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["(1)","Enter amount in column 1 from Worksheet J-1, Part I, column 29, line 21."]
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[null,"and the amounts from line 29, columns 5, 7, and 9.  (3)"]
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["(1)"," From Worksheet C, Part I, column 9, lines as appropriate"]
["(2)"," Charges for columns 4, 6, and 8 are obtained from your records."]
["(3)"," Transfer the amounts on line 29, columns 5, 7, and 9, as appropriate, to Worksheet J-3, line 1."]
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["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4054.2)"]
["Rev. 1",{"$nulls":10},"40-629"]

{"sheet":"J3","index":4,"n_rows":64,"n_cols":31,"rows_kept":64,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["   4090 (Cont.)",null,null,"FORM CMS-2552-10",null,null,null,"DRAFT"]
["HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND",null,null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET J-3",{"$nulls":23},"  ."]
["OTHER OUTPATIENT REHABILITATION",null,null,null,"_______________","FROM___________"]
["PROVIDER STATISTICAL DATA",null,null,null,"COMPONENT NO.:","TO____________"]
[{"$nulls":4},"_______________"]
["Check",null," [ ] Title V","  [  ]  CMHC     [  ]  OOT"]
["Applicable ",null," [ ] Title XVIII","  [  ]  CORF      [  ]  OSP"]
["Box:",null," [ ] Title XIX","  [  ]  OPT"]
[{"$nulls":6},"PROGRAM"]
[{"$nulls":6},"COST"]
[{"$nulls":6},"1"]
[1,"Cost of component services (from Worksheet J-2, Part II, line 30)",{"$nulls":5},1]
[2,"PPS payments received excluding outliers",{"$nulls":5},2]
[3,"Outlier Payments",{"$nulls":5},3]
[4,"Primary payer payments",{"$nulls":5},4]
[5,"Total reasonable cost (see instructions)",{"$nulls":5},5]
[6,"Total charges for program services",{"$nulls":5},6]
[null,"CUSTOMARY CHARGES"]
[7,"Aggregate amount actually collected from patients liable for services on a charge basis",{"$nulls":5},7]
[null,"Amount that would have been realized from patients liable for payment for services on a charge"]
[8,"basis had such payment been made in accordance with 42 CFR 413.13(e)",{"$nulls":5},8]
[9,"Ratio of line 7 to line 8 (not to exceed 1.000000) (see instructions)",{"$nulls":5},9]
[10,"Total customary charges (see instructions)",{"$nulls":5},10]
[11,"Excess of customary charges over reasonable cost (see instructions) ",{"$nulls":5},11]
[12,"Excess of reasonable cost over customary charges (see instructions) ",{"$nulls":5},12]
[null,"COMPUTATION OF REIMBURSEMENT SETTLEMENT"]
[13,"Total reasonable cost (from line 5)",{"$nulls":5},13]
[14,"Part B deductible billed to program patients",{"$nulls":5},14]
[15,"Net cost (line 13 minus line 14)",{"$nulls":5},15]
[16,"Excess of reasonable cost over customary charges (from line 12)",{"$nulls":5},16]
[17,"Subtotal (line 15 minus line 16)",{"$nulls":5},17]
[18,"80 percent of costs (80% of line 17) (see instructions)",{"$nulls":5},18]
[19,"Actual coinsurance billed to program patients (from provider records)",{"$nulls":5},19]
[20,"Net cost less actual billed coinsurance (line 17 minus line 19)",{"$nulls":5},20]
[21,"Reimbursable bad debts (from provider records) (see instructions)",{"$nulls":5},21]
[22,{"$nulls":6},22]
[23,"Reimbursable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":5},23]
[24,"Net reimbursable amount (see instructions)",{"$nulls":5},24]
[25,"Other adjustments (see instructions) (specify)",{"$nulls":5},25]
[26,"Total cost (line 24 plus or minus line 25)",{"$nulls":5},26]
[27,"Interim payments  (see instructions)",{"$nulls":5},27]
[28,"Tentative settlement (for contractor use only)",{"$nulls":5},28]
[29,"Balance due component/program (line 26 minus lines 27 and 28)",{"$nulls":5},29]
[30,"Protested amounts (nonallowable cost report items in accordance with CMS Pub. 15-II, section 115.2)",{"$nulls":5},30]
{"$rows_empty":17}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4055)"]
[]
["40-630",{"$nulls":6},"Rev. 1"]

{"sheet":"J4","index":5,"n_rows":63,"n_cols":33,"rows_kept":63,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,"                 FORM CMS-2552-10",{"$nulls":5},"4090 (Cont.)"]
["HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND",null,null,"PROVIDER NO.:",null,null,"PERIOD","WORKSHEET J-4",{"$nulls":24},"  ."]
["OTHER OUTPATIENT REHABILITATION",{"$nulls":5},"FROM__________"]
["PROVIDER STATISTICAL DATA",null,null,"COMPONENT NO.:",null,null,"TO_____________"]
["BENEFICIARIES"]
["Check ",null," [ ] Title V",null,"  [  ]  CMHC     [  ]  OOT"]
["Applicable",null," [ ] Title XVIII",null,"  [  ]  CORF      [  ]  OSP"]
["Box:",null," [ ] Title XIX",null,"  [  ]  OPT"]
[{"$nulls":6},"Part B"]
[null,"DESCRIPTION",{"$nulls":4},"1","2"]
[{"$nulls":6},"mm/dd/yyyy","Amount"]
["1","Total interim payments paid to providers",{"$nulls":6},1]
["2","Interim payments payable on individual bills, either",{"$nulls":6},2]
[null,"submitted or to be submitted to the intermediary, for"]
[null,"services rendered in the cost reporting periods. If"]
[null,"none, write \"NONE\", or enter zero."]
["3","List separately each retroactive ",null,null,null,".01",null,null,3.01]
[null,"lump sum adjustment amount",null,null,"Program",".02",null,null,3.02]
[null,"based on subsequent revision of",null,null,"to",".03",null,null,3.03]
[null,"the interim  rate for the ",null,null,"Provider",".04",null,null,3.04]
[null,"cost reporting period. Also show",null,null,null,".05",null,null,3.05]
[null,"date of each payment.",null,null,null,".50",null,null,3.5]
[null,"If none, write \"NONE\",",null,null,"Provider",".51",null,null,3.51]
[null,"or enter zero (1).",null,null,"to",".52",null,null,3.52]
[{"$nulls":4},"Program",".53",null,null,3.53]
[{"$nulls":5},".54",null,null,3.54]
[null,"Subtotal (sum of lines 3.01-3.49"]
[null,"minus sum of lines 3.50-3.98)",null,null,null,".99",null,null,3.99]
["4","Total interim payments (sum of lines 1, 2, and 3.99)",{"$nulls":6},4]
[null,"(transfer to Worksheet J-3, line 35)"]
[]
[null,"TO BE COMPLETED BY INTERMEDIARY"]
["5","List separately each tentative",null,null,"Program ",".01",null,null,5.01]
[null,"settlement payment after desk review.",null,null,"to",".02",null,null,5.02]
[null,"Also show date of each payment.",null,null,"Provider",".03",null,null,5.03]
[null,"If none, write \"NONE,\"",null,null,"Provider",".50",null,null,5.5]
[null,"or enter zero (1).",null,null,"to",".51",null,null,5.51]
[{"$nulls":4},"Program",".52",null,null,5.52]
[null,"Subtotal (sum of lines 5.01-5.49 minus"]
[null,"sum of lines 5.50-5.98)",null,null,null,".99",null,null,5.99]
["6","Determine net settlement amount",null,null,"Program "]
[null,"(balance due) based on the cost",null,null,"to"]
[null,"report (see instructions). (1)",null,null,"Provider",".01",null,null,6.01]
[{"$nulls":4},"Provider"]
[{"$nulls":4},"to"]
[{"$nulls":4},"Program",".02",null,null,6.02]
[]
["7","Total Medicare liability (see instructions)",{"$nulls":6},7]
[8,"Name of Contractor","Contractor Number",null,null,"(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 you agree to the amount of"]
[null,"repayment, even though the total repayment is not accomplished until a later date."]
[]
[]
[]
[]
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4056)"]
[{"$nulls":7}," "]
["Rev. 1",{"$nulls":7},"40-631"]