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FORM CMS-339
1102.3 (Cont.)
EXHIBIT 1
FORM APPROVED
OMB NO. 0938-0301
This questionnaire is required under the authority of sections 1815(a) and 1833(e) of the Social
Security Act. Failure to submit this questionnaire will result in suspension of Medicare payments.
To the degree that the information in CMS-339: 1) constitutes commercial or financial information
which is confidential, and/or 2) is of a highly sensitive personal nature, the information will be
protected from release under the Freedom of Information Act.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0301. The time required to complete this information collection is
estimated to average 17 hours and 20 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
(You MUST USE Instructions For Completing This Form
Located In PRM-II, §§1100ff.)
Provider Name:
Provider Number(s):
______________________________________________________________________________
Filed with Form CMSPeriod:
/ /1728 / /2552 / /2088 / /2540 / / 2540S
____________________
From
/ /
To ____________________
(Other - Specify)
INTENTIONAL MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION
CONTAINED IN THIS QUESTIONNAIRE MAY BE PUNISHABLE BY FINE AND/OR
IMPRISONMENT UNDER FEDERAL LAW
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I HEREBY CERTIFY that I have read the above statement and that I have examined the
accompanying information prepared by _____________________________________________
(Provider name(s) and number(s)) for the cost report period beginning _____________________
and ending ________________, and that to the best of my knowledge and belief, it is a true, correct
and complete statement prepared from the books and records of the provider(s) in accordance with
applicable instructions, except as noted.
(Signed)
Officer or Administrator of Provider(s)
Date
Title
Name and Telephone Number of Person to Contact for More Information
Rev. 6
11-15
1102.3 (Cont.)
EXHIBIT 1 (Cont.)
04-06
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
NOTE: 42 CFR 413.20 and instructions contained in the PRM-1
require that the provider maintain adequate financial and
statistical data necessary for the intermediary to use for a
proper determination of costs payable under the program.
Providers are, therefore, required to maintain and have
available for audit all records necessary to verify the amounts
and allowability of costs and equity capital included in the
filed cost report. Failure to have such records available for
review by fiscal intermediaries acting under the authority of
the Secretary of the Department of Health and Human Services
will render the amount claimed in the cost report unallowable.
A.
Provider Organization and Operation
NOTE: Section A to be completed by all providers.
1. The provider has:
a.
Changed ownership.
If "yes", submit name and address of new owner, date of
change, copy of sales agreement, or any similar
agreement affecting change of ownership.
b.
Terminated participation.
If "yes", list date of termination, and reason
(Voluntary/Involuntary).
2. The provider, members of the board of directors, officers,
medical staff or management personnel are associated with or
involved in business transactions with the following:
a.
Related organizations, management contracts and services
under arrangements as owners (stockholders),
management, by family relationship, or any other similar
type relationship.
b. Management personnel of major suppliers of the provider
(drug, medical supply companies, etc.).
If "yes" to question 2a and/or 2b, attach a list of the
individuals, the organizations involved, and description of
the transactions.
11-16
Rev. 6
04-06
EXHIBIT 1 (Cont.)
1102.3 (Cont.)
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
B.
NO
N/A
Financial Data and Reports
NOTE: Section B to be completed by all providers.
1. During this cost reporting period, the financial statements are
prepared by Certified Public Accountants or Public
Accountants (submit complete copy or indicate available date)
and are:
a.
Audited;
b.
Compiled; and
c.
Reviewed.
NOTE: Where there is no affirmative response to the above
described financial statements, attach a copy of the financial
statements prepared and a description of the changes in accounting
policies and practices if not mentioned in those statements.
2. Cost report total expenses and total revenues differ from those
on the filed financial statement.
If "yes", submit reconciliation.
C.
Capital Related Cost
NOTE: Section C to be completed only by hospitals excluded from
PPS (except Children’s) and PPS hospitals that have a unit
excluded from PPS.
1. Assets have been relifed for Medicare purposes.
If "yes", attach detailed listing of these specific assets, by
classes, as shown in the Fixed Asset Register.
NOTE: For cost reporting periods beginning on or after
October 1, 1991 and before October 1, 2001, under the
capital - PPS consistency rule (42 CFR 412.302 (d)), PPS
hospitals are precluded from relifing old capital.
2. Due to appraisals made during this cost reporting period,
changes have occurred to Medicare depreciation expense.
If "yes", attach copy of Appraisal Report and Appraisal
Summary by class of asset.
Rev. 6
11-17
1102.3 (Cont.)
EXHIBIT 1 (Cont.)
04-06
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
3. New leases and/or amendments to existing leases for land,
equipment, or facilities with annual rental payment in excess
of the amounts listed in the instructions, have been entered into
during this cost reporting period.
If "yes", submit a listing of these new leases and/or
amendments to existing leases that have the following
information:
o
A new lease or lease renewal;
o
Parties to the lease;
o
Period covered by the lease;
o
Description of the asset being leased; and
o
Annual charge by the lessor.
NOTE: Providers are required to submit copies of the lease, or
significant extracts, upon request from the intermediary.
4. There have been new capitalized leases entered into during the
current cost reporting period.
If "yes", attach a list of the individual assets by class, the
department assigned to, and respective dollar amounts for all
capitalized leases in accordance with the thresholds discussed
in the instructions.
5. Assets which were subject to §2314 of DEFRA were acquired
during the period.
If "yes", supply a computation of the basis.
6. Provider's capitalization policy changed during cost reporting
period.
If "yes", submit copy.
7. Obligated capital has been placed into use during the cost
reporting period.
If "yes", attach schedule listing each project, the cost of these
projects and the date placed into service for patient care.
11-18
Rev. 6
04-06
EXHIBIT 1 (Cont.)
1102.3 (Cont.)
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
D.
NO
N/A
Interest Expense
NOTE: Section D to be completed only by hospitals excluded
from PPS (except Children’s) and PPS hospitals that have a unit
excluded from PPS.
1. New loan, mortgage agreements or letters of credit were
entered into during the cost reporting period.
If "yes", state the purpose and submit copies of debt
documents and amortization schedules.
2. The provider has a funded depreciation account and/or bond
funds (Debt Service Reserve Fund) treated as a funded
depreciation account.
If "yes", submit a detailed analysis of the funded depreciation
account for the cost reporting period. (See PRM-1, §226.4.)
3. Provider replaced existing debt prior to its scheduled maturity
with new debt.
If "yes", submit support for new debt and calculation of
allowable cost. (See §233.3 for description of allowable cost.)
4. Provider recalled debt before scheduled maturity without
issuance of new debt.
If "yes", submit detail of debt cancellation costs. (See §215 for
description and treatment of debt cancellation costs.)
E.
Approved Educational Activities
NOTE: Section E to be completed by all providers.
1. Costs were claimed for Nursing School and Allied Health
Programs.
If "yes", attach list of the programs and annotate for each
whether the provider is the legal operator of the program.
2. Approvals and/or renewals were obtained during this cost
reporting period for Nursing School and/or Allied Health
Programs.
If "yes", submit copies.
3. Provider has claimed Intern-Resident costs on the current cost
report.
If "yes", submit the current year Intern-Resident Information
System (IRIS) on diskette.
Rev. 6
11-19
1102.3 (Cont.)
EXHIBIT 1 (Cont.)
04-06
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
4. Provider has initiated an Intern-Resident program in the
current year or obtained a renewal of an existing program. If
"yes", submit certification/program approval.
5. Graduate Medical Education costs have been directly assigned
to cost centers other than the Intern-Resident Services in an
Approved Teaching Program, on Worksheet A, Form
CMS-2552.
If "yes", submit appropriate workpapers indicating to which
cost centers assigned and the amounts.
F.
Purchased Services
NOTE: Questions 1 and 2 to be completed only by hospitals
excluded from PPS (except Children’s) and PPS hospitals that
have a unit excluded from PPS. Question 3 to be completed only
by Inpatient PPS (IPPS) hospitals, hospitals with an IPPS
subprovider, hospitals that would be subject to IPPS if not
granted a waiver, and SNFs.
1. Changes or new agreements have occurred in patient care
services furnished through contractual arrangements with
suppliers of services.
If "yes", submit copies of changes or contracts, or where
there are no written agreements, attach description.
NOTE: Hospitals are only required to submit such information
where the cost of the individual's services exceeds $25,000 per
year.
2. The requirements of §2135.2 were applied pertaining to
competitive bidding.
If "no", attach explanation.
3. Contract services are reported on Worksheet S-3, Part II,
line 9 (hospitals) or line 17 (SNFs).
If yes, submit a schedule showing the total direct patient care
related contract labor, hours and calculated rate for each
invoice paid during the year for the direct patient care related
contract labor reported on Worksheet S-3, Part II, line 9
(hospitals) or line 17 (SNFs). Contracted labor will include
any wage related costs. The contracted amounts for the top
four management personnel (CEO, CFO, COO and Nursing
Administrator) are not required to be reported by individuals.
11-20
Rev. 6
04-06
EXHIBIT 1 (Cont.)
1102.3 (Cont.)
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
The total aggregate wage and hours will be reported for these
management contracts. Other contracts or contracts for other
management personnel should NOT be reported as they are not
allowed in the computation of the wage index.
G.
Provider-Based Physicians
NOTE: Section G to be completed only by hospitals excluded
from PPS (except Children’s) and PPS hospitals that have a unit
excluded from PPS.
1. Services are furnished at the provider facility under an
arrangement with provider-based physicians.
If "yes", submit completed provider-based physician
questionnaire (Exhibits 2 through 4A).
2.
H.
The provider has entered into new agreements or amended
existing agreements with provider-based physicians during
this cost reporting period.
If "yes", submit copies of new agreements or amendments to
existing agreements and assignment authorizations.
Home Office Costs
NOTE: Questions 1 through 6 to be completed only by hospitals
excluded from PPS (except Children’s) and PPS hospitals that
have a unit excluded from PPS. Question 7 to be completed only
by IPPS hospitals, hospitals with an IPPS subprovider, hospitals
that would be subject to IPPS if not granted a waiver, and SNFs.
1. The provider is part of a chain organization.
If "yes", give full name and address of the home office:
Name _____________________
Address ___________________
State _____
City
Zip _________
Designated Intermediary: _____________________
2. A home office cost statement has been prepared by the home
office.
Rev. 6
11-21
1102.3 (Cont.)
EXHIBIT 1 (Cont.)
04-06
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
If "yes", submit a schedule displaying the entire chain's direct,
functional and pooled cost as provided to the designated home
office intermediary as part of the home office cost statement.
3. The fiscal year end of the home office is different from that of
the provider.
If "yes", indicate the fiscal year end of the home office.
FYE
.
NOTE: Where the year ends of the provider and home office are
not the same (nonconcurrent year ends), the summary listing, as
described in number 2 above, will be necessary to support the
provider's cost report.
4. Describe the operation of the intercompany accounts. Include
in this description the types of costs included from these
intercompany accounts and their location on the cost report.
(Provide informative attachments not shown on Worksheet
A-8-1).
5. Actual expense amounts are transferred by the home office to
the provider components on an interim basis. (Provide
informative attachments if not shown on Worksheet A-8-1.)
6. The provider renders services to:
a. Other chain components.
b. The home office.
If "yes", to either of the above, provide informative attachments.
7.
11-22
Home Office or Related Organization personnel cost are
reported on Worksheet S-3, Part II, Line 11 (hospitals) or
line 18 (SNFs). If yes, submit a schedule displaying the
wages, wage related costs, and hours allocated to the
individual chain components as provided to the designated
home office intermediary to support the amount reported on
Worksheet S-3, Part II, line 11 (hospitals) or line 18 (SNFs).
Rev. 6
04-06
EXHIBIT 1 (Cont.)
1102.3 (Cont.)
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
I.
NO
N/A
Bad Debts
NOTE: Section I to be completed by all providers.
1. The provider seeks Medicare reimbursement for bad debts. If
"yes", complete Exhibit 5 or submit internal schedules
duplicating documentation required on Exhibit 5 to support
bad debts claimed. (see instructions)
2. The provider's bad debt collection policy changed during the
cost reporting period.
If "yes", submit copy.
3. The provider waives patient deductibles and/or copayments.
If yes, insure that they are not included on Exhibit 5.
J.
Bed Complement
NOTE: Section J to be completed by all providers.
The provider's total available beds have changed from prior cost
reporting period.
If "yes", provide an analysis of available beds and explain any
changes during the cost reporting period.
K.
PS&R Data
NOTE 1: Section K to be completed by all providers.
NOTE 2: Refer to the instructions regarding required
documentation and attachments.
1. The cost report was prepared using the PS&R only?
Rev. 6
a)
Part A (including subproviders, SNF, etc.)?
b)
Part B (inpatient and outpatient).
11-23
1102.3 (Cont.)
EXHIBIT 1 (Cont.)
04-06
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
If yes, attach a crosswalk between revenue codes and charges
found on the PS&R to the cost center groupings on the cost
report. This crosswalk will reflect a cost center to revenue
code match only.
2. The cost report was prepared using the PS&R for totals and
the provider records for allocation.
a)
Part A (including subproviders, SNF, etc).
b)
Part B (inpatient and outpatient).
If yes, include a detailed crosswalk between revenue codes,
departments and charges on the PS&R to the cost center
groupings on the cost report. This crosswalk must include
which revenue codes were allocated to each cost center.
Supporting workpapers must accompany this crosswalk to
provide sufficient documentation as to the accuracy of the
provider records.
If the PS&R is used for the allocation of ASC, Radiology,
Other Diagnostic, and All Other Part B, explain how the total
charges are detailed to the various PS&R Medicare outpatient
types. Include workpapers supporting the allocation of
charges into the various cost centers. If internal records are
used for either the type of service breakdown or the charge
allocation, the source of this information must be included in
the documentation.
3. Provider records only were used to complete the cost report?
a)
Part A (including subproviders, SNF, etc.).
b)
Part B (inpatient and outpatient).
If yes, attach detailed documentation of the system used to
support the data reported on the cost report. If the detail
documentation was previously supplied, submit only
necessary updated documentation.
11-24
Rev. 6
04-06
EXHIBIT 1 (Cont.)
1102.3 (Cont.)
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
The minimum requirements are:
-
Copies of input tables, calculations, or charts supporting data
elements for PPS operating rate components, capital PPS rate
components, ASC payment group rates, Radiology and Other
Diagnostic prevailing rates and other claims PRICING
information.
-
Log summaries and log detail supporting program utilization
statistics, charges, prevailing rates and payment information
broken into each Medicare bill type in a consistent manner
with the PS&R.
-
Reconciliation of remittance totals to the provider
consolidated log totals.
Additional information may be supplied such as narrative
documentation, internal flow charts, or outside vendor
informational material.
Include the name of the system used and indicate how the
system was maintained (vendor or provider). If the provider
maintained the system, include date of last software update.
4. If yes to questions 1 or 2 above, were any of the following
adjustments made to the Part A PS&R data?
Part A:
Rev. 6
a)
Addition of claims billed but not on PS&R? Indicate the
paid claims through date from the PS&R used and the
final pay date of the claims that supplement the original
PS&R. Also indicate the total charges for the claims
added to the PS&R. Include a summary of the unpaid
claims log.
b)
Correction of other PS&R information?
11-25
1102.3 (Cont.)
EXHIBIT 1 (Cont.)
04-06
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
c)
Late charges?
d)
Other (describe)?
NO
N/A
Part B (inpatient and outpatient):
a)
Addition of claims billed but not on PS&R? Indicate the
paid claims through date from the PS&R used and the
final pay date of the claims that supplement the original
PS&R. Also indicate the total charges for the claims
added to the PS&R. Include a summary of the unpaid
claims log.
b)
Correction of other PS&R information?
c)
Late charges?
d)
Other (describe)?
Attach documentation which provides an audit trail from the
PS&R to the cost report. The documentation should include
the details of the PS&R, reclassifications, adjustments, and
groupings necessary to trace to the cost center totals and in
addition, for outpatient services, there should be an audit trail
from the PS&R to the amounts shown on the cost report for
outpatient charges by ASC, radiology, other diagnostic and all
other service categories including standard overhead amounts
and prevailing charges.
L.
Wage Related Costs
NOTE: Section L to be completed only by IPPS hospitals,
hospitals with an IPPS subprovider, hospitals that would be
subject to IPPS if not granted a waiver, and SNFs.
11-26
Rev. 6
04-06
EXHIBIT 1 (Cont.)
1102.3 (Cont.)
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
1. Complete EXHIBIT 6, Part I (Per instructions). Part III must
be completed to reconcile any differences between any fringe
benefit cost reported on Worksheet A, Column 2, using
Medicare principles and the corresponding wage related costs
reported under GAAP for purposes of the wage index
computation.
2. The individual wage related cost exceeds one percent of total
adjusted salaries after removing excluded salaries. (Salaries
reported on Worksheet S-3, Part III, Column 3, line 3 (CMS2552-96), or Worksheet S-3, Part II, Column 3, Line 26 (CMS2540-96).)
3. Additional wage related costs were provided that meet ALL of
the following tests:
Rev. 6
a.
The cost is not listed on Part I of EXHIBIT 6.
b.
If any of the additional wage related cost applies to the
excluded areas of the hospital, the cost associated with
the excluded areas has been removed prior to making the
1 percent threshold test in question 2 above.
c.
The wage related cost has been reported to the IRS, as a
fringe benefit if so required by the IRS.
d.
The individual wage related cost is not included in
salaries reported on Worksheet S-3, Part III, column 3,
line 3, (CMS-2552-96) or Worksheet S-3, Part II,
Column 3, Line 16 (CMS-2540-96).
e.
The wage related cost is not being furnished for the
convenience of the employer.
11-27
N/A
1102.3 (Cont.)
EXHIBIT 2
Allocation of Physician
04-06
Provider Name:__________________________________________
Compensation: Hours
Provider Number:
Department: ___________________________
Physician Name: ___________________________________________
Cost Reporting Year:
___
Basis of Allocation: Time Study /__/;
Beginning___________________ Ending ___________________
___
Other /__/; Describe ______________________________
Services
Total
Hours
1.
Provider Services - Teaching and Supervision of I/R's and other GME Related Functions.
_________________________
1A.
Provider Services - Teaching and Supervision of Allied Health Students
_________________________
1B.
Provider Services - Non Teaching Reimbursable Activities such as Departmental Administration,
Supervision of Nursing, and Technical Staff, Utilization Review, etc.
_________________________
1C.
Provider Services - Emergency Room Physician Availability
(Do not include minimum guarantee arrangements for Emergency Room Physicians.)
_________________________
1D.
Sub-Total - Provider Administrative Services (Lines 1, 1A, 1B, 1C).
_________________________
2.
Physician Services: Medical and Surgical Services
to Individual Patients
_________________________
Non-Reimbursable Activities: Research, Teaching of I/R's in Non-Approved Programs, Teaching
and Supervision of Medical Students, Writing for Medical Journals, etc.
_________________________
4.
Total Hours: (Lines 1D, 2, and 3)
_________________________
5.
6.
Professional Component Percentage (Line 2 / Line 4)
Provider Component Percentage - (Line 1D / Line 4)
_________________________
_________________________
3.
__________________________________________
Signature: Physician or Physician Department Head
11-28
________________________
Date
Rev. 6
04-06
EXHIBIT 3
1102.3 (Cont.)
Hospital Emergency Department
Provider-Based Physician
Provider Name: ______________________________________________________
Provider Number: ____________________________________________________
Allowable Availability Service Costs
Cost Reporting Year: Beginning _______________ Ending ______________
Under Hourly Rate or Salary Arrangements
Geographic Location of Provider: ____________________________________
(City & State)
Data Elements
Specialty:____________________________________
Name of Physician: __________________________________________________
Allocation Agreement:
Time - Percentage
Availability Services
Supervision & Administrative Services
Total Hours Worked
________%
________%
_______
_______
Reasonable Compensation Equivalent (RCE) from Table I, Estimate of FTE
___
___
RCE Area: Non-Metropolitan /__/; Metropolitan, Less Than One Million /__/;
___
or Metropolitan, Greater Than One Million /__/
Actual Provider Payments:
Supervision and Administration
Availability Services
Membership in Professional Associations
Continuing Medical Education
Malpractice Insurance Premiums
$__________________
Total Charges:
$_____________
$_____________
$_____________
$_____________
$_____________
Billed Inpatient Charges
Billed Outpatient Charges
Imputed Inpatient Charges
Imputed Outpatient Charges
Imputed Employee Charges
Other :
_________________
$______________
$______________
$______________
$______________
$______________
$______________
$______________
Compensation Based on:
Hourly Rate $_____________ or Salary Basis $___________________
Note: Attach copy of Approved Allocation Agreements
Rev. 6
11-29
1102.3 (Cont.)
EXHIBIT 3A
04-06
Hospital Emergency Department
Provider Name: ________________________________
Provider-Based Physician
Provider Number: ______________________________
Allowable Availability Service Costs
Cost Reporting Year: Beginning __________________
Under Hourly Rate or Salary
Ending _____________ RCE Year ________________
Arrangements: Computation
Name of Physician: ___________________________
Specialty: ___________________________________
The Reasonable Cost of the Supervisory, Administrative and Availability Services Time is
Computed as Follows:
1. Determine the Applicable RCE Base:
Total Hours
(Supervisory, Administrative
and Availability Services)
Work Year Hours (2,080)
_____________________
2,080
X RCE (Use RCE from Table I) =
X
$_____________________
=
RCE Base
$_________________
2. Determine the Limit on the Allowance for Membership in Professional Associations and
Continuing Education.
RCE Base
X 5%
$____________ X .05
=
Limit
= $_________________
3. Provider Payments for Membership in Professional Associations and Continuing Medical
Education:
Membership in Professional Associations
$_________________
Continuing Medical Education
$_________________
Total
$_________________
4. Malpractice Insurance Expense
(Provider Services Portion)
$_________________
5. Adjusted RCE Base:
(Sum of #1 $________ + the lesser of #2 or #3 $________
+ #4 $________)
11-30
= $_________________
Rev. 6
04-06
EXHIBIT 3A (Cont.)
Provider Name ______________________________
1102.3 (Cont.)
Provider Number ________________
Name of Physician ___________________________
6. Actual Provider Payments
Supervision and Administration
Availability Services
Membership in Professional Associations
Continuing Medical Education
Malpractice (Provider Services Related)
$_______________
$_______________
$_______________
$_______________
$_______________
Total
$_______________
7. Amount Includable in Allowable Costs:
(Lesser of #5 or #6)
$_______________
8. Allocation of Allowable Costs:
Billed Outpatient Charges
(Emergency Department)
Imputed Outpatient and Employee Charges
Total Outpatient Charges
$_______________
$_______________
$_______________
Imputed Inpatient Charges
Billed Inpatient Charges
Total Inpatient Charges
$_______________
$_______________
$_______________
Total Outpatient and Inpatient Charges
$_______________
Total Outpatient Charges X Allowable Provider Costs = Allowable Part B Costs
Total Charges
___________________ X
_________________
= $_______________
Total Inpatient Charges X Allowable Provider Costs = Allowable Part A Costs
Total Charges
______________________ X ____________________ = $__________________
Rev. 6
11-31
1102.3 (Cont.)
Hospital Emergency Department
Provider-Based Physician
Allowable Unmet Guarantee Amounts
Under Minimum Guarantee Arrangements:
Data Elements
EXHIBIT 4
04-06
Provider Name: ______________________________________________________
Provider Number: ____________________________________________________
Cost Reporting Year: Beginning _______________ Ending ______________
Geographic Location of Provider: ____________________________________
(City and State)
_
Specialty: _____________________________________
Name of Physician: __________________________________________________
_
Allocation Agreement:
A) Professional Services to Individual
Patients (includes inpatients and
employees) and Availability Services
B) Supervision & Administrative Services
Total
Time - Percentage
Total Hours Worked
________%
________%
%
Reasonable Compensation Equivalent (RCE) from Table I, Estimate of FTE
___
___
RCE Area: Non-Metropolitan /__/; Metropolitan, Less Than One Million /__/;
___
or Metropolitan, Greater Than One Million /__/
Actual Provider Payments:
Supervision and Administration
Unmet Guarantee Amount
Membership in Professional Associations
Continuing Medical Education
Malpractice Insurance Premiums
Other
$_____________
$_____________
$_____________
$_____________
$_____________
$_____________
Actual Minimum Guarantee Amount
$_____________
________
________
$__________________
Total Charges:
Billed Outpatient Charges
Billed Inpatient Charges
Imputed Inpatient Charges
Imputed Outpatient Charges
Imputed Employee Charges
Other: _________________
_________________
Total Outpatient Charges
Total Inpatient Charges
$______________
$______________
$______________
$______________
$______________
$______________
$______________
$______________
$______________
Note: Attach copy of Approved Allocation Agreement
11-32
Rev. 6
04-06
EXHIBIT 4A
1102.3 (Cont.)
Hospital Emergency Department
Provider Name: ___________________________________
Provider-Based Physician
Provider Number: _________________________________
Allowable Unmet Guarantee
Cost Reporting Year: Beginning __________________
Amounts Under Minimum Guarantee
Ending _____________ RCE Year ___________________
Arrangements: Computation
Name of Physician: ______________________________
Specialty:___________________________________
Computation of Reasonable Allowable Cost for Supervisory and Administrative Duties
1.
Determine the Applicable RCE Base:
Total Hours (Supervisory and
Administrative Services)
Work Year Hours (2,080)
X RCE (Use RCE from Table I)
________________________ X $_________________________
2,080
2.
3.
=
RCE Base
= $________________
Determine the Limit on the Allowance for Membership in Professional Associations and
Continuing Medical Education.
RCE Base
X 5%
=
Limit
$____________
X .05
= $________________
Determine Actual Provider Payment for Membership in Professional Associations and
Continuing Medical Education Applicable to Supervisory and Administrative Services
Total Hours (Supervisory and
Administrative Services)
Total Hours Worked
X
________________________
X
Rev. 6
Total Payments for Membership
in Professional Associations and
Continuing Medical Education
= Actual Provider Payment
$______________________________
= $________________
11-33
1102.3 (Cont.)
EXHIBIT 4A (Cont.)
04-06
Provider Name __________________________________Provider Number ___________________________
Name of Physician _________________________________________________________________________
4.
5.
Determine the Allowance for Malpractice Insurance (Supervision and Administration
(S&A)):
Supervisory and Administrative Hours X Total Payment for Malpractice Insurance
Total Hours Worked
= Allowance
_______________________________ X $_______________________
= $_______________
Adjusted RCE Base for Supervision and Administrative Services:
(Sum of #1 _____________ + the Lesser of #2 or #3 _____________+ #4________________)
6.
= $_______________
Determine Provider Payments Attributable to Supervision and Administrative Services:
Supervision and Administration (S&A):
S& A Hours X Rate
__________ X $ ________________
= $_______________
Membership in Professional Associations:
S&A Hours X Cost
Total Hours
__________ X $________________
= $_______________
Continuing Medical Education:
S&A Hours X Cost
Total Hours
__________ X $________________
= $_______________
Malpractice Insurance Premiums:
S&A Hours X Cost
Total Hours
__________ X $________________
= $_______________
Total
7.
11-34
Amount Includable in Allowance Costs (Lesser of #5 or #6)
= $_______________
= $_______________
Rev. 6
04-06
EXHIBIT 4A (Cont.)
1102.3 (Cont.)
Provider Name __________________________________Provider Number ___________________________
Name of Physician _________________________________________________________________________
Computation of Reasonable Allowable Cost for an Unmet Guarantee Amount
8.
Determine the Applicable RCE Base:
Total Hours (Professional
and Availability Services) X
Work Year Hours (2,080)
_____________________
2,080
9.
10.
11.
RCE (Use RCE from Table I)
X $ _________________________
=
RCE Base
= $________________
Determine the Limit on the Allowance for Membership in Professional Associations
and Continuing Medical Education:
RCE Base
X 5%
=
Limit
$____________
X .05
= $________________
Determine Actual Provider Payment for Membership in Professional Associations and
Continuing Medical Education Applicable to Professional and Availability Services:
Total Hours (Professional and
Total Payments for Membership
Availability Services)
X in Professional Associations and
Total Hours Worked
Continuing Medical Education
=
________________________ X $______________________________
= $________________
Actual Provider Payment
Determine the Allowance for Malpractice Insurance:
(Professional and Availability Services)
Total Hours (Professional and
X Total Payments for
Availability Services)
Total Hours Worked
Malpractice Insurance
=
________________________ X $______________________________
= $________________
Rev. 6
Actual Provider Payment
11-35
1102.3 (Cont.)
EXHIBIT 4A (Cont.)
04-06
Provider Name __________________________________Provider Number ___________________________
Name of Physician _________________________________________________________________________
12. Adjusted RCE Base:
(Sum of #8 ______________ + the Lesser of #9 or #10 ______________ + #11 ______________)
= $_______________
13. Actual Minimum Guarantee Amount
$_______________
14. Reasonable Minimum Guarantee Amount
(Lesser of #12 or #13)
$_______________
15. Total Charges:
Billed Inpatient Charges
Billed Outpatient Charges
Imputed Inpatient Charges
Imputed Outpatient Charges
Imputed Employee Charges
$______________
$______________
$______________
$______________
$______________
Total
$_______________
16. Reasonable Unmet Guarantee Amount
(#14 Less #15)
$_______________
17. Summary of Allowable Provider Costs:
Supervisory and Administrative Services (#7)
Reasonable Unmet Guarantee Amount (#16)
Total
11-36
$_______________
$_______________
$_______________
Rev. 6
04-06
EXHIBIT 5
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
1102.3 (Cont.)
PROVIDER ____________________
PREPARED BY __________________________________
NUMBER ______________________
DATE PREPARED ________________________________
FYE _________________________
INPATIENT __________ OUTPATIENT ______________
(1)
Patient
Name
(2)
HIC. NO.
(3)
DATES OF
SERVICE
FROM
TO
(4)
INDIGENCY &
WEL. RECIP.
(CK IF APPL)
YES
(5)
DATE FIRST
BILL SENT TO
BENEFICIARY
(6)
WRITE-OFF
DATE
(7)
REMITTANCE
ADVICE
DATES
(8)*
DEDUCT
(9)*
CO-INS
(10)
TOTAL
MEDICAID
NUMBER
* THESE AMOUNTS MUST NOT BE CLAIMED UNLESS THE PROVIDER BILLS FOR THESE SERVICES WITH THE INTENTION OF PAYMENT.
SEE INSTRUCTIONS FOR COLUMN 4 - INDIGENCY/WELFARE RECIPIENT, FOR POSSIBLE EXCEPTION
Rev. 6
11-37
1102.3 (Cont.)
PART I - Wage Related Cost (Core List)
RETIREMENT COSTS:
1.
401K Employer Contributions
2.
EXHIBIT 6
1. $
Tax Sheltered Annuity (TSA) Employer
Contribution
2. $
3.
Qualified and Non-Qualified Pension Plan Cost
3. $
4.
Prior Year Pension Service Cost
4. $
PLAN ADMINISTRATIVE COSTS (Paid to External Organization):
5.
401K/TSA Plan Administration fees
5. $
6.
Legal/Accounting/Management Fees-Pension Plan
6. $
7.
Employee Managed Care Program Administration Fees
7. $
HEALTH AND INSURANCE COSTS:
8.
Health Insurance (Purchased or Self-Funded)
8. $
9.
Prescription Drug Plan
9. $
10.
Dental, Hearing & Vision Plans
10. $
11.
Life Insurance (If employee is owner or beneficiary)
11. $
12.
Accident Ins. (If employee is owner or beneficiary)
12. $
13.
Disability Ins. (If employee is owner or beneficiary)
13. $
14.
Long-Term Care Ins. (If employee is owner or
beneficiary)
14. $
15.
Workmen's Compensation Ins.
15. $
16.
Retiree Health Care Cost (Only current year, not the
extraordinary accrual required by FASB 106. This is
the non-cumulative portion.)
16. $
TAXES:
17.
FICA-Employers Portion Only
17. $
18.
Medicare Taxes - Employers Portion Only
18. $
19.
Unemployment Insurance
19. $
20.
State or Federal Unemployment Taxes
OTHER:
21.
Executive Deferred Compensation
20. $
22.
Day Care Cost and Allowances
22. $
23.
Tuition Reimbursement
23. $
TOTAL WAGE RELATED COST (CORE)
11-38
04-06
21. $
$
Rev. 6
04-06
EXHIBIT 6 (Cont.)
1102.3 (Cont.)
Part II - Other Wage Related Cost
List below detail for each wage related cost that exceeds the 1% threshold. Each wage
related cost listed below must be recognized as a wage related cost in conformity with
published criteria and instructions.
________________________________________________ $_______________________
________________________________________________ $_______________________
TOTAL OTHER WAGE RELATED COST
$__________________________________
Part III - WAGE RELATED COST RECONCILIATION TO FRINGE BENEFITS REPORTED
IN THE COST REPORT
DESCRIPTION
COST PER MEDICARE
COST PER GAAP
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
Rev. 6
11-39
| File Type | application/pdf |
| File Title | Microsoft Word - pr2_1102 3__Cont __ex_6.doc |
| Author | XB08 |
| File Modified | 2006-05-16 |
| File Created | 2006-04-26 |