version 1.1 | |||||||||||
This report is required by law (42 USC 1395mm and 42 USC 1995I). | FORM APPROVED | ||||||||||
Failure to report can result in all interim payments made since | OMB NO. 0938-0165 | ||||||||||
the beginning of the cost reporting period being deemed overpayments. | |||||||||||
PREPAID HEALTH PLAN COST REPORT | WORKSHEET S | ||||||||||
GENERAL INFORMATION | |||||||||||
1 | Name and Address of Plan: | ||||||||||
2 | Reporting Period: | Plan Number: | |||||||||
From: | |||||||||||
H-xxxx | |||||||||||
To: | |||||||||||
3 | a. Type of Report: | b. Bill Processing Option: | c. Reimbursement Under: | ||||||||
[ ] Budget Forecast | Budget Forecast | Select Option | 1876 | ||||||||
[ ] | Interim Reports | ||||||||||
[x] | Final Cost Report | ||||||||||
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST | |||||||||||
REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW | |||||||||||
CERTIFICATION BY OFFICER OF THE PLAN | |||||||||||
I HEREBY CERTIFY that I have examined the accompanying Statement of Reimbursable Cost, the allocation of | |||||||||||
expenses and services, and the attached Worksheets for the period from 12/30/1899 to 12/30/1899 | |||||||||||
and that to the best of my knowledge and belief they are true and correct statements prepared from the books | |||||||||||
and records of the Plan in accordance with applicable instructions, except as noted. | |||||||||||
SIGNATURE (Officer or Administrator of the Plan) | DATE | ||||||||||
TITLE | PHONE NUMBER | ||||||||||
FORM CMS 276-08 (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 OMB control number. The valid | |||||||||||
OMB control number for this information collection is 0938-0165. The time required to complete this information is estimated to average as follows: (1) for HMOs/CMPs, | |||||||||||
24 hours to complete the budget forecast, 80 hours to complete the fourth quarter and final cost reports, and 12 hours to complete the first, 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 8 hours to complete the mid-year report. If you have any comments | |||||||||||
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HCFA, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland | |||||||||||
21244-1850 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503. |
PLAN STATISTICS | WORKSHEET D | ||||||||||||||
PART I | |||||||||||||||
Name of Plan: | 0 | Page 1 | |||||||||||||
Plan #: | H-xxxx | ||||||||||||||
PERIOD FROM: | 12/30/99 | ||||||||||||||
TO: | 12/30/99 | ||||||||||||||
BILLS | TOTAL | MEDICARE | MEDICARE | ||||||||||||
PROVIDER | RELATION- | PROCESSED | TOTAL | MEDICARE | PRIMARY | SECONDARY | |||||||||
NUMBER | SHIP (1) | BY (2) | DAYS | DAYS* | DAYS | DAYS | |||||||||
LIST OF PROVIDERS | |||||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | |||||||||
A. Hospitals & SNF's: | |||||||||||||||
1 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
2 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
3 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
4 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
5 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
6 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
7 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
8 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
9 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
10 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
11 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
12 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
13 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
14 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
15 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
16 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
17 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
18 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
19 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
20 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
21 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
22 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
23 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
24 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
25 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
26 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
27 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
28 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
29 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
30 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
31 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
32 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
33 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
34 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
35 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
36 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
37 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
38 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
39 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
40 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
41 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
42 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
43 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
44 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
45 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
46 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
47 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
48 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
49 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
50 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
51 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
52 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
* Note: Col 5 minus 6 & 7 = Non-covered | |||||||||||||||
(1) | (2) | ||||||||||||||
O - OWNED OR CONTROLLED | H - PROCESSED BY HCFA | ||||||||||||||
P - PURCHASED | P - PROCESSED BY PLAN | ||||||||||||||
FORM HCFA 276-99 | |||||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306) | |||||||||||||||
PLAN STATISTICS | WORKSHEET D | ||||||||||||||
PART 1 | |||||||||||||||
Name of Plan: | 0 | Page 2 | |||||||||||||
Plan #: | H-xxxx | ||||||||||||||
PERIOD FROM: | 12/30/99 | ||||||||||||||
TO: | 12/30/99 | ||||||||||||||
BILLS | TOTAL | MEDICARE | MEDICARE | ||||||||||||
PROVIDER | RELATION- | PROCESSED | TOTAL | MEDICARE | PRIMARY | SECONDARY | |||||||||
NUMBER | SHIP (1) | BY (2) | VISITS | VISITS* | VISITS | VISITS | |||||||||
LIST OF PROVIDERS | |||||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | |||||||||
B. HHA's: | |||||||||||||||
1 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
2 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
3 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
4 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
5 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
6 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
7 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
8 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
9 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
10 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
11 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
12 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
13 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
14 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
15 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
16 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
17 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
18 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
19 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
20 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
21 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
22 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
23 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
24 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
25 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
C. Other (Specify Name & Type): | |||||||||||||||
1 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
2 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
3 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
4 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
5 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
6 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
7 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
8 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
9 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
10 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
11 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
12 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
13 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
14 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
15 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
16 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
17 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
18 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
19 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
20 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
21 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
22 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
23 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
24 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
25 | ________________________________ | ________ | _ | _ | 0 | 0 | 0 | 0 | |||||||
* Note: Col 5 minus 6 & 7 = Non-covered | |||||||||||||||
(1) | (2) | ||||||||||||||
O - OWNED OR CONTROLLED | H - PROCESSED BY HCFA | ||||||||||||||
P - PURCHASED | P - PROCESSED BY PLAN | ||||||||||||||
FORM HCFA 276-99 | |||||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306) | |||||||||||||||
PLAN STATISTICS | WORKSHEET D | ||||||||||||||
PART II | |||||||||||||||
Name of Plan: | 0 | Page 1 | |||||||||||||
Plan #: | H-xxxx | ||||||||||||||
PERIOD FROM: | 12/30/99 | ||||||||||||||
TO: | 12/30/99 | ||||||||||||||
HOW | STATISTICS | ||||||||||||||
TYPE OF | PAYMENT | PHYSICIANS | TOTAL | MEDICARE | MEDICARE | ||||||||||
GROUP | MECHANISM | PAID | TOTAL | MEDICARE * | PRIMARY | SECONDARY | |||||||||
LIST OF SUPPLIERS | (1) | (2) | (2) | ||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | |||||||||
A. | Physician Services: | ||||||||||||||
1 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
2 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
3 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
4 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
5 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
6 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
7 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
8 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
9 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
10 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
11 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
12 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
13 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
14 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
15 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
16 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
17 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
18 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
19 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
20 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
21 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
22 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
23 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
24 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
25 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
26 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
27 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
28 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
29 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
30 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
31 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
32 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
33 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
34 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
35 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
36 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
37 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
38 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
39 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
40 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
41 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
42 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
43 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
44 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
45 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
46 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
47 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
48 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
(1) | (2) | ||||||||||||||
A - IPA | A - FEE-FOR-SERVICE | ||||||||||||||
B - GROUP PRACTICE | B - CAPITATION | ||||||||||||||
C - STAFF | C - OTHER-SPECIFY | ||||||||||||||
D - INDIVIDUAL PRACTITIONERS | |||||||||||||||
* | Note Col 5 minus 6 & 7 = Non-covered | ||||||||||||||
FORM HCFA 276-99 | |||||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306) | |||||||||||||||
PLAN STATISTICS | WORKSHEET D | ||||||||||||||
PART II | |||||||||||||||
Name of Plan: | 0 | Page 2 | |||||||||||||
Plan #: | H-xxxx | ||||||||||||||
PERIOD FROM: | 12/30/99 | ||||||||||||||
TO: | 12/30/99 | ||||||||||||||
HOW | STATISTICS | ||||||||||||||
TYPE OF | PAYMENT | PHYSICIANS | TOTAL | MEDICARE | MEDICARE | ||||||||||
GROUP | MECHANISM | PAID | TOTAL | MEDICARE* | PRIMARY | SECONDARY | |||||||||
LIST OF SUPPLIERS | (1) | (2) | (2) | ||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | |||||||||
B. Certified Labs: | |||||||||||||||
1 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
2 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
3 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
4 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
5 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
6 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
7 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
8 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
9 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
C. X-Ray Units: | |||||||||||||||
1 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
2 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
3 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
4 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
5 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
6 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
7 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
8 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
9 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
D. Others (Specify): | |||||||||||||||
1 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
2 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
3 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
4 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
5 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
6 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
7 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
8 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
9 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
10 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
11 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
12 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
13 | ____________________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
14 | ________________________________ | _ | _ | _ | 0 | 0 | 0 | 0 | |||||||
* Note: Col 5 minus 6 & 7 = Non-covered | |||||||||||||||
(1) | (1) | (2) | |||||||||||||
A - IPA | A - IPA | A - FEE-FOR-SERVICE | |||||||||||||
B - GROUP PRACTICE | B - GROUP PRACTICE | B - CAPITATION | |||||||||||||
C - STAFF | C - STAFF | C - OTHER-SPECIFY | |||||||||||||
D - INDIVIDUAL PRACTITIONERS | D - INDIVIDUAL PRACTITIONERS | ||||||||||||||
MEDICARE | MEDICARE | ||||||||||||||
E. MEMBERSHIP: | PART A | PART B | |||||||||||||
1 | 2 | ||||||||||||||
1 | Total Medicare Member Months....................................................................................................................................................................................………………. | ||||||||||||||
2 | Medicare Secondary Liable (Employer Groups) Member Months................................................................................................................................................................................ | ||||||||||||||
__________ | __________ | ||||||||||||||
3 | Medicare Primary Member Months (Line 1 minus Line 2)....................................................................................................................................................................................................... | 0 | 0 | ||||||||||||
4 | Ratio (Line 3 & Line 1).................................................................................................................................................................................................................................... | 0.0000 | 0.0000 | ||||||||||||
(3) | |||||||||||||||
Part B Member Months = Total Member Months | |||||||||||||||
FORM CMS 276-08 | |||||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2306) |
SUMMARY TRIAL BALANCE | WORKSHEET E | ||||||||||||
Name of Plan: | 0 | ||||||||||||
Plan #: | H-xxxx | ||||||||||||
PERIOD FROM: | 12/30/99 | ||||||||||||
TO: | 12/30/99 | ||||||||||||
A & G | TRANSFER | ||||||||||||
TRIAL | RECLASSIFI- | ADJUSTMENTS | ALLOWABLE | ALLOCATION | TOTALS | TO | |||||||
COST CENTER | BALANCE | CATIONS | COST | (WKST I, | WKST, LINE | ||||||||
(WKST F) | (WKST G) | (Col 1 thru 3) | Part I) | (Col 4 + Col 5) | |||||||||
1 | 2 | 3 | 4 | 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 | ||||||
3 | Skilled Nursing Facilities.......….… | 0 | 0 | 0 | 0 | 0 | J 52-61 | ||||||
4 | Home Health Agencies........….…. | 0 | 0 | 0 | 0 | 0 | J 66-74 | ||||||
5 | Clinics..........……….........….......… | 0 | 0 | 0 | 0 | 0 | K | 1 | ||||||
6 | Physician Groups.......................… | 0 | 0 | 0 | 0 | 0 | K | 2-6 | ||||||
7 | Individual Physicians.....…...….… | 0 | 0 | 0 | 0 | 0 | K | 7 | ||||||
8 | Certified Labs..................…......… | 0 | 0 | 0 | 0 | 0 | K | 8-10 | ||||||
9 | X-Ray Units....................……....… | 0 | 0 | 0 | 0 | 0 | K | 11-13 | ||||||
10 | ESRD Facilities.........................… | 0 | 0 | 0 | 0 | 0 | K | 14-15 | ||||||
11 | Durable Medical Equipment.......… | 0 | 0 | 0 | 0 | 0 | K | 16 | ||||||
12 | Ambulance...............……….......… | 0 | 0 | 0 | 0 | 0 | K | 17 | ||||||
13 | Pharmacy (Outpatient).......…...… | 0 | 0 | 0 | 0 | 0 | |||||||
13a | Pharmacy-Medicare Covered Rx | 0 | 0 | 0 | 0 | 0 | |||||||
14 | Emergency-Urgent Needed Svcs.. | 0 | 0 | 0 | 0 | 0 | K | 18 | ||||||
15 | Mental Health Services....….…… | 0 | 0 | 0 | 0 | 0 | K | 19&20 | ||||||
16 | DED+CO pd by MAC/Carrier/Inter | 0 | 0 | 0 | 0 | 0 | L | 18 | ||||||
17 | Other - Medicare Bad Debts...… | 0 | 0 | 0 | 0 | 0 | L | 9 | ||||||
18 | Other - Blood Deductible.....… | 0 | 0 | 0 | 0 | 0 | L | 12 | ||||||
19 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | J&K | | ||||||
20 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | J&K | | ||||||
21 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | J&K | | ||||||
22 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | J&K | | ||||||
23 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | J&K | | ||||||
_____________ | _____________ | _____________ | _____________ | _____________ | ___________ | ||||||||
24 | Subtotal (Sum Lines 1-23)................................................................................................. | 0 | 0 | 0 | 0 | 0 | 0 | ||||||
25 | Plan Administration..............…..… | 0 | 0 | 0 | 0 | 0 | L | 3 | ||||||
26 | Special Admin Costs................… | 0 | 0 | 0 | 0 | 0 | L | 6 | ||||||
_____________ | _____________ | _____________ | _____________ | _____________ | ___________ | ||||||||
27 | Subtotal: (Sum Lns 25+26)................................................................................................................................... | 0 | 0 | 0 | 0 | 0 | 0 | ||||||
28 | Admin & General Costs...…......… | 0 | 0 | 0 | 0 | 0 | |||||||
_____________ | _____________ | _____________ | _____________ | _____________ | ___________ | ||||||||
29 | Total Program Costs (24+27+28)...................................................................................................................... | 0 | 0 | 0 | 0 | 0 | 0 | ||||||
========= | ========= | ========= | ========= | ========= | ========= | ||||||||
FORM CMS 276-08 | |||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2307) | |||||||||||||
RECLASSIFICATIONS | WORKSHEET F | |||||||||
Name of Plan: | 0 | Page 1 | ||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | |||||||
TO: | 12/30/99 | |||||||||
CC LINE | AMOUNT (2) | |||||||||
CODE | COST CENTER | NUMBER | ||||||||
LINE | EXPLANATION OF RECLASSIFICATION ENTRY | (1) | (Worksheet E) | (WKST E) | INCREASES | (DECREASES) | ||||
1 | 2 | 3 | 4 | 5 | ||||||
1 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
2 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
3 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
4 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
5 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
6 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
7 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
8 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
9 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
10 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
11 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
12 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
13 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
14 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
15 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
16 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
17 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
18 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
19 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
20 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
21 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
22 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
23 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
24 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
25 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
26 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
27 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
28 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
29 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
30 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
31 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
32 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
33 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
34 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
35 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
36 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
37 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
38 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
39 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
40 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
41 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
42 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
43 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
44 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
45 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
46 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
47 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
48 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
49 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
50 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
___________ | ___________ | |||||||||
51 | Page total...................................................................................................................... | . | . | . | 0 | 0 | ||||
52 | a. Subtotal from Page 2................................................................................................................. | . | . | . | 0 | 0 | ||||
b. Subtotal from Page 3................................................................................................................. | . | . | . | 0 | 0 | |||||
c. Subtotal from Page 4................................................................................................................. | . | . | . | 0 | 0 | |||||
53 | Total Reclassifications (Col 4 must equal Col 5)...................................................................................................... | . | . | . | 0 | 0 | ||||
============ | ============ | |||||||||
(1) A Letter (A, B, etc.) Must Be Entered on Each Line to Identify Each Reclassification Entry. | Net, must be 0 | 0 | ||||||||
(2) Transfer to Worksheet E, Col. 2, lines as appropriate. | ============ | |||||||||
Summarized on Worksheet F, Page 3 | ||||||||||
FORM CMS 276-08 | ||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308) | ||||||||||
RECLASSIFICATIONS | WORKSHEET F | |||||||||
Name of Plan: | 0 | Page 2 | ||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | |||||||
TO: | 12/30/99 | |||||||||
CC LINE | AMOUNT | |||||||||
CODE | COST CENTER | NUMBER | ||||||||
LINE | EXPLANATION OF RECLASSIFICATION ENTRY | (1) | (Worksheet E) | (WKST E) | INCREASES | (DECREASES) | ||||
1 | 2 | 3 | 4 | 5 | ||||||
54 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
55 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
56 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
57 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
58 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
59 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
60 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
61 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
62 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
63 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
64 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
65 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
66 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
67 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
68 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
69 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
70 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
71 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
72 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
73 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
74 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
75 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
76 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
77 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
78 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
79 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
80 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
81 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
82 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
83 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
84 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
85 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
86 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
87 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
88 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
89 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
90 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
91 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
92 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
93 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
94 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
95 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
96 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
97 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
98 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
99 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
100 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
101 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
102 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
103 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
104 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
105 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
106 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
107 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
108 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
109 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
___________ | ___________ | |||||||||
110 | Total Page 2 (Col 4 must equal Col 5).............................................................. | . | . | . | 0 | 0 | ||||
============ | ============ | |||||||||
(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry. | Summarized on Worksheet F, Page 3 | |||||||||
(2) Transfer to Worksheet E, Col. 2, lines as appropriate. | ||||||||||
FORM CMS 276-08 | ||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308) | ||||||||||
RECLASSIFICATIONS | WORKSHEET F | |||||||||
Name of Plan: | 0 | Page 3 | ||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | |||||||
TO: | 12/30/99 | |||||||||
CC LINE | AMOUNT | |||||||||
CODE | COST CENTER | NUMBER | ||||||||
LINE | EXPLANATION OF RECLASSIFICATION ENTRY | (1) | (Worksheet E) | (WKST E) | INCREASES | (DECREASES) | ||||
1 | 2 | 3 | 4 | 5 | ||||||
111 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
112 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
113 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
114 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
115 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
116 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
117 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
118 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
119 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
120 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
121 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
122 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
123 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
124 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
125 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
126 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
127 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
128 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
129 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
130 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
131 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
132 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
133 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
134 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
135 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
136 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
137 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
138 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
139 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
140 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
141 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
142 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
143 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
144 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
145 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
146 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
147 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
148 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
149 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
150 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
151 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
152 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
153 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
154 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
155 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
156 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
157 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
158 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
159 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
160 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
161 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
162 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
163 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
164 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
165 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
166 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
___________ | ___________ | |||||||||
167 | Total Page 3 (Col 4 must equal Col 5).............................................................. | . | . | . | 0 | 0 | ||||
============ | ============ | |||||||||
(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry. | Summarized on Worksheet F, Page 3 | |||||||||
(2) Transfer to Worksheet E, Col. 2, lines as appropriate. | ||||||||||
FORM CMS 276-08 | ||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308) | ||||||||||
RECLASSIFICATIONS | WORKSHEET F | |||||||||
Name of Plan: | 0 | Page 4 | ||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | |||||||
TO: | 12/30/99 | |||||||||
CC LINE | AMOUNT | |||||||||
CODE | COST CENTER | NUMBER | ||||||||
LINE | EXPLANATION OF RECLASSIFICATION ENTRY | (1) | (Worksheet E) | (WKST E) | INCREASES | (DECREASES) | ||||
1 | 2 | 3 | 4 | 5 | ||||||
168 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
169 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
170 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
171 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
172 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
173 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
174 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
175 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
176 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
177 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
178 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
179 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
180 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
181 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
182 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
183 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
184 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
185 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
186 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
187 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
188 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
189 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
190 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
191 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
192 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
193 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
194 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
195 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
196 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
197 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
198 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
199 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
200 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
201 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
202 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
203 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
204 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
205 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
206 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
207 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
208 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
209 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
210 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
211 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
212 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
213 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
214 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
215 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
216 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
217 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
218 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
219 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
220 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
221 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
222 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
223 | ____________________________________________ | ______ | _________________________ | ___________ | 0 | 0 | ||||
___________ | ___________ | |||||||||
224 | Total Page 4 (Col 4 must equal Col 5).............................................................. | . | . | . | 0 | 0 | ||||
============ | ============ | |||||||||
(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry. | Summarized on Worksheet F, Page 3 | |||||||||
(2) Transfer to Worksheet E, Col. 2, lines as appropriate. | ||||||||||
FORM CMS 276-08 | ||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308) | ||||||||||
SUMMARY OF RECLASSIFICATIONS | WORKSHEET F | |||||||||
Name of Plan: | 0 | Page 5 | ||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | |||||||
TO: | 12/30/99 | |||||||||
SUMMARY OF RECLASSIFICATIONS | ||||||||||
INCREASES | (DECREASES) | NET | ||||||||
CC | (From Worksheet F, Pgs 1 & 2) | |||||||||
LINE | COST CENTER DESCRIPTIONS | 4 | 5 | 6 | ||||||
1 | Inpatient Hospitals ……………………………………………………………….. | ……………….. | . | 0 | 0 | 0 | ||||
2 | Outpatient Hospitals …………………………………………………………… | ………………… | . | 0 | 0 | 0 | ||||
3 | Skilled Nursing Facilities............................................................................................................................. | . | . | 0 | 0 | 0 | ||||
4 | Home Health Agencies.......................................................................................................................................... | . | . | 0 | 0 | 0 | ||||
5 | Clinics.......................................................................................................................................................... | . | . | 0 | 0 | 0 | ||||
6 | Physician Groups................................................................................................................................................ | . | . | 0 | 0 | 0 | ||||
7 | Individual Physicians........................................................................................................................................... | . | . | 0 | 0 | 0 | ||||
8 | Certified Labs.................................................................................................................................................. | . | . | 0 | 0 | 0 | ||||
9 | X-Ray Units................................................................................................................................................. | . | . | 0 | 0 | 0 | ||||
10 | ESRD Facilities........................................................................................................................ | . | . | 0 | 0 | 0 | ||||
11 | Durable Medical Equipment.............................................................................................................. | . | . | 0 | 0 | 0 | ||||
12 | Ambulances................................................................................................................................ | . | . | 0 | 0 | 0 | ||||
13 | Pharmacy (Outpatient).......................................................................................................................................... | . | . | 0 | 0 | 0 | ||||
13a | Pharmacy-Medicare Covered Rx............................................................................................................................... | . | . | 0 | 0 | 0 | ||||
14 | Emergency-Urgently Needed Svcs................................................................................................. | . | . | 0 | 0 | 0 | ||||
15 | Mental Health Services........................................................................................................................................... | . | . | 0 | 0 | 0 | ||||
16 | DED+CO pd by the MAC/Carriers/Intermediaries........................................................................................................... | . | . | 0 | 0 | 0 | ||||
17 | Other - Medicare Bad Debts...… | . | . | 0 | 0 | 0 | ||||
18 | Other - Blood Deductible.....… | . | . | 0 | 0 | 0 | ||||
19 | Other - (Specify)...…….......… | . | . | 0 | 0 | 0 | ||||
20 | Other - (Specify)...…….......… | . | . | 0 | 0 | 0 | ||||
21 | Other - (Specify)...…….......… | . | . | 0 | 0 | 0 | ||||
22 | Other - (Specify)...…….......… | . | . | 0 | 0 | 0 | ||||
23 | Other - (Specify)...…….......… | . | . | 0 | 0 | 0 | ||||
24 | ||||||||||
25 | Plan Administration.................................................................................................. | . | . | 0 | 0 | 0 | ||||
26 | Special Admin Costs.................................................................................... | . | . | 0 | 0 | 0 | ||||
27 | ||||||||||
28 | Admin & General Costs............................................................................. | . | . | 0 | 0 | 0 | ||||
____________ | ____________ | ____________ | ||||||||
29 | Total Reclassifications (Lines 1 thru 28) (Col 6 must net to zero)...................................... | . | 0 | 0 | 0 | |||||
============= | ============= | ============= | ||||||||
DIFFERENCES from total of pages 1 & 2 on page 1, Line 53…………………………………………………………………………….. | 0 | 0 | ||||||||
============= | ============= | Must net to zero. | ||||||||
To Worksheet E | ||||||||||
If these differences are not | Column 2 | |||||||||
zero there is a problem!! | ||||||||||
FORM CMS 276-08 | ||||||||||
(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: | 12/30/99 | ||||||
To: | 12/30/99 | AD181...AN240 | ||||||||
THIS IS A SUPPLEMENTAL WORKSHEET TO SUM UP RECLASSIFICATIONS BY COST CENTER | ||||||||||
CCNO | INCREASES | (DECREASES) | ||||||||
1 | IP Hosp | Err:504 | 0 | |||||||
CCNO | ||||||||||
2 | OP Hosp | Err:504 | 0 | |||||||
CCNO | ||||||||||
3 | SNF | Err:504 | 0 | |||||||
CCNO | ||||||||||
4 | HHA | Err:504 | 0 | |||||||
CCNO | ||||||||||
5 | Clinic | Err:504 | 0 | |||||||
CCNO | ||||||||||
6 | Physicians Groups | Err:504 | 0 | |||||||
CCNO | ||||||||||
7 | Ind Phy | Err:504 | 0 | |||||||
CCNO | ||||||||||
8 | Labs | Err:504 | 0 | |||||||
CCNO | ||||||||||
9 | Xray | Err:504 | 0 | |||||||
CCNO | ||||||||||
10 | ESRD | Err:504 | 0 | |||||||
CCNO | ||||||||||
11 | DME | Err:504 | 0 | |||||||
CCNO | ||||||||||
12 | Amb | Err:504 | 0 | |||||||
CCNO | ||||||||||
13 | Phrm | Err:504 | 0 | |||||||
CCNO | ||||||||||
14 | Emerg | Err:504 | 0 | |||||||
CCNO | ||||||||||
15 | Mental | Err:504 | 0 | |||||||
CCNO | ||||||||||
16 | Ded & Coins | Err:504 | 0 | |||||||
CCNO | ||||||||||
17 | Err:504 | 0 | ||||||||
CCNO | ||||||||||
18 | Other | Err:504 | 0 | |||||||
CCNO | ||||||||||
19 | Nonallowable | Err:504 | 0 | |||||||
CCNO | ||||||||||
21 | Plan Admin | Err:504 | 0 | |||||||
CCNO | ||||||||||
22 | Spec Admin | Err:504 | 0 | |||||||
CCNO | ||||||||||
24 | A&G | Err:504 | 0 | |||||||
------------ | ------------ | |||||||||
Err:504 | 0 | |||||||||
============= | ============= | |||||||||
ADJUSTMENTS TO EXPENSES | WORKSHEET G | ||||||||
Name of Plan: | 0 | PART I | |||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | Page 1 | |||||
TO: | 12/30/99 | ||||||||
BASIS | Amount (2) | CC LINE | |||||||
CC | FOR | (To Wkst E as | COST CENTER | NUMBER | |||||
LINE | DESCRIPTIONS | ADJ (1) | appropriate) | (Wkst E) | (Wkst E) | ||||
1 | 2 | 3 | 4 | ||||||
1 | Investment income on commingled restricted & unrestricted funds....................................................... | _ | 0 | _____________________________ | __ | ||||
2 | Trade, quantity, time & other discounts on purchases....................................................... | _ | 0 | _____________________________ | __ | ||||
3 | Rebates & refunds of expenses...................................................................................................... | _ | 0 | _____________________________ | __ | ||||
4 | Rental of space by suppliers................................................................................................. | _ | 0 | _____________________________ | __ | ||||
5 | Telephone service..................................................................................................................... | _ | 0 | _____________________________ | __ | ||||
6 | Television & radio service.................................................................................................... | _ | 0 | _____________________________ | __ | ||||
7 | Parking lot................................................................................................................................... | _ | 0 | _____________________________ | __ | ||||
8 | Home Office Costs (Attach copy of Home Office Cost Statemenmt).......... | _ | 0 | _____________________________ | __ | ||||
9 | Sale of scrap, waste, etc...................................................................................................... | _ | 0 | _____________________________ | __ | ||||
10 | Adj. resulting from transactions with related organizations (3)..................................... | _ | 0 | _____________________________ | __ | ||||
10a | Adj. resulting from transactions with related organizations (3)..................................... | _ | 0 | _____________________________ | __ | ||||
10b | Adj. resulting from transactions with related organizations (3)..................................... | _ | 0 | _____________________________ | __ | ||||
10c | Adj. resulting from transactions with related organizations (3)..................................... | _ | 0 | _____________________________ | __ | ||||
11 | Laundry and linen service......................................................................................................... | _ | 0 | _____________________________ | __ | ||||
12 | Cafeteria - employees, guests, etc................................................................................... | _ | 0 | _____________________________ | __ | ||||
13 | Rental of living quarters to employees and others..................................................... | _ | 0 | _____________________________ | __ | ||||
14 | Sale of medical and surgical supplies to other than patients............................... | _ | 0 | _____________________________ | __ | ||||
15 | Sale of drugs to other than patients............................................................................... | _ | 0 | _____________________________ | __ | ||||
16 | Sale of medical records and abstracts.......................................................................... | _ | 0 | _____________________________ | __ | ||||
17 | Nursing school (tuition, fees, uniforms, finance charges)........................................ | _ | 0 | _____________________________ | __ | ||||
18 | Income from vending machines.......................................................................................... | _ | 0 | _____________________________ | __ | ||||
19 | Income from imposition of interest and finance charges....................................... | _ | 0 | _____________________________ | __ | ||||
20 | Payments - Physicians' assumption of operating costs........................................ | _ | 0 | _____________________________ | __ | ||||
21 | Undistributed risk pool........................................................................................................ | _ | 0 | _____________________________ | __ | ||||
22 | Charges in excess of MAC screens............................................................................ | _ | 0 | _____________________________ | __ | ||||
23 | Part B coinsurance on services paid by CMS's MAC/Carriers......................................... | _ | 0 | _____________________________ | __ | ||||
24 | Part B coinsurance on services paid by CMS's MAC/Intermediaries.......................................... | _ | 0 | _____________________________ | __ | ||||
25 | Adjustment for physicial therapy costs in excess of limit (4)...................................................................................................................... | _ | 0 | _____________________________ | __ | ||||
26 | Reinsurance........................................................................................................................... | _ | 0 | _____________________________ | __ | ||||
27 | Depreciation in excess of limits (Attach worksheet) ........................................................................................................ | _ | 0 | _____________________________ | __ | ||||
28 | Noncovered purchased service (Attach worksheet)................................................................................................................... | _ | 0 | _____________________________ | __ | ||||
29 | Medicare Bad Debts | _ | 0 | _____________________________ | __ | ||||
30 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
31 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
32 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
33 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
34 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
35 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
36 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
37 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
38 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
39 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
40 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
41 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
42 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
43 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
44 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
45 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
46 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
47 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
48 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
49 | .................................................................................................................................................................. | _ | 0 | _____________________________ | __ | ||||
____________ | |||||||||
50 | Page total...................................................... | . | . | 0 | |||||
51 | a. Subtotal from Page 2........................................... | . | . | 0 | |||||
b. Subtotal from Page 3........................................... | . | . | 0 | ||||||
c. Subtotal from Page 4........................................... | . | . | 0 | ||||||
____________ | |||||||||
52 | TOTAL ADJUSTMENTS................................................. | . | . | 0 | |||||
============ | |||||||||
(1) | 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 276-08 | |||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1) | |||||||||
ADJUSTMENTS TO EXPENSES | WORKSHEET G | ||||||||
Name of Plan: | 0 | ||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | PART I | |||||
TO: | 12/30/99 | PAGE 2 | |||||||
BASIS | Amount | CC LINE | |||||||
CC | FOR | (To Wkst E as | COST CENTER | NUMBER | |||||
LINE | DESCRIPTIONS | ADJ(1) | appropriate) | (Wkst E) | (Wkst E) | ||||
1 | 2 | 3 | 4 | ||||||
53 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
54 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
55 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
56 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
57 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
58 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
59 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
60 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
61 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
62 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
63 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
64 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
65 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
66 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
67 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
68 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
69 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
70 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
71 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
72 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
73 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
74 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
75 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
76 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
77 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
78 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
79 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
80 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
81 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
82 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
83 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
84 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
85 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
86 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
87 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
88 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
89 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
90 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
91 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
92 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
93 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
94 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
95 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
96 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
97 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
98 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
99 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
100 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
101 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
102 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
103 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
104 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
105 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
106 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
107 | Page total (to Page 1, Line 51a)...................................................................................... | . | . | 0 | |||||
============ | |||||||||
(1) | Basis for Adjustment: | ||||||||
| | A = Cost - including applicable overhead, if determinable. | ||||||||
| | B = Amounts Received - if cost cannot be determined. | ||||||||
FORM CMS 276-08 | |||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1) | |||||||||
ADJUSTMENTS TO EXPENSES | WORKSHEET G | ||||||||
Name of Plan: | 0 | ||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | PART I | |||||
TO: | 12/30/99 | PAGE 3 | |||||||
BASIS | Amount | CC LINE | |||||||
CC | FOR | (To Wkst E as | COST CENTER | NUMBER | |||||
LINE | DESCRIPTIONS | ADJ(1) | appropriate) | (Wkst E) | (Wkst E) | ||||
1 | 2 | 3 | 4 | ||||||
108 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
109 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
110 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
111 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
112 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
113 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
114 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
115 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
116 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
117 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
118 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
119 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
120 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
121 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
122 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
123 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
124 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
125 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
126 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
127 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
128 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
129 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
130 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
131 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
132 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
133 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
134 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
135 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
136 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
137 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
138 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
139 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
140 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
141 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
142 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
143 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
144 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
145 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
146 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
147 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
148 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
149 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
150 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
151 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
152 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
153 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
154 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
155 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
156 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
157 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
158 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
159 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
160 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
161 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
162 | Page total (to Page 1, Line 51b)...................................................................................... | . | . | 0 | |||||
============ | |||||||||
(1) | Basis for Adjustment: | ||||||||
| | A = Cost - including applicable overhead, if determinable. | ||||||||
| | B = Amounts Received - if cost cannot be determined. | ||||||||
FORM CMS 276-08 | |||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1) | |||||||||
ADJUSTMENTS TO EXPENSES | WORKSHEET G | ||||||||
Name of Plan: | 0 | ||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | PART I | |||||
TO: | 12/30/99 | PAGE 4 | |||||||
BASIS | Amount | CC LINE | |||||||
CC | FOR | (To Wkst E as | COST CENTER | NUMBER | |||||
LINE | DESCRIPTIONS | ADJ(1) | appropriate) | (Wkst E) | (Wkst E) | ||||
1 | 2 | 3 | 4 | ||||||
163 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
164 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
165 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
166 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
167 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
168 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
169 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
170 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
171 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
172 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
173 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
174 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
175 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
176 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
177 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
178 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
179 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
180 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
181 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
182 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
183 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
184 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
185 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
186 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
187 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
188 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
189 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
190 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
191 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
192 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
193 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
194 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
195 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
196 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
197 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
198 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
199 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
200 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
201 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
202 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
203 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
204 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
205 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
206 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
207 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
208 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
209 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
210 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
211 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
212 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
213 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
214 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
215 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
216 | _________________________________________________ | _ | 0 | _____________________________ | __ | ||||
217 | Page total (to Page 1, Line 51c)...................................................................................... | . | . | 0 | |||||
============ | |||||||||
(1) | Basis for Adjustment: | ||||||||
| | A = Cost - including applicable overhead, if determinable. | ||||||||
| | B = Amounts Received - if cost cannot be determined. | ||||||||
FORM CMS 276-08 | |||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1) | |||||||||
SUMMARY OF ADJUSTMENTS TO EXPENSES | WORKSHEET G | ||||||||
Name of Plan: | 0 | PART II | |||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | ||||||
TO: | 12/30/99 | ||||||||
LINE | Amount | TRANSFER TO | CC LINE | ||||||
CC | NUMBERS | (To Wkst E as | WORKSHEET E | NUMBER | |||||
LINE | COST CENTER DESCRIPTIONS | FROM | appropriate) | LINE # AS SHOWN | Wkst E | ||||
PART I | |||||||||
1 | 2 | 3 | 4 | ||||||
1 | Inpatient Hospitals……………………………… | . | ___________ | 0 | 1 | ||||
2 | Outpatient Hospitals………………………….. | . | ___________ | 0 | 2 | ||||
3 | Skilled Nursing Facilities................................. | . | ___________ | 0 | 3 | ||||
4 | Home Health Agencies...................................... | . | ___________ | 0 | 4 | ||||
5 | Clinics.............................................................................. | . | ___________ | 0 | 5 | ||||
6 | Physician Groups....................................... | . | ___________ | 0 | 6 | ||||
7 | Individual Physicians..................................... | . | ___________ | 0 | 7 | ||||
8 | Certified Labs............................................... | . | ___________ | 0 | 8 | ||||
9 | X-Ray Units................................................... | . | ___________ | 0 | 9 | ||||
10 | ESRD Facilities........................................................................................................................ | . | ___________ | 0 | 10 | ||||
11 | Durable Medical Equipment.............................................................................................................. | . | ___________ | 0 | 11 | ||||
12 | Ambulances................................................... | . | ___________ | 0 | 12 | ||||
13 | Pharmacy (Outpatient).................................... | . | ___________ | 0 | 13 | ||||
13a | Pharmacy-Medicare Covered Rx....... | . | ___________ | 0 | 13 | ||||
14 | Emergency-Urgently Needed Svcs................................................................................................. | . | ___________ | 0 | 14 | ||||
15 | Mental Health Services............................ | . | ___________ | 0 | 15 | ||||
16 | DED+CO on Svcs pd by the CMS MAC…………………………................................................... | ___________ | 0 | 16 | |||||
17 | Other - Medicare Bad Debts...… | . | ___________ | 0 | 17 | ||||
18 | Other - Blood Deductible.....… | . | ___________ | 0 | 18 | ||||
19 | Other - (Specify)...…….......… | . | ___________ | 0 | 19 | ||||
20 | Other - (Specify)...…….......… | . | ___________ | 0 | 20 | ||||
21 | Other - (Specify)...…….......… | . | ___________ | 0 | 21 | ||||
22 | Other - (Specify)...…….......… | . | ___________ | 0 | 22 | ||||
23 | Other - (Specify)...…….......… | . | ___________ | 0 | 23 | ||||
24 | 24 | ||||||||
25 | Plan Administration...................................... | . | ___________ | 0 | 25 | ||||
26 | Special Admin Costs..................................... | . | ___________ | 0 | 26 | ||||
27 | 27 | ||||||||
28 | Admin & General Costs...................................................................... | . | ___________ | 0 | 28 | ||||
____________ | |||||||||
29 | Total Adjustments (Lines 1 thru 28)............................................................................................................. | 0 | 29 | ||||||
============ | |||||||||
FORM CMS 276-08 | |||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.2) | |||||||||
STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS | WORKSHEET H | ||||||||||
Name of Plan: | 0 | PERIOD FROM: | 12/30/99 | ||||||||
Plan #: | H-xxxx | TO: | 12/30/99 | ||||||||
A. | Are there any costs included on Worksheet E which resulted from transactions with related organizations? | ||||||||||
Select | (If "YES", complete Parts B and C.) | ||||||||||
B. | Costs incurred and adjustments required as a result of transactions with related organizations. | ||||||||||
AMOUNT | NET | ||||||||||
ALLOWABLE | ADJUSTMENTS (1) | ||||||||||
LINE | COST CENTER (Worksheet E) | EXPENSE ITEMS | AMOUNT | IN COST | (5) | ||||||
(Wkst E) | 1 | 2 | 3 | 4 | (5 = 4 - 3) | ||||||
1 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
2 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
3 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
4 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
5 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
6 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
7 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
8 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
9 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
10 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
11 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
12 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
13 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
14 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
15 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
16 | _____ | ___________________________ | ___________________________ | 0 | 0 | 0 | |||||
_____________ | _____________ | _____________ | |||||||||
17 | TOTALS.........................................................................…………………………………………………………………………….. | 0 | 0 | 0 | |||||||
============= | ============= | ============= | |||||||||
(1) Transfer the sum of this column to Worksheet G, Part I, Column 2 line 10 | |||||||||||
C. | 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. | |||||||||||
----------RELATED ORGANIZATION(S)-------- | |||||||||||
SYMBOL (2) | NAME OF INDIVIDUAL | OWNERSHIP OF PLAN | ORGANIZATION | OWNERSHIP | TYPE OF | ||||||
NAME | % | BUSINESS | |||||||||
1 | 2 | 3 | 4 | 5 | 6 | ||||||
1 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
2 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
3 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
4 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
5 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
6 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
7 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
8 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
9 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
10 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
11 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
12 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
13 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
14 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
15 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
16 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
17 | _ | ________________________________ | _______________________________ | ______________ | 0.00% | _____________ | |||||
(2) | Use the following symbols to indicate the interrelationship of the Plan to related organizations: | ||||||||||
A | Individual has financial interest (stockholder, partner, etc) in both related organization and in the Plan. | ||||||||||
B | Corporation, partnership, or other organization has financial interest in the Plan. | ||||||||||
D | Director, officer, administrator or key person of the Plan or relative of such person has financial interest | ||||||||||
in related organization. | |||||||||||
E | Individual is director, officer, administrator, or key person of the Plan and related organization. | ||||||||||
F | Director, officer, administrator, or key person of related organization or relative of such person has | ||||||||||
financial interest in the Plan. | |||||||||||
G | Other (financial or nonfinancial) specify. | ||||||||||
FORM CMS 276-08 | |||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2310) | |||||||||||
ADMINISTRATIVE AND GENERAL COST ALLOCATION | WORKSHEET I | ||||||||||||||
Name of Plan: | 0 | PART I | |||||||||||||
Plan #: | #REF! | H-xxxx | PERIOD FROM: | 12/30/99 | |||||||||||
TO: | 12/30/99 | ||||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | |||||||||
EMPLOYEE | STATISTICS | PHARMACY | OTHER | TOTALS | POOLED | TOTALS | |||||||||
BENEFITS | & DATA | & | (SPECIFY) | (Sum Cols | ADMIN & GEN | (Col 5 + | |||||||||
COST CENTER | (Salaries) | PROCESSING | SUPPLIES | 1 Thru 4) | COSTS | Col 6) | |||||||||
(Time Spent) | (Cost Req's) | ||||||||||||||
1 | Inpatient Hospitals ………………. | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
2 | Outpatient Hospitals ……………. | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
3 | Skilled Nursing Facilities.......….… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
4 | Home Health Agencies........….…. | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
5 | Clinics..........……….........….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
6 | Physician Groups.......................… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
7 | Individual Physicians.....…...….… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
8 | Certified Labs..................…......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
9 | X-Ray Units....................……....… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
10 | ESRD Facilities.........................… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
11 | Durable Medical Equipment.......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
12 | Ambulance...............……….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
13 | Pharmacy (Outpatient).......…...… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
13a | Pharmacy-Medicare Covered Rx | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
14 | Emergency-Urgent Needed Svcs.. | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
15 | Mental Health Services....….…… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
16 | DED+CO pd by MAC/Carrier/Inter | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
17 | Other - Medicare Bad Debts...… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
18 | Other - Blood Deductible.....… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
19 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
20 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
21 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
22 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
23 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
___________ | ___________ | ___________ | ___________ | ___________ | ___________ | ___________ | |||||||||
24 | Subtotal (Sum of Lines 1 thru 23)...........… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
25 | Plan Administration.................................... | 0 | 0 | 0 | |||||||||||
26 | Special Administrative Costs............… | 0 | 0 | 0 | |||||||||||
___________ | ___________ | ___________ | ___________ | ___________ | ___________ | ___________ | |||||||||
27 | Subtotal (Sum of 25 and 26) ................... | 0 | 0 | 0 | |||||||||||
___________ | ___________ | ___________ | ___________ | ___________ | ___________ | ___________ | |||||||||
Total (Sum of Lines 24 & 27)........................... | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||||||||
28 | Admin & General Costs............................... | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
___________ | ___________ | ___________ | ___________ | ___________ | ___________ | ___________ | |||||||||
29 | Net A&G Costs (Lines 24+27+28).................................... | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
=========== | =========== | ====== | =========== | ============ | ============ | =========== | =========== | ||||||||
30 | Computation - Fr Worksheet, Col........ | Fr Wkst I, | Fr Wkst I, | Fr Wkst I, | Fr Wkst I, | Fr Wkst I, | |||||||||
Pt II, Col 1 | Pt II, Col 2 | Pt II, Col 3 | Pt II, Col 4 | Pt II, Col 7 | |||||||||||
31 | To Worksheet, Column........................ | To Wkst I, | To Wkst E, | ||||||||||||
Pt II, Col 6 | Col 5 | ||||||||||||||
FORM CMS 276-08 | |||||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2311.1) | |||||||||||||||
ADMINISTRATIVE AND GENERAL STATISTICS | WORKSHEET I | ||||||||||||||
Name of Plan: | #REF! | 0 | PART II | ||||||||||||
Plan #: | #REF! | H-xxxx | PERIOD FROM: | 12/30/99 | |||||||||||
TO: | 12/30/99 | ||||||||||||||
EMPLOYEE | STATISTICS | PHARMACY | OTHER | TOTALS | TOTALS | POOLED | |||||||||
BENEFITS | & DATA | & | (SPECIFY) | (From | (From | ADMIN & GEN | |||||||||
COST CENTER | (Salaries) | PROCESSING | SUPPLIES | Worksheet E | Wkst I, | STATS | |||||||||
(Time Spent) | (Cost Req's) | Column 4) | Pt I, Col 5) | (Cols 5+6) | |||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | |||||||||
1 | Inpatient Hospitals ………………. | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
2 | Outpatient Hospitals ……………. | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
3 | Skilled Nursing Facilities.......….… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
4 | Home Health Agencies........….…. | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
5 | Clinics..........……….........….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
6 | Physician Groups.......................… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
7 | Individual Physicians.....…...….… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
8 | Certified Labs..................…......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
9 | X-Ray Units....................……....… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
10 | ESRD Facilities.........................… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
11 | Durable Medical Equipment.......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
12 | Ambulance...............……….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
13 | Pharmacy (Outpatient).......…...… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
13a | Pharmacy-Medicare Covered Rx | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
14 | Emergency-Urgent Needed Svcs.. | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
15 | Mental Health Services....….…… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
16 | DED+CO pd by MAC/Carrier/Inter | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
17 | Other - Medicare Bad Debts...… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
18 | Other - Blood Deductible.....… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
19 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
20 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
21 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
22 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
23 | Other - (Specify)...…….......… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
___________ | ___________ | ___________ | ___________ | ___________ | ___________ | ___________ | |||||||||
24 | Subtotal (Sum of Lines 1 thru 23)...........… | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
25 | Plan Administration.................................... | 0 | |||||||||||||
26 | Special Administrative Costs............… | 0 | |||||||||||||
___________ | ___________ | ___________ | ___________ | ||||||||||||
27 | Subtotal (Sum of 25 and 26) ................... | 0 | |||||||||||||
___________ | ___________ | ___________ | ___________ | ___________ | ___________ | ___________ | |||||||||
Total (Sum of Lines 24 & 27).................... | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||||||||
28 | Administrative & General Costs.......................................... | ||||||||||||||
___________ | ___________ | ___________ | ___________ | ___________ | ___________ | ___________ | |||||||||
29 | TOTAL STATS (Sum of 24 & 27)........... | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||
=========== | ============ | ============ | ============= | ============= | ============= | ============ | |||||||||
Col 5 - (1+2+3+4) | |||||||||||||||
30 | COSTS TO BE ALLOCATED..................... | 0 | 0 | 0 | 0 | 0 | 0 | ||||||||
(Input here) | |||||||||||||||
31 | UNIT COST MULTIPLIER.......................................... | 0.000000 | 0.000000 | 0.00000 | 0.000000 | 0.000000 | |||||||||
(Line 30 / Line 29) | |||||||||||||||
FORM CMS 276-08 | |||||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2311.1) |
SUMMARY OF PROVIDER COSTS | WORKSHEET J | ||||||||||||||||
PAGE 1 | |||||||||||||||||
Name of Plan: | 0 | ||||||||||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | ||||||||||||||
TO: | 12/30/99 | ||||||||||||||||
1 | 2 | 3 | 4 | 5 | |||||||||||||
PART A | PART B | ||||||||||||||||
PROVIDERS | PROVIDER | REIMBURSABLE | DEDUCTIBLE + | REIMBURSABLE | DEDUCTIBLE | ||||||||||||
NUMBER | PART A | COINSURANCE | PART B | ||||||||||||||
1 | Medicare Memb Mos (WS D, Pt II, Sec E, Ln 3) | 0 | 0 | 0 | 0 | ||||||||||||
========= | ========= | ========= | ========= | ||||||||||||||
2 | Hospitals | ||||||||||||||||
3 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
4 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
5 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
6 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
7 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
8 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
9 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
10 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
11 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
12 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
13 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
14 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
15 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
16 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
17 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
18 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
19 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
20 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
21 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
22 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
23 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
24 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
25 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
26 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
27 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
28 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
29 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
30 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
31 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
32 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
33 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
34 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
35 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
36 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
37 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
38 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
39 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
40 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
41 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
42 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
43 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
44 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
45 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
46 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
47 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
48 | Total Hospital ……………………………………………………………………………………… | 0 | 0 | 0 | 0 | 0 | |||||||||||
========= | ========= | ========= | ========= | ||||||||||||||
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 276-08 | |||||||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2312) | |||||||||||||||||
SUMMARY OF PROVIDER COSTS | WORKSHEET J | ||||||||||||||||
(Continued) | |||||||||||||||||
PAGE 2 | |||||||||||||||||
Name of Plan: | 0 | ||||||||||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | ||||||||||||||
TO: | 12/30/99 | ||||||||||||||||
1 | 2 | 3 | 4 | 5 | |||||||||||||
PART A | PART B | ||||||||||||||||
PROVIDERS | PROVIDER | REIMBURSABLE | DEDUCTIBLE+ | REIMBURSABLE | DEDUCTIBLE | ||||||||||||
NUMBER | PART A | COINSURANCE | PART B | ||||||||||||||
51 | Skilled Nursing Facilities: | ||||||||||||||||
52 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
53 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
54 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
55 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
56 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
57 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
58 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
59 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
60 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
61 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
62 | Total (Sum of Lines 52 thru 61)……………………………………………………………… | 0 | 0 | 0 | 0 | ||||||||||||
========= | ========= | ========= | ========= | ||||||||||||||
63 | Cost PMPM (Line 63 / Line 1)...................................................................... | 0.0000 | 0.0000 | 0.0000 | 0.0000 | ||||||||||||
64 | Enter on Wkst, Col, Line................................................................................. | M, 2, 2 | M, 2, 2&8 | M, 3, 2 | M, 3, 2 | ||||||||||||
65 | Home Health Agencies: | ||||||||||||||||
66 | __________________________________ | ____________ | |||||||||||||||
67 | __________________________________ | ____________ | |||||||||||||||
68 | __________________________________ | ____________ | |||||||||||||||
69 | __________________________________ | ____________ | |||||||||||||||
70 | __________________________________ | ____________ | |||||||||||||||
71 | __________________________________ | ____________ | |||||||||||||||
72 | __________________________________ | ____________ | |||||||||||||||
73 | __________________________________ | ____________ | |||||||||||||||
74 | __________________________________ | ____________ | |||||||||||||||
75 | Total (Sum of Lines 68 thru 76)……………………………………………………………… | ||||||||||||||||
76 | Cost PMPM (Line 78 / Line 1)...................................................................... | ||||||||||||||||
77 | Enter on Wkst, Col, Line................................................................................. | ||||||||||||||||
78 | Other Providers (Specify Type): | ||||||||||||||||
79 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
80 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
81 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
82 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
83 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
84 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
85 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
86 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
87 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
88 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
89 | __________________________________ | ____________ | 0 | 0 | 0 | 0 | |||||||||||
_____________ | _____________ | _____________ | _____________ | ||||||||||||||
90 | Total (Sum Lines 82 thru 92).......................................................................... | 0 | 0 | 0 | 0 | ||||||||||||
========= | ========= | ========= | ======== | ||||||||||||||
91 | Cost PMPM (Line 93 / Line 1)...................................................................... | 0.0000 | 0.0000 | 0.0000 | 0.0000 | ||||||||||||
92 | Enter on Wkst, Col, Line................................................................................ | M, 2, 4 | M, 2, 4&8 | M, 3, 4 | M, 3, 4 | ||||||||||||
FORM CMS 276-08 | |||||||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2312) |
SUMMARY APPORTIONMENT OF NON-PROVIDER COSTS | |||||||||||||||||
Name of Plan: | 0 | ||||||||||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | ||||||||||||||
TO: | 12/30/99 | ||||||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | |||||||||||
COVERED MED | SUBPART E | RATIO | TOTAL COSTS | MEDICARE | |||||||||||||
COST CENTERS | STATISTIC | TOTAL | ENROLLEE | LIMITS IF | Col 3 or Col | (Fr Wkst E | COSTS | ||||||||||
USED | STATISTICS | STATISTICS | APPLICABLE | 4 / Col 2 | Col 6) | Col 5 X Col 6 | |||||||||||
1 | Clinics (furnished directly)............................................. | ___________ | 0 | 0 | 0.00000 | 0 | |||||||||||
2 | Physician Groups: | ||||||||||||||||
3 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | |||||||||
4 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | |||||||||
5 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
6 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
7 | Individual Physicians....................................................... | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
8 | Certified Labs.................................................................... | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
9 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
10 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
11 | X-Ray Units......................................................................... | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
12 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
13 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
14 | ESRD Facilities................................................................ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
15 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
16 | Durable Medical Equipment......................................... | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
17 | Ambulance.......................................................................... | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
18 | Emergency-Urgently Needed Svcs............................ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
19 | Professional Component - Mental Health…….. | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
20 | Mental Health Svcs - Non-Prof Component…… | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
21 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
22 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
23 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
24 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
25 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
26 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
27 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
28 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
29 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
30 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
31 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
32 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
33 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
34 | _________________________________ | ___________ | 0 | 0 | 0 | 0.00000 | 0 | 0 | 0 | ||||||||
35 | Total (Sum Lines 1 thru 34)............................................................................. | 0 | 0 | ||||||||||||||
========= | |||||||||||||||||
36 | Member Months - Part B (W/S D, Part II, Pg 2, Pt E, Col 2, Line 1).......................................................................................................... | 0 | |||||||||||||||
========= | |||||||||||||||||
37 | Cost PMPM (Line 51 / Line 52)..............................................................….. | 0.0000 | |||||||||||||||
38 | Enter on Worksheet, Col, Line..................................................................…. | M, 3, 5 | |||||||||||||||
FORM CMS 276-08 | |||||||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2313) |
SUMMARY OF MISCELLANEOUS ITEMS | WORKSHEET L | ||||||||||||||||
Name of Plan: | 0 | ||||||||||||||||
Plan #: | H-xxxx | PERIOD FROM: | 12/30/99 | ||||||||||||||
TO: | 12/30/99 | ||||||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | ||||||||||||
NON- | |||||||||||||||||
DESCRIPTION | MEDICARE | MEDICARE | TOTAL | MEDICARE | ENTER ON | ||||||||||||
PART A | PART B | Col 1+Col 2 | Col 5 - Col 2 | TOTAL | WKST LINE | ||||||||||||
1 | Member Months (Wkst D, Pt II, Pg 2, Pt E, Col 1 and 2, Ln 1) | 0 | 0 | 0 | |||||||||||||
2 | |||||||||||||||||
3 | Plan Administration (Wkst E, Col 6, Ln 21)................................................ | 0 | |||||||||||||||
4 | Cost PMPM (Line 3 / Line 1).......................................................................... | 0.0000 | 0.0000 | 0.0000 | M 6 | ||||||||||||
5 | |||||||||||||||||
6 | Special Admin Costs (Wkst E, Col 6, Ln 22)............................................ | 0 | |||||||||||||||
7 | Cost PMPM (Line 6 / Line 1).......................................................................... | 0.0000 | M 15 | ||||||||||||||
8 | |||||||||||||||||
9 | Allowable Medicare Bad Debts (Wkst E, Col 6, Line 17)..................... | 0 | |||||||||||||||
10 | Cost PMPM (Line 9 / Line 1).......................................................................... | 0.0000 | 0.0000 | 0.0000 | M 16 | ||||||||||||
11 | |||||||||||||||||
12 | Part B Blood Deductible................................................................................. | 0 | |||||||||||||||
13 | Cost PMPM (Line 12 / Line 1)......................................................................... | 0.0000 | 0.0000 | M 10 | |||||||||||||
14 | |||||||||||||||||
15 | Third Party Insurer Revenue (see Instructions)...................................... | 0 | |||||||||||||||
16 | Cost PMPM (Line 15 / Line 1)........................................................................ | 0.0000 | 0.0000 | 0.0000 | M 18 | ||||||||||||
17 | |||||||||||||||||
18 | Part B Ded on Svcs Pd by CMS Carrier (Wkst E, Col 9, Ln 16)...... | 0 | 0 | ||||||||||||||
19 | Cost PMPM (Line 18 / Line 1)......................................................................... | 0.0000 | 0.0000 | M 5a | |||||||||||||
20 | |||||||||||||||||
21 | Pro Component of Mental Hlth Svcs (W/S K, Line 19)........................ | 0 | 0 | ||||||||||||||
22 | Line 21 times 37.5%............................................................................................. | 0 | 0 | ||||||||||||||
23 | Cost PMPM (Line 22 / Line 1)........................................................................ | 0.0000 | 0.0000 | M 11 | |||||||||||||
FORM CMS 276-08 | |||||||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2314) |
SETTLEMENT SHEET | Name of Plan: | PERIOD FROM: | 12/30/99 | WORKSHEET M | ||||||||
Plan #: H-xxxx | TO: | 12/30/99 | ||||||||||
DESCRIPTION | FROM | MEDICARE | MEDICARE | TOTAL | ||||||||
WKST | PART A | PART B | Col 2 + Col 3 | |||||||||
1 | 2 | 3 | 4 | |||||||||
1 | Hospital Costs…………………………………………………………………………………………………………......... | J | 0.0000 | 0.0000 | 0.0000 | |||||||
2 | Skilled Nursing Facility Costs……………………………………………………………………………………….. | J | 0.0000 | 0.0000 | 0.0000 | |||||||
3 | Home Health Agency Costs…………………………………………………………………………………………. | J | 0.0000 | 0.0000 | 0.0000 | |||||||
4 | Other Provider's Costs …………………………………………………………………………………………………. | J | 0.0000 | 0.0000 | 0.0000 | |||||||
5 | Nonprovider Costs…………………………………………………………………………………………………………. | K | 0.0000 | 0.0000 | ||||||||
5a | Part B Deduct on Svcs Pd by CMS' Carriers/Intermediaries/MAC ………..……………………………………………………….. | L | 0.0000 | 0.0000 | ||||||||
6 | Plan Administration Costs……………………………………………………………………………………………. | L | 0.0000 | 0.0000 | 0.0000 | |||||||
___________ | ___________ | |||||||||||
7 | Totals (Sum Lines 1 - 6)…………………………………………………………………………………………………. | 0.0000 | 0.0000 | 0.0000 | ||||||||
8 | Part A Deductible and Coinsurance……………………………………………………………………………. | J | 0 | 0.0000 | ||||||||
9 | Part B Standard Deductible…………………………………………………………………………………………… | 0.0000 | ||||||||||
10 | Part B Blood Deductible………………………………………………………………………………………………… | L | 0.0000 | 0.0000 | ||||||||
11 | Copayment on Mental Health Services………………………………………………………………………. | L | 0.0000 | 0.0000 | ||||||||
___________ | ___________ | |||||||||||
12 | Line 7 Minus (The Sum of Lines 8 - 11)…………………………………………………………………………. | 0.0000 | 0.0000 | 0.0000 | ||||||||
13 | 20% of (Col 3 Line 12 minus Col 3 Line 3)……………………………………………………………………. | 0.0000 | 0.0000 | |||||||||
___________ | ___________ | |||||||||||
14 | Reimbursable Costs (Line 12 Minus Line 13)………………………………………………………………. | 0.0000 | 0.0000 | 0.0000 | ||||||||
15 | Special Administrative Costs………………………………………………………………………………………. | L | 0.0000 | 0.0000 | ||||||||
16 | Medicare Bad Debts………………………………………………………………………………………………………. | L | 0.0000 | 0.0000 | 0.0000 | |||||||
16a | Part B Cost Not Subject to Coinsurance………………………………………………………………………………………………………. | 0.0000 | 0.0000 | |||||||||
17 | Total (Sum Lines 14 thru 16a)……………………………………………………………………………………………. | 0.0000 | 0.0000 | 0.0000 | ||||||||
18 | Less: Third Party Insurer Revenue……………………………………………………………………………….. | L | 0.0000 | 0.0000 | 0.0000 | |||||||
___________ | ___________ | |||||||||||
19 | Medicare Costs (Line 17 minus Line 18)………………………………………………………………………. | 0.0000 | 0.0000 | 0.0000 | ||||||||
20 | Medicare Primary Member Months……………………………………………………………………………. | D | 0 | 0 | ||||||||
___________ | ___________ | |||||||||||
21 | Reimbursable Costs (Line 19 X Line 20)………………………………………………………………………. | 0 | 0 | 0 | ||||||||
22 | Interim Payments (by) to HCFA……………………………………………………………………………………. | |||||||||||
___________ | ||||||||||||
23 | Balance (Line 21 minus Line 22)……………………………………………………………………………………. | 0 | ||||||||||
Adjustments from Prior Years: | ||||||||||||
24 | ____________________________________________ | |||||||||||
25 | ____________________________________________ | |||||||||||
26 | ____________________________________________ | |||||||||||
___________ | ||||||||||||
27 | Balance Due Plan (CMS) (Line 23 + or - Lines 24-26).....………………………………………. | 0 | ||||||||||
========= | ||||||||||||
FORM CMS 276-08 | ||||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2315) |
MEDICARE PREMIUM RECONCILIATION | WORKSHEET N | |||||||||
Name of Plan: | 0 | Period From: | 12/30/99 | |||||||
Plan Number: | H-xxxx | To: | 12/30/99 | |||||||
Under and Over Collection of Medicare Premiums - Current Year | ||||||||||
Member | Cost Per | |||||||||
Premium Determinations Covered by this Part | Totals | Months | Member Month | Line | ||||||
1 | 2 | 3 | ||||||||
0 | Total Medicare Member Months | XXXXXXXXXXXX | XXXXXXXXXXXX | 0 | ||||||
1 | Total Premiums/Dues collected during the period | XXXXXXXXXXXX | - | 1 | ||||||
2 | Total Copayments collected during the period | XXXXXXXXXXXX | - | 2 | ||||||
XXXXXXXXXXXX | ||||||||||
3 | Total Collections (Line 1 plus Line 2) | - | XXXXXXXXXXXX | - | 3 | |||||
XXXXXXXXXXXX | ||||||||||
4 | Less: Accounts Receivable for premiums/dues and copayments (beg of period) | XXXXXXXXXXXX | - | 4 | ||||||
XXXXXXXXXXXX | ||||||||||
5 | Net Collections for period (Line 3 minus Line 4) | - | XXXXXXXXXXXX | - | 5 | |||||
6 | Add: Accounts Receivable for premiums/dues and copayments (end of period) | XXXXXXXXXXXX | - | 6 | ||||||
XXXXXXXXXXXX | ||||||||||
7 | Net Collections and Amounts to be Collected (Line 5 plus Line 6) | - | XXXXXXXXXXXX | - | 7 | |||||
8 | Total Medicare Deductible and Coinsurance from Cost Report: | 8 | ||||||||
a. Deductible and copayments (Worksheet M, Col 2 + 3 , Sum lines 8 thru 11) | XXXXXXXXXXXX | XXXXXXXXXXXX | 8a | |||||||
b. Part B Coinsurance (Worksheet M, Col 3, Line 13) | XXXXXXXXXXXX | XXXXXXXXXXXX | 8b | |||||||
c. Part B Coinsurance on services paid by CMS (Worksheet G, Col 2, Lines 23 + 24) | XXXXXXXXXXXX | XXXXXXXXXXXX | 8c | |||||||
d. Total (Sum of Lines 8a thru 8c) | XXXXXXXXXXXX | XXXXXXXXXXXX | 0.0000 | 8d | ||||||
9 | Voluntary under collection for the period (Worksheet B, Part II, Line 7) | XXXXXXXXXXXX | XXXXXXXXXXXX | 9 | ||||||
10 | Over collection from prior period (Prior Worksheet B, Part II, Excess of Ln 6 over Ln 5) | XXXXXXXXXXXX | XXXXXXXXXXXX | 10 | ||||||
11 | Total amount allowed to be charged (Line 8d minus sum of Lines 9 and 10) | XXXXXXXXXXXX | XXXXXXXXXXXX | 0.0000 | 11 | |||||
12 | Under (over) collection for the period (Line 11 minus Line 7) | XXXXXXXXXXXX | XXXXXXXXXXXX | 0.0000 | 12 | |||||
FORM CMS 276-08 | ||||||||||
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2316) |
Special Administration Costs | Amount |
Accretion/Deletion Cost | |
Certification Cost | |
Special Studies | |
Other (Specify) | |
Total Special Administration Cost | 0 |
SUBPART E LIMITS | ||||||||||
Name of Plan: | 0 | Period From: | 0 | |||||||
Plan #: | H-xxxx | To: | 0 | |||||||
Is this Plan an HCPP subject to the Subpart E Limits? | ||||||||||
COMPARABLE CARRIER PAYMENTS | ||||||||||
COST CENTERS | ||||||||||
1 | Physician Groups: | |||||||||
2 | _________________________________ | |||||||||
3 | _________________________________ | |||||||||
4 | _________________________________ | |||||||||
5 | _________________________________ | |||||||||
6 | Individual Physicians..................................................................................................................... | |||||||||
7 | Certified Labs................................................................................................................................... | |||||||||
8 | _________________________________ | |||||||||
9 | _________________________________ | |||||||||
10 | X-Ray Units....................................................................................................................................... | |||||||||
11 | _________________________________ | |||||||||
12 | _________________________________ | |||||||||
13 | ESRD Facilities............................................................................................................................... | |||||||||
14 | _________________________________ | |||||||||
15 | Durable Medical Equipment........................................................................................................ | |||||||||
16 | Ambulance......................................................................................................................................... | |||||||||
17 | Emergency-Urgently Needed Svcs.......................................................................................... | |||||||||
18 | Professional Component - Mental Health…………………………………………………………….….. | |||||||||
19 | Mental Health Svcs - Non-Prof Component……………………………………………………….…… | |||||||||
20 | _________________________________ | |||||||||
21 | _________________________________ | |||||||||
22 | _________________________________ | |||||||||
23 | _________________________________ | |||||||||
24 | _________________________________ | |||||||||
25 | _________________________________ | |||||||||
26 | _________________________________ | |||||||||
27 | _________________________________ | |||||||||
28 | _________________________________ | |||||||||
29 | _________________________________ | |||||||||
30 | _________________________________ | |||||||||
31 | _________________________________ | |||||||||
32 | _________________________________ | |||||||||
33 | _________________________________ | |||||||||
Yes | ||||||||||
No |
File Type | application/vnd.ms-excel |
Author | bunting |
Last Modified By | CMS |
File Modified | 2009-08-17 |
File Created | 2001-08-31 |