Form CMS-2088-17 Community Mental Health Cost Center Report

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Overview

S
S-1 I & II
S-2
A
A6
A8
A81
A82
B
B-1
C
D
D-1
F

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Sheet 1: S

08-22

FORM CMS-2088-17

4590 (Cont.)

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim

FORM APPROVED

payments made since the beginning of the cost reporting period being deemed as overpayments (42 USC 1395g).

OMB NO. 0938-0037

EXPIRES: 03/31/2025

COMMUNITY MENTAL HEALTH CENTER COST REPORT

PROVIDER CCN:

PERIOD:

WORKSHEET S

IDENTIFICATION DATA, CERTIFICATION

FROM _______________

PARTS I, II & III

AND SETTLEMENT SUMMARY

____________________

TO _______________

PART I - COST REPORT STATUS

Provider use

1. [ ] Electronically prepared cost report

Date:

Time:

only

2. [ ] Manually prepared cost report

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

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

Contractor

5. [ ] Cost Report Status

6. Date Received:_________

10. NPR Date:__________

use only

(1) As Submitted

7. Contractor No.:________

11. Contractor's Vendor Code: ___________

(2) Settled without audit

8. [ ] Initial Report for this Provider CCN

12. [ ] If line 5, column 1 is 4: Enter 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

SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR

CHECKBOX

ELECTRONIC

1

2

SIGNATURE STATEMENT

1

1

2

Signatory Printed Name

2

3

Signatory Title

3

4

Signature date

4

PART III - SETTLEMENT SUMMARY

TITLE XVIII

1

1

COMMUNITY MENTAL HEALTH CENTER

1

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

FORM CMS-2088-17 (08-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4502 THROUGH 4502.3)

Rev. 3

45-303

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Sheet 2: S-1 I & II

4590 (Cont.)											FORM CMS-2088-17																08-22
COMMUNITY MENTAL HEALTH CENTER IDENTIFICATION DATA													PROVIDER CCN:					PERIOD:					WORKSHEET S-1
																						FROM _______________	PARTS I & II
															____________________							TO _______________
PART I - 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 CMHC part of a HO/CO as defined in §2150 of CMS Pub. 15-1 that claims HO/CO costs in a home office cost statement?																										5
	Enter "Y for yes or "N" for no in column 1. If yes, enter the HO/CO information below.
6	Name of HO/CO:																										6
7	Street:										P O Box:				HO/CO CCN:												7
8	City:										State:				ZIP Code:												8
Medical Malpractice
9	Is this CMHC legally required to carry malpractice insurance? Enter "Y" for yes or "N" for no.																										9
10	If line 9 is "Y", is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.																										10
																									SELF
																			PREMIUMS			PAID LOSSES			INSURANCE
																			1			2			3
11	Enter total malpractice premiums in col. 1, total paid losses in col. 2, and total self insurance in col. 3																										11
12	Are malpractice premiums and/or paid losses reported in other than the A&G cost center? Enter "Y" for yes or "N" for no. (see instructions)																										12
Miscellaneous
																								DEMONSTRA-
																					Y/N			TION TYPE
																					1			2
13	Did this facility participate in any payment demonstration during this cost reporting period? Enter "Y" for yes or "N" for no.																										13
	If column 1 is yes, enter the type of demonstration in column 2. If the CMHC participated in more than one demonstration,
	subscript this line accordingly.
14	Are there any costs included in Worksheet A that resulted from transactions with related organizations as defined in																										14
	CMS Pub. 15-1, chapter 10? If yes, complete Worksheet A-8-1.
PART II - STATISTICAL DATA
												VISITS
	REIMBURSABLE								MEDICARE			OTHER						PATIENT DAYS
	COST CENTERS						WKST		PATIENTS			PATIENTS			TOTAL			MEDICARE			OTHER			TOTAL
							A		1			2			3			4			5			6
1	Drugs & Biologicals						23																				1
2	Occupational Therapy						24																				2
3	Behavioral Health Treatment/Services						25																				3
4	Individual Therapy						26																				4
5	Group Therapy						27																				5
6	Activity Therapy						28																				6
7	Family Therapy						29																				7
8	Psychiatric Testing						30																				8
9	Education Training						31																				9
10	Other (specify)						32																				10
11	TOTAL (sum of lines 1 through 10)																										11
12	Unduplicated Census																										12
									FTES ON PAYROLL
	REIMBURSABLE								STAFF						SOCIAL
	COST CENTERS						WKST.		THERAPISTS			PHYSICIANS			WORKERS			OTHERS
							A		7			8			9			10
1	Drugs & Biologicals						23																				1
2	Occupational Therapy						24																				2
3	Behavioral Health Treatment/Services						25																				3
4	Individual Therapy						26																				4
5	Group Therapy						27																				5
6	Activity Therapy						28																				6
7	Family Therapy						29																				7
8	Psychiatric Testing						30																				8
9	Education Training						31																				9
10	Other (specify)						32																				10
11	TOTAL (sum of lines 1 through 10)																										11
12	Unduplicated Census																										12
FORM CMS-2088-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4503 THROUGH 4503.2)
45-304																											Rev. 3

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Sheet 3: S-2

02-21													FORM CMS-2088-17													4590 (Cont.)
COST REPORT REIMBURSEMENT QUESTIONNAIRE												PROVIDER CCN:					PERIOD:					WORKSHEET S-2
																					FROM _______________
														____________________							TO _______________
																	Y/N			DATE			V/I
PROVIDER ORGANIZATION AND OPERATION																	1			2			3
1	Has the provider changed ownership immediately prior to the beginning of the cost reporting period?																									1
	Enter "Y" for yes or "N" for no in column 1. If yes, enter the date (mm/dd/yyyy) of the change in column 2.
	(see instructions)
2	Has the provider terminated participation in the Medicare Program? Enter "Y" for yes or "N" for no in																									2
	column 1. If yes, enter in column 2 the termination date (mm/dd/yyyy); and, enter in column 3,
	"V" for voluntary or "I" for involuntary.
3	Is the provider involved in business transactions, including management contracts, with individuals or entities																									3
	(e.g., chain home offices, drug or medical supply companies) that were related to the provider or its officers,
	medical staff, management personnel, or members of the board of directors through ownership, control, or
	family and other similar relationships? Enter "Y" for yes or "N" for no in column 1. (see instructions)
																	Y/N			A/C/R			DATE
FINANCIAL DATA AND REPORTS																	1			2			3
4	Column 1: Were the financial statements prepared by a Certified Public Accountant? Enter "Y" for yes or																									4
	"N" for no.
	Column 2: If yes, enter in col. 2: "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit
	complete copy of financial statements or enter date available (mm/dd/yyyy) in column 3. (see
	instructions) If no, see instructions.
5	Are the cost report total expenses and total revenues different from those on the filed financial statements?																									5
	Enter "Y" for yes or "N" for no in column 1. If yes, submit reconciliation.
BAD DEBTS																							Y/N
6	Is the provider seeking reimbursement for bad debts? Enter "Y" for yes or "N" for no. If yes, see instructions.																									6
7	If line 6 is yes, did the provider's bad debt collection policy change during the cost reporting period? "Y" for yes or "N" for no. If yes, submit a copy.																									7
8	If line 6 is yes, were patient deductibles and/or co-payments waived? Enter "Y" for yes or "N" for no. If yes, see instructions.																									8
																				Y/N			DATE
PS&R REPORT DATA																				1			2
9	Was the cost report prepared using the PS&R report only? Enter "Y" for yes or "N" for no in column 1. If yes, enter in																									9
	column 2 the paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions)
10	Was the cost report prepared using the PS&R report for totals and the provider's records for allocation? Enter "Y" for yes or																									10
	"N" for no in col. 1.
	If yes, enter in col. 2 the paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions)
11	If line 9 or 10 is yes, were adjustments made to PS&R report data for additional claims that have been billed but are not included																									11
	on the PS&R report used to file the cost report? Enter "Y" for yes or "N" for no. If yes, see instructions.
12	If line 9 or 10 is yes, were adjustments made to PS&R report data for corrections of other PS&R report information? Enter "Y"																									12
	for yes or "N" for no. If yes, see instructions.
13	If line 9 or 10 is yes, were adjustments made to PS&R report data for Other? Enter "Y" for yes or "N" for no.																									13
	If yes, describe the other adjustments:
14	Was the cost report prepared only using the provider's records? Enter "Y" for yes or "N" for no.																									14
	If yes, see instructions.
COST REPORT PREPARER CONTACT INFORMATION
15	First name:									Last name:									Title:							15
16	Employer:																									16
17	Phone number:												E-mail Address:													17
FORM CMS-2088-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4504)
Rev. 2																										45-305

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Sheet 4: A

4590 (Cont.)																FORM CMS-2088-17																			04-21
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES																					PROVIDER CCN:					PERIOD:					WORKSHEET A
																														FROM _______________
																							____________________							TO _______________
																		CON-									RECLASSIFIED						NET EXPENSES
																		TRACTED			TOTAL						TRIAL						FOR
																		PURCHASED			(sum of col. 1			RECLASSIFI-			BALANCE						ALLOCATION
		COST CENTERS (Omit Cents)										SALARIES			OTHER			SERVICES			through col. 3)			CATIONS			(col. 4 ± col. 5)			ADJUSTMENTS			(col. 6 ± col. 7)
												1			2			3			4			5			6			7			8
		GENERAL SERVICE COST CENTERS
1	0100	Cap Rel Costs - Bldgs & Fixt																																	1
2	0200	Cap Rel Costs - Mvble Equip																																	2
3	0300	Employee Benefits																																	3
4	0400	Administrative & General																																	4
5	0500	Maintenance & Repairs																																	5
6	0600	Operation of Plant																																	6
7	0700	Laundry & Linen Service																																	7
8	0800	Housekeeping																																	8
9	0900	Cafeteria																																	9
10	1000	Central Services & Supply																																	10
11	1100	Medical Records & Library																																	11
12	1200	Pro Ed & Training (Approved)																																	12
13		Other (specify)																																	13
		REIMBURSABLE COST CENTERS
23	2300	Drugs & Biologicals																																	23
24	2400	Occupational Therapy																																	24
25	2500	Behavioral Health Treatment/Services																																	25
26	2600	Individual Therapy																																	26
27	2700	Group Therapy																																	27
28	2800	Activity Therapy																																	28
29	2900	Family Therapy																																	29
30	3000	Psychiatric Testing																																	30
31	3100	Education Training																																	31
32		Other (specify)																																	32
		NONREIMBURSABLE COST CENTERS
42	4200	Sheltered Workshops																																	42
43	4300	Recreational Programs																																	43
44	4400	Resident Day Camps																																	44
45	4500	Diagnostic Clinics																																	45
46	4600	Physicians' Private Offices																																	46
47	4700	Fund Raising																																	47
48	4800	Coffee Shops & Canteen																																	48
49	4900	Research																																	49
50	5000	Investment Property																																	50
51	5100	Advertising																																	51
52	5200	Franchise Fees & Other Assessments																																	52
53	5300	Pro Ed & Training (Not Approved)																																	53
54	5400	Meals & Transportation																																	54
55	5500	Activity Therapies																																	55
56	5600	Psychosocial Programs																																	56
57	5700	Vocational Training																																	57
58		Other (specify)																																	58
100		TOTAL (sum of lines 1 through 58)																																	100
FORM CMS-2088-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4505)
45-306																																			Rev. 2

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Sheet 5: A6

04-21																FORM CMS-2088-17																			4590 (Cont.)
RECLASSIFICATIONS																					PROVIDER CCN:					PERIOD:					WORKSHEET A
																														FROM _______________
																							____________________							TO _______________
											INCREASE												DECREASE
	EXPLANATION OF RECLASSIFICATION(S)								CODE (1)		COST CENTER				LINE NO.			SALARY (2)			NON SALARY (2)		COST CENTER				LINE NO.			SALARY (2)			NON SALARY (2)
									1		2				3			4			5		6				7			8			9
1																																			1
2																																			2
3																																			3
4																																			4
5																																			5
6																																			6
7																																			7
8																																			8
9																																			9
10																																			10
11																																			11
12																																			12
13																																			13
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
36																																			36
37																																			37
38																																			38
39																																			39
40																																			40
100	Total reclassifications (sum of columns 4 and 5																																		100
	must equal sum of columns 8 and 9)
	(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
	(2) Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A. column 5, line as appropriate.
FORM CMS-2088-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4506)
Rev. 2																																			45-307

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Sheet 6: A8

4590 (Cont.)													FORM CMS-2088-17													04-21
ADJUSTMENTS TO EXPENSES												PROVIDER CCN:					PERIOD:					WORKSHEET A-8
																					FROM _______________
														____________________							TO _______________
																					EXPENSE CLASSIFICATION ON
																					WORKSHEET A TO/FROM WHICH
																					THE AMOUNT IS TO BE ADJUSTED
	DESCRIPTION (1)									BASIS (2)				AMOUNT						COST CENTER				LINE NO.
										1				2						3				4
1	Capital Related Costs - Buildings									A							Capital Related Costs							1		1
	& fixtures																Buildings & Fixtures
2	Capital Related Costs - Movable									A							Capital Related Costs							2		2
	Equipment																Movable Equipment
3	Payments received from									B																3
	specialists
4	Investment income																									4
	(chapter 2)
5	Trade, quantity, and time discounts									B																5
	(chapter 8)
6	Refunds and rebates of expenses									B																6
	(chapter 8)
7	Laundry and linen service																Laundry and Linen Service							7		7
8	Cafeteria-employees,									A							Cafeteria							9		8
	guests, etc.
9	Sale of medical and surgical																Central Services and							10		9
	supplies to other than patients																Supplies
10	Sale of workshop products																									10
	or services
11	Coffee shops and canteen																									11
12	Vending Machines									A																12
13	Rental of building or office																									13
	space to others
14	Sale of scrap, waste,																									14
	etc. (chapter 23)
15	Related organization transactions									Wkst.																15
	(chapter 10)									A-8-1
16	Provider-based physician									Wkst.																16
	adjustment									A-8-2
17	Other adjustments (specify) (3)																									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
50	TOTAL (sum of lines 1 through 49)																									50
	(Transfer to Worksheet A, col. 7, line 100.)
	(1) Include amounts not already applied against expenses included on Worksheet A, column 4
	(2) Basis for adjustment (SEE INSTRUCTIONS).
	A. Costs -- if cost, including applicable overhead, can be determined.
	B. Amount Received -- if cost cannot be determined.
	(3) Additional adjustments may be made on lines 17 thru 49 and subscripts thereof.
	Chapter references are to CMS Pub.15-1
FORM CMS-2088-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4507)
45-308																										Rev. 2

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Sheet 7: A81

04-21

FORM CMS-2088-17

4590 (Cont.)

STATEMENT OF COSTS OF SERVICES

PROVIDER CCN:

PERIOD:

WORKSHEET A-8-1

FROM RELATED ORGANIZATIONS

FROM _______________

____________________

TO _______________

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

OR CLAIMED HOME OFFICE COSTS

AMOUNT

NET

AMOUNT

INCLUDED

ADJUSTMENTS

WKST A

ALLOWABLE

IN WKST A,

(COL 4 MINUS

LINE NO.

COST CENTER

EXPENSE ITEMS

IN COST

COL 6

COL 5) *

1

2

3

4

5

6

1

1

2

2

3

3

4

4

5

TOTALS (sum of lines 1 through 4) Transfer col. 6, line 5, to Worksheet A-8,

5

col. 2, line 15.

*

The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 7, lines as appropriate. Positive amounts increase cost and

negative amounts decrease cost. For related organization or home office cost which have not been posted to Worksheet A, columns 1, 2 and/or 3, the amount allowable should be

indicated in column 4 of this part.

PART II - INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE

The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish the information requested under Part II of this

worksheet.

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

furnished by organizations related to you by common ownership or control, represent reasonable costs as determined under section 1861 of the Social Security Act. If you

do not provide all or any part of the requested information, the cost report is considered incomplete and not acceptable for purposes of claiming reimbursement under Medicare.

RELATED ORGANIZATIONS AND/OR HO/CO

PERCENT

PERCENT

SYMBOL

OF

OF

(1)

NAME

OWNERSHIP

NAME

OWNERSHIP

TYPE OF 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 provider.

B.

Corporation, partnership or other organization has financial interest in provider.

C.

Provider has financial interest in corporation, partnership, or other organization.

D.

Director, officer, administrator or key person of provider or relative of such

person has financial interest in related organization.

E.

Individual is director, officer, administrator or key person of provider and

related organization.

F.

Director, officer, administrator or key person of related organization or relative

of such person has financial interest in provider.

G.

Other (financial or non-financial) specify __________________________________________________

FORM CMS-2088-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4508)

Rev. 2

45-309

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Sheet 8: A82

4590 (Cont.)																FORM CMS-2088-17																			04-21
PROVIDER-BASED PHYSICIANS ADJUSTMENTS																					PROVIDER CCN:					PERIOD:					WORKSHEET A-8-2
																														FROM _______________
																							____________________							TO _______________
																											PHYSICIAN/
															TOTAL												PROVIDER						5 PERCENT OF
	WKST A							COST CENTER/							REMUN-			PROFESSIONAL			PROVIDER			RCE			COMPONENT			UNADJUSTED			UNADJUSTED
	LINE NO.							PHYSICIAN IDENTIFIER							ERATION			COMPONENT			COMPONENT			AMOUNTS			HOURS			RCE LIMIT			RCE LIMIT
	1							2							3			4			5			6			7			8			9
1																																			1
2																																			2
3																																			3
4																																			4
5																																			5
6																																			6
7																																			7
8																																			8
9																																			9
10																																			10
100			TOTAL																																100
															COST OF			PROVIDER			PHYSICIAN			PROVIDER
															MEMBERSHIPS			COMPONENT			COST OF			COMPONENT
	WKST A							COST CENTER/							& CONTINUING			SHARE OF			MALPRACTICE			SHARE OF			ADJUSTED			RCE
	LINE NO.							PHYSICIAN IDENTIFIER							EDUCATION			COLUMN 12			INSURANCE			COLUMN 14			RCE LIMIT			DISALLOWANCE			ADJUSTMENT
	10							11							12			13			14			15			16			17			18
1																																			1
2																																			2
3																																			3
4																																			4
5																																			5
6																																			6
7																																			7
8																																			8
9																																			9
10																																			10
100			TOTAL																																100
FORM CMS-2088-17 (05-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4509)
45-310																																			Rev. 2

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Sheet 9: B

04-21																FORM CMS-2088-17																			4590 (Cont.)	4590 (Cont.)																FORM CMS-2088-17																			04-21
COST ALLOCATION GENERAL SERVICE COSTS																					PROVIDER CCN:					PERIOD:					WORKSHEET B					COST ALLOCATION GENERAL SERVICE COSTS																					PROVIDER CCN:					PERIOD:					WORKSHEET B
																														FROM _______________																																				FROM _______________
																							____________________							TO _______________																													____________________							TO _______________
												NET EXPENSES		CAPITAL RELATED										SUBTOTAL			ADMINIS-			MAIN-																											CENTRAL			MEDICAL			PROF
												FROM WKST A			BLDGS &			MOVABLE			EMPLOYEE			(SUM OF COLS			TRATIVE &			TENANCE &			OPRATION															LAUNDRY			HOUSE-						SERVICE &			RECORDS &			EDUCATION			OTHER
	COST CENTERS											COL 8			FIXTURES			EQUIPMENT			BENEFITS			0 THROUGH 3)			GENERAL			REPAIRS			OF PLANT				COST CENTERS											& LINEN			KEEPING			CAFETERIA			SUPPLY			LIBRARY			& TRAINING			(SPECIFY)			TOTAL
												0			1			2			3			3A			4			5			6															7			8			9			10			11			12			13			14
	GENERAL SERVICE COST CENTERS																																				GENERAL SERVICE COST CENTERS
1	Cap Rel Costs - Bldgs & Fixt																																		1	1	Cap Rel Costs - Bldgs & Fixt																																		1
2	Cap Rel Costs - Mvble Equip																																		2	2	Cap Rel Costs - Mvble Equip																																		2
3	Employee Benefits																																		3	3	Employee Benefits																																		3
4	Administrative & General																																		4	4	Administrative & General																																		4
5	Maintenance & Repairs																																		5	5	Maintenance & Repairs																																		5
6	Operation of Plant																																		6	6	Operation of Plant																																		6
7	Laundry & Linen Service																																		7	7	Laundry & Linen Service																																		7
8	Housekeeping																																		8	8	Housekeeping																																		8
9	Cafeteria																																		9	9	Cafeteria																																		9
10	Central Services & Supply																																		10	10	Central Services & Supply																																		10
11	Medical Records & Library																																		11	11	Medical Records & Library																																		11
12	Pro Ed & Training (Approved)(1)																																		12	12	Pro Ed & Training (Approved)(1)																																		12
13	Other (specify)																																		13	13	Other (specify)																																		13
	REIMBURSABLE COST CENTERS																																				REIMBURSABLE COST CENTERS
23	Drugs & Biologicals																																		23	23	Drugs & Biologicals																																		23
24	Occupational Therapy																																		24	24	Occupational Therapy																																		24
25	Behavioral Health Treatment/Services																																		25	25	Behavioral Health Treatment/Services																																		25
26	Individual Therapy																																		26	26	Individual Therapy																																		26
27	Group Therapy																																		27	27	Group Therapy																																		27
28	Activity Therapy																																		28	28	Activity Therapy																																		28
29	Family Therapy																																		29	29	Family Therapy																																		29
30	Psychiatric Testing																																		30	30	Psychiatric Testing																																		30
31	Education Training																																		31	31	Education Training																																		31
32	Other (specify)																																		32	32	Other (specify)																																		32
	NONREIMBURSABLE COST CENTERS																																				NONREIMBURSABLE COST CENTERS
42	Sheltered Workshops																																		42	42	Sheltered Workshops																																		42
43	Recreational Programs																																		43	43	Recreational Programs																																		43
44	Resident Day Camps																																		44	44	Resident Day Camps																																		44
45	Diagnostic Clinics																																		45	45	Diagnostic Clinics																																		45
46	Physicians' Private Offices																																		46	46	Physicians' Private Offices																																		46
47	Fundraising																																		47	47	Fundraising																																		47
48	Coffee Shops &Canteen																																		48	48	Coffee Shops &Canteen																																		48
49	Research																																		49	49	Research																																		49
50	Investment Property																																		50	50	Investment Property																																		50
51	Advertising																																		51	51	Advertising																																		51
52	Franchise Fees & Other Assessments																																		52	52	Franchise Fees & Other Assessments																																		52
53	Pro Ed & Training (Not Approved)(2)																																		53	53	Pro Ed & Training (Not Approved)(2)																																		53
54	Meals & Transportation																																		54	54	Meals & Transportation																																		54
55	Activity Therapies																																		55	55	Activity Therapies																																		55
56	Psychosocial Programs																																		56	56	Psychosocial Programs																																		56
57	Vocational Training																																		57	57	Vocational Training																																		57
58	Other (specify)																																		58	58	Other (specify)																																		58
99	Negative Cost Centers																																		99	99	Negative Cost Centers																																		99
100	TOTAL (sum of lines 1 through 99)																																		100	100	TOTAL (sum of lines 1 through 99)																																		100
		(1) Approved Educational Activity					(2) Not an Approved Educational Activity																															(1) Approved Educational Activity					(2) Not an Approved Educational Activity
FORM CMS-2088-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)																																				FORM CMS-2088-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)
Rev. 2																																			45-311	45-312																																			Rev. 2

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Sheet 10: B-1

04-21																FORM CMS-2088-17																			4590 (Cont.)	4590 (Cont.)																FORM CMS-2088-17																			04-21
COST ALLOCATION - STATISTICAL BASIS																					PROVIDER CCN:					PERIOD:					WORKSHEET B-1					COST ALLOCATION - STATISTICAL BASIS																					PROVIDER CCN:					PERIOD:					WORKSHEET B-1
																														FROM _______________																																				FROM _______________
																							____________________							TO _______________																													____________________							TO _______________
														CAPITAL RELATED													ADMINIS-			MAIN-																											CENTRAL			MEDICAL			PROF
															BLDGS &			MOVABLE			EMPLOYEE						TRATIVE &			TENANCE &			OPRATION															LAUNDRY			HOUSE-						SERVICE &			RECORDS &			EDUCATION
	COST CENTERS														FIXTURES			EQUIPMENT			BENEFITS						GENERAL			REPAIRS			OF PLANT				COST CENTERS											& LINEN			KEEPING			CAFETERIA			SUPPLY			LIBRARY			& TRAINING			OTHER
															(SQUARE			(DOLLAR			(GROSS			RECON-			(ACCUM			(SQUARE			(SQUARE															(POUNDS OF			(HOURS OF			(MEALS			(COSTED			(TIME			(ASSIGNED
															FEET)			VALUE)			SALARIES)			CILIATION			COST)			FEET)			FEET)															LAUNDRY)			SERVICE)			SERVED)			REQUIS)			SPENT)			TIME)			(SPECIFY)			TOTAL
															1			2			3			4A			4			5			6															7			8			9			10			11			12			13			14
	GENERAL SERVICE COST CENTERS																																				GENERAL SERVICE COST CENTERS
1	Cap Rel Costs - Bldgs & Fixt																																		1	1	Cap Rel Costs - Bldgs & Fixt																																		1
2	Cap Rel Costs - Mvble Equip																																		2	2	Cap Rel Costs - Mvble Equip																																		2
3	Employee Benefits																																		3	3	Employee Benefits																																		3
4	Administrative & General																																		4	4	Administrative & General																																		4
5	Maintenance & Repairs																																		5	5	Maintenance & Repairs																																		5
6	Operation of Plant																																		6	6	Operation of Plant																																		6
7	Laundry & Linen Service																																		7	7	Laundry & Linen Service																																		7
8	Housekeeping																																		8	8	Housekeeping																																		8
9	Cafeteria																																		9	9	Cafeteria																																		9
10	Central Services & Supply																																		10	10	Central Services & Supply																																		10
11	Medical Records & Library																																		11	11	Medical Records & Library																																		11
12	Pro Ed & Training (Approved)(1)																																		12	12	Pro Ed & Training (Approved)(1)																																		12
13	Other (specify)																																		13	13	Other (specify)																																		13
	REIMBURSABLE COST CENTERS																																				REIMBURSABLE COST CENTERS
23	Drugs & Biologicals																																		23	23	Drugs & Biologicals																																		23
24	Occupational Therapy																																		24	24	Occupational Therapy																																		24
25	Behavioral Health Treatment/Services																																		25	25	Behavioral Health Treatment/Services																																		25
26	Individual Therapy																																		26	26	Individual Therapy																																		26
27	Group Therapy																																		27	27	Group Therapy																																		27
28	Activity Therapy																																		28	28	Activity Therapy																																		28
29	Family Therapy																																		29	29	Family Therapy																																		29
30	Psychiatric Testing																																		30	30	Psychiatric Testing																																		30
31	Education Training																																		31	31	Education Training																																		31
32	Other (specify)																																		32	32	Other (specify)																																		32
	NONREIMBURSABLE COST CENTERS																																				NONREIMBURSABLE COST CENTERS
42	Sheltered Workshops																																		42	42	Sheltered Workshops																																		42
43	Recreational Programs																																		43	43	Recreational Programs																																		43
44	Resident Day Camps																																		44	44	Resident Day Camps																																		44
45	Diagnostic Clinics																																		45	45	Diagnostic Clinics																																		45
46	Physicians' Private Offices																																		46	46	Physicians' Private Offices																																		46
47	Fundraising																																		47	47	Fundraising																																		47
48	Coffee Shops &Canteen																																		48	48	Coffee Shops &Canteen																																		48
49	Research																																		49	49	Research																																		49
50	Investment Property																																		50	50	Investment Property																																		50
51	Advertising																																		51	51	Advertising																																		51
52	Franchise Fees & Other Assessments																																		52	52	Franchise Fees & Other Assessments																																		52
53	Pro Ed & Training (Not Approved)(2)																																		53	53	Pro Ed & Training (Not Approved)(2)																																		53
54	Meals & Transportation																																		54	54	Meals & Transportation																																		54
55	Activity Therapies																																		55	55	Activity Therapies																																		55
56	Psychosocial Programs																																		56	56	Psychosocial Programs																																		56
57	Vocational Training																																		57	57	Vocational Training																																		57
58	Other (specify)																																		58	58	Other (specify)																																		58
100	Negative Cost Center																																		100	100	Negative Cost Center																																		100
101	Cost to be Allocated																																		101	101	Cost to be Allocated																																		101
102	Unit Cost Multiplier																																		102	102	Unit Cost Multiplier																																		102
	(1) Approved Educational Activity						(2) Not an Approved Educational Activity																														(1) Approved Educational Activity						(2) Not an Approved Educational Activity
FORM CMS-2088-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)																																				FORM CMS-2088-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4510)
Rev. 2																																			45-313	45-314																																			Rev. 2

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Sheet 11: C

02-24

FORM CMS-2088-17

4590 (Cont.)

APPORTIONMENT OF PATIENT SERVICE COSTS

PROVIDER CCN:

PERIOD:

WORKSHEET C

FROM _______________

____________________

TO _______________

FROM

WKST B,

RATIO

MEDICARE

COL. 14,

OF COST

MEDICARE

MEDICARE

MEDICARE

IOP COST

REIMBURSABLE COST CENTERS

REIMBURSABLE

TOTAL

TO CHARGES

PHP

IOP

PHP COST

(COL 3 X

COSTS

CHARGES

(COL 1 ÷ COL. 2)

CHARGES

CHARGES

(COL 3 X COL 4)

COL 4.01)

1

2

3

4

4.01

5

5.01

23

Drugs & Biologicals

23

24

Occupational Therapy

24

25

Behavioral Health Treatment/Services

25

26

Individual Therapy

26

27

Group Therapy

27

28

Activity Therapy

28

29

Family Therapy

29

30

Psychiatric Testing

30

31

Education Training

31

32

Other (specify)

32

50

TOTAL (lines 23 through 32)

50

FORM CMS-2088-17 (02-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4511)

Rev. 4

45-315

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Sheet 12: D

4590 (Cont.)													FORM CMS-2088-17													02-24
CALCULATION OF REIMBURSEMENT SETTLEMENT												PROVIDER CCN:					PERIOD:					WORKSHEET D
																					FROM _______________
														____________________							TO _______________
	DESCRIPTION
1	Gross APC/OPPS payments																									1
2	Outlier payments																									2
3	Outlier reconciliation amount (transfer from line 54)																									3
4	Gross reimbursement (sum of lines 1 through 3)																									4
5	Primary payer payments																									5
6	Deductibles billed to program patients (do not include coinsurance)																									6
7	Coinsurance billed to program patients (see instructions)																									7
8	Subtotal (line 4 minus lines 5, 6, and 7)																									8
9	Reimbursable bad debts (see instructions)																									9
10	Adjusted reimbursable bad debts																									10
11	Reimbursable bad debts for dual eligible beneficiaries (see instructions)																									11
12	Subtotal (line 8 plus line 10)																									12
13	Other adjustments (specify) (see instructions)																									13
14	Other demonstration payment adjustment amount before sequestration																									14
15	Amount due prior to the sequestration adjustment (see instructions)																									15
16	Sequestration adjustment (see instructions)																									16
17	Other demonstration payment adjustment amount after sequestration																									17
18	Amount due after sequestration adjustment (see instructions)																									18
19	Interim payments																									19
20	Tentative settlement (for contractor use only)																									20
21	Balance due provider/program (line 18 minus lines 19 and 20) (indicate overpayment in brackets)																									21
22	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1, §115.2																									22
	TO BE COMPLETED BY CONTRACTOR
50	Original outlier amount (see instructions)																									50
51	Outlier reconciliation adjustment amount (see instructions)																									51
52	The rate used to calculate the Time Value of Money																									52
53	Time Value of Money (see instructions)																									53
54	Total (sum of lines 51 and 53)																									54
FORM CMS-2088-17 (02-2024) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4512
45-316																										Rev. 4

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Sheet 13: D-1

08-22																FORM CMS-2088-17																			4590 (Cont.)
ANALYSIS OF PAYMENTS FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES																					PROVIDER CCN:					PERIOD:					WORKSHEET D-1
																														FROM _______________
																							____________________							TO _______________
																												PART B
																											MM/DD/YYYY					AMOUNT
																											1					2
1	Total interim payments paid to CMHC																																		1
2	Interim payments payable on individual bills either, submitted or to																																		2
	be submitted to the contractor, for services rendered in the
	cost reporting period. If none, write "NONE" or enter a zero.
3	List separately each retroactive lump sum																							.01											3.01
	adjustment amount based on subsequent revision																				Program			.02											3.02
	of the interim rate for the cost reporting period.																				to			.03											3.03
	Also show date of each payment. If none write																				Provider			.04											3.04
	'"NONE" or enter a zero. (1)																							.05											3.05
																								.50											3.50
																					Provider			.51											3.51
																					to			.52											3.52
																					Program			.53											3.53
																								.54											3.54
	SUBTOTAL (sum of lines 3.01 through 3.49, minus sum of lines 3.50 through 3.98)																							.99											3.99
4	TOTAL INTERIM PAYMENTS (sum of lines 1, 2 and 3.99) (Transfer to Wkst. D, line 19)																																		4
	TO BE COMPLETED BY CONTRACTOR
5	List separately each tentative settlement payment																				Program			.01											5.01
	after desk review. Also show date of each																				to			.02											5.02
	payment. If none, write "NONE" or enter																				Provider			.03											5.03
	a zero. (1)																				Provider			.50											5.50
																					to			.51											5.51
																					Program			.52											5.52
	SUBTOTAL (sum of lines 5.01 through 5.49, minus sum of lines 5.50 through 5.98)																							.99											5.99
6	Determine net settlement amount (balance due) based																				Program
	on the cost report (see instructions) (1)																				to			.01											6.01
																					Provider
																					Provider
																					to			.02											6.02
																					Program
7	TOTAL MEDICARE PROGRAM LIABILITY (see instructions)																																		7
												0													1							2
8	Name of																				Contractor						NPR Date								8
	Contractor																				Number						(MM/DD/YYYY)
	(1)	On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the provider
		agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS-2088-17 (08-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4513)
Rev. 3																																			45-317

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Sheet 14: F

08-22													FORM CMS-2088-17													4590 (Cont.)
STATEMENT OF REVENUES AND EXPENSES												PROVIDER CCN:					PERIOD:					WORKSHEET F
																					FROM _______________
														____________________							TO _______________
	DESCRIPTION
1	Total patient revenue																									1
2	Less: Allowance and discounts on patients' accounts																									2
3	Net patient revenues (line 1 minus line 2)																									3
4	Less: Total operating expenses (per Worksheet A, column 4, line 100)																									4
5	Net income from service to patients (line 3 minus line 4)																									5
	OTHER INCOME
6	Grants, gifts, and income designated by donor for specific expenses																									6
7	Payments received from specialists																									7
8	Investment income on unrestricted funds																									8
9	Trade, quantity, time and other discounts on purchases																									9
10	Rebates and refunds of expenses																									10
11	Income from laundry and linen service																									11
12	Income from cafeteria - employees, guests, etc.																									12
13	Sale of medical supplies to other than patients																									13
14	Sale of workshop products or services																									14
15	Coffee shops and canteen																									15
16	Vending machines																									16
17	Rental of building or office space to others																									17
18	Sale of scrap, waste, etc.																									18
19	Sale of medical records and abstracts																									19
20	Other (Specify)																									20
20.50	COVID-19 PHE funding																									20.50
21	Total other income (sum of lines 6 through 20)																									21
22	Total (line 5 plus line 21)																									22
	OTHER EXPENSES
23	Fund raising																									23
24	Gift, coffee shops, and canteen																									24
25	Investment property																									25
26	Other (specify)																									26
27	Total other expenses (sum of lines 23 through 26)																									27
28	Net income (or loss) for the period (line 22 minus line 27)																									28
FORM CMS-2088-17 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4514.1)
Rev. 3																										45-318