{"text_format":"2","workbook":"xls","n_sheets":5,"sheets":["M1","M2","M3","M4","M5"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":1,"defined_names":4,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"run_cost":"one","rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900","formulas":"cached_only"}

{"sheet":"M1","index":0,"n_rows":52,"n_cols":10,"rows_kept":52,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,"FORM CMS-2552-10",{"$nulls":6},"4090 (Cont.)"]
["ANALYSIS OF PROVIDER-BASED RURAL HEALTH CLINIC/",null,null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET M-1"]
["FEDERALLY QUALIFIED HEALTH CENTER COSTS",null,null,null,"_______________",null,"FROM_______________"]
[{"$nulls":4},"COMPONENT NO.:",null,"TO__________________"]
[{"$nulls":4},"_______________"]
["Check  Applicable Box",null,"  [  ]  RHC   [  ] FQHC"]
[{"$nulls":6},"RECLASSIFIED",null,"NET EXPENSES"]
[{"$nulls":6},"TRIAL",null,"FOR"]
[null,null,"COMPENSAT-",null,"TOTAL","RECLASSFI-","BALANCE",null,"ALLOCATION"]
[null,null,"ION","OTHER COSTS","(col. 1 + col. 2)","CATIONS","(col. 3 + col. 4)","ADJUSTMENTS","(col. 5 + col. 6)"]
[null,null,"1","2","3","4","5","6","7"]
[" ","FACILITY HEALTH CARE STAFF COSTS",{"$nulls":7}," "]
[1,"Physician",{"$nulls":7},1]
[2,"Physician Assistant",{"$nulls":7},2]
[3,"Nurse Practitioner",{"$nulls":7},3]
[4,"Visiting Nurse",{"$nulls":7},4]
[5,"Other Nurse",{"$nulls":7},5]
[6,"Clinical Psychologist",{"$nulls":7},6]
[7,"Clinical Social Worker",{"$nulls":7},7]
[8,"Laboratory Technician",{"$nulls":7},8]
[9,"Other Facility Health Care Staff Costs",{"$nulls":7},9]
[10,"Subtotal (sum of lines 1-9)",{"$nulls":7},10]
[" ","COSTS UNDER AGREEMENT",{"$nulls":7}," "]
[11,"Physician Services Under Agreement",{"$nulls":7},11]
[12,"Physician Supervision Under Agreement",{"$nulls":7},12]
[13,"Other Costs Under Agreement",{"$nulls":7},13]
[14,"Subtotal (sum of lines 11-13)",{"$nulls":7},14]
[" ","OTHER HEALTH CARE COSTS",{"$nulls":7}," "]
[15,"Medical Supplies",{"$nulls":7},15]
[16,"Transportation (Health Care Staff)",{"$nulls":7},16]
[17,"Depreciation-Medical Equipment",{"$nulls":7},17]
[18,"Professional Liability Insurance",{"$nulls":7},18]
[19,"Other Health Care Costs",{"$nulls":7},19]
[20,"Allowable GME Costs",{"$nulls":7},20]
[21,"Subtotal (sum of lines 15-20)",{"$nulls":7},21]
[22,"Total Cost of Health Care Services",{"$nulls":7},22]
[" ","(sum of lines 10, 14, and 21)",{"$nulls":7}," "]
[null,"COSTS OTHER THAN RHC/FQHC SERVICES"]
[23,"Pharmacy",{"$nulls":7},23]
[24,"Dental",{"$nulls":7},24]
[25,"Optometry",{"$nulls":7},25]
[26,"All other nonreimbursable costs",{"$nulls":7},26]
[27,"Nonallowable GME costs",{"$nulls":7},27]
[28,"Total Nonreimbursable Costs (sum of lines 23-27)",{"$nulls":7},28]
[null,"FACILITY OVERHEAD"]
[29,"Facility Costs",{"$nulls":7},29]
[30,"Administrative Costs",{"$nulls":7},30]
[31,"Total Facility Overhead (sum of lines 29 and 30)",{"$nulls":7},31]
[32,"Total facility costs (sum of lines 22,  28 and 31)",{"$nulls":7},32]
["The net expenses for cost allocation on Worksheet A for the RHC/FQHC cost center line must equal the total facility costs in column 7, line 32 of this worksheet."]
["FORM CMS-2552-10  (DRAFT)   (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION  4066)"]
["Rev. 1",{"$nulls":8},"40-659"]

{"sheet":"M2","index":1,"n_rows":67,"n_cols":8,"rows_kept":67,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,"FORM CMS-2552-10",{"$nulls":4},"DRAFT"]
["ALLOCATION OF OVERHEAD",null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET M-2"]
["TO RHC/FQHC SERVICES",null,"_______________",null,"FROM____________"]
[null,null,"COMPONENT NO.:",null,"TO_____________"]
[null,null,"_______________"]
["Check Applicable Box:",null," [ ] RHC    "," [ ] FQHC"]
["VISITS AND PRODUCTIVITY"]
[null,null,"Number",null,null,"Minimum","Greater of"]
[null,null,"of FTE","Total","Productivity","Visits (col. 1","col. 2 or"]
[null,null,"Personnel","Visits","Standard (1)","x col. 3)","col. 4"]
[null,"    Positions","1","2","3","4","5"]
[1,"Physicians",{"$nulls":5},1]
[2,"Physician Assistants",{"$nulls":5},2]
[3,"Nurse Practitioners",{"$nulls":5},3]
[4,"Subtotal (sum of lines 1-3)",{"$nulls":5},4]
[5,"Visiting Nurse",{"$nulls":5},5]
[6,"Clinical Psychologist",{"$nulls":5},6]
[7,"Clinical Social Worker",{"$nulls":5},7]
[8,"Total FTEs and Visits (sum of lines 4-7)",{"$nulls":5},8]
[9,"Physician Services Under Agreements",{"$nulls":5},9]
["DETERMINATION OF ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES"]
[10,"Total costs of health care services (from Worksheet M-1, column 7, line 22)",{"$nulls":5},10]
[11,"Total nonreimbursable costs (from Worksheet M-1, column 7, line 28)",{"$nulls":5},11]
[12,"Cost of all services (excluding overhead) (sum of lines 10 and 11)",{"$nulls":5},12]
[13,"Ratio of RHC/FQHC services (line 10 divided by line 12)",{"$nulls":5},13]
[14,"Total facility overhead - (from Worksheet M-1, column 7, line 31)",{"$nulls":5},14]
[15,"Parent provider overhead allocated to facility (see instructions)",{"$nulls":5},15]
[16,"Total overhead (sum of lines 14 and 15)",{"$nulls":5},16]
[17,"Allowable GME overhead (see instructions)",{"$nulls":5},17]
[18,"Subtract line 17 from line 16",{"$nulls":5},18]
[19,"Overhead applicable to RHC/FQHC services (line 13 x line 18)",{"$nulls":5},19]
[20,"Total allowable cost of RHC/FQHC services (sum of lines 10 and 19)",{"$nulls":5},20]
[]
["(1)","The productivity standard for physicians is 4,200 and 2,100 for physician assistants and nurse practitioners.  If an exception"]
[null,"to the standard has been granted (Worksheet S-8, line 14 equals \"Y\"), column 3, lines 1thru 3 of this worksheet should contain,"]
[null,"at a minimum, one element that is different than the standard."]
{"$rows_empty":28}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4067)"]
[]
["40-660",{"$nulls":6},"Rev. 1"]

{"sheet":"M3","index":2,"n_rows":67,"n_cols":7,"rows_kept":67,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,"FORM CMS-2552-10",null,null,null,"4090(Cont.)"]
["CALCULATION OF REIMBURSEMENT",null,"PROVIDER NO.:","PERIOD:",null,"WORKSHEET M-3"]
["SETTLEMENT FOR RHC/FQHC SERVICES",null,"_______________","FROM____________"]
[null,null,"COMPONENT NO.:","TO______________"]
[null,null,"_______________"]
["Check ",null," [ ] RHC"," [ ] Title V           [ ] Title XIX"]
["Applicable Box:",null," [ ] FQHC"," [ ] Title XVIII"]
["DETERMINATION OF RATE FOR RHC/FQHC SERVICES"]
[1,"Total Allowable Cost of RHC/FQHC Services (from Worksheet M-2, line 20)",{"$nulls":4},1]
[2,"Cost of vaccines and their administration (from Worksheet M-4, line 15)",{"$nulls":4},2]
[3,"Total allowable cost excluding vaccine (line 1 minus line 2)",{"$nulls":4},3]
[4,"Total Visits (from Worksheet M-2, column 5, line 8)",{"$nulls":4},4]
[5,"Physicians visits under agreement (from Worksheet M-2, column 5, line 9)",{"$nulls":4},5]
[6,"Total adjusted visits (line 4 plus line 5)",{"$nulls":4},6]
[7,"Adjusted cost per visit (line 3 divided by line 6)",{"$nulls":4},7]
[]
[{"$nulls":4},"Calculation of Limit (1)"]
[{"$nulls":4},"Prior to","On or after"]
[{"$nulls":4},"January 1","January 1"]
[{"$nulls":4},1,2]
[8,"Per visit payment limit (from CMS Pub. 27,Sec. 505 or your intermediary)",{"$nulls":4},8]
[9,"Rate for Program covered visits (see instructions)",{"$nulls":4},9]
["CALCULATION OF SETTLEMENT"]
[10,"Program covered visits excluding mental health services (from intermediary records)",{"$nulls":4},10]
[11,"Program cost excluding costs for mental health services (line 9 x line 10)",{"$nulls":4},11]
[12,"Program covered visits for mental health services (from intermediary records)",{"$nulls":4},12]
[13,"Program covered cost from mental health services (line 9 x line 12)",{"$nulls":4},13]
[14,"Limit adjustment for mental health services (see instructions)",{"$nulls":4},14]
[15,"Graduate Medical Education Pass Through Cost (see instructions)",{"$nulls":4},15]
[16,"Total Program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3) *",{"$nulls":4},16]
[17,"Primary payer amounts",{"$nulls":4},17]
[18,"Less:  Beneficiary deductible (from intermediary records)",{"$nulls":4},18]
[19,"Net Program cost excluding vaccines (line 16 minus sum of lines 17 and 18)",{"$nulls":4},19]
[20,"Reimbursable cost of RHC/FQHC services, excluding vaccine (80% of line 19)",{"$nulls":4},20]
[21,"Program cost of vaccines and their administration (from Wkst. M-4, line 16)",{"$nulls":4},21]
[22,"Total reimbursable Program cost (line 20 plus line 21)",{"$nulls":4},22]
[23,"Reimbursable bad debts (see instructions)",{"$nulls":4},23]
[24,"Reimbursable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},24]
[25,"Other adjustments (see instructions) (specify)",{"$nulls":4},25]
[26,"Net reimbursable amount (lines 22 plus 23 plus or minus line 25)",{"$nulls":4},26]
[27,"Interim payments",{"$nulls":4},27]
[28,"Tentative settlement (for fiscal intermediary use only)",{"$nulls":4},28]
[29,"Balance due component/program (line 26 minus lines 27 and 28)",{"$nulls":4},29]
[30,"Protested amounts (nonallowable cost report items) in accordance with CMS",{"$nulls":4},30]
[null,"Pub. 15-II, chapter I, section 115.2"]
[]
["(1)  Lines 8 through 14:  Fiscal year providers use columns 1 & 2, calendar year providers use column 2 only."]
["  *    For line 15, use column 2 only for  graduate medical education pass through cost."]
{"$rows_empty":16}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4068)"]
[]
["Rev. 1",{"$nulls":5},"40-661"]

{"sheet":"M4","index":3,"n_rows":67,"n_cols":7,"rows_kept":67,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,"                        FORM CMS-2552-10",null,null,null,"4090(Cont.)"]
["COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET M-4"]
["VACCINE COST",null,null,"______________","FROM _________"]
[null,null,null,"COMPONENT NO.:","TO: __________"]
[null,null,null,"_____________"]
["Check ",null,null," [  ]  RHC"," [  ]  Title V                 [   ] Title XIX"]
["Applicable Box:",null,null," [  ]  FQHC"," [  ]  Title XVIII"]
[{"$nulls":4},"PNEUMOCOCCAL","INFLUENZA"]
[{"$nulls":4},1,2]
[1,"Health care staff cost (from Worksheet M-1, column 7, line 10)",{"$nulls":4},1]
[2,"Ratio of pneumococcal and influenza vaccine staff time to total",{"$nulls":4},2]
[null,"health care staff time"]
[3,"Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)",{"$nulls":4},3]
[4,"Medical supplies cost - pneumococcal and influenza vaccine",{"$nulls":4},4]
[null,"(from your records)"]
[5,"Direct cost of pneumococcal and influenza vaccine (line 3 plus line 4)",{"$nulls":4},5]
[6,"Total direct cost of the facility (from Worksheet M-1, column 7, line 22)",{"$nulls":4},6]
[7,"Total overhead (from Worksheet M-2, line 16)",{"$nulls":4},7]
[8,"Ratio of pneumococcal and influenza vaccine direct cost to total direct ",{"$nulls":4},8]
[null,"cost (line 5 divided by line 6)"]
[9,"Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)",{"$nulls":4},9]
[10,"Total pneumococcal and influenza vaccine cost and its (their)",{"$nulls":4},10]
[null,"administration (sum of lines 5 and 9)"]
[11,"Total number of pneumococcal and influenza vaccine injections ",{"$nulls":4},11]
[null,"(from your records)"]
[12,"Cost per pneumococcal and influenza vaccine injection (line 10/line 11)",{"$nulls":4},12]
[13,"Number of pneumococcal and influenza vaccine injections administered",{"$nulls":4},13]
[null,"to Program beneficiaries"]
[14,"Program cost of pneumococcal and influenza vaccine and its (their)",{"$nulls":4},14]
[null,"administration (line 12 x line 13)"]
[15,"Total cost of pneumococcal and influenza vaccine and its (their) administration (sum of columns ",{"$nulls":4},15]
[null,"1 and 2, line 10)  (transfer this amount to Worksheet M-3, line 2)"]
[16,"Total Program cost of pneumococcal and influenza vaccine and its (their) administration (sum",{"$nulls":4},16]
[null,"of columns 1 and 2, line 14)  (transfer this amount to Worksheet M-3, line 21)"]
{"$rows_empty":30}
["FORM CMS 2552-10 (DRAFT)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4069)"]
[]
["40-662",{"$nulls":5},"Rev. 1"]

{"sheet":"M5","index":4,"n_rows":66,"n_cols":33,"rows_kept":66,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,"                FORM CMS-2552-10",{"$nulls":5},"4090 (Cont.)"]
["ANALYSIS OF PAYMENTS TO HOSPITAL-BASED",null,null,"PROVIDER NO.:",null,null,"PERIOD","WORKSHEET M-5",{"$nulls":24},"  ."]
["RHC/FQHC PROVIDER FOR SERVICES RENDERED",{"$nulls":5},"FROM__________"]
["TO PROGRAM BENEFICIARIES",null,null,"COMPONENT NO.:",null,null,"TO_____________"]
[]
["Check  Applicable Box:",null," [ ] RHC"," [ ] FQHC"]
[{"$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)",{"$nulls":6},4]
[null,"(transfer to Worksheet M-3, line 28)"]
[]
[null,"TO BE COMPLETED BY INTERMEDIARY"]
["5","List separately each tentative",null,null,"Program ",".01",null,null,5.01]
[null,"settlement payment after desk review.",null,null,"to",".02",null,null,5.02]
[null,"Also show date of each payment.",null,null,"Provider",".03",null,null,5.03]
[null,"If none, write \"NONE,\"",null,null,"Provider",".50",null,null,5.5]
[null,"or enter zero (1).",null,null,"to",".51",null,null,5.51]
[{"$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",null,null,null,"Contractor Number",null,null,8]
[]
[]
[null,"Signature of Authorized Person",null,null,null,"(Month, Day, Year)"]
[]
[]
["(1) On lines 3, 5, and 6, where an amount is due provider to program,"]
[null,"show the amount and date on which you agree to the amount of repayment,"]
[null,"even though the total repayment is not accomplished until a later date."]
{"$rows_empty":8}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4070)"]
[]
["Rev. 1",{"$nulls":7},"40-663"]