Cms-10897 Supplemental To Form Cms-2552-10

Supplemental to Form CMS-2552-10 Payment Adjustment for Establishing and Maintaining Access to Buffer Stock of Essential Medicines (CMS-10897)

Supplemental to Form CMS-2552-10-f

OMB: 0938-1473

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SUPPLEMENTAL TO FORM CMS-2552-10
FORM APPROVED
OMB NO. 0938-XXXX
EXPIRES XX-XX-XXXX

THIS REPORT IS REQUIRED BY LAW (42 USC 1395g; 42 CFR 413.20(b)). FAILURE TO REPORT CAN RESULT IN ALL INTERIM
PAYMENTS MADE SINCE THE BEGINNING OF THE COST REPORTING PERIOD BEING DEEMED OVERPAYMENTS (42 USC 1395g).

PAYMENT ADJUSTMENT FOR ESTABLISHING AND MAINTAINING ACCESS TO A BUFFER STOCK OF ESSENTIAL MEDICINES

PROVIDER CCN:
________________

PERIOD:
FROM: ______________
TO:
______________

PART
1
2
3

I - ESSENTIAL MEDICINES PAYMENT ADJUSTMENT ELIGIBILITY
NUMBER OF BEDS
IS THIS AN INDEPENDENT HOSPITAL?
DID THE HOSPITAL INCUR COST IN ORDER TO ESTABLISH AND MAINTAIN ACCESS TO A BUFFER SUPPLY OF ESSENTIAL MEDICINES?

1
2
3

PART
1
2
3

II - ADDITIONAL RESOURCE COST OF ESSENTIAL MEDICINES
COST TO ESTABLISH AND MAINTAIN BUFFER STOCK OF ESSENTIAL MEDICINES - DIRECTLY INCURRED
COST TO ESTABLISH AND MAINTAIN BUFFER STOCK OF ESSENTIAL MEDICINES - CONTRACT
TOTAL COST TO ESTABLISH AND MAINTAIN BUFFER STOCK OF ESSENTIAL MEDICINES

1
2
3

PART
1
2
3
4
5
6
7

III - CALCULATION OF MEDICARE PAYMENT ADJUSTMENT FOR ESSENTIAL MEDICINES
MEDICARE ROUTINE/ANCILLARY COST
MEDICARE ACQUISITION COST
COST OF PHYSICIANS' SERVICES IN A TEACHING HOSPITAL
TOTAL MEDICARE REASONABLE COST
TOTAL FACILITY COST
MEDICARE PERCENTAGE
ESSENTIAL MEDICINES PAYMENT ADJUSTMENT

1
2
3
4
5
6
7

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-XXXX. THE TIME REQUIRED TO COMPLETE THIS INFORMATION COLLECTION IS ESTIMATED TO BE 1.00 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: 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.


File Typeapplication/pdf
File TitleEssential Medicines Supplemental Form CMS-2552-10-f.xlsx
AuthorMarci Muffley
File Modified2024-04-10
File Created2024-04-10

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