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{"sheet":"S","index":0,"n_rows":73,"n_cols":11,"rows_kept":73,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",{"$nulls":5},"FORM CMS-2552-10",null,null,null,"           4090 (Cont.)"]
["This report is required by law (42 USC 1395g; 42 CFR 413.20(b)).  Failure to report can result in all interim",{"$nulls":8},"FORM APPROVED"]
["payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).",{"$nulls":8},"OMB NO. 0938-0050"]
["HOSPITAL AND HOSPITAL HEALTH CARE",{"$nulls":4},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET S,"]
["COMPLEX COST REPORT CERTIFICATION",{"$nulls":6},"FROM _____________",null,"PARTS  I, II & III"]
["AND SETTLEMENT SUMMARY",{"$nulls":4},"_____________",null,"TO ________________"]
["PART I - COST REPORT STATUS"]
["Provider use only",{"$nulls":4},"  [  ]  Electronically filed cost report",null,null,"Date:","Time:"]
[{"$nulls":5},"  [  ]  Manually submitted cost report"]
[{"$nulls":5},"  [  ]  If this is an amended report enter the  number of times the provider resubmitted this cost report"]
["Contractor ",null,"[    ] Cost Report Status",null,null,"If 3 or 4:",null,null,"Date Received: _________"]
["use only",null,"(1) As Submitted",null,"(3) Settled","[  ] Desk Reviewed",null,null,"Contractor No._________"]
[null,null,"(2) Amended",null,"(4) Reopened ","[  ] Audited",null,null,"[  ]  First Report Processed by  Contractor"]
[null,null," ",null," ","If 4, number of times reopened [  ]",null,null,"[  ]  Last Report to be Processed by Contractor"]
["PART II - CERTIFICATION"]
["MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, "]
["CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW.  FURTHERMORE, IF SERVICES IDENTIFIED IN THIS"]
["REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE"]
["ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT."]
[]
[null,null,"     CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)"]
[]
[null,"I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically filed or manually submitted cost"]
[null,"report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Number(s)}"]
[null,"for the cost reporting period beginning ______________ and ending ______________ and to the best of my knowledge and belief, it is a true, correct"]
[null,"and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted.  I further "]
[null,"certify that I am familiar with the laws and regulations regarding the provision of health care services identified in this cost report were provided in "]
[null,"compliance with such laws and regulations."]
[{"$nulls":5},"                   (Signed)________________________________________________"]
[{"$nulls":6},"         Officer or Administrator of Provider(s)"]
[{"$nulls":6},"  ______________________________________________"]
[{"$nulls":6},"     Title"]
[{"$nulls":6},"  ______________________________________________"]
[{"$nulls":6},"     Date"]
[]
["PART III - SETTLEMENT SUMMARY"]
[{"$nulls":6},"                      TITLE XVIII"]
[{"$nulls":5},"TITLE V","PART A","PART B","HIT","TITLE XIX"]
[{"$nulls":5},"1","2","3",4,5]
[]
[1,"HOSPITAL",{"$nulls":8},1]
[]
[2,"SUBPROVIDER - IPF",{"$nulls":8},2]
[]
[3,"SUBPROVIDER - IRF",{"$nulls":8},3]
[]
[4,"SUBPROVIDER (OTHER)",{"$nulls":8},4]
[]
[5,"SWING BED - SNF",{"$nulls":8},5]
[]
[6,"SWING BED - NF",{"$nulls":8},6]
[]
[7,"SKILLED NURSING FACILITY",{"$nulls":8},7]
[]
[8,"NURSING FACILITY",{"$nulls":8},8]
[]
[9,"HOME HEALTH AGENCY",{"$nulls":8},9]
[]
[10,"HEALTH CLINIC - RHC",{"$nulls":8},10]
[]
[11,"HEALTH CLINIC - FQHC",{"$nulls":8},11]
[null,"OUTPATIENT REHABILITATION"]
[12,"PROVIDER (Specify)",{"$nulls":8},12]
[]
[200,"TOTAL",{"$nulls":8},200]
["The above amounts represent \"due to\" or \"due from\" the applicable program for the element of the above complex indicated."]
["According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control"]
["number for this information collection is 0938-0050.  The time required to complete this information collection is estimated 673 hours per response, including the time to review instructions,"]
["search existing resources, gather the data needed, and complete and review the information collection.  If you have any comments concerning the accuracy of the time estimate(s) or suggestions"]
["for improving this form, please write to:  CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop  C4-26-05, Baltimore, Maryland 21244-1850."]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4003.1-4003.3)"]
["Rev. 1",{"$nulls":9},"                     40-503"]

{"sheet":"S2I","index":1,"n_rows":726,"n_cols":45,"rows_kept":726,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,null,"FORM CMS-2552-10",{"$nulls":6},"DRAFT"]
["HOSPITAL AND HOSPITAL HEALTH CARE",null,null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET S-2",{"$nulls":22},"  .",{"$nulls":12},"  ."]
["COMPLEX IDENTIFICATION DATA",{"$nulls":5},"FROM_____________",null,"Part I "]
[{"$nulls":4},"______________",null,"TO________________"]
["Hospital and Hospital Health Care Complex Address:"]
[1," Street:",null,"P.O. Box:",{"$nulls":6},1]
[2," City:","State:","Zip Code:","County:",{"$nulls":5},2]
["Hospital and Hospital-Based Component Identification:",{"$nulls":6},"Payment System"]
[null,null,null,"Provider","CBSA","Provider","Date","(P, T, O, or N)"]
[null,"Component","Component Name","Number","Number","Type","Certified","V","XVIII","XIX"]
[null,"0","1","2",3,4,5,6,7,8]
[3," Hospital",{"$nulls":8},3]
[4," Subprovider- IPF",{"$nulls":8},4]
[5," Subprovider- IRF",{"$nulls":8},5]
[6," Subprovider- (Other)",{"$nulls":8},6]
[7," Swing Beds-SNF",{"$nulls":8},7]
[8," Swing Beds-NF",{"$nulls":8},8]
[9," Hospital-Based SNF",{"$nulls":8},9]
[10," Hospital-Based NF",{"$nulls":8},10]
[11," Hospital-Based OLTC",{"$nulls":8},11]
[12," Hospital-Based HHA",{"$nulls":8},12]
[13," Separately Certified ASC",{"$nulls":8},13]
[14," Hospital-Based Hospice",{"$nulls":8},14]
[15," Hospital-Based Health Clinic-RHC",{"$nulls":8},15]
[16," Hospital-Based Health Clinic-FQHC",{"$nulls":8},16]
[17," Hospital-Based (CMHC)",{"$nulls":8},17]
[18," Renal Dialysis",{"$nulls":8},18]
[19," Other ",{"$nulls":8},19]
[]
[20," Cost Reporting Period (mm/dd/yyyy)         ",null,null,"From:_______________",null,"To: ______________",null,null,null,20]
[{"$nulls":7},"1",2]
[21,"Type of Control (see instructions)",{"$nulls":8},21]
["Inpatient PPS Information"]
[22,"Does your facility qualify and is currently receiving disproportionate share hospital payment in accordance with 42 CFR §412.106, or low income payment in accordance with",{"$nulls":8},22]
[null,"  42 CFR §412.624 (e)(2)? Enter in column 1,  \"Y\" for yes and \"N\" for no.  Is this facility subject to 42 CFR §412.06 (c )(2) (Pickle amendment hospital?) "]
[null,"  Enter in column 2 Y\"Y for yes or \"N\" for no.  "]
[23,"Which method is used to determine Medicaid days on Worksheet S-3, Part I column 7? Enter in column 1, 1 if it is based on date of admission, 2 if it is based on census days, ",{"$nulls":8},23]
[null,"  or 3 if it is based on date of discharge. Enter in column 2 \"Y\" for yes or \"N\" for no.  "]
[{"$nulls":4},"In-State ","In-State ","Out-of State","Out-of State","Medicaid ","Other"]
[{"$nulls":4},"Medicaid","Medicaid","Medicaid","Medicaid","HMO ","Medicaid"]
[null,"If line 22 is \"yes\", and this provider is an IPPS hospital enter the in-state Medicaid paid days in col. 1, in-state ",null,null,"paid days","eligible days","paid days","eligible days","days","days"]
[null,"Medicaid eligible days in col. 2 out-of-state Medicaid paid days in col. 3, out-of-state Medicaid eligible days",null,null,1,2,3,4,5,6]
[24,"in col. 4, Medicaid HMO days in col. 5, and other Medicaid days in col. 6.",{"$nulls":8},24]
[null,"If line 22 is \"yes\", and this provider is an IRF then, enter the in-state Medicaid paid days in col. 1, in-state"]
[null,"Medicaid eligible days in col. 2, out-of-state Medicaid days in col. 3, out-of state Medicaid eligible days"]
[25,"in col. 4 Medicaid HMO days in col. 5 and other Medicaid days in col. 6.",{"$nulls":8},25]
[26,"For standard Geographic classification ( not wage), what is your status at the beginning of the cost reporting period. Enter (1) for urban and (2) for rural.",{"$nulls":8},26]
[27,"For standard Geographic classification ( not wage), what is your status at the end of the cost reporting period. Enter (1) for urban and (2) for rural.",{"$nulls":8},27]
[]
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)"]
["40-504",{"$nulls":9},"Rev. 1"]
["DRAFT",null,null,"FORM CMS-2552-10",{"$nulls":6},"4090 (Cont.)"]
["HOSPITAL AND HOSPITAL HEALTH CARE",null,null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET S-2"]
["COMPLEX IDENTIFICATION DATA",{"$nulls":5},"FROM_____________",null,"Part I (CONT.)"]
[{"$nulls":4},"______________",null,"TO________________"]
[null," If this is a sole community hospital (SCH), enter the number of periods SCH status in effect in the C/R period. "]
[35," Enter beginning and ending dates of SCH status on line 36.  Subscript line 36 for number of periods in excess of one and enter subsequent dates.",{"$nulls":8},35]
[36," Enter the applicable SCH dates: ",null,null,"Beginning:_______________",null,"Ending: ______________",null,null,null,36]
[null," If you are a Medicare dependent hospital (MDH), enter the number of periods MDH status in effect in this C/R period."]
[37," Enter beginning and ending dates of MDH status on line 38.  Subscript line 38 for number of periods in excess of one and enter subsequent dates.",{"$nulls":8},37]
[38," MDH period",null,null,"Beginning:_______________",null,"Ending: ______________",null,null,null,38]
[{"$nulls":7},"V","XVIII","XIX"]
[" Prospective Payment System (PPS)-Capital",{"$nulls":6},"1","2","3"]
[45," Does your facility qualify and receive Capital payment for disproportionate share in accordance with  42 CFR §412.320? (see instructions)",{"$nulls":5}," ",null," ",45]
[46,"If you are eligible for the special exceptions payment pursuant to 42 CFR §412.348(g)? If yes, Worksheet L, Part III and L-1, Parts I-III",{"$nulls":8},46]
[47,"Is this a new hospital under 42 CFR §412.300 PPS capital?  Enter \"Y for yes and \"N\" for no in column 1. ",{"$nulls":8},47]
[null,"Are you electing full federal payment? Enter \"Y\" for yes and \"N\" for no in col. 2"]
[{"$nulls":7},"V","XVIII","XIX"]
["Teaching Hospitals",{"$nulls":6},"1","2","3"]
[55," Is this a teaching hospital? Enter \"Y\" for yes or \"N\" for no.",{"$nulls":8},55]
[56," Is this teaching program approved in accordance with CMS Pub. 15-1, chapter 4?",{"$nulls":8},5]
[57," If line 56 is yes, was Medicare participation and approved teaching program status in effect during the first month of the cost reporting period? ",{"$nulls":8},57]
[null," If yes, complete Worksheet E-4 .  If no, complete Worksheet D, Part III & IV D-2, Parts II if applicable."]
[58," As a teaching hospital, did you elect cost reimbursement for physicians' services as defined",{"$nulls":8},58]
[null," in CMS Pub. 15-I, section 2148?  If yes, complete Worksheet D-4."]
[59," Are you claiming costs on line 100 of Worksheet A?  If yes, complete Worksheet D-2, Part I.",{"$nulls":8},59]
[60,"Has your facility direct GME FTE cap (column 1) or IME FTE cap (column 2) been reduced under  42 CFR §413.79(c)(3) or42 CFR §412.105(f)(1)(iv)(B)?",{"$nulls":8},60]
[null,"Enter \"Y\" for yes and \"N\" for no in the applicable columns (see instructions)"]
[61,"Has your facility received additional direct GME FTE resident cap slots or IME FTE residents cap slots under 42 CFR §413.79(c)(4)or 42 CFR §412.105(f)(1)(iv)(C)?",{"$nulls":8},61]
[null,"Enter \"Y\" for yes and \"N\" for no in the applicable columns (see instructions)"]
[62,"Are you claiming nursing and allied health costs?  (see instructions)",{"$nulls":8},62]
[]
["Inpatient Psychiatric Facility PPS"]
[70," Are you an Inpatient Psychiatric Facility (IPF), or are you an IPF Subprovider? Enter in column 1 \"Y\" for yes and \"N\"  for no.",{"$nulls":8},70]
[71,"  If line 70 column 1 is Y, does the facility have a teaching program in the most recent cost report filed on or before November 15, 2004?",{"$nulls":8},71]
[null,"  Enter in column 1 \"Y\" for yes or \"N\" for no. Is this facility training residents in a new teaching program in accordance with 42 CFR §412.424 (d)(1)(iii)(D )?"]
[null,"  Enter  in column 2 \"Y\" for yes and \"N\" for no."]
[null,"  If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions). If the current cost reporting period covers the beginning of the fourth year enter 4 in column 3,"]
[null,"  or if the subsequent academic years of the new teaching program in existence, enter 5 . (see instructions)"]
[]
["Inpatient Rehabilitation Facility PPS"]
[75," Are you an Inpatient Rehabilitation Facility (IRF), or do you contain an IRF subprovider? Enter in column 1 \"Y\" for yes and \"N\"  for no.",{"$nulls":8},75]
[76,"  If line 70 column 1 is Y, does the facility have a teaching program in the most recent cost reporting  period ending on or before November 15, 2004? ",{"$nulls":8},76]
[null,"  Enter in column 1 \"Y\" for yes or \"N\" for no.  Is the facility training  residents in a new teaching programs in accordance with 42 CFR § 412.424 (d)(1)(iii)(2)?"]
[null,"  Enter in column 2 \"Y\" for yes or \"N\" for no.  If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions). If the current cost reporting period covers"]
[null,"  the beginning of the fourth enter 4 in column 3,  or if the subsequent academic years of the teaching program in existence, enter 5. (see instructions)"]
[]
[]
[]
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)"]
["Rev. 1",{"$nulls":9},"      40-505"]
["DRAFT",null,null,"FORM CMS-2552-10",{"$nulls":6},"4090 (Cont.)"]
["HOSPITAL AND HOSPITAL HEALTH CARE",null,null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET S-2"]
["COMPLEX IDENTIFICATION DATA",{"$nulls":5},"FROM_____________",null,"Part I (CONT.)"]
[{"$nulls":4},"______________",null,"TO________________"]
["Long Term Care Hospital PPS"]
[80," Are you a Long Term Care Hospital (LTCH)? Enter \"Y\" for yes or \"N\" for no.",{"$nulls":8},80]
["TEFRA Providers"]
[85," Is this a new hospital under 42 CFR §413.40(f)(1)(i) TEFRA? Enter \"Y\" for yes, and \"N\" for no.",{"$nulls":8},85]
[86," Have you established a new Other subprovider (excluded unit) under 42 CFR §413.40(f)(1)(ii)? Enter \"Y\" for yes, and \"N\" for no.",{"$nulls":8},86]
[{"$nulls":7},"V","XIX"]
[" Title V or XIX Inpatient Services",{"$nulls":6},"1",2]
[90," Do you have title  V  and XIX inpatient hospital services?",{"$nulls":8},90]
[91," Is this hospital reimbursed for title V and XIX through the cost report either in full or in part?",{"$nulls":8},91]
[92," Does the title V and XIX program reduce capital following the Medicare methodology?",{"$nulls":8},92]
[93," Do you operate an ICF\\MR facility for purposes of title V and XIX? ",{"$nulls":8},94]
[94," Does Title XIX reduces Capital Cost? Enter \"Y\" for yes or \"N\" for no.",{"$nulls":8},94]
[95," If line 95 is \"Y\", by what percentage?",{"$nulls":8},95]
[96," Does Title XIX reduces Operating Cost? Enter \"Y\" for yes or \"N\" for no.",{"$nulls":8},96]
[97," If line 97 is \"Y\", by what percentage?",{"$nulls":8},97]
["Rural Providers"]
[105," Does this hospital qualify as a Critical Access Hospital (CAH)?",{"$nulls":8},105]
[106," If this facility qualifies as an CAH, has it elected the all-inclusive method of payment for outpatient services? (see instructions)",{"$nulls":8},106]
[107,"If this facility qualifies as a CAH, is it eligible for cost reimbursement for I &R training programs? Enter \"Y\" for yes and \"N\" for no. If yes, the GME elimination would not be on ",{"$nulls":8},107]
[null," Worksheet B, Part I, column 26 and the program  would be cost reimbursed. If yes complete Worksheet D-2, Part II."]
[null,"If this facility is a CAH, do I&Rs in an approved medical education program train in the CAH's excluded IPF and/or IRF unit? Enter \"Y\" for yes or \"N\" for no in column 2.  (see inst.)"]
[108," Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42 CFR §412.113(c).",{"$nulls":8},108]
[{"$nulls":6},"Physical","Occupational","Speech","Respiratory"]
[null,"If this hospital qualifies as a CAH or a cost provider, are therapy services provided by outside supplier? Enter \"Y\" for yes, or \"N\" for no for the type of "]
[109,"therapy as follow: physical therapy in column 1, occupational therapy in column 2, speech therapy in column 3 and respiratory therapy in column 4.",{"$nulls":8},109]
["Miscellaneous Cost Reporting Information"]
[115," Is this an all-inclusive provider?  If yes, enter the method used (A, B, or E only) in column 2.",{"$nulls":8},115]
[116," Are you classified as a referral center?",{"$nulls":8},116]
[117," Are you legally-required to carry malpractice insurance?",{"$nulls":8},117]
[118," Is the malpractice a claims-made or occurrence policy? If the policy is claims made enter 1. If the policy is occurrence, enter 2. ",{"$nulls":8},118]
[119," What is the liability limit for the malpractice insurance policy?",{"$nulls":8},119]
[null," Enter in column 1 the monetary limit per lawsuit. Enter in column 2 the  monetary limit per policy year."]
[null,"Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in PPACA §3121?Enter in column 1 \"Y\" for yes or \"N\" for no.  "]
[120,"Is this a rural hospital with <100 beds which qualifies for the Outpatient Hold Harmless provision in PPACA §3221?. Enter in column 2 \"Y\" for yes or \"N\" for no.",{"$nulls":8},120]
["Transplant Center Information"]
[125," Does this facility operate a transplant center?  If yes, enter certification date(s) (mm/dd/yyyy) below.",{"$nulls":8},125]
[126," If this is a Medicare certified kidney transplant center, enter the certification date in column 1 and termination date if applicable in column 2.",{"$nulls":8},126]
[127," If this is a Medicare certified heart transplant center, enter the certification date in column 1 and termination date if applicable  in column 2.",{"$nulls":8},127]
[128," If this is a Medicare certified liver transplant center, enter the certification date in column 1 and termination date if applicable in column 2.",{"$nulls":8},128]
[129," If this is a Medicare certified lung transplant center, enter the certification date in column 1 and termination date if applicable in column 2.",{"$nulls":8},129]
[130," If this is a Medicare certified pancreas transplant center, enter the certification date in column 1 and termination date if applicable  in column 2.",{"$nulls":8},130]
[131," If this is a Medicare certified intestinal transplant center, enter the certification date in column 1 and termination if applicable in column 2.",{"$nulls":8},131]
[132," If this is a Medicare certified islet transplant center, enter the certification date in column 1 and termination date if applicable in column 2.",{"$nulls":8},132]
[133," If this is a Medicare certified other transplant center, enter the certification date in column 1 and termination date if applicable in column 2.",{"$nulls":8},133]
[134," If this is an organ procurement organization (OPO), enter the OPO number in column 1 and termination date if applicable in column 2.",{"$nulls":8},134]
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)"]
["40-506",{"$nulls":9},"Rev. 1"]
["4090 (Cont.)",null,null,"FORM CMS-2552-10",{"$nulls":6},"DRAFT"]
["HOSPITAL AND HOSPITAL HEALTH CARE",null,null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET S-2"]
["COMPLEX IDENTIFICATION DATA",{"$nulls":5},"FROM_____________",null," Part I (CONT.)"]
[{"$nulls":4},"______________",null,"TO________________"]
[]
["All Providers"]
[140," Are there any related organization or home office costs as defined in CMS Pub. 15-1, chapter 10?  If yes, and there are home office cost, enter in column 2 the home",{"$nulls":8},140]
[null," office chain number.  (See instructions.) If this is facility is part of a chain organization enter the name and address of the home office on lines 111-113."]
[141,"Name:",null,null,"Contractor's Name:    ___________________",null,null,"Contractor's Number:    __________",null,null,141]
[142,"Street:",{"$nulls":5},"P. O. Box",null,null,142]
[143,"City:",{"$nulls":5},"State:","Zip Code:",null,143]
[144," Are provider based physicians' costs included in Worksheet A?",{"$nulls":8},144]
[145," If you are claiming cost for renal services on Worksheet A, are they inpatient services only?",{"$nulls":8},145]
[146," Have you changed your cost allocation methodology from the previously filed cost report?  See",{"$nulls":8},146]
[null," CMS Pub. 15-2, section 4020.  If yes, enter the approval date (mm/dd/yyyy) in column 2."]
[147," Was there a change in the statistical basis?",{"$nulls":8},147]
[148," Was there a change in the order of allocation?",{"$nulls":8},148]
[149," Was the change to the simplified cost finding method?",{"$nulls":8},149]
[" If this facility contains a provider that qualifies for an exemption from the application of the lower of costs or charges, enter \"Y\" for each component and type of service that qualifies for exemption. "]
[" Enter \"N\" if not exempt in the applicable columns below. (See 42 CFR §413.13.)"]
[]
[{"$nulls":8},"Part A","Part B"]
[{"$nulls":8},1,2]
[155," Hospital",{"$nulls":8},155]
[156," Subprovider - IPF",{"$nulls":8},156]
[157," Subprovider - IRF",{"$nulls":8},157]
[158," Subprovider - Other",{"$nulls":8},158]
[159," SNF",{"$nulls":8},159]
[160," HHA ",{"$nulls":8},160]
[161," CMHC",{"$nulls":8},161]
[]
["Multicampus "]
[165,"Is this hospital part of a Multicampus hospital that has one or more campuses in different CBSA?  Enter \"Y\" for yes and \"N\" for no. ",{"$nulls":8},165]
[null,"If line 165 is yes, enter the name in col. 0, county in column 1, state in column 2, zip in column 3, CBSA in column 4,",null,null,null,"County","State","Zip Code","CBSA"," FTE/Campus"]
[null,"FTE/Campus in col. 5.",null,null,null,1,2,3,4,5]
[166,"Name:                                               ",{"$nulls":8},166]
[]
["Health Information Technology  incentive in the American Recovery and Reinvestment Act (HIT)"]
[167,"Is this provider a meaningful user under §1886 (n)? Enter \"Y\" for yes or \"N\" for no.",{"$nulls":8},167]
[168,"If this provider is a CAH, line  105 is \"Y\" and is a meaningful user, line 167 is \"Y\" enter the reasonable cost incurred for the   HIT assets (see instructions)",{"$nulls":8},168]
{"$rows_empty":9}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)"]
["Rev. 1",{"$nulls":9},"40-507"]
{"$rows_empty":521}
[""]
[""]

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["4090 (Cont.)",null,null,"FORM CMS-2552-10",{"$nulls":5},"DRAFT"]
["HOSPITAL AND HOSPITAL HEALTH CARE",null,null,null,"PROVIDER NO.:","PERIOD:",null,"WORKSHEET S-2"]
["REIMBURSEMENT QUESTIONNAIRE",{"$nulls":4},"FROM  ",null,"Part II"]
[{"$nulls":5},"TO   "]
["General Instruction:  For all column 1 responses enter in column 1, \"Y\" for Yes or \"N\" for No"]
[null,null,"For all the dates responses the format will be (mm/dd/yyyy)"]
[]
["Completed by All Hospitals, Provider Organization and Operation"]
[{"$nulls":6},1,2]
[{"$nulls":6},"Y/N","Date"]
[1,"Has the Provider changed ownership immediately prior to the beginning of the cost reporting period? ",{"$nulls":7},1]
[null,"If column 1 is \"Y\", enter the date of the change in column 2. (see instructions)"]
[{"$nulls":6},1,2,3]
[{"$nulls":6},"Y/N","Date","V/I"]
[2,"Has the provider terminated participation in the Medicare Program?",{"$nulls":7},2]
[null,"If column 1 is yes enter in column 2 the date of termination and in column 3, \"V\" for voluntary or \"I\" for involuntary"]
[3,"Is the provider involved in business transactions, including management contracts, with individuals or entities ",{"$nulls":7},3]
[null,"(e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers,"]
[null,"medical staff, management personnel, or members of the board of directors through ownership, control, or"]
[null,"family and other similar relationships? (see instructions)"]
[]
["Financial Data and Reports"]
[{"$nulls":6},1,2,3]
[{"$nulls":6},"Y/N","Type","Date"]
[4,"Were the financial statements prepared by a Certified Public Accountant? If column 1 is \"Y\" enter \"A\" for Audited,",{"$nulls":7},4]
[null,"\"C\" for Compiled, or \"R\" for Reviewed in column 2.  Submit complete copy or enter date available "]
[null,"in column 3. (see instructions)If column 1 is \"N\" see instructions."]
[5,"Are the cost report total expenses and total revenues different from those on the filed financial statements? ",{"$nulls":7},5]
[null,"If column 1 is \"Y\", submit reconciliation."]
[]
[{"$nulls":7},1,2]
["Approved Educational Activities",{"$nulls":6},"Y/N","Legal Oper."]
[6,"Were costs claimed for Nursing School? If column 1 is \"Y\", enter \"Y\" or \"N\" in column 2 to indicate whether the provider is the",{"$nulls":7},6]
[null,"legal operator of the program"]
[7,"Were costs claimed for Allied Health Programs? If \"Y\" see instructions.",{"$nulls":7},7]
[8,"Were approvals and/or renewals obtained during the cost reporting period for Nursing School and/or Allied Health Programs? ",{"$nulls":7},8]
[null,"If \"Y\", see instructions."]
[9,"Are Intern-Resident costs claimed on the current cost report? If \"Y\" see instructions.",{"$nulls":7},9]
[10,"Has an Intern-Resident program been initiated or renewed in the current cost reporting period? If \"Y\" see instructions.",{"$nulls":7},10]
[]
["Bad Debts"]
[{"$nulls":8},1]
[{"$nulls":8},"Y/N"]
[11,"Is the provider seeking reimbursement for bad debts? If \"Y\", see instructions.",{"$nulls":7},11]
[12,"If line 11 is \"Y\", did the provider's bad debt collection policy change during this cost reporting period? If \"Y\", submit copy.",{"$nulls":7},12]
[13,"If line 11 is \"Y\", are  patient deductibles and/or co-payments waived? If \"Y\", see instructions.",{"$nulls":7},13]
[]
["Bed Complement"]
[14,"Have total beds available changed from prior cost reporting period? If \"Y\", see instructions.",{"$nulls":7},14]
[]
[{"$nulls":5},1,2,3,4]
[{"$nulls":5},"Y/N","Date","Y/N","Date"]
["PS&R Data",{"$nulls":4},"Part A","Part A","Part B","Part B"]
[15,"Was the cost report prepared using the PS&R only?   If either col. 1 or 3 is \"Y\", enter the paid through",{"$nulls":7},15]
[null,"date of the PS&R used to prepare this cost report in cols. 2 and 4 .(see Instructions.)"]
[16,"Was the cost report prepared using the PS&R for total and the provider's records for allocation?",{"$nulls":7},16]
[null,"If either col. 1 or 3 is \"Y\" enter the paid through date in cols. 2 and 4. (see Instructions)"]
[17,"If line 15 or 16 is \"Y\", were adjustments made to PS&R data for additional claims that have been ",{"$nulls":7},17]
[null,"billed but are not included on the PS&R used to file this cost report? If \"Y\", see Instructions."]
[18,"If line 15 or 16 is \"Y\", then were adjustments made to PS&R data for corrections of other ",{"$nulls":7},18]
[null,"PS&R information? If \"Y\", see Instructions."]
[19,"If line 15 or 16 is \"Y\", then were adjustments made to PS&R data for Other?",{"$nulls":7},19]
[null,"Describe the other adjustments:",null,"_________________________________"]
[20,"Was the cost report prepared only using the provider's records? If \"Y\" see Instructions.",{"$nulls":7},20]
[]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4004.2)"]
["40-508",{"$nulls":8},"Rev. 1"]
["DRAFT",null,null,"FORM CMS-2552-10",{"$nulls":5},"4090 (Cont.)"]
["HOSPITAL AND HOSPITAL HEALTH CARE",null,null,null,"PROVIDER NO.:","PERIOD:",null,"WORKSHEET S-2"]
["REIMBURSEMENT QUESTIONNAIRE",{"$nulls":4},"FROM  ",null,"Part II"]
[{"$nulls":5},"TO   "]
["General Instruction:  For all column 1 responses enter in column 1, \"Y\" for Yes or \"N\" for No"]
[null,null,"For all the dates responses the format will be (mm/dd/yyyy)"]
[]
["COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS  ONLY"]
[]
["Capital Related Cost"]
[21,"Have assets been relifed for Medicare purposes? If \"Y\" see instructions",{"$nulls":7},21]
[22,"Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost reporting period?",{"$nulls":7},22]
[null,"If \"Y\", see instructions."]
[23,"Were new leases and/or amendments to existing leases entered into during this cost reporting period? If \"Y\", see instructions",{"$nulls":7},23]
[24,"Have there been new capitalized leases entered into during the cost reporting period? If \"Y\" see instructions.  ",{"$nulls":7},24]
[25,"Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period?  If \"Y\", see instructions.",{"$nulls":7},25]
[26,"Has the provider's capitalization policy changed during the cost reporting period? If \"Y\", submit copy.",{"$nulls":7},26]
[]
["Interest Expense"]
[27,"Were new loans, mortgage agreements or letters of credit entered into during the cost reporting period? If \"Y\", see instructions.",{"$nulls":7},27]
[28,"Does the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund) treated as a funded depreciation",{"$nulls":7},28]
[null,"account?  If \"Y\" see instructions"]
[29,"Has existing debt been replaced prior to its scheduled maturity with new debt?  If \"Y\" see instructions.",{"$nulls":7},29]
[30,"Has debt been recalled before scheduled maturity without issuance of new debt? If \"Y\" see instructions.",{"$nulls":7},30]
[]
["Purchased Services"]
[31,"Have changes or new agreements occurred in patient care services furnished through contractual arrangements with suppliers of services?",{"$nulls":7},31]
[null,"If \"Y\" see instructions."]
[32,"If line 31 is \"Y\", were the requirements of Sec. 2135.2 applied pertaining to competitive bidding?.",{"$nulls":7},32]
[null,"If \"N\" see instructions."]
[33,"Are GME costs directly assigned to cost centers other than I/R Services in an Approved Teaching Program on Worksheet A?",{"$nulls":7},33]
[null,"If \"Y\", see instructions."]
[]
[]
["Provider-Based Physicians"]
[34,"Are services furnished at the provider facility under an arrangement with provider-based physicians? If \"Y\" see instructions.",{"$nulls":7},34]
[35,"If line 34 is \"Y\", are there new agreements or amended existing agreements with the provider-based physicians during the cost",{"$nulls":7},35]
[null,"reporting period? If \"Y\" (see instructions)"]
[]
[{"$nulls":7},1,2]
["Home Office Costs",{"$nulls":6},"Y/N","Date"]
[36,"Are Home Office Cost claimed on the cost report?",{"$nulls":7},36]
[37,"If line 36 is \"Y\", has a home office cost statement been prepared by the home office?  If \"Y\" see instructions.",{"$nulls":7},37]
[38,"If line 36 \"Y\", is the fiscal year end of the home office different from that of the provider?",{"$nulls":7},38]
[null,"If column 1 is \"Y\", enter in column 2 the fiscal year end of the home office."]
[39,"If line 36 is \"Y\", does the provider render services to other chain components? If \"Y\" see instructions.",{"$nulls":7},39]
[40,"If line 36 is \"Y\", does the provider render services to the home office?  If \"Y\" see instructions.",{"$nulls":7},40]
{"$rows_empty":19}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4004.2)"]
["Rev. 1",{"$nulls":8},"40-509"]

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["4090 (Cont.)",{"$nulls":5},"FORM CMS-2552-10",{"$nulls":10},"DRAFT"]
["HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX",{"$nulls":8},"PROVIDER NO.:",null,null,"PERIOD",null,null,"WORKSHEET S-3,"]
["STATISTICAL DATA",{"$nulls":11},"FROM ____________",null,null,"PART I"]
[{"$nulls":9},"____________________",null,null,"TO _______________"]
[{"$nulls":6},"   I/P Days / O/P Visits / Trips",null,null,null,"           Full Time Equivalents",null,null,"Discharges"]
[null,null,"Worksheet "]
[null,null,"A",{"$nulls":6},"Total ","Total","Employees",{"$nulls":4},"Total"]
[null,null,"Line ","No. of","Bed Days","CAH",null,"Title","Title","All","Interns &","On","Nonpaid",null,"Title","Title ","All"]
[null,"Component","Number","Beds","Available","Hours","Title V","XVIII","XIX","Patients","Residents","Payroll","Workers","Title V","XVIII","XIX","Patients"]
[null,null,1,2,3,4,5,6,7,8,9,10,11,12,13,14,15]
[1,"Hospital Adults & Peds. (columns 5,",{"$nulls":15},1]
[null,"6, 7 and 8 exclude Swing Bed,"]
[null,"Observation Bed and Hospice days)"]
[2,"HMO",{"$nulls":15},2]
[3,"HMO IPF",{"$nulls":15},3]
[4,"HMO IRF",{"$nulls":15},4]
[5,"Hospital Adults & Peds. Swing Bed SNF",{"$nulls":15},5]
[6,"Hospital Adults & Peds.Swing Bed NF",{"$nulls":15},6]
[7,"Total Adults and Peds. (exclude",{"$nulls":15},7]
[null,"observation beds) (see instructions)"]
[8,"Intensive Care Unit",{"$nulls":15},8]
[9,"Coronary Care Unit",{"$nulls":15},9]
[10,"Burn Intensive Care Unit",{"$nulls":15},10]
[11,"Surgical Intensive Care Unit",{"$nulls":15},11]
[12,"Other Special Care",{"$nulls":15},12]
[13,"Nursery",{"$nulls":15},13]
[14,"Total (see instructions)",{"$nulls":15},14]
[15,"CAH visits",{"$nulls":15},15]
[16,"Subprovider - IPF",{"$nulls":15},16]
[17,"Subprovider - IRF",{"$nulls":15},17]
[18,"Subprovider - Other",{"$nulls":15},18]
[19,"Skilled Nursing Facility",{"$nulls":15},19]
[20,"Nursing Facility",{"$nulls":15},20]
[21,"Other Long Term Care",{"$nulls":15},21]
[22,"Home Health Agency",{"$nulls":15},22]
[23,"ASC (Distinct Part)",{"$nulls":15},23]
[24,"Hospice (Distinct Part)",{"$nulls":15},24]
[25,"CMHC",{"$nulls":15},25]
[26,"RHC/FQHC (specify)",{"$nulls":15},26]
[27,"Total (sum of lines 14-26)",{"$nulls":15},27]
[28,"Observation Bed Days",{"$nulls":15},28]
[29,"Ambulance Trips ",{"$nulls":15},29]
[30,"Employee discount days (see instruction)",{"$nulls":15},30]
[31,"Employee discount days -IRF",{"$nulls":15},31]
[32,"Labor & delivery days (see instructions)",{"$nulls":15},32]
[33,"LTCH non-covered days",{"$nulls":15},33]
[]
[]
[]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.1)"]
["40-510",{"$nulls":16},"Rev. 1"]
["4090 (Cont.)",{"$nulls":5},"FORM CMS-2552-10",{"$nulls":10},"DRAFT"]
{"$rows_empty":24}
[{"$nulls":5},"This page is reserved for future use"]
{"$rows_empty":25}
["Rev. 1",{"$nulls":16},"40-511"]

{"sheet":"S3II &III","index":4,"n_rows":126,"n_cols":9,"rows_kept":126,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,null,"FORM CMS-2552-10",{"$nulls":4},"DRAFT"]
["HOSPITAL WAGE INDEX INFORMATION",null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET S-3,"]
[{"$nulls":5},"FROM __________",null,"PART II"]
[null,null,null,"______________",null,"TO _____________"]
["PART II - WAGE DATA"]
[null,null,"Worksheet ",null,"Reclass.","Adjusted","Paid Hours","Average"]
[null,null,"A",null,"of Salaries","Salaries","Related","Hourly Wage"]
[null,null,"Line ","Amount","(from ","(col. 2 ±","to Salaries","(col. 4 ÷"]
[null,null,"Number","Reported","Wkst. A-6)","col. 3)","in col. 4","col. 5)"]
[null,null,1,2,3,4,5,6]
[null,"SALARIES"]
[1,"Total salaries (see instructions)",{"$nulls":6},1]
[2,"Non-physician anesthetist Part A",{"$nulls":6},2]
[3,"Non-physician anesthetist Part B",{"$nulls":6},3]
[4,"Physician-Part A",{"$nulls":6},4]
[5,"Physician-Part B",{"$nulls":6},5]
[6,"Non-physician-Part B",{"$nulls":6},6]
[7,"Interns & residents (in an approved program)",{"$nulls":6},7]
[8,"Home office personnel",{"$nulls":6},8]
[9,"SNF",{"$nulls":6},9]
[10,"Excluded area salaries (see instructions)",{"$nulls":6},10]
[null,"OTHER WAGES & RELATED COSTS"]
[11,"Contract labor (see instructions)",{"$nulls":6},11]
[12,"Management and administrative services",{"$nulls":6},12]
[13,"Contract labor: physician-Part A",{"$nulls":6},13]
[14,"Home office salaries & wage-related costs",{"$nulls":6},14]
[15,"Home office: physician Part A",{"$nulls":6},15]
[16,"Teaching physician salaries (see instructions)",{"$nulls":6},16]
[" ","WAGE-RELATED COSTS",{"$nulls":6}," "]
[17,"Wage-related costs (core) Wkst S-3, Part IV line 24",{"$nulls":6},17]
[18,"Wage-related costs (other)Wkst S-3, Part IV line 25",{"$nulls":6},18]
[19,"Excluded areas",{"$nulls":6},19]
[20,"Non-physician anesthetist Part A",{"$nulls":6},20]
[21,"Non-physician anesthetist Part B",{"$nulls":6},21]
[22,"Physician Part A",{"$nulls":6},22]
[23,"Physician Part B",{"$nulls":6},23]
[24,"Wage-related costs (RHC/FQHC)",{"$nulls":6},24]
[25,"Interns & residents (in an approved program)",{"$nulls":6},25]
{"$rows_empty":22}
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[]
["46-512",{"$nulls":7},"Rev. 1"]
["DRAFT",null,null,"FORM CMS-2552-10",{"$nulls":4},"4090 (Cont.)"]
["HOSPITAL WAGE INDEX INFORMATION",null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET S-3,"]
[{"$nulls":5},"FROM __________",null,"PART II & III"]
[null,null,null,"______________",null,"TO _____________"]
["PART II - WAGE DATA"]
[null,null,"Worksheet ",null,"Reclass.","Adjusted","Paid Hours","Average"]
[null,null,"A",null,"of Salaries","Salaries","Related","Hourly Wage"]
[null,null,"Line ","Amount","(from ","(col. 2 ±","to Salaries","(col. 4 ÷"]
[null,null,"Number","Reported","Wkst. A-6)","col. 3)","in col. 4","col. 5)"]
[null,null,1,2,3,4,5,6]
[null,"OVERHEAD COSTS - DIRECT SALARIES"]
[26,"Employee Benefits",{"$nulls":6},26]
[27,"Administrative & General",{"$nulls":6},27]
[28,"Administrative & General under contract (see inst.)",{"$nulls":6},28]
[29,"Maintenance & Repairs",{"$nulls":6},29]
[30,"Operation of Plant",{"$nulls":6},30]
[31,"Laundry & Linen Service",{"$nulls":6},31]
[32,"Housekeeping",{"$nulls":6},32]
[33,"Housekeeping under contract (see instructions)",{"$nulls":6},33]
[34,"Dietary",{"$nulls":6},34]
[35,"Dietary under contract (see instructions)",{"$nulls":6},35]
[36,"Cafeteria",{"$nulls":6},36]
[37,"Maintenance of Personnel",{"$nulls":6},37]
[38,"Nursing Administration",{"$nulls":6},38]
[39,"Central Services and Supply",{"$nulls":6},39]
[40,"Pharmacy",{"$nulls":6},40]
[41,"Medical Records & Medical Records Library",{"$nulls":6},41]
[42,"Social Service",{"$nulls":6},42]
[43,"Other General Service ",{"$nulls":6},43]
[]
["PART III - HOSPITAL WAGE INDEX SUMMARY"]
[1,"Net salaries (see instructions)",{"$nulls":6},1]
[2,"Excluded area salaries (see instructions)",{"$nulls":6},2]
[3,"Subtotal salaries (line 1 minus line 2)",{"$nulls":6},3]
[4,"Subtotal other wages & related costs (see inst.)",{"$nulls":6},4]
[5,"Subtotal wage-related costs (see inst.)",{"$nulls":6},5]
[6,"Total (sum of lines 3 thru 5)",{"$nulls":6},6]
[7,"Total overhead cost (see instructions",{"$nulls":6},7]
{"$rows_empty":22}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.2 - 4005.3)"]
[]
["Rev. 1",{"$nulls":7},"40-513"]

{"sheet":"S3IV","index":5,"n_rows":63,"n_cols":9,"rows_kept":63,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,null,"FORM CMS-2552-10",{"$nulls":4},"DRAFT"]
["HOSPITAL WAGE RELATED COSTS",null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET S-3,"]
[{"$nulls":5},"FROM __________",null,"PART IV"]
[null,null,null,"______________",null,"TO _____________"]
["PART IV - Wage Related Cost "]
[]
["Part A - Core List"]
[]
[]
[{"$nulls":7},"Amount"]
[{"$nulls":7},"Reported"]
[]
[null,"RETIREMENT COST"]
[1,"401K Employer Contributions ",{"$nulls":6},1]
[2,"Tax Sheltered Annuity (TSA) Employer Contribution",{"$nulls":6},2]
[3,"Qualified and Non-Qualified Pension Plan Cost ",{"$nulls":6},3]
[4,"Prior Year Pension Service Cost              ",{"$nulls":6},4]
[null,"PLAN ADMINISTRATIVE COSTS (Paid to External Organization):"]
[5,"401K/TSA Plan Administration fees                    ",{"$nulls":6},5]
[6,"Legal/Accounting/Management Fees-Pension Plan        ",{"$nulls":6},6]
[7,"Employee Managed Care Program Administration Fees   ",{"$nulls":6},7]
[null,"HEALTH AND  INSURANCE COST"]
[8,"Health Insurance (Purchased or Self Funded)",{"$nulls":6},8]
[9,"Prescription Drug Plan",{"$nulls":6},9]
[10,"Dental, Hearing and Vision Plan",{"$nulls":6},10]
[11,"Life Insurance (If employee is owner or beneficiary)",{"$nulls":6},11]
[12,"Accidental Insurance (If employee is owner or beneficiary)",{"$nulls":6},12]
[13,"Disability Insurance (If employee is owner or beneficiary)",{"$nulls":6},13]
[14,"Long-Term Care Insurance (If employee is owner or beneficiary)",{"$nulls":6},14]
[15,"Workers' Compensation Insurance",{"$nulls":6},15]
[16,"Retirement Health Care Cost (Only current year, not the extraordinary accrual required by FASB 106. Non cumulative portion) ",{"$nulls":6},16]
[" ","TAXES",{"$nulls":6}," "]
[17,"FICA-Employers Portion Only",{"$nulls":6},17]
[18,"Medicare Taxes - Employers Portion Only",{"$nulls":6},18]
[19,"Unemployment Insurance",{"$nulls":6},19]
[20,"State or Federal Unemployment Taxes",{"$nulls":6},20]
[null,"OTHER"]
[21,"Executive Deferred Compensation",{"$nulls":6},21]
[22,"Day Care Cost and Allowances",{"$nulls":6},22]
[23,"Tuition Reimbursement",{"$nulls":6},23]
[24,"Total Wage Related cost (Sum of lines 1 -23)",{"$nulls":6},24]
[]
[]
[]
["Part B Other than Core Related Cost"]
[25,"Other Wage Related Costs (specify)_________________________________________",{"$nulls":6},25]
{"$rows_empty":14}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.4)"]
[]
["40-514",{"$nulls":7},"Rev. 1"]

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["DRAFT",null,"FORM CMS-2552-10",null,null,null,"4090 (Cont.)"]
["HOSPITAL CONTRACT LABOR AND BENEFIT COST",null,null,"PROVIDER NO.:","PERIOD:","WORKSHEET S-3,"]
[{"$nulls":4},"FROM __________","PART V"]
[null,null,null,"______________","TO _____________"]
["PART V - Contract Labor and Benefit Cost"]
[]
[]
["Hospital and Hospital-Based Component Identification:"]
[null,null,null,"Provider","Contract","Benefit "]
[null,"Component","Component Name","Number","Labor","Cost"]
[null,"0","1","2",3,4]
[1,"Total facility's contract labor and benefit cost",{"$nulls":4},1]
[2," Hospital",{"$nulls":4},2]
[3," Subprovider- IPF",{"$nulls":4},3]
[4," Subprovider- IRF",{"$nulls":4},4]
[5," Subprovider- (Other)",{"$nulls":4},5]
[6," Swing Beds-SNF",{"$nulls":4},6]
[7," Swing Beds-NF",{"$nulls":4},7]
[8," Hospital-Based SNF",{"$nulls":4},8]
[9," Hospital-Based NF",{"$nulls":4},9]
[10," Hospital-Based OLTC",{"$nulls":4},10]
[11," Hospital-Based HHA",{"$nulls":4},11]
[12," Separately Certified ASC",{"$nulls":4},12]
[13," Hospital-Based Hospice",{"$nulls":4},13]
[14," Hospital-Based Health Clinic RHC",{"$nulls":4},14]
[15," Hospital-Based Health Clinic FQHC",{"$nulls":4},15]
[16," Hospital-Based-CMHC",{"$nulls":4},16]
[17," Renal Dialysis",{"$nulls":4},17]
{"$rows_empty":38}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.5)"]
[]
["Rev. 1",{"$nulls":5},"40-515"]

{"sheet":"S4","index":7,"n_rows":69,"n_cols":27,"rows_kept":69,"cut":false,"hidden":false,"merged":[[44,7,44,8]],"flags":["formulas_cached_only"]}
["4090 (Cont.)",{"$nulls":4},"FORM CMS-2552-10",{"$nulls":6},"DRAFT"]
["HOSPITAL-BASED HOME HEALTH AGENCY",{"$nulls":5},"  PROVIDER NO.:",null,"  PERIOD:",null,"WORKSHEET S-4",{"$nulls":15},"{APP4}IALLWAYS~/PCOPB1~Q/PGQ/1"]
["STATISTICAL DATA",{"$nulls":5},"  _______________",null,"  FROM ____________"]
[{"$nulls":6},"  HHA NO.:",null,"  TO _______________"]
[{"$nulls":6},"  _______________"]
[]
[null,"    HOME HEALTH AGENCY STATISTICAL DATA",{"$nulls":6},"        County: __________________"]
[]
[{"$nulls":7},"Title","Title","Title"]
[null,"     DESCRIPTION",{"$nulls":5},"V","XVIII","XIX","Other","Total"]
[{"$nulls":7},"1","2","3","4","5"]
[1," Home Health Aide Hours",{"$nulls":10},1]
[2," Unduplicated Census Count (see instructions)",{"$nulls":10},2]
[]
[null,"    HOME HEALTH AGENCY - NUMBER OF EMPLOYEES"]
[null,"          (FULL TIME EQUIVALENT)"]
[]
[null,"Enter the number of hours in"]
[null,"your normal work week _______",{"$nulls":7},"Staff","Contract","Total"]
[{"$nulls":9},"1","2","3"]
[3," Administrator and Assistant Administrator(s)",{"$nulls":10},3]
[4," Directors and Assistant Director(s)",{"$nulls":10},4]
[5," Other Administrative Personnel",{"$nulls":10},5]
[6," Direct Nursing Service",{"$nulls":10},6]
[7," Nursing Supervisor",{"$nulls":10},7]
[8," Physical Therapy Service",{"$nulls":10},8]
[9," Physical Therapy Supervisor",{"$nulls":10},9]
[10," Occupational Therapy Service",{"$nulls":10},10]
[11," Occupational Therapy Supervisor",{"$nulls":10},11]
[12," Speech Pathology Service",{"$nulls":10},12]
[13," Speech Pathology Supervisor",{"$nulls":10},13]
[14," Medical Social Service",{"$nulls":10},14]
[15," Medical Social Service Supervisor",{"$nulls":10},15]
[16," Home Health Aide",{"$nulls":10},16]
[17," Home Health Aide Supervisor",{"$nulls":10},17]
[18," Other (specify)",{"$nulls":10},18]
[]
[null,"HOME HEALTH AGENCY CBSA CODES"]
[{"$nulls":11},1]
[19," How many CBSAs in column 1 did you provide services to during this cost reporting period.",{"$nulls":10},19]
[20," List those CBSA code(s) in column 1 serviced during this cost reporting period (line 20 contains the first code).",{"$nulls":10},20]
[]
[null,"PPS ACTIVITY DATA "]
[]
[{"$nulls":7},"Full Episodes"]
[{"$nulls":7},"Without","With","LUPA","PEP only","Total"]
[{"$nulls":7},"Outliers","Outliers","Episodes","Episodes","(cols. 1-4)"]
[{"$nulls":7},1,2,3,4,5]
[21,"Skilled Nursing Visits",{"$nulls":10},21]
[22,"Skilled Nursing Visit Charges",{"$nulls":10},22]
[23,"Physical Therapy Visits",{"$nulls":10},23]
[24,"Physical Therapy Visit Charges",{"$nulls":10},24]
[25,"Occupational Therapy Visits",{"$nulls":10},25]
[26,"Occupational Therapy Visit Charges",{"$nulls":10},26]
[27,"Speech Pathology Visits",{"$nulls":10},27]
[28,"Speech Pathology Visit Charges",{"$nulls":10},28]
[29,"Medical Social Service Visits",{"$nulls":10},29]
[30,"Medical Social Service Visit Charges",{"$nulls":10},30]
[31,"Home Health Aide Visits",{"$nulls":10},31]
[32,"Home Health Aide Visit Charges",{"$nulls":10},32]
[33,"Total visits (sum of lines 21, 23, 25, 27, 29, and 31)",{"$nulls":10},33]
[34,"Other Charges",{"$nulls":10},34]
[35,"Total Charges (sum of lines 22, 24, 26, 28, 30, 32, and 34)",{"$nulls":10},35]
[36,"Total Number of Episodes (standard/non outlier)",{"$nulls":10},36]
[37,"Total Number of Outlier Episodes",{"$nulls":10},37]
[38,"Total Non-Routine Medical Supply Charges",{"$nulls":10},38]
[]
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4006)"]
["40-516",{"$nulls":11},"Rev. 1"]

{"sheet":"S5","index":8,"n_rows":69,"n_cols":106,"rows_kept":69,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,null,"FORM CMS-2552-10",{"$nulls":5},"4090 (Cont.)"]
["HOSPITAL RENAL DIALYSIS DEPARTMENT",null,null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET S-5",{"$nulls":96},"{APP4}IALLWAYS~/PCOPB1~Q/PGQ/1"]
["STATISTICAL DATA",null,null,null," ________________",null,"FROM ___________"]
[{"$nulls":6},"TO ______________"]
[null,"RENAL DIALYSIS STATISTICS"]
[null,null,null,"           Outpatient",null,"              Training",null,"              Home"]
[{"$nulls":5},"Hemo-","CAPD","Hemo-","CAPD"]
[null,null,"DESCRIPTION","Regular","High Flux","dialysis","CCPD","dialysis","CCPD"]
[null,null,null,"1","2","3","4","5","6"]
[1," Number of patients in program at",{"$nulls":7},1]
[null," end of cost reporting period"]
[2," Number of times per week patient",{"$nulls":7},2]
[null,"  receives dialysis"]
[3," Average patient dialysis time including setup",{"$nulls":7},3]
[4," CAPD exchanges per day",{"$nulls":7},4]
[5," Number of days in year dialysis furnished",{"$nulls":7},5]
[6," Number of stations",{"$nulls":7},6]
[7," Treatment capacity per day per station",{"$nulls":7},7]
[8," Utilization (see instructions)",{"$nulls":7},8]
[9," Average times dialyzers re-used",{"$nulls":7},9]
[10," Percentage of patients re-using dialyzers",{"$nulls":7},10]
[]
[null,"TRANSPLANT INFORMATION"]
[11," Number of patients on transplant list",{"$nulls":7},11]
[12," Number of patients transplanted during the cost reporting period",{"$nulls":7},12]
[]
[null,"EPOETIN"]
[13," Net costs of Epoetin furnished to all maintenance dialysis patients by the provider.",{"$nulls":7},13]
[14,"Epoetin amount from Worksheet A for Home Dialysis program",{"$nulls":7},14]
[15," Number of EPO units furnished relating to the renal dialysis department",{"$nulls":7},15]
[16," Number of EPO units furnished relating to the home dialysis department",{"$nulls":7},16]
[]
[null,"ARANESP"]
[17," Net costs of ARANESP furnished to all maintenance dialysis patients by the provider.",{"$nulls":7},17]
[18,"ARANESP amount from Worksheet A for Home Dialysis program",{"$nulls":7},18]
[19," Number of ARANESP units furnished relating to the renal dialysis department",{"$nulls":7},19]
[20," Number of ARANESP units furnished relating to the home dialysis department",{"$nulls":7},20]
[]
[]
[null,"PHYSICIAN PAYMENT METHOD (enter \"X\" if method(s) is applicable)"]
[21," MCP_________",null,"INITIAL METHOD__________",{"$nulls":5},21]
{"$rows_empty":26}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4007)"]
["Rev. 1",{"$nulls":8},"40-517"]

{"sheet":"S6","index":9,"n_rows":62,"n_cols":32,"rows_kept":62,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,"                                FORM CMS-2552-10",{"$nulls":4},"DRAFT"]
["HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND",null,null,null," PROVIDER NO.:","PERIOD:","WORKSHEET S-6",{"$nulls":24},"  ."]
["OTHER OUTPATIENT REHABILITATION",null,null,null," _______________","FROM__________"]
["PROVIDER STATISTICAL DATA",null,null,null," COMPONENT NO.:","TO_____________"]
[{"$nulls":4}," _______________"]
[]
["COMMUNITY MENTAL HEALTH & OTHER OUTPATIENT REHABILITATION PROVIDER- NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)"]
[]
["Check ",null,"  [  ]  CMHC     [  ]  OOT"]
["Applicable",null,"  [  ]  CORF      [  ]  OSP"]
["Box",null,"  [  ]  OPT"]
[]
["Enter the number of hours in your normal workweek ________"]
[]
[{"$nulls":6},"Total"]
[{"$nulls":4},"Staff","Contract","(col. 1 + col. 2)"]
[{"$nulls":4},"1","2","3"]
[1,"Administrator and Assistant Administrator(s)",{"$nulls":5},1]
[2,"Director(s) and Assistant Director(s)",{"$nulls":5},2]
[3,"Other Administrative Personnel",{"$nulls":5},3]
[4,"Direct Nursing Service",{"$nulls":5},4]
[5,"Nursing Supervisor",{"$nulls":5},5]
[6,"Physical Therapy Service",{"$nulls":5},6]
[7,"Physical Therapy Supervisor",{"$nulls":5},7]
[8,"Occupational Therapy Service",{"$nulls":5},8]
[9,"Occupational Therapy Supervisor",{"$nulls":5},9]
[10,"Speech Pathology Service",{"$nulls":5},10]
[11,"Speech Pathology Supervisor",{"$nulls":5},11]
[12,"Medical Social Service",{"$nulls":5},12]
[13,"Medical Social Service Supervisor",{"$nulls":5},13]
[14,"Respiratory Therapy Service",{"$nulls":5},14]
[15,"Respiratory Therapy Supervisor",{"$nulls":5},15]
[16,"Psychiatric/Psychological Service",{"$nulls":5},16]
[17,"Psychiatric/Psychological Service Supervisor",{"$nulls":5},17]
[18,"Other (specify)",{"$nulls":5},18]
{"$rows_empty":25}
["FORM CMS-2552-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4008)"]
["40-518",{"$nulls":6},"Rev. 1"]

{"sheet":"S7","index":10,"n_rows":139,"n_cols":13,"rows_kept":139,"cut":false,"hidden":false,"merged":[[8,3,8,4],[8,5,8,6],[70,3,70,4],[70,5,70,6]],"flags":["formulas_cached_only"]}
["DRAFT",null,null,null,"            FORM CMS-2552-10",{"$nulls":7},"4090 (Cont.)"]
["PROSPECTIVE PAYMENT FOR SNF",{"$nulls":4}," PROVIDER  NO.:",null,null," PERIOD:",null,null," WORKSHEET  S-7"]
["STATISTICAL  DATA",{"$nulls":7}," FROM ____________"]
[{"$nulls":5}," ________________",null,null," TO _______________"]
[null,"If this facility contains a hospital-based SNF, are all patients are under managed care or there was no"]
[1,"Medicare utilization enter \"Y\" and do not complete the rest of this worksheet.",{"$nulls":10},1]
[null," Does this hospital have an agreement under either section 1883 or section 1913 for swing "]
[2," beds?  If yes, enter the agreement date (mm/dd/yyyy) in column 2.",{"$nulls":10},2]
[{"$nulls":9},"SNF","Swing Bed SNF","TOTAL"]
[{"$nulls":4},"GROUP",{"$nulls":4},"Days","Days","(sum of col. 2 + 3)"]
[{"$nulls":4},1,{"$nulls":4},2,3,4]
[3,"RUC",{"$nulls":10},3]
[4,"RUB",{"$nulls":10},4]
[5,"RUA",{"$nulls":10},5]
[6,"RUX",{"$nulls":10},6]
[7,"RUL",{"$nulls":10},7]
[8,"RVC",{"$nulls":10},8]
[9,"RVB",{"$nulls":10},9]
[10,"RVA",{"$nulls":10},10]
[11,"RVX",{"$nulls":10},11]
[12,"RVL",{"$nulls":10},12]
[13,"RHC",{"$nulls":10},13]
[14,"RHB",{"$nulls":10},14]
[15,"RHA",{"$nulls":10},15]
[16,"RHX",{"$nulls":10},16]
[17,"RHL",{"$nulls":10},17]
[18,"RMC",{"$nulls":10},18]
[19,"RMB",{"$nulls":10},19]
[20,"RMA",{"$nulls":10},20]
[21,"RMX",{"$nulls":10},21]
[22,"RML",{"$nulls":10},22]
[23,"RLB",{"$nulls":10},23]
[24,"RLA",{"$nulls":10},24]
[25,"RLX",{"$nulls":10},25]
[26,"SE3",{"$nulls":10},26]
[27,"SE2",{"$nulls":10},27]
[28,"SE1",{"$nulls":10},28]
[29,"SSC",{"$nulls":10},29]
[30,"SSB",{"$nulls":10},30]
[31,"SSA",{"$nulls":10},31]
[32,"CC2",{"$nulls":10},32]
[33,"CC1",{"$nulls":10},33]
[34,"CB2",{"$nulls":10},34]
[35,"CB1",{"$nulls":10},35]
[36,"CA2",{"$nulls":10},36]
[37,"CA1",{"$nulls":10},37]
[38,"IB2",{"$nulls":10},38]
[39,"IB1",{"$nulls":10},39]
[40,"IA2",{"$nulls":10},40]
[41,"IA1",{"$nulls":10},41]
[42,"BB2",{"$nulls":10},42]
[43,"BB1",{"$nulls":10},43]
[44,"BA2",{"$nulls":10},44]
[45,"BA1",{"$nulls":10},45]
[46,"PE2",{"$nulls":10},46]
[47,"PE1",{"$nulls":10},47]
[48,"PD2",{"$nulls":10},48]
{"$rows_empty":7}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4009)"]
["Rev. 1",{"$nulls":11},"40-519"]
["4090 (Cont.)",null,null,null,"            FORM CMS-2552-10",{"$nulls":7},"DRAFT"]
["PROSPECTIVE PAYMENT FOR SNF",{"$nulls":4}," PROVIDER  NO.:",null,null," PERIOD:",null,null," WORKSHEET  S-7"]
["STATISTICAL  DATA",{"$nulls":7}," FROM ____________"]
[{"$nulls":5}," ________________",null,null," TO _______________"]
[{"$nulls":9},"SNF","Swing Bed SNF","TOTAL"]
[{"$nulls":4},"GROUP",{"$nulls":4},"Days","Days","(sum of col. 2 + 3)"]
[{"$nulls":4},1,{"$nulls":4},2,3,4]
[49,"PD1",{"$nulls":10},49]
[50,"PC2",{"$nulls":10},50]
[51,"PC1",{"$nulls":10},51]
[52,"PB2",{"$nulls":10},52]
[53,"PB1",{"$nulls":10},53]
[54,"PA2",{"$nulls":10},54]
[55,"PA1",{"$nulls":10},55]
[56,"Default rate",{"$nulls":10},56]
[57,"TOTAL",{"$nulls":10},57]
[]
["SNF SERVICES"]
[" ","Enter in column 1 the SNF CBSA code or 5 character code if Rural based facility, in effect at the beginning of the cost ",{"$nulls":10}," "]
[58,"reporting period. Enter in column 2, the code in effect on or after October 1, of the cost reporting period (if applicable).",{"$nulls":10},58]
[null," A notice published in the \"Federal Register\"  Vol. 68, No. 149 August 4, 2003 provided for an increase in the RUG payments beginning 10/01/2003.  Congress"]
[null,"expected this increase to be used for direct patient care and related expenses.   Enter in column 1 the amount of the expense for each category. Enter in "]
[null," column 2 the percentage of total expenses for each category to total SNF revenue from Worksheet G-2, Part I, line 6, column 3.   Indicate in column 3 \"Y\" "]
[null,"for yes or \"N\" for no if the spending reflects increases associated with direct patient care and related expenses for each category. (See instructions)"]
[{"$nulls":9},"Expenses","Percentage","Y/N"]
[59," Staffing",{"$nulls":10},59]
[60," Recruitment",{"$nulls":10},60]
[61," Retention of employees",{"$nulls":10},61]
[62," Training",{"$nulls":10},62]
[63," Other  (Specify)",{"$nulls":10},63]
[64,"Total SNF revenue (Worksheet G-2, Part I, line 6, column 3)",{"$nulls":10},64]
{"$rows_empty":40}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4009)"]
["40-520",{"$nulls":11},"Rev. 1"]

{"sheet":"S8","index":11,"n_rows":62,"n_cols":19,"rows_kept":62,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,"FORM CMS-2552-10",{"$nulls":15},"4090 (Cont.)"]
["PROVIDER-BASED RURAL HEALTH CLINIC/",{"$nulls":8},"PROVIDER NO.:",null,null,null,"PERIOD:",null,null,"WORKSHEET S-8"]
["FEDERALLY QUALIFIED HEALTH CENTER",{"$nulls":8},"_____________",null,null,null,"FROM________"]
["PROVIDER STATISTICAL DATA",{"$nulls":8},"COMPONENT NO.:",null,null,null,"TO___________"]
[{"$nulls":9},"_____________"]
["Check ",null,null,"  [  ]  RHC"]
["Applicable Box:",null,null,"  [  ]  FQHC"]
[]
["Clinic Address and Identification:"]
[1,"Street:",{"$nulls":16},1]
[2,"City:",null,null,"State:",null,null,"Zip Code:",null,null,null,"County:",{"$nulls":6},2]
[3,"Designation (for FQHCs only) - Enter \"R\" for rural or \"U\" for urban",{"$nulls":16},3]
[]
["Source of Federal Funds:",{"$nulls":11},"Grant Award",null,null,null,"Date"]
[{"$nulls":12},1,null,null,null,2]
[4,"Community Health Center (Section 330(d), PHS Act)",{"$nulls":16},4]
[5,"Migrant Health Center (Section 329(d), PHS Act)",{"$nulls":16},5]
[6,"Health Services for the Homeless (Section 340(d), PHS Act)",{"$nulls":16},6]
[7,"Appalachian Regional Commission",{"$nulls":16},7]
[8,"Look-Alikes",{"$nulls":16},8]
[9,"Other (specify)",{"$nulls":16},9]
[]
[10,"Does this facility operate as other than an RHC or FQHC?  Enter \"Y\" for yes and \"N\" for no in column 1. If yes, indicate number of",{"$nulls":16},10]
[null,"other operations in column 2.(Enter  in subscripts of line 12 the type of other operation(s) and the operating hours.)"]
[]
["Facility hours of operations (1)"]
[{"$nulls":4},"Sunday",null,"Monday",null,"Tuesday",null,"Wednesday",null,"Thursday",null,"Friday",null,"Saturday"]
[null,"Type Operation",null,null,"from","to","from","to","from","to","from","to","from","to","from","to","from","to"]
[null,0,null,null,1,2,3,4,5,6,7,8,9,10,11,12,13,14]
[11,"Clinic",{"$nulls":16},11]
[]
["  (1)  Enter clinic hours of operation on line 13 and other type operations on subscripts of line 13 (both type and hours of operation)."]
["         List hours of operation based on a 24 hour clock.  For example:  8:00am is 0800, 6:30pm is 1830, and midnight is 2400."]
[]
[12,"Have you received an approval for an exception to the productivity standard?",{"$nulls":16},12]
[13,"Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)?  If yes, enter in column 2 the",{"$nulls":16},13]
[null,"number of providers included in this report.  List the names of all providers and numbers below."]
[14,"Provider name: _______________________________________________",{"$nulls":9},"CCN number: ________________",{"$nulls":6},14]
[{"$nulls":14},1,2,3,4]
[{"$nulls":14},"Y/N","V","XVIII","XIX"]
[null,"Have you provided all or substantially all GME costs.  Enter in column 1 ,\"Y\" for yes and \"N\" for no col. 1."]
[15,"If yes, enter in col. 2, 3 and 4 the number of program visits performed by Intern & Residents.  (See instructions)",{"$nulls":16},15]
{"$rows_empty":18}
["FORM CMS-2552-10 (DRAFT)   (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4010)"]
["Rev. 1",{"$nulls":17},"40-521"]

{"sheet":"S9","index":12,"n_rows":68,"n_cols":9,"rows_kept":68,"cut":false,"hidden":false,"merged":[[6,2,6,7]],"flags":["formulas_cached_only"]}
["4090 (Cont.)",null,null,"FORM CMS-2552-10",{"$nulls":4},"DRAFT"]
["HOSPICE IDENTIFICATION DATA ",null,null,"PROVIDER NO.:__________",null,"PERIOD:",null,"WORKSHEET S-9,"]
[{"$nulls":5},"FROM _____________",null,"PARTS I & II"]
[null,null,null,"HOSPICE NO.:___________",null,"TO ________________"]
[]
["PART I - ENROLLMENT DAYS"]
[null,null,"Unduplicated Days"]
[{"$nulls":4},"Title XVIII"]
[{"$nulls":4},"Skilled","Title XIX",null,"Total"]
[{"$nulls":4},"Nursing","Nursing","All","(sum of"]
[null,"Enrollment Days","Title XVIII","Title XIX","Facility ","Facility","Other","cols. 1, 2 & 5)"]
[null,null,1,2,3,4,5,6]
[1,"Continuous Home Care",{"$nulls":6},1]
[2,"Routine Home Care",{"$nulls":6},2]
[3,"Inpatient Respite Care ",{"$nulls":6},3]
[4,"General Inpatient Care",{"$nulls":6},4]
[5,"Total Hospice Days",{"$nulls":6},5]
[]
["PART II - CENSUS DATA"]
[{"$nulls":4},"Title XVIII"]
[{"$nulls":4},"Skilled","Title XIX",null,"Total"]
[{"$nulls":4},"Nursing","Nursing","All","(sum of"]
[null,null,"Title XVIII","Title XIX","Facility ","Facility","Other","cols. 1, 2 & 5)"]
[null,null,1,2,3,4,5,6]
[6,"Number of Patients Receiving Hospice Care",{"$nulls":6},6]
[7,"Total Number of Unduplicated Continuous",{"$nulls":6},7]
[null," Care Hours Billable to Medicare"]
[8,"Average Length of Stay (line 5/line 6)",{"$nulls":6},8]
[9,"Unduplicated Census Count",{"$nulls":6},9]
[]
[]
["NOTE:  Parts I & II, columns 1 and 2 also include the days reported in columns 3 and 4 ."]
{"$rows_empty":33}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4011)"]
[]
["40-522",{"$nulls":7},"Rev. 1"]

{"sheet":"S10","index":13,"n_rows":64,"n_cols":9,"rows_kept":64,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,"FORM CMS-2552-10",{"$nulls":5},"4090 (Cont.)"]
["HOSPITAL UNCOMPENSATED  AND INDIGENT",null,null,null,"PROVIDER NO.:","PERIOD:",null,"WORKSHEET S-10"]
["CARE DATA",{"$nulls":4},"FROM_____________"]
[{"$nulls":4},"______________","TO________________"]
["Uncompensated and indigent care cost computation",{"$nulls":6},1]
[1,"Cost to charge ratio (Worksheet C, Part I line 200 column 3 divided by line 200 column 8)",{"$nulls":6},1]
["Medicaid (see instructions for each line)"]
[2,"Net revenue from Medicaid ",{"$nulls":6},2]
[3,"Did you receive DSH or supplemental payments from Medicaid?",{"$nulls":6},3]
[4,"  If line 3 is \"yes\", does line 2 include all DSH or supplemental payments from Medicaid?",{"$nulls":6},4]
[5,"  If line 4 is \"no\", then enter DSH or supplemental payments from Medicaid",{"$nulls":6},5]
[6,"Medicaid charges",{"$nulls":6},6]
[7,"Medicaid cost (line 1 times line 6)",{"$nulls":6},7]
[8,"Difference between net revenue and costs for Medicaid program (line 2 plus line 5 minus line 7)",{"$nulls":6},8]
["State Children's Health Insurance Program (SCHIP) (see instructions for each line)"]
[9,"Net revenue from stand-alone SCHIP",{"$nulls":6},9]
[10,"Stand-alone SCHIP charges",{"$nulls":6},10]
[11,"Stand-alone SCHIP cost (line 1 times line 10)",{"$nulls":6},11]
[12,"Difference between net revenue and costs for stand-alone SCHIP (line 9 minus line 11)",{"$nulls":6},12]
["Other state or local government indigent care program (see instructions for each line)"]
[13,"Net revenue from state or local indigent care program (Not included on lines 2, 5 or 9)",{"$nulls":6},13]
[14,"Charges for patients covered under state or local indigent care program (Not included in lines 6 or 10)",{"$nulls":6},14]
[15,"State or local indigent care program cost (line 1 times line 14)",{"$nulls":6},15]
[16,"Difference between net revenue and costs for state or local indigent care program (line 13 minus line 15)",{"$nulls":6},16]
["Uncompensated care (see instructions for each line)"]
[17,"Private grants, donations, or endowment income restricted to funding charity care",{"$nulls":6},17]
[18,"Government grants, appropriations or transfers for support of hospital operations",{"$nulls":6},18]
[19,"Total unreimbursed cost for Medicaid , SCHIP and state and local indigent care programs (sum of lines 8, 12 and 16)",{"$nulls":6},19]
[{"$nulls":5},"Uninsured","Insured","Total"]
[{"$nulls":5},"patients","patients","(col. 1 +  col. 2) "]
[{"$nulls":5},1,2,3]
[20,"Total initial obligation of patients approved for charity care (at full charges excluding",{"$nulls":6},20]
[null,"non-reimbursable cost centers) for the entire facility"]
[21,"Cost of initial obligation of patients approved for charity care (line 1 times line 20)",{"$nulls":6},21]
[22,"Partial payment by patients approved for charity care",{"$nulls":6},22]
[23,"Cost of charity care (line 21 minus line 22)",{"$nulls":6},23]
[{"$nulls":7},1]
[null,"Does the amount in line 20 column 2 include charges for patient days beyond a length of stay limit imposed on "]
[24,"patients covered by Medicaid or other indigent care program?",{"$nulls":6},24]
[25,"If line 24 is \"yes,\"  charges for patient days beyond an indigent care program's length of stay limit",{"$nulls":6},25]
[26,"Total bad debt expense for the entire facility (see instructions)",{"$nulls":6},26]
[27,"Medicare bad debts for §1886(d) hospitals fromWorksheets E, Part A and E, Part B, or CAHs from Worksheet E-3, Part V.",{"$nulls":6},27]
[28,"Non-Medicare and Non-Reimbursable bad debt expense (line 26 minus line 27)",{"$nulls":6},28]
[29,"Cost of non-Medicare bad debt expense (line 1 times line 28)",{"$nulls":6},29]
[30,"Cost of non-Medicare uncompensated care (line 23 column 3 plus line 29) ",{"$nulls":6},30]
[31,"Total unreimbursed and uncompensated care cost (line 19 plus line 30)",{"$nulls":6},31]
{"$rows_empty":16}
["FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4012)"]
["Rev. 1",{"$nulls":7},"40-523"]