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FORM APPROVED
OMB NO. 0938-0165
This report is required by law (42 USC 1395mm and 42 USC 1995I).
Failure to report can result in all interim payments made since
the beginning of the cost reporting period being deemed overpayments.
PREPAID HEALTH PLAN COST REPORT
GENERAL INFORMATION
1
Name and Address of Plan:
2
Reporting Period:
WORKSHEET S
Plan Number:
From:
H-xxxx
To:
3
a. Type of Report:
b. Bill Processing Option:
[ ] Budget Forecast
c. Reimbursement Under:
Select Option
1876
[x] Interim Reports
[ ] Final Cost Report
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN
REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERA
CERTIFICATION BY OFFICER OF THE PLAN
I HEREBY CERTIFY that I have examined the accompanying Statement of Reimbursable Co
expenses and services, and the attached Worksheets for the period from
01/00/1900 to
and that to the best of my knowledge and belief they are true and correct statements prepare
and records of the Plan in accordance with applicable instructions.
SIGNATURE (Officer or Administrator of the Plan)
DATE
TITLE
PHONE NUMBER
FORM CMS 276-25 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2302)
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid O
OMB control number for this information collection is 0938-0165. The time required to complete this information is estimated to average as follo
24 hours to complete the budget forecast, 80 hours to complete the fourth quarter and final cost reports, 4 hours to complete the semi-annual in
second, and third quarterly reports; and (2) for HCPPs, 16 hours to complete the budget forecast, 60 hours to complete the final cost report, and
interim report. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to
Mail Stop C3-14-16, Baltimore, Maryland 21244-1850 and to the Office of the Information and Regulatory Affairs, Office of Management and Bu
Form Expiration Date:
PLAN STATISTICS
Name of Plan:
Plan #: H-xxxx
LIST OF PROVIDERS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
A. Hospitals & SNF's:
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
WORKSHEET D
PART I
Page 1
0
PROVIDER
NUMBER
RELATIONSHIP (1)
BILLS
PROCESSED
BY (2)
1
2
3
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
(1)
O - OWNED OR CONTROLLED
P - PURCHASED
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306)
PLAN STATISTICS
Name of Plan:
Plan #: H-xxxx
PERIOD FROM:
TO:
TOTAL
DAYS
TOTAL
MEDICARE
DAYS*
4
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
COV MED
PRIMARY
DAYS
COV MED
SECONDARY
DAYS
6
7
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
* Note: Col 5 minus 6 & 7 = Non-covered
(2)
H - PROCESSED BY HCFA
P - PROCESSED BY PLAN
WORKSHEET D
PART 1
Page 2
0
PERIOD FROM:
TO:
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
LIST OF PROVIDERS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
B. HHA's:
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
C. Other (Specify Name & Type):
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
PROVIDER
NUMBER
RELATIONSHIP (1)
BILLS
PROCESSED
BY (2)
TOTAL
VISITS
TOTAL
MEDICARE
VISITS*
COV MED
PRIMARY
VISITS
COV MED
SECONDARY
VISITS
1
2
3
4
5
6
7
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(1)
O - OWNED OR CONTROLLED
P - PURCHASED
LIST OF SUPPLIERS
1
A.
Physician Services:
________________________________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
* Note: Col 5 minus 6 & 7 = Non-covered
PAYMENT
MECHANISM
(2)
2
HOW
PHYSICIANS
PAID
(2)
3
_
_
_
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
WORKSHEET D
PART II
Page 1
0
TYPE OF
GROUP
(1)
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(2)
H - PROCESSED BY HCFA
P - PROCESSED BY PLAN
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306)
PLAN STATISTICS
Name of Plan:
Plan #: H-xxxx
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
PERIOD FROM:
TO:
TOTAL
4
0
0
STATISTICS
TOTAL
COVERED MED
MEDICARE *
PRIMARY
5
0
6
0
COVERED MED
SECONDARY
7
0
0
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Physician Groups:
Fee For Service
Capitation
Other
Individual Physicians:
Fee For Service
Capitation
Other
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
(1)
A - IPA
B - GROUP PRACTICE
C - STAFF
D - INDIVIDUAL PRACTITIONERS
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(2)
A - FEE-FOR-SERVICE
B - CAPITATION
C - OTHER-SPECIFY
*
Note Col 5 minus 6 & 7 = Non-covered
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306)
PLAN STATISTICS
Name of Plan:
Plan #: H-xxxx
LIST OF SUPPLIERS
1
2
3
B. Certified Labs:
________________________________
________________________________
________________________________
WORKSHEET D
PART II
Page 2
0
PERIOD FROM:
TO:
TYPE OF
GROUP
(1)
1
PAYMENT
MECHANISM
(2)
2
HOW
PHYSICIANS
PAID
(2)
3
_
_
_
_
_
_
_
_
_
0
0
TOTAL
TOTAL
MEDICARE*
4
5
0
0
0
STATISTICS
COVERED MED
PRIMARY
6
0
0
0
COVERED MED
SECONDARY
7
0
0
0
0
0
0
4
5
6
7
8
9
10
11
________________________________
________________________________
________________________________
________________________________
Certified Labs
Fee For Service
Capitation
Other
1
2
3
4
5
6
7
8
9
10
11
C. X-Ray Units:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
X-Ray Units
Fee For Service
Capitation
Other
1
2
3
4
5
6
7
8
9
10
11
12
13
14
D. Others (Specify):
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
________________________________
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
(1)
A - IPA
B - GROUP PRACTICE
C - STAFF
D - INDIVIDUAL PRACTITIONERS
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
* Note: Col 5 minus 6 & 7 = Non-covered
(2)
A - FEE-FOR-SERVICE
B - CAPITATION
C - OTHER-SPECIFY
E. MEMBERSHIP:
1
2
Total Medicare Member Months............................................................................................................................................................
Medicare Secondary Liable (Employer Groups) Member Months.........................................................................................................
3
4
Medicare Primary Member Months (Line 1 minus Line 2).....................................................................................................................
Ratio (Line 3 & Line 1)...........................................................................................................................................................................
MEDICARE
PART A
1
0
__________
0
0
MEDICARE
PART B
2
__________
0
0
(3)
Part B Member Months = Total Member Months
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2306)
End of Document
0
SUMMARY TRIAL BALANCE
WORKSHEET E
Name of Plan:
Plan #:
COST CENTER
TRIAL
BALANCE
0
H-xxxx
PERIOD FROM:
TO:
RECLASSIFICATIONS
(WKST F)
2
1
ADJUSTMENTS
(WKST G)
3
01/00/00
01/00/00
A&G
ALLOCATION
(WKST I,
Part I)
5
ALLOWABLE
COST
(Col 1 thru 3)
4
TRANSFER
TO
WKST, LINE
TOTALS
(Col 4 + Col 5)
6
7
1 Inpatient Hospitals
0
0
0
0
0
J 2-47
2 Outpatient Hospitals
0
0
0
0
0
J 2-47
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
J
J
K
K
K
K
K
K
K
K
52-61
66-74
| 1
| 3-5
| 7-9
| 11-13
| 15-17
| 18
| 20
| 21
K
K
L
L
L
L
|
|
|
|
|
|
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0
0
0
0
_____________
0
0
0
_____________
0
0
0
_____________
0
0
0
_____________
0
0
_____________
0
_____________
0
_____________
0
_____________
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23
Skilled Nursing Facilities.......….…
Home Health Agencies........….….
Clinics..........……….........….......…
Physician Groups.......................…
Individual Physicians.....…...….…
Certified Labs..................…......…
X-Ray Units....................……....…
ESRD Facilities.........................…
Durable Medical Equipment.......…
Ambulance...............……….......…
Pharmacy (Outpatient).......…...…
Pharmacy-Medicare Covered Rx
Emergency-Urgent Needed Svcs..
Mental Health Services....….……
DED+CO on claims processed by MACs
Other - Medicare Bad Debts...…
Other - Blood Deductible.....…
Part B Cost Not Subj to Coins.
Non-Allowable Costs
Other - (Specify)...…….......…
Other - (Specify)...…….......…
Other - (Specify)...…….......…
24 Subtotal (Sum Lines 1-23)...........................
25 Plan Administration..............…..…
26 Special Admin Costs................…
27 Subtotal: (Sum Lns 25+26)..........................
28 Admin & General Costs...…......…
29 Total Program Costs (24+27+28)................
0
=========
0
=========
0
=========
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2307)
0
=========
0
=========
___________
___________
___________
22
24
18
9
12
21
J&K |
J&K |
J&K |
0
0
0
0
0
0
=========
L | 3
L | 6
RECLASSIFICATIONS
LINE
1
2
3
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50
Name of Plan:
0
Plan #: H-xxxx
EXPLANATION OF RECLASSIFICATION ENTRY
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CODE
(1)
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PERIOD FROM:
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51 Page total............................................................................. ................. ....................................................... ...............................
52 a. Subtotal from Page 2....................................................... ................. ....................................................... ...............................
b. Subtotal from Page 3....................................................... ................. ....................................................... ...............................
c. Subtotal from Page 4....................................................... ................. ....................................................... ...............................
53 Total Reclassifications (Col 4 must equal Col 5)................. ................. ....................................................... ...............................
(1) A Letter (A, B, etc.) Must Be Entered on Each Line to Identify Each Reclassification Entry.
(2) Transfer to Worksheet E, Col. 2, lines as appropriate.
01/00/00
01/00/00
WORKSHEET F
Page 1
AMOUNT (2)
INCREASES
4
(DECREASES)
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
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0
0
0
0
0
============
Net, must be 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
0
0
0
0
============
0
============
Summarized on Worksheet F, Page 3
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)
RECLASSIFICATIONS
Name of Plan:
0
Plan #: H-xxxx
PERIOD FROM:
01/00/00
WORKSHEET F
Page 2
TO:
LINE
54
55
56
57
58
59
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EXPLANATION OF RECLASSIFICATION ENTRY
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CODE
(1)
1
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CC LINE
NUMBER
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110 Total Page 2 (Col 4 must equal Col 5)................................. ................. ....................................................... ...............................
(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.
(2) Transfer to Worksheet E, Col. 2, lines as appropriate.
01/00/00
AMOUNT
INCREASES
4
(DECREASES)
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
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0
0
============
============
Summarized on Worksheet F, Page 3
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)
RECLASSIFICATIONS
Name of Plan:
0
Plan #: H-xxxx
PERIOD FROM:
TO:
01/00/00
01/00/00
WORKSHEET F
Page 3
LINE
111
112
113
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166
EXPLANATION OF RECLASSIFICATION ENTRY
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CODE
(1)
1
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2
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CC LINE
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(WKST E)
3
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167 Total Page 3 (Col 4 must equal Col 5)................................. ................. ....................................................... ...............................
(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.
(2) Transfer to Worksheet E, Col. 2, lines as appropriate.
AMOUNT
INCREASES
4
(DECREASES)
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
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0
0
============
============
Summarized on Worksheet F, Page 3
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)
RECLASSIFICATIONS
LINE
Name of Plan:
0
Plan #: H-xxxx
EXPLANATION OF RECLASSIFICATION ENTRY
CODE
(1)
PERIOD FROM:
TO:
COST CENTER
(Worksheet E)
CC LINE
NUMBER
(WKST E)
01/00/00
01/00/00
WORKSHEET F
Page 4
AMOUNT
INCREASES
(DECREASES)
168
169
170
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173
174
175
176
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209
210
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213
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2
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3
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4
224 Total Page 4 (Col 4 must equal Col 5)................................. ................. ....................................................... ...............................
(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.
(2) Transfer to Worksheet E, Col. 2, lines as appropriate.
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
___________
0
0
============
============
Summarized on Worksheet F, Page 3
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)
SUMMARY OF RECLASSIFICATIONS
Name of Plan:
0
Plan #: H-xxxx
PERIOD FROM:
TO:
01/00/00
01/00/00
WORKSHEET F
Page 5
SUMMARY OF RECLASSIFICATIONS
CC
LINE COST CENTER DESCRIPTIONS
INCREASES
(DECREASES)
(From Worksheet F, Pgs 1 & 2)
4
5
NET
6
1 Inpatient Hospitals
2
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
……..
.......................................................
Outpatient Hospitals ………………………………………………………….......................................................
Skilled Nursing Facilities...................................................... ................. .......................................................
Home Health Agencies........................................................ ................. .......................................................
Clinics.................................................................................. ................. .......................................................
Physician Groups................................................................. ................. .......................................................
Individual Physicians............................................................ ................. .......................................................
Certified Labs....................................................................... ................. .......................................................
X-Ray Units.......................................................................... ................. .......................................................
ESRD Facilities.................................................................... ................. .......................................................
Durable Medical Equipment................................................. ................. .......................................................
Ambulances......................................................................... ................. .......................................................
Pharmacy (Outpatient)......................................................... ................. .......................................................
Pharmacy-Medicare Covered Rx......................................... ................. .......................................................
Emergency-Urgently Needed Svcs...................................... ................. .......................................................
Mental Health Services........................................................ ................. .......................................................
DED+CO on claims processed by MACs
................. .......................................................
Other - Medicare Bad Debts...…
................. .......................................................
Other - Blood Deductible.....…
................. .......................................................
Part B Cost Not Subj to Coins.
................. .......................................................
Non-Allowable Costs
................. .......................................................
Other - (Specify)...…….......…
................. .......................................................
Other - (Specify)...…….......…
................. .......................................................
Other - (Specify)...…….......…
................. .......................................................
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Plan Administration.............................................................. ................. .......................................................
Special Admin Costs............................................................ ................. .......................................................
0
0
0
0
0
0
Admin & General Costs....................................................... ................. .......................................................
29 Total Reclassifications (Lines 1 thru 28) (Col 6 must net to zero)......... .......................................................
DIFFERENCES from total of pages 1 & 2 on page 1, Line 53……………………………………………………
0
____________
0
=============
0
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0
=============
0
=============
0
=============
0
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0
=============
Must net to zero.
To Worksheet E
Column 2
If these differences are not
zero there is a problem!!
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)
SUPPLEMENT TO WORKSHEET F - RECLASSIFICATIONS
Name of Plan:
0
Plan #: H-xxxx
Period
From:
To:
01/00/00
01/00/00
THIS IS A SUPPLEMENTAL WORKSHEET TO SUM UP RECLASSIFICATIONS BY COST CENTER
CCNO
1
CCNO
2
CCNO
3
CCNO
4
CCNO
5
CCNO
6
CCNO
7
CCNO
8
CCNO
9
CCNO
10
CCNO
11
CCNO
12
0
(DECREASES)
0
OP Hosp
0
0
SNF
0
0
HHA
0
0
Clinic
0
0
Physicians Groups
0
0
Ind Phy
0
0
Labs
0
0
Xray
0
0
ESRD
0
0
DME
0
0
Amb
0
0
IP Hosp
INCREASES
AD181...AN240
CCNO
13
CCNO
14
CCNO
15
CCNO
16
CCNO
17
CCNO
18
CCNO
19
CCNO
21
CCNO
22
CCNO
24
Phrm
0
0
Emerg
0
0
Mental
0
0
Ded & Coins
0
0
0
0
Other
0
0
Nonallowable
0
0
Plan Admin
0
0
Spec Admin
0
0
A&G
------------
0
0
=============
------------
0
0
=============
ADJUSTMENTS TO EXPENSES
Name of Plan:
Plan #: H-xxxx
CC
LINE
1
2
3
4
5
6
7
8
9
10
10a
10b
10c
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
(1)
0
PERIOD FROM:
TO:
BASIS
FOR
ADJ (1)
1
DESCRIPTIONS
Investment income on commingled restricted & unrestricted funds........................
Trade, quantity, time & other discounts on purchases.............................................
Rebates & refunds of expenses...............................................................................
Rental of space by suppliers....................................................................................
Telephone service....................................................................................................
Television & radio service........................................................................................
Parking lot................................................................................................................
Home Office Costs (Attach copy of Home Office Cost Statement)..........
Sale of scrap, waste, etc..........................................................................................
Adj. resulting from transactions with related organizations (3)................................
Adj. resulting from transactions with related organizations (3)................................
Adj. resulting from transactions with related organizations (3)................................
Adj. resulting from transactions with related organizations (3)................................
Laundry and linen service........................................................................................
Cafeteria - employees, guests, etc...........................................................................
Rental of living quarters to employees and others...................................................
Sale of medical and surgical supplies to other than patients...............................
Sale of drugs to other than patients.........................................................................
Sale of medical records and abstracts.....................................................................
Nursing school (tuition, fees, uniforms, finance charges)........................................
Income from vending machines...............................................................................
Income from imposition of interest and finance charges.......................................
Payments - Physicians' assumption of operating costs........................................
Undistributed risk pool.............................................................................................
Charges in excess of MAC screens.........................................................................
Part B coinsurance on services processed by MACs.........................................
Adjustment for physicial therapy costs in excess of limit (4)....................................
Reinsurance.............................................................................................................
Depreciation in excess of limits (Attach worksheet) ................................................
Noncovered purchased service (Attach worksheet)................................................
Medicare Bad Debts
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
01/00/00
01/00/00
Amount (2)
(To Wkst E as
appropriate)
2
WORKSHEET G
PART I
Page 1
CC LINE
NUMBER
(Wkst E)
4
COST CENTER
(Wkst E)
3
_____________________________
0
_____________________________
0
_____________________________
0
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0
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0
_____________________________
0
_____________________________
0
_____________________________
0
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0
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0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
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0
_____________________________
0
_____________________________
0
_____________________________
0
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0
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0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
_____________________________
0
____________
Page total..................................................... ........................................................... .............................
0
a. Subtotal from Page 2............................... ........................................................... .............................
0
b. Subtotal from Page 3............................... ........................................................... .............................
0
c. Subtotal from Page 4............................... ........................................................... .............................
0
____________
TOTAL ADJUSTMENTS......................................................................................... .............................
0
============
Basis for Adjustment:
(2) Transfer to Worksheet E lines as appropriate.
A = Cost - including applicable overhead, if determinable.
(3) From Worksheet H.
B = Amounts Received - if cost cannot be determined.
(4) See Chapter 4 of HCFA Pub 15-II; attach Worksheet A-8-3.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)
ADJUSTMENTS TO EXPENSES
Name of Plan:
0
WORKSHEET G
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
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__
Plan #: H-xxxx
CC
LINE
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
PERIOD FROM:
TO:
BASIS
FOR
ADJ(1)
1
DESCRIPTIONS
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
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_
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_
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_
_________________________________________________
_
_________________________________________________
_
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_
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_
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_
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_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
Page total (to Page 1, Line 51a).................. ........................................................... .............................
01/00/00
01/00/00
Amount
(To Wkst E as
appropriate)
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
============
PART I
PAGE 2
CC LINE
NUMBER
(Wkst E)
4
COST CENTER
(Wkst E)
3
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
(1) Basis for Adjustment:
A = Cost - including applicable overhead, if determinable.
B = Amounts Received - if cost cannot be determined.
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)
ADJUSTMENTS TO EXPENSES
Name of Plan:
Plan #: H-xxxx
0
WORKSHEET G
PERIOD FROM:
TO:
01/00/00
01/00/00
PART I
PAGE 3
__
__
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CC
LINE
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
BASIS
FOR
ADJ(1)
1
DESCRIPTIONS
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
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_________________________________________________
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_________________________________________________
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_________________________________________________
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_________________________________________________
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_________________________________________________
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_________________________________________________
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_________________________________________________
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_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
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_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
_________________________________________________
_
Page total (to Page 1, Line 51b).................. ........................................................... .............................
Amount
(To Wkst E as
appropriate)
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
============
CC LINE
NUMBER
(Wkst E)
4
COST CENTER
(Wkst E)
3
_____________________________
_____________________________
_____________________________
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__
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__
__
__
(1) Basis for Adjustment:
A = Cost - including applicable overhead, if determinable.
B = Amounts Received - if cost cannot be determined.
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)
ADJUSTMENTS TO EXPENSES
Name of Plan:
Plan #: H-xxxx
CC
LINE
DESCRIPTIONS
0
WORKSHEET G
PERIOD FROM:
TO:
BASIS
FOR
ADJ(1)
01/00/00
01/00/00
Amount
(To Wkst E as
appropriate)
PART I
PAGE 4
COST CENTER
(Wkst E)
CC LINE
NUMBER
(Wkst E)
1
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
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_
_________________________________________________
_
Page total (to Page 1, Line 51c).................. ........................................................... .............................
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
============
3
4
_____________________________
_____________________________
_____________________________
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__
__
__
__
__
__
__
(1) Basis for Adjustment:
A = Cost - including applicable overhead, if determinable.
B = Amounts Received - if cost cannot be determined.
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)
SUMMARY OF ADJUSTMENTS TO EXPENSES
Name of Plan:
Plan #: H-xxxx
CC
LINE
COST CENTER DESCRIPTIONS
0
PERIOD FROM:
TO:
LINE
NUMBERS
FROM
PART I
1
WORKSHEET G
PART II
01/00/00
01/00/00
Amount
(To Wkst E as
appropriate)
2
TRANSFER TO
WORKSHEET E
LINE # AS SHOWN
3
CC LINE
NUMBER
Wkst E
4
1 Inpatient
2
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
...........................................................
...........................................................
Outpatient
Skilled Nursing Facilities.............................. ...........................................................
Home Health Agencies................................ ...........................................................
Clinics.......................................................... ...........................................................
Physician Groups....................................... ...........................................................
Individual Physicians.................................... ...........................................................
Certified Labs............................................... ...........................................................
X-Ray Units.................................................. ...........................................................
ESRD Facilities............................................ ...........................................................
Durable Medical Equipment......................... ...........................................................
Ambulances................................................. ...........................................................
Pharmacy (Outpatient)................................. ...........................................................
Pharmacy-Medicare Covered Rx.......
...........................................................
Emergency-Urgently Needed Svcs.............. ...........................................................
Mental Health Services............................ ...........................................................
DED+CO on claims processed by MACs……
...........................................................
Other - Medicare Bad Debts...…
...........................................................
Other - Blood Deductible.....…
...........................................................
Part B Cost Not Subj to Coins.
...........................................................
Non-Allowable Costs
...........................................................
Other - (Specify)...…….......…
...........................................................
Other - (Specify)...…….......…
...........................................................
Other - (Specify)...…….......…
...........................................................
___________
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___________
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___________
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___________
___________
___________
___________
___________
___________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Plan Administration...................................... ........................................................... ___________
Special Admin Costs.................................... ........................................................... ___________
0
0
Admin & General Costs............................... ........................................................... ___________
29 Total Adjustments (Lines 1 thru 28).......................................................................................................
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.2)
0
____________
0
============
1
2
3
4
5
6
7
8
9
10
11
12
13
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS
Name of Plan:
0
Plan #: H-xxxx
Are there any costs included on Worksheet E which resulted from transactions with related organizations?
(If "YES", complete Parts B and C.)
Select
Costs incurred and adjustments required as a result of transactions with related organizations.
A.
B.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
LINE
(Wkst E)
_____
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_____
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_____
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_____
_____
_____
_____
_____
_____
17
COST CENTER (Worksheet E)
1
___________________________
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___________________________
EXPENSE ITEMS
2
___________________________
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___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
TOTALS.........................................................................…………………………………………
(1) Transfer the amounts in column 5 to Worksheet G, Part I, Column 2 lines 10
C.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
PERIOD FROM:
TO:
AMOUNT
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0
=============
01/00/00
01/00/00
AMOUNT
ALLOWABLE
IN COST
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0
=============
WORKSHEET H
NET
ADJUSTMENTS (1)
(5)
(5 = 4 - 3)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
_____________
0
=============
Interrelationship of Plan to related organization(s):
The Secretary, by virtue of authority granted under section 1814(b)(1) of the Health Insurance for the Aged and Disabled Act,
required organizations to furnish the information requested on Part C of this worksheet. The information will be used by the Health
Care Financing Administration in determining that the costs applicable to services, facilities and supplies furnished by
organizations related to the Plan by common ownership or control, represent reasonable costs as determined under section 1861 of the
Health Insurance for the Aged and Disabled Act. If the Plan does not provide all or any part of the requested information, the cost
report will be considered incomplete and not acceptable for purposes of claiming reimbursement under Title XVIII.
SYMBOL (2)
NAME OF INDIVIDUAL
OWNERSHIP OF PLAN
1
2
3
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
(2)
A
B
D
E
F
G
----------RELATED ORGANIZATION(S)-------ORGANIZATION
OWNERSHIP
NAME
%
4
5
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Use the following symbols to indicate the interrelationship of the Plan to related organizations:
Individual has financial interest (stockholder, partner, etc) in both related organization and in the Plan.
Corporation, partnership, or other organization has financial interest in the Plan.
Director, officer, administrator or key person of the Plan or relative of such person has financial interest
in related organization.
Individual is director, officer, administrator, or key person of the Plan and related organization.
Director, officer, administrator, or key person of related organization or relative of such person has
financial interest in the Plan.
Other (financial or nonfinancial) specify.
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2310)
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
TYPE OF
BUSINESS
6
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
ADMINISTRATIVE AND GENERAL COST ALLOCATION
WORKSHEET I
Name of Plan:
Plan #: # H-xxxx
0
1
EMPLOYEE
BENEFITS
(Salaries)
COST CENTER
1 Inpatient Hospitals ……………….
2
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23
Outpatient Hospitals …………….
Skilled Nursing Facilities.......….…
Home Health Agencies........….….
Clinics..........……….........….......…
Physician Groups.......................…
Individual Physicians.....…...….…
Certified Labs..................…......…
X-Ray Units....................……....…
ESRD Facilities.........................…
Durable Medical Equipment.......…
Ambulance...............……….......…
Pharmacy (Outpatient).......…...…
Pharmacy-Medicare Covered Rx
Emergency-Urgent Needed Svcs..
Mental Health Services....….……
DED+CO on claims processed by MACs
Other - Medicare Bad Debts...…
Other - Blood Deductible.....…
Part B Cost Not Subj to Coins.
Non-Allowable Costs
Other - (Specify)...…….......…
Other - (Specify)...…….......…
Other - (Specify)...…….......…
24 Subtotal (Sum of Lines 1 thru 23)...........…
25 Plan Administration....................................
26 Special Administrative Costs............…
27 Subtotal (Sum of 25 and 26) ...................
Total (Sum of Lines 24 & 27)..........................
28 Admin & General Costs...............................
29 Net A&G Costs (Lines 24+27+28)..................
30 Computation - Fr Worksheet, Col........
PERIOD FROM:
TO:
2
STATISTICS
& DATA
PROCESSING
(Time Spent)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
3
PHARMACY
&
SUPPLIES
(Cost Req's)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
PART I
01/00/00
01/00/00
4
OTHER
(SPECIFY)
SEE-WKST I SUPPL
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
5
TOTALS
(Sum Cols
1 Thru 4)
0
6
POOLED
ADMIN & GEN
COSTS
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
0
0
___________
0
___________
0
0
___________
0
===========
___________
___________
___________
___________
0
___________
0
___________
0
0
0
___________
0
___________
0
0
___________
0
==========
0
___________
0
==========
0
___________
0
==========
0
___________
0
============
Fr Wkst I,
Pt II, Col 1
Fr Wkst I,
Pt II, Col 2
Fr Wkst I,
Pt II, Col 3
Fr Wkst I,
Pt II, Col 4
31 To Worksheet, Column........................
7
TOTALS
(Col 5 +
Col 6)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
___________
0
0
0
___________
0
___________
0
0
___________
0
==========
0
___________
0
==========
___________
Fr Wkst I,
Pt II, Col 7
To Wkst I,
Pt II, Col 6
To Wkst E,
Col 5
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2311.1)
ADMINISTRATIVE AND GENERAL STATISTICS
WORKSHEET I
Name of Plan: #
Plan #: # H-xxxx
COST CENTER
0
EMPLOYEE
BENEFITS
(Salaries)
1
PERIOD FROM:
TO:
STATISTICS
& DATA
PROCESSING
(Time Spent)
2
PHARMACY
&
SUPPLIES
(Cost Req's)
3
PART II
01/00/00
01/00/00
OTHER
(SPECIFY)
4
TOTALS
(From
Worksheet E
Column 4)
5
TOTALS
(From
Wkst I,
Pt I, Col 5)
6
POOLED
ADMIN & GEN
STATS
(Cols 5+6)
7
1 Inpatient Hospitals ……………….
2 Outpatient Hospitals …………….
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23
Skilled Nursing Facilities.......….…
Home Health Agencies........….….
Clinics..........……….........….......…
Physician Groups.......................…
Individual Physicians.....…...….…
Certified Labs..................…......…
X-Ray Units....................……....…
ESRD Facilities.........................…
Durable Medical Equipment.......…
Ambulance...............……….......…
Pharmacy (Outpatient).......…...…
Pharmacy-Medicare Covered Rx
Emergency-Urgent Needed Svcs..
Mental Health Services....….……
DED+CO on claims processed by MACs
Other - Medicare Bad Debts...…
Other - Blood Deductible.....…
Part B Cost Not Subj to Coins.
Non-Allowable Costs
Other - (Specify)...…….......…
Other - (Specify)...…….......…
Other - (Specify)...…….......…
24 Subtotal (Sum of Lines 1 thru 23)...........…
25 Plan Administration....................................
26 Special Administrative Costs............…
27 Subtotal (Sum of 25 and 26) ...................
Total (Sum of Lines 24 & 27)....................
28 Administrative & General Costs..................
29 TOTAL STATS (Sum of 24 & 27)...........
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
___________
___________
___________
___________
___________
0
___________
0
___________
0
___________
___________
0
===========
___________
0
============
___________
0
============
___________
___________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
___________
0
___________
0
___________
0
___________
0
============
___________
0
============
0
0
0
0
=============
30 COSTS TO BE ALLOCATED.....................
(Input here)
31 UNIT COST MULTIPLIER..........................
(Line 30 / Line 29)
0
0.000000
0.000000
0.00000
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2311.1)
0.000000
___________
0
============
Col 5 - (1+2+3+4)
0
0.000000
SUMMARY OF PROVIDER COSTS
Name of Plan:
Plan #:
PROVIDERS
WORKSHEET J
H-xxxx
PAGE 1
0
PERIOD FROM:
TO:
1
2
PROVIDER
NUMBER
REIMBURSABLE
PART A
1 Medicare Memb Mos (WS D, Pt II, Sec E, Ln 3)
2 Hospitals
3
__________________________________
____________
4
__________________________________
____________
5
__________________________________
____________
6
__________________________________
____________
7
__________________________________
____________
8
__________________________________
____________
9
____________
10
__________________________________
____________
11
__________________________________
____________
12
__________________________________
____________
13
__________________________________
____________
14
__________________________________
____________
15
__________________________________
____________
16
__________________________________
____________
17
__________________________________
____________
18
__________________________________
____________
19
__________________________________
____________
20
__________________________________
____________
21
__________________________________
____________
22
__________________________________
____________
23
__________________________________
____________
24
__________________________________
____________
25
__________________________________
____________
26
__________________________________
____________
27
__________________________________
____________
28
__________________________________
____________
29
__________________________________
____________
30
__________________________________
____________
31
__________________________________
____________
32
__________________________________
____________
33
__________________________________
____________
34
__________________________________
____________
35
__________________________________
____________
36
__________________________________
____________
37
__________________________________
____________
38
__________________________________
____________
39
__________________________________
____________
40
__________________________________
____________
41
__________________________________
____________
42
__________________________________
____________
43
__________________________________
____________
44
__________________________________
____________
45
__________________________________
____________
46
__________________________________
____________
47
__________________________________
____________
48 Total Hospital ……………………………………………………………
01/00/00
01/00/00
3
PART A
DEDUCTIBLE +
COINSURANCE
REIMBURSABLE
PART B
0
=========
0
=========
0
=========
0
0
0
=========
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
=========
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 #
=========
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
=========
0
=========
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4
5
PART B
DEDUCTIBLE
49
Cost PMPM (Line 48 / Line 1)..........................................................
0.0000
=========
0.0000
=========
0.0000
=========
0.0000
=========
50
Enter on Worksheet, Col, Line........................................................
M, 2, 1
M, 2, 1&8
M, 3, 1
M, 3, 1
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2312)
SUMMARY OF PROVIDER COSTS
WORKSHEET J
(Continued)
Name of Plan:
Plan #:
H-xxxx
PAGE 2
0
PERIOD FROM:
TO:
1
PROVIDERS
51 Skilled Nursing Facilities:
52
__________________________________
53
__________________________________
54
__________________________________
55
__________________________________
56
__________________________________
57
__________________________________
58
__________________________________
59
__________________________________
60
__________________________________
61
__________________________________
62 Total (Sum of Lines 52 thru 61)… … … … … … … …
PROVIDER
NUMBER
2
REIMBURSABLE
PART A
63
Cost PMPM (Line 62 / Line 1)..........................................................
0
0
0
0
0
0
0
0
0
0
0
=========
0.0000
64
Enter on Wkst, Col, Line..................................................................
M, 2, 2
65 Home Health Agencies:
66
__________________________________
67
__________________________________
68
__________________________________
69
__________________________________
70
__________________________________
71
__________________________________
72
__________________________________
73
__________________________________
74
__________________________________
75 Total (Sum of Lines 66 thru 74)… … … … … … … …
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
… … … … … … … …
3
PART A
DEDUCTIBLE+
COINSURANCE
4
5
PART B
DEDUCTIBLE
REIMBURSABLE
PART B
0
0
0
0
0
0
0
0
0
0
0
=========
0.0000
0
0
0
0
0
0
0
0
0
0
0
=========
0.0000
0
0
0
0
0
0
0
0
0
0
0
=========
0.0000
M, 2, 2&8
M, 3, 2
M, 3, 2
0
0
0
0
0
0
0
0
0
0
0
_____________
0
=========
0.0000
0
0
0
0
0
0
0
0
0
0
0
_____________
0
=========
0.0000
0
0
0
0
0
0
0
0
0
0
0
_____________
0
========
0.0000
M, 2, 4&8
M, 3, 4
M, 3, 4
____________
____________
____________
____________
____________
____________
____________
____________
____________
… … … … … … … … … … … … … … … …
76
Cost PMPM (Line 75 / Line 1)......................................................................
77
Enter on Wkst, Col, Line.................................................................................
78 Other Providers (Specify Type):
79
__________________________________
80
__________________________________
81
__________________________________
82
__________________________________
83
__________________________________
84
__________________________________
85
__________________________________
86
__________________________________
87
__________________________________
88
__________________________________
89
__________________________________
01/00/00
01/00/00
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
90
Total (Sum Lines 79 thru 89)...........................................................
91
Cost PMPM (Line 90 / Line 1)..........................................................
0
0
0
0
0
0
0
0
0
0
0
_____________
0
=========
0.0000
92
Enter on Wkst, Col, Line.................................................................
M, 2, 4
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2312)
SUMMARY APPORTIONMENT OF NON-PROVIDER COSTS
Name of Plan:
Plan #: H-xxxx
COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
Clinics (furnished directly)........................................
Physician Groups:
Fee For Service…………………………………………
Capitation………………………………………………
Other……………………………………………………
Individual Physicians:
Fee For Service…………………………………………
Capitation………………………………………………
Other……………………………………………………
Certified Labs:
Fee For Service…………………………………………
Capitation………………………………………………
Other……………………………………………………
X-Ray Units:
Fee For Service…………………………………………
Capitation………………………………………………
Other……………………………………………………
ESRD Facilities........................................................
_________________________________
Durable Medical Equipment.....................................
Ambulance...............................................................
Emergency-Urgently Needed Svcs..........................
_________________________________
Mental Health Svcs
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
Worksheet K
0
PERIOD FROM:
TO:
1
2
STATISTIC
USED
TOTAL
STATISTICS
3
COVERED PRIM
MED ENROLLEE
STATISTICS
01/00/00
01/00/00
4
SUBPART E
LIMITS IF
APPLICABLE
5
RATIO
Col 3 or Col
4 / Col 2
6
TOTAL COSTS
(Fr Wkst E
Col 6)
___________
0
0
___________
___________
___________
0
0
0
0
0
0
0
0
0
0.0000
0.0000
0.0000
0
0
0
0
0
0
___________
___________
___________
0
0
0
0
0
0
0
0
0
0.0000
0.0000
0.0000
0
0
0
0
0
0
___________
___________
___________
0
0
0
0
0
0
0
0
0
0.0000
0.0000
0.0000
0
0
0
0
0
0
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
35 Total (Sum Lines 1 thru 34).....................................................................
36 Member Months - Part B (W/S D, Part II, Pg 2, Pt E, Col 2, Line 1).......
37 Cost PMPM (Line 35 / Line 36)..............................................................…
38 Enter on Worksheet, Col, Line................................................................
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2313)
0.0000
7
MEDICARE
COSTS
Col 5 X Col 6
0
0
=========
0
=========
0.0000
M, 3, 5
SUMMARY OF MISCELLANEOUS ITEMS
Name of Plan:
Plan #: H-xxxx
WORKSHEET L
0
DESCRIPTION
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Member Months (Wkst D, Pt II, Pg 2, Pt E, Col 1 and 2, Ln 1)
Plan Administration (Wkst E, Col 6, Ln 25).......................................
Cost PMPM (Line 3 / Line 1)..............................................................
PERIOD FROM:
TO:
1
2
3
4
5
6
MEDICARE
PART A
MEDICARE
PART B
TOTAL
Col 1+Col 2
NONMEDICARE
TOTAL
Col 2+Col 4
ENTER ON
WKST LINE
0
0
0
0.0000
0.0000
0
0.0000
Special Admin Costs (Wkst E, Col 6, Ln 26).....................................
Cost PMPM (Line 6 / Line 1)..............................................................
Allowable Medicare Bad Debts (Wkst E, Col 6, Line 17)..................
Cost PMPM (Line 9 / Line 1)..............................................................
01/00/00
01/00/00
0
0.0000
M
6
M
14
0.0000
0
0.0000
M
15
0
0.0000
0
0.0000
M
10
0.0000
0
0.0000
M
18
Pt B DED on claims processed by MACs (Wkst E, Col 6, Ln 16).....
Cost PMPM (Line 18 / Line 1)............................................................
0
0.0000
0
0.0000
M 5a
Part B Cost Not Subject to Coinsurance (Wkst E, Col 6, Ln 19)…..……
Cost PMPM (Line 21 / Line 1)………………………………………………
0
0.0000
0
0.0000
M
0.0000
Part B Blood Deductible (Wkst E, Col 6, Line 18).....................
Cost PMPM (Line 12 / Line 1)............................................................
Third Party Insurer Revenue (see Instructions).................................
Cost PMPM (Line 15 / Line 1)............................................................
0.0000
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2314)
16
SETTLEMENT SHEET
Name of Plan:
Plan #: H-xxxx
DESCRIPTION
1
2
3
4
5
5a
6
Hospital Costs………………………………………………………………………………
Skilled Nursing Facility Costs……………………………………………………………
Home Health Agency Costs………………………………………………………………
Other Provider's Costs ……………………………………………………………………
Nonprovider Costs…………………………………………………………………………
DED on claims processed by MACs……………………...……………..………………
Plan Administration Costs…………………………………………………………………
7
Totals (Sum Lines 1 - 6)…………………………………………………………………
8
9
10
Part A Deductible and Coinsurance……………………………………………………
Part B Standard Deductible………………………………………………………………
Part B Blood Deductible…………………………………………………………………
11
Line 7 Minus (The Sum of Lines 8 - 10)…………………………………………………
12
20% of (Col 3 Line 11 minus Col 3 Line 3)………………………………………………
13
14
15
16
17
18
Reimbursable Costs (Line 11 Minus Line 12)…………………………………………
Special Administrative Costs……………………………………………………………
Medicare Bad Debts………………………………………………………………………
Part B Cost Not Subject to Coinsurance………………………………………………
Total (Sum Lines 13 thru 16)……………………………………………………………
Less: Third Party Insurer Revenue………………………………………………………
19
20
Medicare Costs (Line 17 minus Line 18)………………………………………………
Medicare Primary Member Months………………………………………………………
21
22
Reimbursable Costs (Line 19 X Line 20)………………………………………………
Interim Payments (by) to CMS……………………………………………………………
PERIOD FROM:
TO:
FROM
WKST
1
J
J
J
J
K
L
L
J
L
L
L
L
L
D
23 Balance (Line 21 plus Line 22)……………………………………………………………
Adjustments:
24 Sequestration Adjustment
25 ____________________________________________
26 ____________________________________________
27 ____________________________________________
28 ____________________________________________
29 ____________________________________________
30
Balance Due Plan (CMS) (Line 23 + or - Lines 24-29).....……………………………
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2315)
MEDICARE
PART A
2
0.0000
0.0000
0.0000
0.0000
0.0000
___________
0.0000
0
___________
0.0000
___________
0.0000
0.0000
0.0000
0.0000
0.0000
___________
0.0000
0
___________
0
01/00/00 WORKSHEET M
01/00/00
MEDICARE
PART B
3
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
___________
0.0000
0.0000
0.0000
___________
0.0000
0.0000
___________
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
___________
0.0000
0
___________
0
TOTAL
Col 2 + Col 3
4
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0
___________
0
0
=========
MEDICARE PREMIUM RECONCILIATION
Name of Plan: 0
Plan Number: H-xxxx
WORKSHEET N
Period From:
To:
Under and Over Collection of Medicare Premiums - Current Year
Premium Determinations Covered by this Part
0 Total Medicare Member Months
Totals
1
XXXXXXXXXXXX
1 Total Premiums/Dues collected during the period
2 Total Copayments collected during the period
-
3 Total Collections (Line 1 plus Line 2)
-
4 Less: Accounts Receivable for premiums/dues and copayments (beg of period)
-
5 Net Collections for period (Line 3 minus Line 4)
6 Add: Accounts Receivable for premiums/dues and copayments (end of period)
-
7 Net Collections and Amounts to be Collected (Line 5 plus Line 6)
-
8 Total Medicare Deductible and Coinsurance from Cost Report:
a. Deductible and copayments (Worksheet M, Col 2 + 3 , Sum lines 8 thru 10)
b. Part B Coinsurance (Worksheet M, Col 3, Line 12)
c. CO on claims processed by MACs (Worksheet G, Col 2, Line 23/Col 2, Ln 0)
9a
9b
9c
9d
d. Total (Sum of Lines 8a thru 8c)
(Over)/Involuntary Under collection from
prior period (Worksheet N, Line 11/12b,
respectively)
Prior Period Member Months (Worksheet
Gross (over)/under collections from prior
Adjusted (over)/under collection from the prior period
01/00/00
01/00/00
Member
Months
2
Cost Per
Member Month Line
3
0 XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
0
-
1
2
-
3
-
4
-
5
6
-
7
XXXXXXXXXXXX XXXXXXXXXXXX
XXXXXXXXXXXX XXXXXXXXXXXX
XXXXXXXXXXXX XXXXXXXXXXXX
0.0000
0.0000
#DIV/0!
8
8a
8b
8c
XXXXXXXXXXXX XXXXXXXXXXXX
#DIV/0!
8d
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX
0 XXXXXXXXXXXX XXXXXXXXXXXX
XXXXXXXXXXXX XXXXXXXXXXXX
#DIV/0!
9
10 Total amount allowed to be charged (Line 8d plus line 9d)
XXXXXXXXXXXX XXXXXXXXXXXX
#DIV/0!
10
11 Actual (Over) under collection for the period (Line 10 minus Line 7). Stop here if (over)collection
XXXXXXXXXXXX XXXXXXXXXXXX
#DIV/0!
11
XXXXXXXXXXXX XXXXXXXXXXXX
XXXXXXXXXXXX XXXXXXXXXXXX
XXXXXXXXXXXX XXXXXXXXXXXX
0.0000 12
#DIV/0!
12a
#DIV/0!
12b
12 Budgeted Voluntary under collection for the period (Worksheet B, Line 8)
12a Actual Voluntary under collection - No recoupment
12b Involuntary Under collection - may recoup during subsequent period
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2316)
Special Administration Costs
Accretion/Deletion Cost
Certification Cost
Special Studies
Other (Specify)
Total Special Administration Cost
Amount
0
SUBPART E LIMITS
Name of Plan:
Plan #:
0
H-xxxx
Period From:
To:
Is this Plan an HCPP subject to the Subpart E Limits?
COMPARABLE
CARRIER
PAYMENTS
COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
Physician Groups:
Fee For Service… … … … … … … … … … … … … … … … … …
Capitation… … … … … … … … … … … … … … … … … … … … … …
Other… … … … … … … … … … … … … … … … … … … … … … … …
Individual Physicians:
Fee For Service… … … … … … … … … … … … … … … … … …
Capitation… … … … … … … … … … … … … … … … … … … … … …
Other… … … … … … … … … … … … … … … … … … … … … … … …
Certified Labs:
Fee For Service… … … … … … … … … … … … … … … … … …
Capitation… … … … … … … … … … … … … … … … … … … … … …
Other… … … … … … … … … … … … … … … … … … … … … … … …
X-Ray Units:
Fee For Service… … … … … … … … … … … … … … … … … …
Capitation… … … … … … … … … … … … … … … … … … … … … …
Other… … … … … … … … … … … … … … … … … … … … … … … …
ESRD Facilities................................................................
_________________________________
Durable Medical Equipment.........................................
Ambulance..........................................................................
Emergency-Urgently Needed Svcs............................
Mental Health Svcs
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
..
..
..
..
0
0
Yes
No
STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS
Name of Plan:
Plan #: H-xxxx
C.
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
0
PERIOD FROM:
TO:
01/00/00
01/00/00
WORKSHEET H
Interrelationship of Plan to related organization(s):
The Secretary, by virtue of authority granted under section 1814(b)(1) of the Health Insurance for the Aged and Disabled Act,
required organizations to furnish the information requested on Part C of this worksheet. The information will be used by the Health
Care Financing Administration in determining that the costs applicable to services, facilities and supplies furnished by
organizations related to the Plan by common ownership or control, represent reasonable costs as determined under section 1861 of the
Health Insurance for the Aged and Disabled Act. If the Plan does not provide all or any part of the requested information, the cost
report will be considered incomplete and not acceptable for purposes of claiming reimbursement under Title XVIII.
SYMBOL (2)
NAME OF INDIVIDUAL
OWNERSHIP OF PLAN
1
2
3
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
(2)
A
B
D
E
F
G
----------RELATED ORGANIZATION(S)-------ORGANIZATION
OWNERSHIP
NAME
%
4
5
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Use the following symbols to indicate the interrelationship of the Plan to related organizations:
Individual has financial interest (stockholder, partner, etc) in both related organization and in the Plan.
Corporation, partnership, or other organization has financial interest in the Plan.
Director, officer, administrator or key person of the Plan or relative of such person has financial interest
in related organization.
Individual is director, officer, administrator, or key person of the Plan and related organization.
Director, officer, administrator, or key person of related organization or relative of such person has
financial interest in the Plan.
Other (financial or nonfinancial) specify.
FORM CMS 276-25
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2310)
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
TYPE OF
BUSINESS
6
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
A. If the Plan utilizes any allocation method other than pooled A&G allocation, provide a detailed explanation of the allocation methodology
for each cost center represented on Worksheet I (see 42 CFR 417.564 for guidance on A&G allocation). The Plan shall describe the
specific business component A&G cost, allocation statistic and justification logic used in determining reasonable allocation in relation
to the benefits received by component. Please provide response to Part B below as well.
B. If the A&G allocation (Worksheet E, Column 5) exceeds the amount listed for the corresponding cost center
(Worksheet E, Column 4), then please provide further explanation below, specifically when allocating cost to Medicare only
lines such as Line 16 and Line 19.
A&G
COST CENTER
ALLOWABLE
ALLOCATION TOTALS
COST
(WKST I,
(Col 1 thru 3)
4
Part I)
5
(Col 4 + Col 5)
6
Explanation
1
2
3
4
5
6
7
8
9
10
11
12
13
13a
14
15
16
17
18
19
20
21
22
23
Inpatient Hospitals ……………….
Outpatient Hospitals …………….
Skilled Nursing Facilities.......….…
Home Health Agencies........….….
Clinics..........……….........….......…
Physician Groups.......................…
Individual Physicians.....…...….…
Certified Labs..................…......…
X-Ray Units....................……....…
ESRD Facilities.........................…
Durable Medical Equipment.......…
Ambulance...............……….......…
Pharmacy (Outpatient).......…...…
Pharmacy-Medicare Covered Rx
Emergency-Urgent Needed Svcs..
Mental Health Services....….……
DED+CO on claims processed by MACs
Other - Medicare Bad Debts...…
Other - Blood Deductible.....…
Part B Cost Not Subj to Coins.
Non-Allowable Costs
Other - (Specify)...…….......…
Other - (Specify)...…….......…
Other - (Specify)...…….......…
24 Subtotal (Sum Lines 1-23)........................
25 Plan Administration..............…..…
26 Special Admin Costs................…
27 Subtotal: (Sum Lns 25+26)......................
28 Admin & General Costs...…......…
29 Total Program Costs (24+27+28)............
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
____________ ___________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
___________
0
0
0
0
0
____________ ___________
0
0
0
0
___________
0
0
0
____________ ___________
0
___________
=========
0
=========
0
=========
0
| File Type | application/pdf |
| File Title | FinalCostReport |
| Subject | 1876 and 1833 Final Cost Report |
| Author | Division of Capitated Plan Audits |
| File Modified | 2025-03-24 |
| File Created | 2025-03-24 |