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{"sheet":"EA","index":0,"n_rows":125,"n_cols":11,"rows_kept":125,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,null,null,"CMS FORM-2552-10",{"$nulls":4},"DRAFT"]
["CALCULATION OF REIMBURSEMENT",null,null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET E,"]
["SETTLEMENT",null,null,null,"________________",null,"FROM  ____________",null,"PART A"]
[{"$nulls":4},"COMPONENT NO.:",null,"TO  _______________"]
[{"$nulls":4},"________________"]
["Check",null,null," [ ] Hospital"]
["Applicable Box",null,null," [ ] Subprovider (other)"]
[]
["PART A - INPATIENT HOSPITAL SERVICES UNDER PPS"]
[]
[1,"DRG Amounts Other than Outlier Payments",{"$nulls":6},4995935,1]
[2,"Outlier payments for discharges. (see instructions)",{"$nulls":7},2]
[3,"Managed Care Simulated Payments",{"$nulls":6},822292,3]
[4,"Bed days available divided by number of days in the cost reporting period (see instructions)",{"$nulls":7},4]
[null,"Indirect Medical Education Adjustment ",{"$nulls":6},822292]
[5,"  FTE count for allopathic and osteopathic programs for the most recent cost reporting period ending on or ",{"$nulls":7},5]
[null,"  before 12/31/1996.(see instructions)"]
[6,"  FTE count for allopathic and osteopathic programs which meet the criteria for an add-on to the cap for new programs in",{"$nulls":7},6]
[null,"  accordance with section 1886(d)(5)(B)(viii)"]
[7,"  Adjusted FTE count for allopathic and osteopathic programs for affiliated programs in accordance with ",{"$nulls":7},7]
[null,"   section 1886(d)(5)(B)(viii)"]
[8,"  Reduced Direct GME FTE Cap (see instructions)",{"$nulls":7},8]
[9,"  Sum of lines 5 through 7 plus/minus line 8 (see instructions).",{"$nulls":7},9]
[10,"  FTE count for allopathic and osteopathic programs in the current year from your records",{"$nulls":7},10]
[11,"  FTE count for residents in dental and podiatric programs.",{"$nulls":7},11]
[12,"  Current year allowable FTE (see instructions)",{"$nulls":7},12]
[13,"  Total allowable FTE count for the prior year.",{"$nulls":7},13]
[14,"  Total allowable FTE count for the penultimate year if that year ended on or after September 30, 1997, otherwise enter zero.",{"$nulls":7},14]
[15,"  Sum of lines 12 through 14 divided by 3.",{"$nulls":7},15]
[16,"  Adjustment for residents in initial years of the program",{"$nulls":7},16,"`"]
[17,"  Adjustment for residents displaced by program or hospital closure",{"$nulls":7},17]
[18,"  Adjusted rolling average FTE count",{"$nulls":7},18]
[19,"  Current year resident to bed ratio (line 15 divided by line 4).",{"$nulls":7},19]
[20,"  Prior year resident to bed ratio (see instructions)",{"$nulls":7},20]
[21,"  Enter the lesser of lines 19 or 20 (see instructions)",{"$nulls":7},21]
[22,"  IME payment adjustment (see instructions)",{"$nulls":7},22]
[null,"Indirect Medical Education Adjustment for the MMA section 422 Add-on"]
[23,"  Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 Sec. 412.105 (f)(1)(iv)(C ).",{"$nulls":7},23]
[24,"  IME FTE Resident Count Over Cap (see instructions)",{"$nulls":7},24]
[25,"  If the amount on line 24 is greater than -0-, then enter the lower of line 23 or line 24 (see instructions) ",{"$nulls":7},25]
[26,"  Resident to bed ratio (divide line 25 by line 4)",{"$nulls":7},26]
[27,"  IME factor adjustment. (see instructions)",{"$nulls":7},27]
[28,"  IME add-on Adjustment (see instructions)",{"$nulls":7},28]
[29,"Total IME payment ( sum of lines 22 and 28)",{"$nulls":7},29]
[null,"Disproportionate Share Adjustment"]
[30,"  Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions)",{"$nulls":7},30]
[31,"  Percentage of Medicaid patient days to total days reported on Worksheet S-3, Part I (see instructions)",{"$nulls":7},31]
[32,"  Sum of lines 30 and 31",{"$nulls":7},32]
[33,"  Allowable disproportionate share percentage (see instructions)",{"$nulls":7},33]
[34,"  Disproportionate share adjustment (see instructions)",{"$nulls":7},34]
{"$rows_empty":10}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4030.1)"]
["40-584",{"$nulls":8},"Rev. 1"]
["DRAFT",null,null,null,"CMS FORM-2552-10",{"$nulls":4},"4090 (Cont.)"]
["CALCULATION OF REIMBURSEMENT",null,null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET E,"]
["SETTLEMENT",null,null,null,"________________",null,"FROM  ____________",null,"PART A (Cont.)"]
[{"$nulls":4},"COMPONENT NO.:",null,"TO  _______________"]
[{"$nulls":4},"________________"]
["Check",null,null," [ ] Hospital"," [ ] IPF"]
["Applicable Box",null,null," [ ] IRF"," [ ] Subprovider (other)"]
[]
["PART A - INPATIENT HOSPITAL SERVICES UNDER PPS"]
[]
[null,"Additional payment for high percentage of ESRD beneficiary discharges"]
[40,"Total Medicare discharges on Worksheet S-3, Part I excluding discharges for MS-DRGs 652, 682, 683, ",{"$nulls":7},40]
[null,"684 and 685 (see instructions)"]
[41,"Total ESRD Medicare discharges excluding MS-DRGs  652, 682, 683, 684 an 685. (see instructions)",{"$nulls":7},41]
[42,"Divide line 41 by line 40 (if less than 10%, you do not qualify for adjustment)",{"$nulls":7},42]
[43,"Total Medicare ESRD inpatient days excluding MS-DRGs  652, 682, 683, 684 an 685. (see instructions)",{"$nulls":7},43]
[44,"Ratio of average length of stay to one week (line 43 divided by line 41 divided by 7 days)",{"$nulls":7},44]
[45,"Average weekly cost for dialysis treatments (see instructions)",{"$nulls":7},45]
[46,"Total additional payment (line 45 times line 43 times line 41)",{"$nulls":7},46]
[47,"Subtotal (see instructions)",{"$nulls":7},47]
[48,"Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only.(see instructions)",{"$nulls":7},48]
[49,"Total payment for inpatient operating costs SCH and MDH only (see instructions)",{"$nulls":7},49]
[50,"Payment for inpatient program capital (from Worksheet L, Parts I, II, as applicable)",{"$nulls":7},50]
[51,"Exception payment for inpatient program capital (Worksheet L, Part III, see instructions)",{"$nulls":7},51]
[52,"Direct graduate medical education payment (from Worksheet E-4, line 49 see instructions).",{"$nulls":7},52]
[53,"Nursing and Allied Health Managed Care payment",{"$nulls":7},53]
[54,"Special add-on payments for new technologies",{"$nulls":7},54]
[55,"Net organ acquisition cost (Worksheet D-4 Part III, col. 1, line 62)",{"$nulls":7},55]
[56,"Cost of teaching physicians (Worksheet D-5, Part II, col. 3, line 19)",{"$nulls":7},56]
[57,"Routine service other pass through costs",{"$nulls":7},57]
[58,"Ancillary service other pass through costs Worksheet D, Part IV, col. 13 line 200)",{"$nulls":7},58]
[59,"Total (sum of amounts on lines 49 through 58)",{"$nulls":7},59]
[60,"Primary payer payments",{"$nulls":6},165000,60]
[61,"Total amount payable for program beneficiaries (line 59 minus line 60)",{"$nulls":7},61]
[62,"Deductibles billed to program beneficiaries",{"$nulls":6},467380,62]
[63,"Coinsurance billed to program beneficiaries",{"$nulls":6},18347,63]
[64,"Allowable bad debts (see instructions)",{"$nulls":6},27000,64]
[65,"Adjusted reimbursable bad debts (see instructions)",{"$nulls":7},65]
[66,"Allowable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":7},66]
[67,"Subtotal (line 61 plus line 65 minus lines 62 and 63)",{"$nulls":7},67]
[68,"Credits received from manufacturers for replaced devices applicable to MS-DRG (see instructions)",{"$nulls":7},68]
[69,"Outlier payments reconciliation",{"$nulls":7},69]
[70,"Other adjustments (see instructions) (specify)",{"$nulls":7},70]
[71,"Amount due provider (line 67 minus lines 68 plus/minus lines 69 & 70)",{"$nulls":7},71]
[72,"Interim payments",{"$nulls":7},72]
[73,"Tentative settlement (for fiscal intermediary  use only)",{"$nulls":7},73]
[74,"Balance due provider (Program) (sum of lines 71, 72  and 73)",{"$nulls":7},74]
[75,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2",{"$nulls":7},75]
[]
[null,"TO BE COMPLETED BY CONTRACTOR"]
[90,"Original outlier amount from Worksheet E, Part A line 2",{"$nulls":7},90]
[91,"Original capital outlier from Worksheet L, Part I, line 2",{"$nulls":7},91]
[92,"Operating outlier amount (see instructions)",{"$nulls":7},92]
[93,"Capital outlier reconciliation amount (see instructions)",{"$nulls":7},93]
[94,"The rate used to calculate the Time Value of Money",{"$nulls":7},94]
[95,"Time Value of Money for operating expenses(see instructions)",{"$nulls":7},95]
[96,"Time Value of Money for capital related expenses (see instructions)",{"$nulls":7},96]
[]
[]
[]
[]
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4030.1)"]
["Rev. 1",{"$nulls":8},"40-585"]

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["4090 (Cont.)",null,null,"FORM CMS-2552-10",null,null,null,"DRAFT"]
["CALCULATION OF",null,null,"PROVIDER NO.:",null,"PERIOD:","WORKSHEET E,"]
["REIMBURSEMENT SETTLEMENT",null,null,"___________________",null,"FROM ________","PART B"]
[null,null,null,"COMPONENT NO.:",null,"TO __________"]
[null,null,null,"___________________"]
["Check applicable box",null,"  [  ] Hospital     [  ] IPF        [ ] IRF      [  ] Subprovider(Other)        [  ] SNF"]
["PART B - MEDICAL AND OTHER HEALTH SERVICES"]
[1,"Medical and other services (see instructions)",{"$nulls":5},1]
[2,"Medical and other services reimbursed under OPPS (see instructions).",{"$nulls":5},2]
[3,"PPS payments",{"$nulls":5},3]
[4,"Outlier payment (see instructions)",{"$nulls":5},4]
[5,"Enter the hospital specific payment to cost ratio.(see instructions)",{"$nulls":5},5]
[6,"Line 2 times line 5.",{"$nulls":5},6]
[7,"Sum of lines line 3 plus line 4 divided by line 6.",{"$nulls":5},7]
[8,"Transitional corridor payment (see instructions)",{"$nulls":5},8]
[9,"Enter the amount from Worksheet D, Part IV, column 13, line 200.",{"$nulls":5},9]
[10,"Organ acquisitions",{"$nulls":5},10]
[11,"Total cost (sum of lines 1 and 10)(see instructions)",{"$nulls":5},11]
[null,"COMPUTATION OF LESSER OF COST OR CHARGES"]
[null,"Reasonable charges"]
[12,"Ancillary service charges",{"$nulls":5},12]
[13,"Organ acquisition charges (from Worksheet D-4, Part III, line 62, col. 4)",{"$nulls":5},13]
[14,"Total reasonable charges (sum of lines 12 and 13)",{"$nulls":5},14]
[null,"Customary charges"]
[15,"Aggregate amount actually collected from patients liable for payment for services on a charge basis",{"$nulls":5},15]
[16,"Amounts that would have been realized from patients liable for payment for services on a charge ",{"$nulls":5},16]
[null,"basis had such payment been made in accordance with 42 CFR 413.13(e)"]
[17,"Ratio of line 15 to line 16 (not to exceed 1.000000)",{"$nulls":5},17]
[18,"Total customary charges (see instructions)",{"$nulls":5},18]
[19,"Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see instructions)",{"$nulls":5},19]
[20,"Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see instructions)",{"$nulls":5},20]
[21,"Lesser of cost or charges (line 11 or line 20) (for CAH see instructions)",{"$nulls":5},21]
[22,"Interns and residents (see instructions)",{"$nulls":5},22]
[23,"Cost of teaching physicians (see instructions, 42 CFR 415.160 and CMS Pub. 15-1, §2148)",{"$nulls":5},23]
[24,"Total prospective payment (sum of lines 3, 4, 8 and 9)",{"$nulls":5},24]
[null,"COMPUTATION OF REIMBURSEMENT SETTLEMENT"]
[25,"Deductibles and coinsurance (see instructions)",{"$nulls":5},25]
[26,"Deductibles and Coinsurance relating to amount on line 24 (see instructions)",{"$nulls":5},26]
[27,"Subtotal {(lines 21 and 24 - the sum of lines 25 and 26) plus the sum of lines 22 and 23}(see instructions)",{"$nulls":5},27]
[28,"Direct graduate medical education payments (from Worksheet E-4, line 50)",{"$nulls":5},28]
[29,"ESRD direct medical education costs (from Worksheet E-4, line 36)",{"$nulls":5},29]
[30,"Subtotal (sum of lines 27 through 29)",{"$nulls":5},30]
[31,"Primary payer payments",{"$nulls":5},31]
[32,"Subtotal (line 30 minus line 31)",{"$nulls":5},32]
[" ","ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)",{"$nulls":5}," "]
[33,"Composite rate ESRD (from Worksheet I-5, line 11)",{"$nulls":5},33]
[34,"Allowable bad debts (see instructions)",{"$nulls":5},34]
[35,"Adjusted reimbursable bad debts (see instructions)",{"$nulls":5},35]
[36,"Allowable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":5},36]
[37,"Subtotal (sum of lines 32, 33, and 34 or 35) (line 35 hospital and subprovider only)",{"$nulls":5},37]
[38,"MSP-LCC reconciliation amount from PS&R",{"$nulls":5},38]
[39,"Other adjustments (specify) (see instructions)",{"$nulls":5},39]
[40,"Subtotal (line 37 plus or minus lines 39 minus 38)",{"$nulls":5},40]
[41,"Interim payments",{"$nulls":5},41]
[42,"Tentative settlement (for contractors use only)",{"$nulls":5},42]
[43,"Balance due provider/program (line 40 minus the sum of lines 41, and 42) ",{"$nulls":5},43]
[44,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2",{"$nulls":5},44]
{"$rows_empty":7}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4030.2)"]
["40-586",{"$nulls":6},"Rev.1"]
["DRAFT",null,null,"FORM CMS-2552-10",null,null,null,"4090 (Cont.)"]
["CALCULATION OF",null,null,"PROVIDER NO.:",null,"PERIOD:","WORKSHEET E,"]
["REIMBURSEMENT SETTLEMENT",null,null,"___________________",null,"FROM ________","PART B (Cont.)"]
[null,null,null,"COMPONENT NO.:",null,"TO __________"]
[null,null,null,"___________________"]
["Check applicable box",null,"  [  ] Hospital     [  ] IPF        [ ] IRF      [  ] Subprovider(Other)        [  ] SNF"]
["PART B - MEDICAL AND OTHER HEALTH SERVICES"]
[]
[null,"TO BE COMPLETED BY CONTRACTOR"]
[90,"Original outlier amount (see instructions)",{"$nulls":5},90]
[91,"Outlier reconciliation amount (see instructions)",{"$nulls":5},91]
[92,"The rate used to calculate the Time Value of Money",{"$nulls":5},92]
[93,"Time Value of Money (see instructions)",{"$nulls":5},93]
[94,"Total (sum of lines 91 and 93)",{"$nulls":5},94]
{"$rows_empty":56}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4030.2)"]
[]
["Rev. 1",{"$nulls":6},"40-587"]

{"sheet":"E1","index":2,"n_rows":49,"n_cols":10,"rows_kept":49,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,null,"      FORM CMS-2552-10",{"$nulls":5},"DRAFT"]
["ANALYSIS OF PAYMENTS TO PROVIDERS ",null,null,"PROVIDER NO.: ",null,null,"PERIOD: ",null,"WORKSHEET E-1,"]
["FOR SERVICES RENDERED",null,null,"________________",null,null,"FROM ________________",null,"PART I"]
[null,null,null,"COMPONENT NO.:",null,null,"TO ___________________"]
[null,null,null,"_______________"]
["Check",null," [ ] Hospital          [ ] Subprovider (Other)",null,null,"Inpatient"]
["Applicable",null," [ ] IPF                    [ ] SNF",null,null,"Part A ",null,"Part B"]
["Box",null," [ ] IRF                    [ ] Swing-Bed SNF",null,null,"mm/dd/yyyy","Amount","mm/dd/yyyy","Amount"]
[null,"Description",null,null,null,"1","2","3","4"]
[1,"Total interim payments paid to provider",{"$nulls":7},"1.00"]
[2,"Interim payments payable on individual bills, either submitted or to be submitted to the intermediary",{"$nulls":7},"2.00"]
[null,"for services rendered in the cost reporting period.  If none, write \"NONE\" or enter a zero"]
[3,"List separately each retroactive  ",null,null,".01",{"$nulls":4},"3.01"]
[null,"lump sum adjustment amount based",null,null,".02",{"$nulls":4},"3.02"]
[null,"on subsequent revision of the",null,"Program to ",".03",{"$nulls":4},"3.03"]
[null,"interim rate for the cost reporting period.",null,"Provider",".04",{"$nulls":4},"3.04"]
[null,"Also show date of each payment.",null,null,".05",{"$nulls":4},"3.05"]
[null,"If none, write \"NONE\" or enter a zero. (1)",null,null,".50",{"$nulls":4},"3.50"]
[{"$nulls":4},".51",{"$nulls":4},"3.51"]
[null,null,null,"Provider to ",".52",{"$nulls":4},"3.52"]
[null,null,null,"Program",".53",{"$nulls":4},"3.53"]
[{"$nulls":4},".54",{"$nulls":4},"3.54"]
[null,"Subtotal (sum of lines 3.01- 3.49 minus sum of lines 3.50-3.98)",null,null,".99",{"$nulls":4},"3.99"]
[4,"Total interim payments (sum of lines 1, 2, and 3.99) ",{"$nulls":7},"4.00"]
[null,"(transfer to Wkst. E or Wkst. E-3, line"]
[null,"and column as appropriate)"]
[null,"TO BE COMPLETED BY CONTRACTOR"]
[5,"List separately each tentative settlement",null,"Program to",".01",{"$nulls":4},"5.01"]
[null,"payment after desk review. Also show",null,"Provider",".02",{"$nulls":4},"5.02"]
[null,"date of each payment.",null,null,".03",{"$nulls":4},"5.03"]
[null,"If none, write \"NONE\" or enter a zero. (1)",null,null,".50",{"$nulls":4},"5.50"]
[null,null,null,"Provider to ",".51",{"$nulls":4},"5.51"]
[null,null,null,"Program",".52",{"$nulls":4},"5.52"]
[null,"Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50 -5.98)",null,null,".99",{"$nulls":4},"5.99"]
[6,"Determined net settlement amount (balance",null,"Program to provider",".01",{"$nulls":4},"6.01"]
[null,"due) based on the cost report. (1)",null,"Provider to program",".02",{"$nulls":4},"6.02"]
[7,"Total Medicare program liability (see instructions)",{"$nulls":7},"7.00"]
[8,"Name of Contractor",{"$nulls":4},"Contractor Number",null,"Date (Mo/Day/Yr)","8.00"]
["(1) On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which the provider agrees to the amount of repayment"]
["even though total repayment is not accomplished until a later date."]
[]
[]
[]
[]
[]
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4031)"]
[]
[]
["40-588",{"$nulls":8},"Rev. 1"]

{"sheet":"E1II","index":3,"n_rows":66,"n_cols":10,"rows_kept":66,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,null,null,"CMS FORM-2552-10",{"$nulls":4},"4090 (Cont.)"]
["CALCULATION OF REIMBURSEMENT",null,null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET E-1,"]
["SETTLEMENT FOR HIT",null,null,null,"________________",null,"FROM  ____________",null,"PART II"]
[{"$nulls":4},"COMPONENT NO.:",null,"TO  _______________"]
[{"$nulls":4},"________________"]
["Check",null,null," [ ] Hospital"]
["Applicable Box"]
[]
["DATA COLLECTION NEEDED FOR THE HIT CALCULATION"]
[1,"Total hospital discharges as defined in AARA §4102 from Wkst S-3, Part I, column 15, line 14",{"$nulls":7},1]
[2,"Medicare days from Wkst S-3, Part I, column 6, sum of lines 1 and 8-12",{"$nulls":7},2]
[3,"Medicare HMO days from Wkst S-3, Part I, column 6, line 2",{"$nulls":7},3]
[4,"Total inpatient bed days from S-3, Part I, column 8, sum of lines 1 and 8-12",{"$nulls":7},4]
[5,"Total hospital charges from Wkst C, Part I, column 8 line 200",{"$nulls":7},5]
[6,"Total hospital charity care charges from Wkst S-10, column 3 line 20",{"$nulls":7},6]
[7,"CAH only - The reasonablecost incurred for the purchase of certified HIT technology Worksheet S-2, Part I line 167",{"$nulls":7},7]
{"$rows_empty":34}
["INPATIENT HOSPITAL SERVICES UNDER PPS & CAH"]
[30,"Initial payment",{"$nulls":7},30]
[31,"Other Adjustment (specify)",{"$nulls":7},31]
[32,"Final payment",{"$nulls":7},32]
[33,"Balance due provider (sum of lines 30, ± 31  and 32)",{"$nulls":7},33]
{"$rows_empty":9}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4031.1)"]
["Rev. 1",{"$nulls":8},"40-589"]

{"sheet":"E2","index":4,"n_rows":69,"n_cols":7,"rows_kept":69,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090(Cont.)",null,"                          FORM CMS-2552-10",null,null,null,"DRAFT"]
["CALCULATION OF REIMBURSEMENT ",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET E-2 "]
["SETTLEMENT -  SWING BEDS",null,null,"________________","FROM ________"]
[null,null,null,"COMPONENT NO.:","TO ___________"]
[null,null,null,"___________________"]
["Check",null," [ ] Title V"," [ ] Swing Bed - SNF"]
["Applicable",null," [ ] Title XVIII"," [ ] Swing Bed - NF"]
["Boxes",null," [ ] Title XIX"]
[]
[{"$nulls":4},"PART A","PART B"]
[null,"COMPUTATION OF NET COST OF COVERED SERVICES",null,null,"1","2"]
[1,"Inpatient routine services - swing bed-SNF (see instructions)",{"$nulls":4},1]
[2,"Inpatient routine services - swing bed-NF (see instructions)",null,null,null,4995935,2]
[3,"Ancillary services (from Wkst. D-3, column 3, line 200 for Part A, and sum of Wkst. D, Part V,",{"$nulls":4},3]
[null,"columns 5 and 7, line 203). For CAH Wkst. E, Part B (see instructions)"]
[4,"Per diem cost for interns and residents not in approved teaching program (see instructions)",{"$nulls":4},4]
[5,"Program days",{"$nulls":4},5]
[6,"Interns and residents not in approved teaching program (see instructions)",{"$nulls":4},6]
[7,"Utilization review - physician compensation - SNF optional method only",null,null,null,4995935,7]
[8,"Subtotal (sum of lines 1 through 3 plus lines 6 and 7)",{"$nulls":4},8]
[9,"Primary payer payments (see instructions)",{"$nulls":4},9]
[10,"Subtotal (line 8 minus line 9)",{"$nulls":4},10]
[11,"Deductibles billed to program patients (exclude amounts applicable to physician professional",{"$nulls":4},11]
[null,"services)"]
[12,"Subtotal (line 10 minus line 11)",{"$nulls":4},12]
[13,"Coinsurance billed to program patients (from provider records) (exclude coinsurance for",{"$nulls":4},13]
[null,"physician professional services)"]
[14,"80% of Part B costs (line 12 x 80%)",null,null,4995935,null,14]
[15,"Subtotal (enter the lesser of line 12 minus line 13, or line 14)",{"$nulls":4},15]
[16,"Other adjustments (see instructions) (specify)",{"$nulls":4},16]
[17,"Reimbursable bad debts (see instructions)",{"$nulls":4},17]
[18,"Reimbursable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},18]
[19,"Total (sum of lines 15 and 17, plus/minus line 16)",{"$nulls":4},19]
[20,"Interim payments ",{"$nulls":4},20]
[21,"Tentative settlement (for fiscal contractor use only)",{"$nulls":4},21]
[22,"Balance due provider/program (line 19 minus the sum of lines 20 and 21)",{"$nulls":4},22]
[23,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II,",{"$nulls":4},23]
[null,"section 115.2"]
{"$rows_empty":28}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4032)"]
[]
["40-590",{"$nulls":5},"Rev. 1"]

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["DRAFT",null,"                                 FORM CMS-2552-10",null,null,null,"4090 (Cont.)"]
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["SETTLEMENT UNDER TEFRA, CANCER AND CHILDREN HOSPITALS",null,null," _______________","FROM ____________","PART I"]
[null,null,null,"COMPONENT NO.:","TO _______________"]
[null,null,null," _______________"]
["Check",null," [ ] Hospital"]
["Applicable",null," [ ] Subprovider (Other) "]
["Box"]
[]
["PART I - MEDICARE PART A SERVICES - TEFRA "]
[]
[1,"Inpatient hospital services (see instructions)",{"$nulls":4},1]
[2,"Organ acquisition",{"$nulls":4},2]
[3,"Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 19) (see instructions)",{"$nulls":4},3]
[4,"Subtotal (sum of lines 1 thru 3)",{"$nulls":4},4]
[5,"Primary payer payments",{"$nulls":4},5]
[6,"Subtotal (line 4 less line 5). ",{"$nulls":4},6]
[7,"Deductibles",{"$nulls":4},7]
[8,"Subtotal (line 6 minus line 7)",{"$nulls":4},8]
[9,"Coinsurance",{"$nulls":4},9]
[10,"Subtotal (line 8 minus line 9)",{"$nulls":4},10]
[11,"Allowable bad debts (exclude bad debts for professional services) (see instructions)",{"$nulls":4},11]
[12,"Adjusted reimbursable bad debts (see instructions)",{"$nulls":4},12]
[13,"Allowable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},13]
[14,"Subtotal (sum of lines 10 and 12) ",{"$nulls":4},14]
[15,"Direct graduate medical education payments (from Worksheet E-4, line 49)",{"$nulls":4},15]
[16,"Other pass through costs (see instructions)",{"$nulls":4},16]
[17,"Other adjustments (see instructions) (specify)",{"$nulls":4},17]
[18,"Total amount payable to the provider (see instructions)",{"$nulls":4},18]
[19,"Interim payments",{"$nulls":4},19]
[20,"Tentative settlement (for fiscal intermediary use only)",{"$nulls":4},20]
[21,"Balance due provider/program (line 18 minus the sum lines 19 and 20)",{"$nulls":4},21]
[22,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2",{"$nulls":4},22]
{"$rows_empty":29}
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[]
["Rev. 1",{"$nulls":5},"40-591"]

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["4090 (Cont.)",null,"                                 FORM CMS-2552-10",null,null,null,"DRAFT"]
["CALCULATION OF MEDICARE REIMBURSEMENT",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET E-3,"]
["SETTLEMENT IPF PPS",null,null," _______________","FROM ____________","PART II"]
[null,null,null,"COMPONENT NO.:","TO _______________"]
[null,null,null," _______________"]
[null,null,null,"    [  ] Hospital"]
["PART II - MEDICARE PART A SERVICES - IPF PPS",null,null,"    [  ] Subprovider"]
[]
[1,"Net Federal IPF PPS Payments (excluding outlier, ECT, and medical education payments) ",{"$nulls":4},1]
[2,"Net IPF PPS Outlier Payments",{"$nulls":4},2]
[3,"Net IPF PPS ECT Payments",{"$nulls":4},3]
[4,"Unweighted intern and resident FTE count in the most recent cost report filed on or before November 15, 2004. (see instructions)",{"$nulls":4},4]
[5,"New Teaching program adjustment. (see instructions)",{"$nulls":4},5]
[6,"Current year's unweighted FTE count of I&R other than FTEs in the first 3 years of a \"new teaching program\". (see inst.)",{"$nulls":4},6]
[7,"Current year's unweighted I&R FTE count for residents within the first 3 years of a \"new teaching program\". (see inst.)",{"$nulls":4},7]
[8,"Intern and resident count for IPF PPS medical education adjustment (see instructions)",{"$nulls":4},8]
[9,"Average Daily Census (see instructions)",{"$nulls":4},9]
[10,"Medical Education Adjustment Factor {((1 + (line 8/line 9)) raised to the power of .5150 -1}.",{"$nulls":4},10]
[11,"Medical Education Adjustment  (line 1 multiplied by line 10).",{"$nulls":4},11]
[12,"Adjusted  Net IPF PPS Payments (sum of lines 1, 2, 3 and 11)",{"$nulls":4},12]
[13,"Nursing and Allied Health Managed Care payment (see instruction)",{"$nulls":4},13]
[14,"Organ acquisition",{"$nulls":4},14]
[15,"Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 19) (see instructions)",{"$nulls":4},15]
[16,"Subtotal (see instructions)",{"$nulls":4},16]
[17,"Primary payer payments",{"$nulls":4},17]
[18,"Subtotal (line 16 less line 17). ",{"$nulls":4},18]
[19,"Deductibles",{"$nulls":4},19]
[20,"Subtotal (line 18 minus line 19)",{"$nulls":4},20]
[21,"Coinsurance",{"$nulls":4},21]
[22,"Subtotal (line 20 minus line 21)",{"$nulls":4},22]
[23,"Allowable bad debts (exclude bad debts for professional services) (see instructions)",{"$nulls":4},23]
[24,"Adjusted reimbursable bad debts (see instructions)",{"$nulls":4},24]
[25,"Allowable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},25]
[26,"Subtotal (sum of lines 22 and 24) ",{"$nulls":4},26]
[27,"Direct graduate medical education payments (from Worksheet E-4, line 49)",{"$nulls":4},27]
[28,"Other pass through costs (see instructions)",{"$nulls":4},28]
[29,"Outlier payments reconciliation",{"$nulls":4},29]
[30,"Other adjustments (see instructions) (specify)",{"$nulls":4},30]
[31,"Total amount payable to the provider (see instructions)",{"$nulls":4},31]
[32,"Interim payments",{"$nulls":4},32]
[33,"Tentative settlement (for fiscal intermediary use only)",{"$nulls":4},33]
[34,"Balance due provider/program (line 31 minus the sum lines 32 and 33)",{"$nulls":4},34]
[35,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2",{"$nulls":4},35]
[]
[]
[null,"TO BE COMPLETED BY CONTRACTOR"]
[50,"Original outlier amount from Worksheet E-3, Part II, line 2",{"$nulls":4},50]
[51,"Outlier reconciliation amount (see instructions)",{"$nulls":4},51]
[52,"The rate used to calculate the Time Value of Money",{"$nulls":4},52]
[53,"Time Value of Money (see instructions)",{"$nulls":4},53]
{"$rows_empty":11}
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[]
["40-592",{"$nulls":5},"Rev. 1"]

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["DRAFT",null,"                                 FORM CMS-2552-10",null,null,null,"4090 (Cont.)"]
["CALCULATION OF MEDICARE REIMBURSEMENT",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET E-3,"]
["SETTLEMENT UNDER IRF PPS",null,null," _______________","FROM ____________","PART III"]
[null,null,null,"COMPONENT NO.:","TO _______________"]
[null,null,null," _______________"]
[null,null,null,"    [  ] Hospital"]
["PART III - MEDICARE PART A SERVICES - IRF PPS",null,null,"    [  ] Subprovider"]
[]
[1,"Net Federal PPS Payment (see instructions)",{"$nulls":4},1]
[2,"Medicare SSI ratio (IRF PPS only) (see instructions)",{"$nulls":4},2]
[3,"Inpatient Rehabilitation LIP Payments (see instructions)",{"$nulls":4},3]
[4,"Outlier Payments",{"$nulls":4},4]
[5,"Unweighted intern and resident FTE count in the most recent cost reporting  period ending",{"$nulls":4},5]
[null,"on or prior to November 15, 2004. (see inst.)"]
[6,"New Teaching program adjustment. (see instructions)",{"$nulls":4},6]
[7,"Current year's unweighted FTE count of I&R other than FTEs in the first 3 years of a \"new teaching program\". (see inst.)",{"$nulls":4},7]
[8,"Current year's unweighted I&R FTE count for residents within the first 3 years of a \"new teaching program\". (see inst.)",{"$nulls":4},8]
[9,"Intern and resident count for IRF PPS medical education adjustment (see instructions)",{"$nulls":4},9]
[10,"Average Daily Census (see instructions)",{"$nulls":4},10]
[11,"Medical Education Adjustment Factor {((1 + (line 9/line 10)) raised to the power of .9012 -1}.",{"$nulls":4},11]
[12,"Medical Education Adjustment  (line 1 multiplied by line 11).",{"$nulls":4},12]
[13,"Total PPS Payment (sum of lines 1, 3, 4 and 12)",{"$nulls":4},13]
[14,"Nursing and Allied Health Managed Care payment (see instruction)",{"$nulls":4},14]
[15,"Organ acquisition",{"$nulls":4},15]
[16,"Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 19) (see instructions)",{"$nulls":4},16]
[17,"Subtotal (see instructions)",{"$nulls":4},17]
[18,"Primary payer payments",{"$nulls":4},18]
[19,"Subtotal (line 17 less line 18). ",{"$nulls":4},19]
[20,"Deductibles",{"$nulls":4},20]
[21,"Subtotal (line 19 minus line 20)",{"$nulls":4},21]
[22,"Coinsurance",{"$nulls":4},22]
[23,"Subtotal (line 21 minus line 22)",{"$nulls":4},23]
[24,"Allowable bad debts (exclude bad debts for professional services) (see instructions)",{"$nulls":4},24]
[25,"Adjusted reimbursable bad debts (see instructions)",{"$nulls":4},25]
[26,"Allowable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},26]
[27,"Subtotal (sum of lines 23 and 25) ",{"$nulls":4},27]
[28,"Direct graduate medical education payments (from Worksheet E-4, line 49)",{"$nulls":4},28]
[29,"Other pass through costs (see instructions)",{"$nulls":4},29]
[30,"Outlier payments reconciliation",{"$nulls":4},30]
[31,"Other adjustments (see instructions) (specify)",{"$nulls":4},31]
[32,"Total amount payable to the provider (see instructions)",{"$nulls":4},32]
[33,"Interim payments",{"$nulls":4},33]
[34,"Tentative settlement (for fiscal intermediary use only)",{"$nulls":4},34]
[35,"Balance due provider/program (line 32 minus the sum lines 33 and 34)",{"$nulls":4},35]
[36,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2",{"$nulls":4},36]
[]
[]
[null,"TO BE COMPLETED BY CONTRACTOR"]
[50,"Original outlier amount from Worksheet E-3, Part III line 4",{"$nulls":4},50]
[51,"Outlier reconciliation amount (see instructions)",{"$nulls":4},51]
[52,"The rate used to calculate the Time Value of Money",{"$nulls":4},52]
[53,"Time Value of Money (see instructions)",{"$nulls":4},53]
{"$rows_empty":10}
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[]
["Rev. 1",{"$nulls":5},"40-593"]

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["4090 (Cont.)",null,"                                 FORM CMS-2552-10",null,null,null,"DRAFT"]
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["SETTLEMENT",null,null," _______________","FROM ____________","PART IV"]
[null,null,null,"COMPONENT NO.:","TO _______________"]
[null,null,null," _______________"]
["Check",null," [ ] Hospital"]
["Applicable",null," [ ] Subprovider (Other) "]
["Box"]
[]
["PART IV - MEDICARE PART A SERVICES - LTCH PPS "]
[]
[1,"Net Federal PPS Payments (see instructions)",{"$nulls":4},1]
[2,"Outlier Payments",{"$nulls":4},2]
[3,"Total PPS Payments (sum of lines 1 and 2)",{"$nulls":4},3]
[4,"Nursing and Allied Health Managed Care payments (see instructions)",{"$nulls":4},4]
[5,"Organ acquisition",{"$nulls":4},5]
[6,"Cost of teaching physicians",{"$nulls":4},6]
[7,"Subtotal (see instructions)",{"$nulls":4},7]
[8,"Primary payer payments",{"$nulls":4},8]
[9,"Subtotal (line 7 less line 8). ",{"$nulls":4},9]
[10,"Deductibles",{"$nulls":4},10]
[11,"Subtotal (line 9 minus line 10)",{"$nulls":4},11]
[12,"Coinsurance",{"$nulls":4},12]
[13,"Subtotal (line 11 minus line 12)",{"$nulls":4},13]
[14,"Allowable bad debts (exclude bad debts for professional services) (see instructions)",{"$nulls":4},14]
[15,"Adjusted reimbursable bad debts (see instructions)",{"$nulls":4},15]
[16,"Allowable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},16]
[17,"Subtotal (sum of lines 13 and 15) ",{"$nulls":4},17]
[18,"Direct graduate medical education payments (from Worksheet E-4, line 49)",{"$nulls":4},18]
[19,"Other pass through costs (see instructions)",{"$nulls":4},19]
[20,"Outlier payments reconciliation",{"$nulls":4},20]
[21,"Other adjustments (see instructions) (specify)",{"$nulls":4},21]
[22,"Total amount payable to the provider (see instructions)",{"$nulls":4},22]
[23,"Interim payments",{"$nulls":4},23]
[24,"Tentative settlement (for contractor use only)",{"$nulls":4},24]
[25,"Balance due provider/program (line 22 minus the sum lines 23 and 24)",{"$nulls":4},25]
[26,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2",{"$nulls":4},26]
{"$rows_empty":7}
[null,"TO BE COMPLETED BY CONTRACTOR"]
[50,"Original outlier amount from Worksheet E-3, Part IV line 2",{"$nulls":4},50]
[51,"Outlier reconciliation amount (see instructions)",{"$nulls":4},51]
[52,"The rate used to calculate the Time Value of Money",{"$nulls":4},52]
[53,"Time Value of Money (see instructions)",{"$nulls":4},53]
{"$rows_empty":14}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4033.4)"]
[]
["40-594",{"$nulls":5},"Rev. 1"]

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["DRAFT",null,"                            FORM CMS-2552-10",null,null,null,"4090 (Cont.)"]
["CALCULATION OF REIMBURSEMENT",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET E-3,"]
["SETTLEMENT",null,null,"______________","FROM _________","PART V"]
[null,null,null,"COMPONENT NO.:","TO   _________"]
[null,null,null,"_____________"]
["Check",null,"  [ ] Hospital"]
["Applicable",null,"  [ ] Subprovider"]
["Box"]
[]
["PART V - MEDICARE PART A SERVICES - COST REIMBURSEMENT"]
[]
[1,"Inpatient services",{"$nulls":4},1]
[2,"Nursing and Allied Health Managed Care payment (see instruction)",{"$nulls":4},2]
[3,"Organ acquisition",{"$nulls":4},3]
[4,"Subtotal (sum of lines 1 thru 3)",{"$nulls":4},4]
[5,"Primary payer payments",{"$nulls":4},5]
[6,"Total cost (line 5 less line 6) . For CAH (see instructions)",{"$nulls":4},6]
[null,"COMPUTATION OF LESSER OF COST OR CHARGES",null,null,null,4995935]
[null,"Reasonable charges",null,null,null,4995935]
[7,"Routine service charges",{"$nulls":4},7]
[8,"Ancillary service charges",{"$nulls":4},8]
[9,"Organ acquisition charges, net of revenue",{"$nulls":4},9]
[10,"Total reasonable charges",{"$nulls":4},10]
[null,"Customary charges",null,null,null,4995935]
[11,"Aggregate amount actually collected from patients liable for payment for services on a charge basis",{"$nulls":4},11]
[12,"Amounts that would have been realized from patients liable for payment for services on",{"$nulls":4},12]
[null,"a charge basis had such payment been made in accordance with 42 CFR 413.13(e)"]
[13,"Ratio of line 11 to line 12 (not to exceed 1.000000)",{"$nulls":4},13]
[14,"Total customary charges (see instructions)",{"$nulls":4},14]
[15,"Excess of customary charges over reasonable cost (complete only if line 14 exceeds line 6) (see instructions)",{"$nulls":4},15]
[16,"Excess of reasonable cost over customary charges (complete only if line 6 exceeds line 14) (see instructions)",{"$nulls":4},16]
[17,"Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 19) (see instructions)",{"$nulls":4},17]
[null,"COMPUTATION OF REIMBURSEMENT SETTLEMENT",null,null,null,4995935]
[18,"Direct graduate medical education payments (from Worksheet E-4, line 49)",{"$nulls":4},18]
[19,"Cost of covered services (sum of lines 6, 17 and 18)",{"$nulls":4},19]
[20,"Deductibles (exclude professional component)",{"$nulls":4},20]
[21,"Excess reasonable cost (from line 16)",{"$nulls":4},21]
[22,"Subtotal (line 19 minus sum of lines 20 and 21)",{"$nulls":4},22]
[23,"Coinsurance",{"$nulls":4},23]
[24,"Subtotal (line 22 minus line 23)",{"$nulls":4},24]
[25,"Allowable bad debts (exclude bad debts for professional services) (see instructions)",{"$nulls":4},25]
[26,"Adjusted reimbursable bad debts (see instructions)",{"$nulls":4},26]
[27,"Allowable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},27]
[28,"Subtotal (sum of lines 24 and 25 or 26(line 26 hospital and subprovider only))",{"$nulls":4},28]
[29,"Other adjustments (see instructions) (specify)",{"$nulls":4},29]
[30,"Subtotal (line 28, plus or minus lines 29)",{"$nulls":4},30]
[31,"Interim payments",{"$nulls":4},31]
[32,"Tentative settlement (for contractor use only)",{"$nulls":4},32]
[33,"Balance due provider/program (line 30 minus the sum of lines 31, and 32)",{"$nulls":4},33]
[34,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2",{"$nulls":4},34]
{"$rows_empty":17}
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["Rev. 1",{"$nulls":5},"40-595"]

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["CALCULATION OF REIMBURSEMENT",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET E-3,"]
["SETTLEMENT",null,null,"________________","FROM ________","PART VI"]
[null,null,null,"COMPONENT NO.:","TO ___________"]
[null,null,null,"________________"]
[]
["PART VI - TITLE XVIII SNF PPS ONLY"]
[]
[]
[]
[{"$nulls":5},1]
[null,"PROSPECTIVE PAYMENT AMOUNT (SEE INSTRUCTIONS)"]
[1,"Resource Utilization Group Payment (RUGS)",{"$nulls":4},1]
[2,"Routine service other pass through costs",{"$nulls":4},2]
[3,"Ancillary service other pass through costs",{"$nulls":4},3]
[4,"Subtotal (sum of lines 1 through 3)",{"$nulls":4},4]
[" ","COMPUTATION OF NET COST OF COVERED SERVICES",null,null,null,4995935," "]
[5,"Medical and other services",{"$nulls":4},5]
[6,"Deductible",{"$nulls":4},6]
[7,"Coinsurance",{"$nulls":4},7]
[8,"Allowable bad debts (see instructions)",{"$nulls":4},8]
[9,"Reimbursable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},9]
[10,"Allowable reimbursable bad debts (see instructions)",{"$nulls":4},10]
[11,"Utilization review",{"$nulls":4},11]
[12,"Subtotal  (Sum of lines 4, 5 minus 6 & 7 plus 10 and 11)(see Instructions)",{"$nulls":4},12]
[13,"Inpatient primary payer payments",{"$nulls":4},13]
[14,"Other adjustments (see instructions) (specify)",{"$nulls":4},14]
[15,"Subtotal (line 12 minus 13  ± lines 14",{"$nulls":4},15]
[16,"Interim payments",{"$nulls":4},16]
[17,"Tentative settlement (for fiscal contractor use only)",{"$nulls":4},17]
[18,"Balance due provider/program (line 15 minus the sum of lines 16 and 17) ",{"$nulls":4},18]
[19,"Protested amounts (nonallowable cost report items) in accordance with CMS",{"$nulls":4},19]
[null,"Pub. 15-2, section 115.2"]
{"$rows_empty":33}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4033.6)"]
[]
["40-596",{"$nulls":5},"Rev. 1"]

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["DRAFT",null,null,"FORM CMS-2552-10",null,null,"4090 (Cont.)"]
["CALCULATION OF REIMBURSEMENT",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET E-3,"]
["SETTLEMENT",null,null,"________________","FROM ________","PART VII"]
[null,null,null,"COMPONENT NO.:","TO ___________"]
[null,null,null,"________________"]
["Check",null,"  [ ] Title V","  [ ] Hospital ",null,"  [ ] TEFRA"]
["Applicable",null,"  [ ] Title XIX","  [ ] NF",null,"  [ ] Other"]
["Boxes",null,null,"  [ ] ICF/MR"]
[]
["PART VII - TITLE V OR TITLE XIX SERVICES ONLY"]
[]
[{"$nulls":5},"Title V or"]
[{"$nulls":5},"Title XIX"]
[{"$nulls":5},"1"]
[" ","COMPUTATION OF NET COST OF COVERED SERVICES",null,null,null,4995935]
[1,"Inpatient hospital/SNF/NF services",{"$nulls":4},1]
[2,"Medical and other services",{"$nulls":4},2]
[3,"Organ acquisition (certified transplant centers only)",{"$nulls":4},3]
[4,"Subtotal (sum of lines 1, 2 and 3)",{"$nulls":4},4]
[5,"Inpatient primary payer payments",{"$nulls":4},5]
[6,"Outpatient primary payer payments",{"$nulls":4},6]
[7,"Subtotal (line 4 less sum of lines 5 and 6)",{"$nulls":4},7]
[null,"COMPUTATION OF LESSER OF COST OR CHARGES"]
[null,"Reasonable Charges"]
[8,"Routine service charges",{"$nulls":4},8]
[9,"Ancillary service charges",{"$nulls":4},9]
[10,"Organ acquisition charges, net of revenue",{"$nulls":4},10]
[11,"Incentive from target amount computation",{"$nulls":4},11]
[12,"Total reasonable charges (sum of lines 10 through 15)",{"$nulls":4},12]
[null,"CUSTOMARY CHRGES"]
[13,"Amount actually collected from patients liable for payment for services on a charge basis",{"$nulls":4},13]
[14,"Amounts that would have been realized from patients liable for payment for services",{"$nulls":4},14]
[null,"on a charge basis had such payment been made in accordance with 42 CFR 413.13(e)"]
[15,"Ratio of line 13 to line 14 (not to exceed 1.000000)",{"$nulls":4},15]
[16,"Total customary charges (see instructions)",{"$nulls":4},16]
[17,"Excess of customary charges over reasonable cost (complete only if line 16",{"$nulls":4},17]
[null,"exceeds line 7) (see instructions)"]
[18,"Excess of reasonable cost over customary charges (complete only if line 9 exceeds line 20) (see instructions)",{"$nulls":4},18]
[19,"Interns and Residents (see instructions)",{"$nulls":4},19]
[20,"Cost of teaching physicians (see instructions)",{"$nulls":4},20]
[21,"Cost of covered services (line 7)",{"$nulls":4},21]
[22,"Routine and Ancillary service other pass through costs",{"$nulls":4},22]
[]
[null,"COMPUTATION OF REIMBURSEMENT SETTLEMENT"]
[23,"Excess of reasonable cost (from line 18)",{"$nulls":4},23]
[24,"Subtotal (line 19 through 22 minus 23)",{"$nulls":4},24]
[25,"Deductibles",{"$nulls":4},25]
[26,"Coinsurance",{"$nulls":4},26]
[27,"Allowable bad debts (see instructions)",{"$nulls":4},27]
[28,"Utilization review",{"$nulls":4},28]
[29,"Subtotal (see instructions)",{"$nulls":4},29]
[30,"Other adjustments (see instructions) (specify)",{"$nulls":4},30]
[31,"Subtotal (line 29 ± line 30)",{"$nulls":4},31]
[32,"Direct graduate medical education payments (from Wkst. E-4)",{"$nulls":4},32]
[33,"Total amount payable to the provider (sum of lines 31, and 32)",{"$nulls":4},33]
[34,"Interim payments",{"$nulls":4},34]
[35,"Balance due provider/program (line 33 minus 34) ",{"$nulls":4},35]
[36,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub 15-2, section 115.2",{"$nulls":4},36]
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["Rev. 1",{"$nulls":5},"40-597"]

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["4090 (Cont.)",null,"                                                FORM CMS-2552-10",null,null,null,"DRAFT"]
["DIRECT GRADUATE MEDICAL EDUCATION (GME) ",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET E-4,"]
["& ESRD OUTPATIENT DIRECT MEDICAL ",null,null,null,"FROM  "]
["EDUCATION COSTS",null,null,null,"TO   "]
["Check",null,"  [  ]  Title V"]
["Applicable",null,"  [ ]  Title XVIII"]
["Box",null,"  [  ]  Title XIX"]
[null,"COMPUTATION OF TOTAL DIRECT GME AMOUNT"]
[1,"Unweighted resident FTE count for allopathic and osteopathic programs for cost reporting periods ending on or before December 31, 1996.",{"$nulls":4},1]
[2,"Reduction to Direct GME Cap Under Section 422 of MMA ",{"$nulls":4},2]
[3,"Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add on to",{"$nulls":4},3]
[null,"the cap for new programs in accordance with 42 CFR 413.86(g)(6)."]
[4,"Unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs in accordance with 42 CFR 413.86(g)(4).",{"$nulls":4},4]
[5,"FTE adjustment cap (line 1 minus line 2 plus lines 3 and 4)",{"$nulls":4},5]
[6,"Unweighted resident FTE count for allopathic and osteopathic programs for the current year from your records (see instructions)",{"$nulls":4},6]
[7,"Enter the lesser of line 5 or line 6",{"$nulls":4},7]
[null,null,null,"Primary Care","Other ","Total"," "]
[null,null,null,1,2,3]
[8,"Weighted FTE count for physicians in an allopathic and osteopathic program for the current year.",{"$nulls":4},8]
[9,"If line 6 is less than 5 enter the amount from line 8, otherwise  multiply line 8 times the result ",{"$nulls":4},9]
[null,"of line 5 divided by the amount on line 6."]
[10,"Weighted dental and podiatric resident FTE count for the current year ",{"$nulls":4},10]
[11,"Total weighted FTE count",{"$nulls":4},11]
[12,"Total weighted resident FTE count for the prior cost reporting year (see instructions)",{"$nulls":4},12]
[13,"Total weighted resident FTE count for the penultimate cost reporting year (see instructions)",{"$nulls":4},13]
[14,"Rolling average FTE count (sum of lines 11 through 13 divided by 3).",{"$nulls":4},14]
[15,"Adjustment for residents in initial years of new programs",{"$nulls":4},15]
[16,"Adjustment for residents displaced by program or hospital closure",{"$nulls":4},16]
[17,"Adjusted rolling average FTE count",{"$nulls":4},17]
[18,"Per resident amount",{"$nulls":4},18]
[19,"Approved amount for resident costs",{"$nulls":4},19]
[20,"Additional unweighted allopathic and osteopathic direct GME FTE resident cap slots received under 42 Sec. 413.79(c )(4)",{"$nulls":4},20]
[21,"GME FTE weighted Resident count over Cap (see instructions)",{"$nulls":4},21]
[22,"Allowable additional direct GME FTE Resident Count (see instructions)",{"$nulls":4},22]
[23,"Enter the locality adjustment national average per resident amount (see instructions)",{"$nulls":4},23]
[24,"Multiply line 22 time line 23",{"$nulls":4},24]
[25,"Total direct GME amount (sum of lines 19 and 24)",{"$nulls":4},25]
[null,"COMPUTATION OF PROGRAM PATIENT LOAD",null,"Inpatient Part A","Managed care"]
[26,"Inpatient Days",{"$nulls":4},26]
[27,"Total Inpatient Days",{"$nulls":4},27]
[28,"Ratio of inpatient days to total inpatient days",{"$nulls":4},28]
[29,"Program direct GME amount",{"$nulls":4},29]
[30,"Reduction for nursing/allied health",{"$nulls":4},30]
[31,"Net Program direct GME amount",{"$nulls":4},31]
[null,"DIRECT MEDICAL EDUCATION COSTS FOR ESRD COMPOSITE RATE - TITLE XVIII ONLY (NURSING SCHOOL AND PARAMEDICAL EDUCATION COSTS)"]
[32,"Renal dialysis direct medical education costs (from Worksheet B, Part I, sum of columns 20 and 23, lines 71 and 94)",{"$nulls":4},32]
[33,"Renal dialysis and home dialysis total charges (Worksheet C, Part I, column 8, sum of lines 71 and 94)",{"$nulls":4},33]
[34,"Ratio of direct medical education costs to total charges (line 32 ÷ line 33)",{"$nulls":4},34]
[35,"Medicare outpatient ESRD charges (see instructions)",{"$nulls":4},35]
[36,"Medicare outpatient ESRD direct medical education costs (line 34 x line 35)",{"$nulls":4},36]
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[]
["40-598",{"$nulls":5},"Rev. 1"]
["DRAFT",null,"                                                FORM CMS-2552-09",null,null,null,"4090 (Cont.)"]
["DIRECT GRADUATE MEDICAL EDUCATION (GME) ",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET E-4, "]
["& ESRD OUTPATIENT DIRECT MEDICAL ",null,null,null,"FROM ","(Cont.)"]
["EDUCATION COSTS",null,null,null,"TO  "]
["Check",null,"  [  ]  Title V"]
["Applicable",null,"  [ ]  Title XVIII"]
["Box",null,"  [  ]  Title XIX"]
[null,"APPORTIONMENT BASED ON MEDICARE REASONABLE COST - TITLE XVIII ONLY"]
[null,"Part A Reasonable Cost"]
[37,"Reasonable cost (see instructions)",{"$nulls":4},37]
[38,"Organ acquisition costs (Worksheet D-4, Part III, column 1, line 62)",{"$nulls":4},38]
[39,"Cost of teaching physicians (Worksheet D-5, Part II, column 3, line 19)",{"$nulls":4},39]
[40,"Primary payer payments (see instructions)",{"$nulls":4},40]
[41,"Total Part A reasonable cost (sum of lines 37 through 39 minus line 40)",{"$nulls":4},41]
[null,"Part B Reasonable Cost "]
[42,"Reasonable cost (see instructions)",{"$nulls":4},42]
[43,"Primary payer payments (see instructions)",{"$nulls":4},43]
[44,"Total Part B reasonable cost (line 42 minus line 43)",{"$nulls":4},44]
[45,"Total reasonable cost (sum of lines 41 and 44)",{"$nulls":4},45]
[46,"Ratio of Part A reasonable cost to total reasonable cost (line 41 ÷ line 45)",{"$nulls":4},46]
[47,"Ratio of Part B reasonable cost to total reasonable cost (line 44 ÷ line 45)",{"$nulls":4},47]
[null,"ALLOCATION OF MEDICARE DIRECT GME COSTS BETWEEN PART A AND PART B"]
[48,"Total program GME payment (line 31)",{"$nulls":4},48]
[49,"Part A Medicare GME payment (line 46 x 48)(Title XVIII only)(see instructions)",{"$nulls":4},49]
[50,"Part B Medicare GME payment (line 47 x 48) (title XVIII only) (see instructions)",{"$nulls":4},50]
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[]
["Rev. 1",{"$nulls":5},"40-599"]