Hospitals and Health Care Complex Cost Report (CMS-2552-96)

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Overview

M1
M2
M3
M4
M5

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Sheet 1: M1

DRAFT		FORM CMS-2552-10							4090 (Cont.)
ANALYSIS OF PROVIDER-BASED RURAL HEALTH CLINIC/				PROVIDER NO.:		PERIOD:		WORKSHEET M-1
FEDERALLY QUALIFIED HEALTH CENTER COSTS				_______________		FROM_______________
				COMPONENT NO.:		TO__________________
				_______________
Check Applicable Box		[ ] RHC [ ] FQHC
						RECLASSIFIED		NET EXPENSES
						TRIAL		FOR
		COMPENSAT-		TOTAL	RECLASSFI-	BALANCE		ALLOCATION
		ION	OTHER COSTS	(col. 1 + col. 2)	CATIONS	(col. 3 + col. 4)	ADJUSTMENTS	(col. 5 + col. 6)
		1	2	3	4	5	6	7
	FACILITY HEALTH CARE STAFF COSTS
1	Physician								1
2	Physician Assistant								2
3	Nurse Practitioner								3
4	Visiting Nurse								4
5	Other Nurse								5
6	Clinical Psychologist								6
7	Clinical Social Worker								7
8	Laboratory Technician								8
9	Other Facility Health Care Staff Costs								9
10	Subtotal (sum of lines 1-9)								10
	COSTS UNDER AGREEMENT
11	Physician Services Under Agreement								11
12	Physician Supervision Under Agreement								12
13	Other Costs Under Agreement								13
14	Subtotal (sum of lines 11-13)								14
	OTHER HEALTH CARE COSTS
15	Medical Supplies								15
16	Transportation (Health Care Staff)								16
17	Depreciation-Medical Equipment								17
18	Professional Liability Insurance								18
19	Other Health Care Costs								19
20	Allowable GME Costs								20
21	Subtotal (sum of lines 15-20)								21
22	Total Cost of Health Care Services								22
	(sum of lines 10, 14, and 21)
	COSTS OTHER THAN RHC/FQHC SERVICES
23	Pharmacy								23
24	Dental								24
25	Optometry								25
26	All other nonreimbursable costs								26
27	Nonallowable GME costs								27
28	Total Nonreimbursable Costs (sum of lines 23-27)								28
	FACILITY OVERHEAD
29	Facility Costs								29
30	Administrative Costs								30
31	Total Facility Overhead (sum of lines 29 and 30)								31
32	Total facility costs (sum of lines 22, 28 and 31)								32
The net expenses for cost allocation on Worksheet A for the RHC/FQHC cost center line must equal the total facility costs in column 7, line 32 of this worksheet.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4066)
Rev. 1									40-659

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Sheet 2: M2

4090 (Cont.)		FORM CMS-2552-10					DRAFT
ALLOCATION OF OVERHEAD		PROVIDER NO.:		PERIOD:		WORKSHEET M-2
TO RHC/FQHC SERVICES		_______________		FROM____________
		COMPONENT NO.:		TO_____________
		_______________
Check Applicable Box:		[ ] RHC	[ ] FQHC
VISITS AND PRODUCTIVITY
		Number			Minimum	Greater of
		of FTE	Total	Productivity	Visits (col. 1	col. 2 or
		Personnel	Visits	Standard (1)	x col. 3)	col. 4
	Positions	1	2	3	4	5
1	Physicians						1
2	Physician Assistants						2
3	Nurse Practitioners						3
4	Subtotal (sum of lines 1-3)						4
5	Visiting Nurse						5
6	Clinical Psychologist						6
7	Clinical Social Worker						7
8	Total FTEs and Visits (sum of lines 4-7)						8
9	Physician Services Under Agreements						9
DETERMINATION OF ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES
10	Total costs of health care services (from Worksheet M-1, column 7, line 22)						10
11	Total nonreimbursable costs (from Worksheet M-1, column 7, line 28)						11
12	Cost of all services (excluding overhead) (sum of lines 10 and 11)						12
13	Ratio of RHC/FQHC services (line 10 divided by line 12)						13
14	Total facility overhead - (from Worksheet M-1, column 7, line 31)						14
15	Parent provider overhead allocated to facility (see instructions)						15
16	Total overhead (sum of lines 14 and 15)						16
17	Allowable GME overhead (see instructions)						17
18	Subtract line 17 from line 16						18
19	Overhead applicable to RHC/FQHC services (line 13 x line 18)						19
20	Total allowable cost of RHC/FQHC services (sum of lines 10 and 19)						20
(1)	The productivity standard for physicians is 4,200 and 2,100 for physician assistants and nurse practitioners. If an exception
	to the standard has been granted (Worksheet S-8, line 14 equals "Y"), column 3, lines 1thru 3 of this worksheet should contain,
	at a minimum, one element that is different than the standard.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4067)
40-660							Rev. 1

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Sheet 3: M3

DRAFT		FORM CMS-2552-10				4090(Cont.)
CALCULATION OF REIMBURSEMENT		PROVIDER NO.:	PERIOD:		WORKSHEET M-3
SETTLEMENT FOR RHC/FQHC SERVICES		_______________	FROM____________
		COMPONENT NO.:	TO______________
		_______________
Check		[ ] RHC	[ ] Title V [ ] Title XIX
Applicable Box:		[ ] FQHC	[ ] Title XVIII
DETERMINATION OF RATE FOR RHC/FQHC SERVICES
1	Total Allowable Cost of RHC/FQHC Services (from Worksheet M-2, line 20)					1
2	Cost of vaccines and their administration (from Worksheet M-4, line 15)					2
3	Total allowable cost excluding vaccine (line 1 minus line 2)					3
4	Total Visits (from Worksheet M-2, column 5, line 8)					4
5	Physicians visits under agreement (from Worksheet M-2, column 5, line 9)					5
6	Total adjusted visits (line 4 plus line 5)					6
7	Adjusted cost per visit (line 3 divided by line 6)					7
				Calculation of Limit (1)
				Prior to	On or after
				January 1	January 1
				1	2
8	Per visit payment limit (from CMS Pub. 27,Sec. 505 or your intermediary)					8
9	Rate for Program covered visits (see instructions)					9
CALCULATION OF SETTLEMENT
10	Program covered visits excluding mental health services (from intermediary records)					10
11	Program cost excluding costs for mental health services (line 9 x line 10)					11
12	Program covered visits for mental health services (from intermediary records)					12
13	Program covered cost from mental health services (line 9 x line 12)					13
14	Limit adjustment for mental health services (see instructions)					14
15	Graduate Medical Education Pass Through Cost (see instructions)					15
16	Total Program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3) *					16
17	Primary payer amounts					17
18	Less: Beneficiary deductible (from intermediary records)					18
19	Net Program cost excluding vaccines (line 16 minus sum of lines 17 and 18)					19
20	Reimbursable cost of RHC/FQHC services, excluding vaccine (80% of line 19)					20
21	Program cost of vaccines and their administration (from Wkst. M-4, line 16)					21
22	Total reimbursable Program cost (line 20 plus line 21)					22
23	Reimbursable bad debts (see instructions)					23
24	Reimbursable bad debts for dual eligible beneficiaries (see instructions)					24
25	Other adjustments (see instructions) (specify)					25
26	Net reimbursable amount (lines 22 plus 23 plus or minus line 25)					26
27	Interim payments					27
28	Tentative settlement (for fiscal intermediary use only)					28
29	Balance due component/program (line 26 minus lines 27 and 28)					29
30	Protested amounts (nonallowable cost report items) in accordance with CMS					30
	Pub. 15-II, chapter I, section 115.2
(1) Lines 8 through 14: Fiscal year providers use columns 1 & 2, calendar year providers use column 2 only.
* For line 15, use column 2 only for graduate medical education pass through cost.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4068)
Rev. 1						40-661

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Sheet 4: M4

DRAFT		FORM CMS-2552-10				4090(Cont.)
COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA			PROVIDER NO.:	PERIOD:	WORKSHEET M-4
VACCINE COST			______________	FROM _________
			COMPONENT NO.:	TO: __________
			_____________
Check			[ ] RHC	[ ] Title V [ ] Title XIX
Applicable Box:			[ ] FQHC	[ ] Title XVIII
				PNEUMOCOCCAL	INFLUENZA
				1	2
1	Health care staff cost (from Worksheet M-1, column 7, line 10)					1
2	Ratio of pneumococcal and influenza vaccine staff time to total					2
	health care staff time
3	Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)					3
4	Medical supplies cost - pneumococcal and influenza vaccine					4
	(from your records)
5	Direct cost of pneumococcal and influenza vaccine (line 3 plus line 4)					5
6	Total direct cost of the facility (from Worksheet M-1, column 7, line 22)					6
7	Total overhead (from Worksheet M-2, line 16)					7
8	Ratio of pneumococcal and influenza vaccine direct cost to total direct					8
	cost (line 5 divided by line 6)
9	Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)					9
10	Total pneumococcal and influenza vaccine cost and its (their)					10
	administration (sum of lines 5 and 9)
11	Total number of pneumococcal and influenza vaccine injections					11
	(from your records)
12	Cost per pneumococcal and influenza vaccine injection (line 10/line 11)					12
13	Number of pneumococcal and influenza vaccine injections administered					13
	to Program beneficiaries
14	Program cost of pneumococcal and influenza vaccine and its (their)					14
	administration (line 12 x line 13)
15	Total cost of pneumococcal and influenza vaccine and its (their) administration (sum of columns					15
	1 and 2, line 10) (transfer this amount to Worksheet M-3, line 2)
16	Total Program cost of pneumococcal and influenza vaccine and its (their) administration (sum					16
	of columns 1 and 2, line 14) (transfer this amount to Worksheet M-3, line 21)
FORM CMS 2552-10 (DRAFT)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4069)
40-662						Rev. 1

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Sheet 5: M5

DRAFT		FORM CMS-2552-10						4090 (Cont.)
ANALYSIS OF PAYMENTS TO HOSPITAL-BASED			PROVIDER NO.:			PERIOD	WORKSHEET M-5																								.
RHC/FQHC PROVIDER FOR SERVICES RENDERED						FROM__________
TO PROGRAM BENEFICIARIES			COMPONENT NO.:			TO_____________
Check Applicable Box:		[ ] RHC	[ ] FQHC
						Part B
	DESCRIPTION					1	2
						mm/dd/yyyy	Amount
1	Total interim payments paid to providers							1
2	Interim payments payable on individual bills, either							2
	submitted or to be submitted to the intermediary, for
	services rendered in the cost reporting periods. If
	none, write "NONE", or enter zero.
3	List separately each retroactive				.01			3.01
	lump sum adjustment amount			Program	.02			3.02
	based on subsequent revision of			to	.03			3.03
	the interim rate for the			Provider	.04			3.04
	cost reporting period. Also show				.05			3.05
	date of each payment.				.50			3.50
	If none, write "NONE",			Provider	.51			3.51
	or enter zero (1).			to	.52			3.52
				Program	.53			3.53
					.54			3.54
	Subtotal (sum of lines 3.01-3.49
	minus sum of lines 3.50-3.98)				.99			3.99
4	Total interim payments (sum of lines 1, 2, and 3.99)							4
	(transfer to Worksheet M-3, line 28)
	TO BE COMPLETED BY INTERMEDIARY
5	List separately each tentative			Program	.01			5.01
	settlement payment after desk review.			to	.02			5.02
	Also show date of each payment.			Provider	.03			5.03
	If none, write "NONE,"			Provider	.50			5.50
	or enter zero (1).			to	.51			5.51
				Program	.52			5.52
	Subtotal (sum of lines 5.01-5.49 minus
	sum of lines 5.50-5.98)				.99			5.99
6	Determine net settlement amount			Program
	(balance due) based on the cost			to
	report (see instructions). (1)			Provider	.01			6.01
				Provider
				to
				Program	.02			6.02
7	Total Medicare liability (see instructions)							7
8	Name of Contractor				Contractor Number			8
	Signature of Authorized Person				(Month, Day, Year)
(1) On lines 3, 5, and 6, where an amount is due provider to program,
	show the amount and date on which you agree to the amount of repayment,
	even though the total repayment is not accomplished until a later date.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4070)
Rev. 1								40-663