplied by line 8)



9







10 Total injection/infusion cost and administration



10

(sum of lines 5 and 9)




11 Total number of injections/infusions



11

(from provider records)




12 Cost per injection/infusion (line 10 divided by line 11)



12







13 Number of injections/infusions administered



13

to Medicare beneficiaries




13.01 Number of COVID-19 injections/infusions administered



13.01

to MA enrollees




14 Medicare cost of injections/infusions and administration



14

(line 12 multiplied by the sum of lines 13 and 13.01,





as applicable)




15 Total cost of injections/infusions and administration



15

(sum of columns 1, 2, 2.01, and 2.02, line 10)





Transfer to Worksheet C, Part I, line 2




16 Total Medicare cost of injections/infusions and



16

administration (sum of columns 1, 2, 2.01, and 2.02,





line 14) Transfer to Worksheet C, Part II, line 23

































































































































































































FORM CMS-222-17 (04-2021) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB 15-2, SECTION 4612)












46-314




Rev. 2

Sheet 12: C-Part I & II

04-21
FORM CMS-222-17


4690 (Cont.)
DETERMINATION OF MEDICARE
CCN: PERIOD:
WORKSHEET C
PAYMENT

FROM: ____________
PARTS I & II


____________ TO: ___________









PART I- DETERMINATION OF RATE FOR RHC SERVICES



AMOUNT
1 Total allowable costs (Worksheet B, Part II, line 18)



1







2 Cost of injections/infusions and administration (from Worksheet B-1, line 15)



2







3 Total allowable cost excluding injections/infusions (line 1 minus line 2)



3







4 Greater of minimum visits or actual visits by health care staff (from Worksheet B, Part I, column 5, line 10)



4







5 Physicians visits under agreements (from Worksheet B, Part I, column 5, line 11)



5







6 Total adjusted visits (line 4 plus line 5)



6







7 Adjusted cost per visit (line 3 divided by line 6)



7










Calculation of Limit (1)



Payment Limit Payment Limit Payment Limit



Period 1 Period 2 Period 3
8 Maximum rate per visit (see instructions)



8







9 Rate for Medicare covered visits (lesser of line 7 or line 8)



9





















PART II - DETERMINATION OF TOTAL PAYMENT

Payment Limit Payment Limit Payment Limit



Period 1 Period 2 Period 3
10 Medicare covered visits excluding mental health services (from contractor records)



10







11 Medicare cost excluding costs for mental health services (line 9 multiplied by line 10)



11







12 Medicare covered visits for mental health services (from contractor records)



12







13 Medicare covered cost for mental health services (line 9 multiplied by line 12)



13







14 Total Medicare cost (line 11 plus line 13 )



14







15 Less: Medicare beneficiary deductible (see instructions)



15







16 Net Medicare cost excluding injections/infusions and administration



16

(line 14 minus line 15)




17 Total Medicare charges (see instructions)



17







18 Total Medicare preventive charges (see instructions)



18







19 Total Medicare preventive costs ((line 18 divided by line 17) times line 14)



19







20 Total Medicare non-preventive costs ((line 16 minus line 19) times 80 percent)



20







21 Net Medicare cost (line 19 plus 20) (see instructions)



21






.
22 Graduate medical education pass through cost (see instructions)



22







23 Medicare cost of injections/infusions and administration (from Worksheet B-1, line 16)



23







24 Primary payer payments



24







25 Net Medicare reimbursement excluding bad debts (see instructions)



25







26 Allowable bad debts (see instructions)



26


`



27 Adjusted reimbursable bad debts (see instructions)



27







28 Allowable bad debts for dual eligible beneficiaries (see instructions)



28







29 Subtotal (line 25 plus line 27)



29







30 Other demonstration payment adjustment amount before sequestration



30







31 Other adjustments (specify) (see instructions)



31







32 Amount due RHC prior to sequestration adjustment (line 29 minus lines 30 and 31)



32







33 Sequestration adjustment (see instructions)



33







34 Other demonstration payment adjustment amount after sequestration



34







35 Amount due RHC after sequestration adjustment (line 32 minus lines 33 and 34)



35







36 Interim payments



36







37 Tentative settlement (for contractor use only)



37







38 Balance due RHC/program (line 35 minus lines 36 and 37)



38







39 Protested amounts (nonallowable cost report items) in accordance with 42 CFR 413.24(j)(2)(i)



39














(1) Lines 8 through 16: Fiscal year providers use columns 1 and 2 (and column 3, if applicable); calendar year providers with one rate in effect for the entire





cost reporting period use column 2 only.












FORM CMS-222-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4613 THROUGH 4613.2)












Rev. 2




46-315

Sheet 13: C-1

4490 (Cont.)


FORM CMS-222-17



04-21
ANALYSIS OF PAYMENTS TO THE RURAL HEALTH CLINIC FOR SERVICES RENDERED



CCN: PERIOD:
WORKSHEET C-1






FROM: ____________








TO: ___________







___________














Description




Part B







mm/dd/yyyy Amount







1 2
1 Total interim payments paid to RHC






1
2 Interim payments payable on individual bills, either submitted or to be submitted to the contractor






2

for services rendered in the cost reporting period. If none, write "NONE" or enter a zero







3 List separately each retroactive



.01

3.01

lump sum adjustment amount based



.02

3.02

on subsequent revision of the


Program to .03

3.03

interim rate for the cost reporting period.


Provider .04

3.04

Also show date of each payment.



.05

3.05

If none, write "NONE" or enter a zero. (1)



.50

3.50






.51

3.51





Provider to .52

3.52





Program .53

3.53






.54

3.54

Subtotal (sum of lines 3.01- 3.49 minus sum of lines 3.50-3.98)



.99

3.99
4 Total interim payments (sum of lines 1, 2, and 3.99)






4

(transfer to Wkst. C, Part II, line 36)








TO BE COMPLETED BY CONTRACTOR







5 List separately each tentative settlement


Program to .01

5.01

payment after desk review. Also show


Provider .02

5.02

date of each payment.



.03

5.03

If none, write "NONE" or enter a zero. (1)



.50

5.50





Provider to .51

5.51





Program .52

5.52

Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50-5.98)



.99

5.99
6 Determine net settlement amount (balance


Program to provider .01

6.01

due) based on the cost report (1)


Provider to program .02

6.02
7 Total Medicare program liability (see instructions)






7
8 Name of Contractor

Contractor Number

NPR Date (MM/DD/YYYY)
8




















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












































































































FORM CMS-222-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4614)


















46-316







Rev. 2
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