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[]
[]
["Rev. 1",{"$nulls":9},"40-611","40-612",{"$nulls":10},"Rev. 1","Rev. 1",{"$nulls":8},"40-613"]

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[{"$nulls":11}," FROM ______________",null,"Part I "]
[{"$nulls":8},"HHA NO.:________________",null,null," TO   ________________"]
["Check applicable box",null," [ ] Title V     [ ] Title XVIII     [ ] Title XIX"]
["PART I - COMPUTATION OF LESSER OF AGGREGATE PROGRAM COST, AGGREGATE OF THE PROGRAM LIMITATION COST, OR BENEFICIARY COST LIMITATION"]
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[null,null,"From,","Facility","Shared",null,null,"Average",null,"                    Part B",null,null,"                    Part B"]
[null,null,"Wkst.","Costs","Ancillary","Total",null,"Cost",null,"Not",null,null,"Not",null,"Total"]
[null,null,"H-2,","(from","Costs","HHA",null,"Per Visit",null,"Subject to","Subject to",null,"Subject to","Subject to","Program Cost"]
[null,"Patient Services","Part I,","Wkst. H-2,","(from","Costs","Total","(col. 3 ",null,"Deductibles ","Deductibles ",null,"Deductibles ","Deductibles ","(sum of"]
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[1,"Skilled Nursing Care","2",{"$nulls":12},1]
[2,"Physical Therapy","3",{"$nulls":12},2]
[3,"Occupational Therapy","4",{"$nulls":12},3]
[4,"Speech Pathology","5",{"$nulls":12},4]
[5,"Medical Social Services","6",{"$nulls":12},5]
[6,"Home Health Aide","7",{"$nulls":12},6]
[7,"Total (sum of lines 1-6)",{"$nulls":13},7]
[null,"Limitation Cost Computation",{"$nulls":11},"Program Visits"]
[{"$nulls":13},"                    Part B"]
[{"$nulls":13},"Not Subject to","Subject to"]
[null,"Patient Services",{"$nulls":9},"CBSA",null,"Deductibles ","Deductibles "]
[{"$nulls":11},"No. (1)","Part A","& Coinsurance","& Coinsurance"]
[{"$nulls":11},"1",2,3,4]
[8,"Skilled Nursing Care",{"$nulls":10}," "," ",null,8]
[9,"Physical Therapy",{"$nulls":13},9]
[10,"Occupational Therapy",{"$nulls":13},10]
[11,"Speech Pathology",{"$nulls":13},11]
[12,"Medical Social Services",{"$nulls":13},12]
[13,"Home Health Aide",{"$nulls":13},13]
[14,"Total (sum of lines 8-13)",{"$nulls":13},14]
[]
[]
[]
["Supplies and Drugs Cost Computations",{"$nulls":8},"                  Program Covered Charges",null,null,null,"Cost of Services"]
[{"$nulls":4},"Facility","Shared",{"$nulls":4},"                    Part B",null,null,"                    Part B"]
[null,null,null,"From","Costs","Ancillary","Total","Total",null,null,"Not",null,null,"Not"]
[null,null,null,"Wkst. H-2","(from ","Costs","HHA","Charges","Ratio",null,"Subject to","Subject to",null,"Subject to","Subject to"]
[null,"Other Patient Services",null,"Part I,","Wkst. H-2,","(from","Costs","(from HHA","(col. 3",null,"Deductibles ","Deductibles ",null,"Deductibles ","Deductibles "]
[null,null,null,"col. 28,","Part I)","Part II)","(cols. 1 + 2)","Record)","÷ col. 4)","Part A","& Coinsurance","& Coinsurance","Part A","& Coinsurance","& Coinsurance"]
[null,null,null,"line","1","2","3","4",5,"6","7","8","9","10","11"]
[15,"Cost of Medical Supplies",null,"8",{"$nulls":11},15]
[16,"Cost of Drugs",null,"9",{"$nulls":11},16]
[]
["PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS"]
[{"$nulls":12},"Total"]
[{"$nulls":11},"Cost","HHA Charges","HHA Shared","Transfer to "]
[{"$nulls":10},"From Wkst. C,","to Charge","(from provider","Ancillary Costs","Part I"]
[{"$nulls":10},"Part I, col. 9,","Ratio","records)","(col. 1 x col. 2)","as Indicated"]
[{"$nulls":10},"line","1","2","3","4"]
[1,"Physical Therapy",{"$nulls":8},63,null,null,null,"col. 2, line 2",1]
[2,"Occupational Therapy",{"$nulls":8},64,null,null,null,"col. 2, line 3",2]
[3,"Speech Pathology",{"$nulls":8},65,null,null,null,"col. 2, line 4",3]
[4,"Cost of Medical Supplies",{"$nulls":8},68,null,null,null,"col. 2, line 15",4]
[5,"Cost of Drugs",{"$nulls":8},70,null,null,null,"col. 2, line 16",5]
{"$rows_empty":9}
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[]
["40-614",{"$nulls":14},"Rev. 1"]

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["CALCULATION OF HHA REIMBURSEMENT",null,null,"PROVIDER NO.:"," PERIOD:","WORKSHEET H-4,"]
["SETTLEMENT",null,null,"______________"," FROM___________","Parts I & II"]
[null,null,null,"HHA NO.:"," TO______________"]
[null,null,null,"______________"]
["Check Applicable Box",null," [ ] Title V","[  ]  Title XVIII","[  ]  Title XIX"]
["PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES"]
[{"$nulls":4},"Part B"]
[{"$nulls":4},"Not Subject to","Subject to"]
[{"$nulls":4},"Deductibles","Deductibles"]
[null,null,null,"Part A","& Coinsurance","& Coinsurance"]
[null,"        Description",null,"1","2","3"]
[null,"Reasonable Cost of Part A & Part B Services"]
[1,"Reasonable cost of services (see instructions)",{"$nulls":4},1]
[2,"Total charges ",{"$nulls":4},2]
[null,"Customary Charges"]
[3,"Amount actually collected from patients liable for payment",{"$nulls":4},3]
[null,"for services on a charge basis (from your records)"]
[4,"Amount that would have been realized from patients liable",{"$nulls":4},4]
[null,"for payment for services on a charge basis had such"]
[null,"payment been made in accordance with 42 CFR 413.13(b)"]
[5,"Ratio of line 3 to line 4 (not to exceed 1.000000)",{"$nulls":4},5]
[6,"Total customary charges (see instructions)",{"$nulls":4},6]
[7,"Excess of total customary charges over total reasonable",{"$nulls":4},7]
[null,"cost (complete only if line 6 exceeds line 1)"]
[8,"Excess of reasonable cost over customary charges ",{"$nulls":4},8]
[null,"(complete only if line 1 exceeds line 6)"]
[9,"Primary payer amounts",{"$nulls":4},9]
["PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT"]
[{"$nulls":4},"Part A Services","Part B Services"]
[null,"        Description",null,null,"1","2"]
[10,"Total reasonable cost (see instructions)",{"$nulls":4},10]
[11,"Total PPS Reimbursement - Full Episodes without Outliers",{"$nulls":4},11]
[12,"Total PPS Reimbursement - Full Episodes with Outliers",{"$nulls":4},12]
[13,"Total PPS Reimbursement - LUPA Episodes",{"$nulls":4},13]
[14,"Total PPS Reimbursement - PEP Episodes",{"$nulls":4},14]
[15,"Total PPS Outlier Reimbursement - Full Episodes with Outliers",{"$nulls":4},15]
[16,"Total PPS Outlier Reimbursement - PEP Episodes",{"$nulls":4},16]
[17,"Total Other Payments",{"$nulls":4},17]
[18,"DME Payments",{"$nulls":4},18]
[19,"Oxygen Payments",{"$nulls":4},19]
[20,"Prosthetic and Orthotic Payments",{"$nulls":4},20]
[21,"Part B deductibles billed to Medicare patients (exclude coinsurance)",{"$nulls":4},21]
[22,"Subtotal (sum of lines 10 thru 20 minus line 21)",{"$nulls":4},22]
[23,"Excess reasonable cost (from line 8)",{"$nulls":4},23]
[24,"Subtotal (line 22 minus line 23)",{"$nulls":4},24]
[25,"Coinsurance billed to program patients (from your records)",{"$nulls":4},25]
[26,"Net cost (line 24 minus line 25)",{"$nulls":4},26]
[27,"Reimbursable bad debts (from your records)",{"$nulls":4},27]
[28,"Reimbursable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},28]
[29,"Total costs - current cost reporting period (line 26 plus line 27)",{"$nulls":4},29]
[30,"Other adjustments (see instructions) (specify)",{"$nulls":4},30]
[31,"Subtotal (line 29 plus/minus line 30)",{"$nulls":4},31]
[32,"Interim payments (see instructions)",{"$nulls":4},32]
[33,"Tentative settlement (for contractor use only)",{"$nulls":4},33]
[34,"Balance due provider/program (line 31 minus lines 32 and 33)",{"$nulls":4},34]
[35,"Protested amounts (nonallowable cost report items) in accordance with CMS",{"$nulls":4},35]
[null,"Pub. 15-II, section 115.2"]
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["Rev. 1",{"$nulls":5},"40-615"]

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["    4090 (Cont.)",{"$nulls":5},"FORM CMS-2552-10",{"$nulls":5},"DRAFT"]
["ANALYSIS OF PAYMENTS TO PROVIDER-",{"$nulls":5}," PROVIDER NO.:",null,null," PERIOD:",null,"WORKSHEET H-5",{"$nulls":17},"{APP4}IALLWAYS~/lp2~q/PCOPB1~Q/pGQ/1"]
["BASED HHAs FOR SERVICES ",{"$nulls":5}," ______________________",null,null," FROM _____________"]
["RENDERED TO PROGRAM BENEFICIARIES",{"$nulls":5}," HHA NO.:",null,null," TO ________________"]
[{"$nulls":6}," ______________________"]
[]
[null,null,"     Description",{"$nulls":5},"Part A",null,"Part B"]
[{"$nulls":8},"mm/dd/yyyy","Amount","mm/dd/yyyy","Amount"]
[{"$nulls":8},"1","2","3","4"]
[1," Total interim payments paid to provider ",{"$nulls":10},1]
[2," Interim payments payable on individual bills either submitted or ",{"$nulls":10},2]
[null," to be submitted to the intermediary for services rendered in the"]
[null," cost reporting period.  If none, write \"NONE\" or enter a zero."]
[3," List separately each retroactive lump sum ",{"$nulls":5},".01",{"$nulls":4},3.01]
[null," adjustment amount based on subsequent revision",{"$nulls":5},".02",{"$nulls":4},3.02]
[null," of the interim rate for the cost reporting period.",{"$nulls":4},"Program ",".03",{"$nulls":4},3.03]
[null," Also show date of each payment.  If none, write",{"$nulls":4},"    to   ",".04",{"$nulls":4},3.04]
[null," \"NONE\" or enter a zero.(1)",{"$nulls":4},"Provider",".05",{"$nulls":4},3.05]
[{"$nulls":7},".50",{"$nulls":4},3.5]
[null,"                                ",{"$nulls":5},".51",{"$nulls":4},3.51]
[{"$nulls":6},"Provider",".52",{"$nulls":4},3.52]
[null,"                                 ",{"$nulls":4},"    to   ",".53",{"$nulls":4},3.53]
[{"$nulls":6},"Program ",".54",{"$nulls":4},3.54]
[null," Subtotal (sum of lines 3.01-3.49 minus sum"]
[null," of lines 3.50-3.98)                         ",{"$nulls":5},".99",{"$nulls":4},3.99]
[4," Total interim payments (sum of lines 1, 2, and 3.99)",{"$nulls":10},4]
[null," (transfer to Wkst. H-4, Part II, column as appropriate, line 23)"]
[]
[{"$nulls":4},"TO BE COMPLETED BY INTERMEDIARY"]
[]
[5," List separately each tentative settlement payment ",{"$nulls":4},"Program",".01",{"$nulls":4},5.01]
[null," after desk review.  Also show date of each ",{"$nulls":4},"    to   ",".02",{"$nulls":4},5.02]
[null," payment.  If none, write \"NONE\" or enter     ",{"$nulls":4},"Provider",".03",{"$nulls":4},5.03]
[null," a zero. (1)",{"$nulls":4},"Provider",".50",{"$nulls":4},5.5]
[{"$nulls":6},"    to   ",".51",{"$nulls":4},5.51]
[{"$nulls":6},"Program",".52",{"$nulls":4},5.52]
[null," Subtotal (sum of lines 5.01-5.49 minus sum  "]
[null," of lines 5.50-5.98)      ",{"$nulls":5},".99",{"$nulls":4},5.99]
[6," Determine net settlement amount (balance due)",{"$nulls":4},"Program"]
[null," based on the cost report (see instructions)",{"$nulls":4},"    to   ",".01"]
[{"$nulls":6},"Provider",{"$nulls":5},6.01]
[{"$nulls":6},"Provider"]
[{"$nulls":6},"    to   ",".02"]
[{"$nulls":6},"Program",{"$nulls":5},6.02]
[7," TOTAL MEDICARE PROGRAM LIABILITY ",{"$nulls":10},7]
[null," (see instructions) "]
[8," Name of Contractor",{"$nulls":4},"    Contractor Number",null,null,"    Date:   Month, Day, Year",null,null,8]
[]
[]
[]
[" (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."]
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["40-616",{"$nulls":11},"Rev. 1"]