{"text_format":"2","workbook":"xls","n_sheets":22,"sheets":["S","S_4","S-1","A","A_2","A1","A3","A31","B","B_2","B_3","B-1","B-1_2","B-1_3","C","C_2","D","G","A82","A83","A84","A85"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":1,"defined_names":7,"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":"S","index":0,"n_rows":70,"n_cols":10,"rows_kept":70,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["12-04",null,null,null,"FORM CMS 2088-92",{"$nulls":4},"1890 (Cont.)"]
["This report is required by law (42 USC 1395g; 42 CFR 413.20(b)).  Failure to report can result"]
["in all interim payments made since the beginning of the cost reporting period  being deemed",{"$nulls":6},"         FORM APPROVED"]
["as overpayments (42 USC 1395g).",{"$nulls":6},"         OMB NO. 0938-0037"]
["OUTPATIENT REHABILITATION PROVIDER COST",null,null,null,"   PROVIDER NO.:",null,"   PERIOD:",null,"WORKSHEET S,"]
["REPORT IDENTIFICATION DATA, CERTIFICATION",{"$nulls":5},"From:  ___________",null,"PARTS I - III"]
["AND SETTLEMENT SUMMARY",null,null,null,"    _______________",null,"To: ___________"]
[null,"      Intermediary Use Only:"]
[]
[null,"[  ]  Audited","Date Received",null,"_______________",null,"[  ]  Initial",null,"[  ]  Re-opened"]
[null,"[  ]  Desk Reviewed","Intermediary No.",null,"_______________",null,"[  ]  Final"]
["PART I - IDENTIFICATION DATA"]
["Outpatient Rehabilitation Facility:"]
["1","Name:",{"$nulls":7},"1"]
["1.01","Street:",{"$nulls":4},"P.O. Box:",null,null,"1.01"]
["1.02","City:",null,"State:",null,null,"Zip Code:",null,null,"1.02"]
["1.03","Cost Reporting Period (mm/dd/yyy)",null,"From:",null,null,"To:",null,null,"1.03"]
[]
[null,null,"Type of Control",null,null,"Type of Provider"]
[null,"Provider No.","(see instructions)",null,null,"(see instructions)",null,"          Date Certified"]
[null,1,2,3,null,4,null,5]
[2,{"$nulls":8},2]
[]
[3,"List malpractice premiums and paid losses:",{"$nulls":7},3]
["3.01","Premiums",{"$nulls":7},"3.01"]
["3.02","Paid Losses",{"$nulls":7},"3.02"]
["3.03","Self Insurance",{"$nulls":7},"3.03"]
[4,"Are malpractice premiums and/or paid losses reported in other than the Administrative and General cost center?",{"$nulls":7},4]
[null,"If yes, submit a supporting schedule listing cost centers and amounts contained therein."]
["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,null,"CERTIFICATION BY OFFICER OR DIRECTOR OF THE AGENCY"]
[]
[null,"I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying Outpatient Rehabilitation Provider"]
[null,"Cost Report and the Balance Sheet and Statement of Revenue and Expenses prepared by _______________________________________"]
[null,"(Provider name(s) and number(s)) for the cost report beginning _____________________and ending __________________________, and"]
[null,"that to the best of my knowledge and belief, it is a true, correct and complete report prepared from the books and records of the provider in"]
[null,"accordance with applicable instructions, except as noted.  I further certify that I am familiar with the laws and regulations regarding the"]
[null,"provision of health care services, and that the services identified in this cost report were provided in compliance with such laws and"]
[null,"regulations."]
[]
[null,null,"(Signed)","__________________________________________"]
[null,null,null,"  Officer or Director"]
[null,null,null,"__________________________________________"]
[null,null,null,"  Title"]
[null,null,null,"__________________________________________"]
[null,null,null,"  Date"]
[]
["PART III - SETTLEMENT SUMMARY"]
[{"$nulls":6},"TITLE XVIII"]
[{"$nulls":6},"PART B"]
[{"$nulls":6},"1",null,null," "]
[]
["6","OUTPATIENT REHABILITATION PROVIDER (specify type)",{"$nulls":7},"6"]
[]
["\"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 0938-0037.  The"]
["time required to complete this information collection is estimated to average 226 hours per response, including the time to"]
["review instructions, search existing data 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, N2-14-26, Baltimore, Maryland  21244-1850.\""]
[]
["FORM CMS-2088-92-S  (12-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECS. 1802-1802.3)"]
[]
["Rev. 7",{"$nulls":8},"18-303"]

{"sheet":"S_4","index":1,"n_rows":57,"n_cols":42,"rows_kept":57,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",{"$nulls":28},"FORM CMS 2088-92",{"$nulls":11},"12-04"]
["OUTPATIENT REHABILITATION ",{"$nulls":19},"PERIOD:",{"$nulls":12},"PROVIDER NO:",{"$nulls":4},"WORKSHEET  S"]
["PROVIDER COST REPORT",{"$nulls":19},"FROM __________________",{"$nulls":17},"PART IV"]
["STATISTICAL DATA",{"$nulls":19},"TO _____________________",{"$nulls":12},"___________________"]
[{"$nulls":13},"VISITS",{"$nulls":12},"PATIENTS",{"$nulls":8},"FTE ON PAYROLL"]
[null,"REIMBURSABLE ",{"$nulls":11},"Medicare",null,null,null,"Other",{"$nulls":17},"Staff",null,"Social"]
[null,"COST CENTERS",{"$nulls":11},"Patients",null,null,null,"Patients",null,null,"Total",{"$nulls":5},"Medicare",null,null,null,"Other",null,null,"Total",null,"Therapists","Physicians","Workers","Others"]
[{"$nulls":13},"1",null,null,null,"2",null,null,"3",{"$nulls":5},"4",null,null,null,"5",null,null,"6",null,"7","8","9","10"]
[null,"CORF"]
["1","Skilled Nursing Care",{"$nulls":39},"1"]
["2","Physical Therapy",{"$nulls":39},"2"]
["3","Speech Pathology",{"$nulls":39},"3"]
["4","Occupational Therapy",{"$nulls":39},"4"]
["5","Respiratory Therapy",{"$nulls":39},"5"]
["6","Medical Social Services",{"$nulls":39},"6"]
["7","Psychological Services",{"$nulls":39},"7"]
["8","Prosthetic and Orthotic Devices",{"$nulls":39},"8"]
["8","Drugs and Biologicals",{"$nulls":39},"8"]
["10","Medical Supplies",{"$nulls":39},"10"]
["11","DME-Sold",{"$nulls":39},"11"]
["12","DME-Rented",{"$nulls":39},"12"]
["13","Other Services",{"$nulls":39},"13"]
[null,"CMHC"]
["14","Drugs and Biologicals",{"$nulls":39},"14"]
["15","Occupational Therapy",{"$nulls":39},"15"]
["16","Psychiatric/Psychological Services",{"$nulls":39},"16"]
["17","Individual Therapy",{"$nulls":39},"17"]
["18","Group Therapy",{"$nulls":39},"18"]
["19","Individualized Activity Therapies",{"$nulls":39},"19"]
["20","Family Counseling",{"$nulls":39},"20"]
["21","Diagnostic Services",{"$nulls":39},"21"]
["22","Patient Training & Education",{"$nulls":39},"22"]
["23","Other Services",{"$nulls":39},"23"]
[null,"OTHER PROVIDERS"]
["24","Physical Therapy",{"$nulls":39},"24"]
["25","Speech Pathology",{"$nulls":39},"25"]
["26","Occupational Therapy",{"$nulls":39},"26"]
["27","Other Services",{"$nulls":39},"27"]
["28","Total (Sum of lines 1-27)",{"$nulls":39},"28"]
["29","Unduplicated Census Count",{"$nulls":39},"29"]
{"$rows_empty":14}
["FORM CMS-2088-92-S (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II,SECS.1802.4)"]
[]
["18-304",{"$nulls":40},"Rev. 7"]

{"sheet":"S-1","index":2,"n_rows":59,"n_cols":10,"rows_kept":59,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["12-04",null,null,null,"FORM CMS 2088-92",{"$nulls":4},"1890 (Cont.)"]
["ANALYSIS OF PAYMENTS TO",null,null,null," PROVIDER NO.:"," PERIOD:",null,null,"  SUPPLEMENTAL"]
["OUTPATIENT REHABILITATION",{"$nulls":4}," FROM: ______________",null,null,"  WORKSHEET S-1"]
["PROVIDERS FOR SERVICES RENDERED",null,null,null,"______________"," TO: _______________"]
["TO PROGRAM BENEFICIARIES"]
[]
[null,"DESCRIPTION",{"$nulls":5},"PART B"]
[{"$nulls":7},"1","2"]
[{"$nulls":7},"mm/dd/yyyy","Amount"]
["1","Total interim payments paid to Outpatient Rehabilitation Provider ",{"$nulls":7},"1"]
["2","Interim payments payable on individual bills either, submitted or to",{"$nulls":7},"2"]
[null,"be submitted to the intermediary, for services rendered in the"]
[null,"cost reporting period.  If none, write \"NONE\" or enter a zero."]
["3","List separately each retroactive lump sum ",{"$nulls":4},".01",null,null,"3.01"]
[null,"adjustment amount based on subsequent revision",null,null,null,"Program ",".02",null,null,"3.02"]
[null,"of the interim rate for the cost reporting period.",null,null,null,"to",".03",null,null,"3.03"]
[null,"Also show date of each payment.  If none write",null,null,null,"Provider",".04",null,null,"3.04"]
[null,"\"NONE\" or enter a zero. (1)",{"$nulls":4},".05",null,null,"3.05"]
[{"$nulls":6},".50",null,null,"3.50"]
[{"$nulls":5},"Provider ",".51",null,null,"3.51"]
[{"$nulls":5},"to",".52",null,null,"3.52"]
[{"$nulls":5},"Program",".53",null,null,"3.53"]
[{"$nulls":6},".54",null,null,"3.54"]
[null,"SUBTOTAL (Sum of lines 3.01-3.49, minus sum"]
[null,"of lines 3.50-3.98)                         ",{"$nulls":4},".99",null,null,"3.99"]
["4","TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)",{"$nulls":7},"4"]
[null,"(Transfer to Wkst D, Part I, line 18)"]
[]
[null,null,null,"TO BE COMPLETED BY INTERMEDIARY"]
[]
["5","List separately each tentative settlement payment ",null,null,null,"Program ",".01",null,null,"5.01"]
[null,"after desk review.  Also show date of each ",null,null,null,"to",".02",null,null,"5.02"]
[null,"payment.  If none, write \"NONE\" or enter     ",null,null,null,"Provider",".03",null,null,"5.03"]
[null,"a zero. (1)",null,null,null,"Provider ",".50",null,null,"5.50"]
[{"$nulls":5},"to",".51",null,null,"5.51"]
[{"$nulls":5},"Program",".52",null,null,"5.52"]
[null,"SUBTOTAL (Sum of lines 5.01-5.49, minus sum  "]
[null,"of lines 5.50-5.98)      ",{"$nulls":4},".99",null,null,"5.99"]
["6","Determine net settlement amount (balance due) based",null,null,null,"Program "]
[null,"on the cost report (SEE INSTRUCTIONS). (1)",null,null,null,"to"]
[{"$nulls":5},"Provider",".01",null,null,"6.01"]
[{"$nulls":5},"Provider "]
[{"$nulls":5},"to"]
[{"$nulls":5},"Program",".02",null,null,"6.02"]
["7","TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)",{"$nulls":7},"7"]
[]
[" Name of Intermediary",{"$nulls":5},"    Intermediary Number"]
[]
[]
[" Signature of Authorized Person",{"$nulls":5},"    Date:   (Month, Day, Year)"]
[]
[]
[" (1)  On lines 3, 5 and 6, where an amount is due \"Provider to Program,\" show the amount and date on which the provider"]
["      agrees to the amount of repayment, even though total repayment is not accomplished until a later date."]
[]
["FORM CMS-2088-92-S-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC."]
["1806)"]
[]
["Rev. 7",{"$nulls":8},"18-305"]

{"sheet":"A","index":3,"n_rows":62,"n_cols":11,"rows_kept":62,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",null,null,null,"FORM CMS 2088-92",{"$nulls":5},"12-04"]
[null,null,null," ",null,"PROVIDER NO:",null,"PERIOD:",null,"  WORKSHEET A"]
[null,"RECLASSIFICATION AND ADJUSTMENT OF ",{"$nulls":5},"FROM ___________",null,"  Page 1 of 2"]
[null,"TRIAL BALANCE OF EXPENSES (Omit Cents)",null,null,null,"___________",null,"TO ___________"]
[{"$nulls":6},"RECLASS.","RECLASSIFIED","ADJUSTMENTS","NET EXPENSES"]
[{"$nulls":5},"TOTAL","(from","TRIAL BALANCE","(from","FOR ALLOCATION"]
[null,null," COST CENTERS","SALARIES","OTHER","(Col 1 + Col 2)","Wkst. A-1)","   (Col 3 +/- Col 4)","Wkst. A-3)","   (Col 5 +/- Col 6)"]
[null,null,null,"1","2","3","4","5","6","7"]
[null,null,"GENERAL SERVICE COST CENTERS",null," "," "]
[1,"0100","Capital Related Costs--Buildings and Fixtures",{"$nulls":7},1]
[2,"0200","Capital Related Costs--Movable Equipment",{"$nulls":7},2]
[3,"0300","Employee Benefits",{"$nulls":7},3]
[4,"0400","Administrative and General",{"$nulls":7},4]
[5,"0500","Maintenance and Repairs",{"$nulls":7},5]
[6,"0600","Operation of Plant",{"$nulls":7},6]
[7,"0700","Laundry and Linen Service",{"$nulls":7},7]
[8,"0800","Housekeeping",{"$nulls":7},8]
[9,"0900","Cafeteria",{"$nulls":7},9]
[10,"1000","Central Services and Supply",{"$nulls":7},10]
[11,"1100","Medical Records and Library",{"$nulls":7},11]
[12,"1200","Professional Education and Training (1)",{"$nulls":7},12]
[13,null,"Other (specify)",{"$nulls":7},13]
[14,null,"Other (specify)",{"$nulls":7},14]
[null,null,"REIMBURSABLE SERVICE COST CENTERS"]
[null,null,"CORF"]
[15,"1500","Skilled Nursing Care",{"$nulls":7},15]
[16,"1600","Physical Therapy",{"$nulls":7},16]
[17,"1700","Speech Pathology",{"$nulls":7},17]
[18,"1800","Occupational Therapy",{"$nulls":7},18]
[19,"1900","Respiratory Therapy",{"$nulls":7},19]
[20,"2000","Medical Social Services",{"$nulls":7},20]
[21,"2100","Psychological Services",{"$nulls":7},21]
[22,"2200","Prosthetic and Orthotic Devices",{"$nulls":7},22]
[23,"2300","Drugs and Biologicals",{"$nulls":7},23]
[24,"2400","Medical Supplies Charged to Patients",{"$nulls":7},24]
[25,"2500","DME-Sold",{"$nulls":7},25]
[26,"2600","DME-Rented",{"$nulls":7},26]
[27,null,"Other (specify)",{"$nulls":7},27]
[null,null,"CMHC"]
[29,"2900","Drugs and Biologicals",{"$nulls":7},29]
[30,"3000","Occupational Therapy",{"$nulls":7},30]
[31,"3100","Psychiatric/Psychological Services",{"$nulls":7},31]
[32,"3200","Individual Therapy",{"$nulls":7},32]
[33,"3300","Group Therapy",{"$nulls":7},33]
[34,"3400","Individualized Activity Therapies",{"$nulls":7},34]
[35,"3500","Family Counseling",{"$nulls":7},35]
[36,"3600","Diagnostic Services",{"$nulls":7},36]
[37,"3700","Patient Training & Education",{"$nulls":7},37]
[38,null,"Other (specify)",{"$nulls":7},38]
{"$rows_empty":10}
["FORM CMS-2088-92  (12-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,SEC.1804)"]
[]
["18-306",{"$nulls":9},"Rev. 7"]

{"sheet":"A_2","index":4,"n_rows":62,"n_cols":11,"rows_kept":62,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["12-04",{"$nulls":4},"FORM CMS 2088-92",{"$nulls":4},"1890 (Cont.)"]
[null,null,null," ",null,"PROVIDER NO:",null,"PERIOD:",null,"  WORKSHEET A"]
[null,"RECLASSIFICATION AND ADJUSTMENT OF ",{"$nulls":5},"FROM ___________",null,"  Page 2 of 2"]
[null,"TRIAL BALANCE OF EXPENSES (Omit Cents)",null,null,null," ___________",null,"TO ____________"]
[{"$nulls":6},"RECLASS.","RECLASSIFIED","ADJUSTMENTS","NET EXPENSES"]
[{"$nulls":5},"TOTAL","(from","TRIAL BALANCE","(from","FOR ALLOCATION"]
[null,null," COST CENTERS","SALARIES","OTHER","(Col 1 + Col 2)","Wkst. A-1)","   (Col 3 +/- Col 4)","Wkst. A-3)","   (Col 5 +/- Col 6)"]
[null,null,null,"1","2","3","4","5","6","7"]
[null,null,"OTHER PROVIDERS"]
[40,"4000","Physical Therapy",{"$nulls":7},40]
[41,"4100","Speech Therapy",{"$nulls":7},41]
[42,"4200","Occupational Therapy",{"$nulls":7},42]
[43,"4300","Other (specify)",{"$nulls":7},43]
[null,null,"NONREIMBURSABLE COST CENTERS"]
[45,"4500","Sheltered Workshops",{"$nulls":7},45]
[46,"4600","Recreational Programs",{"$nulls":7},46]
[47,"4700","Resident Day Camps",{"$nulls":7},47]
[48,"4800","Pre-school Programs",{"$nulls":7},48]
[49,"4900","Diagnostic Clinics",{"$nulls":7},49]
[50,"5000","Home Employment Programs",{"$nulls":7},50]
[51,"5100","Equipment Loan Service",{"$nulls":7},51]
[52,"5200","Physicians' Private Offices",{"$nulls":7},52]
[53,"5300","Fund Raising",{"$nulls":7},53]
[54,"5400","Coffee Shops and Canteen",{"$nulls":7},54]
[55,"5500","Research",{"$nulls":7},55]
[56,"5600","Investment Property",{"$nulls":7},56]
[57,"5700","Advertising",{"$nulls":7},57]
[58,"5800","Franchise Fees and Other Assessments",{"$nulls":7},58]
[59,"5900","Professional Education and Training(2)",{"$nulls":7},59]
[60,null,"Other (specify)",{"$nulls":7},60]
[null,null,"CMHC NON-REIMBURSABLE COST CENTERS"]
[61,"6100","Meals and Transportation",{"$nulls":7},61]
[62,"6200","Activity Therapies",{"$nulls":7},62]
[63,"6300","Psychosocial Programs",{"$nulls":7},63]
[64,"6400","Vocational Training",{"$nulls":7},64]
[65,null,"TOTAL(sum of lines 1- 64)",{"$nulls":7},65]
{"$rows_empty":18}
[null,null,"(1) Approved Educational Activity"]
[null,null,"(2) Not An Approved Educational Activity "]
[]
[]
[]
["FORM CMS-2088-92  (12-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 1804)"]
[]
["Rev. 7",{"$nulls":9},"18-307"]

{"sheet":"A1","index":5,"n_rows":62,"n_cols":10,"rows_kept":62,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",null,null,null,"FORM CMS 2088-92",{"$nulls":4},"12-04"]
[null,null," ",null,"PROVIDER NO:",null,"PERIOD:",null,"  WORKSHEET A-1"]
[null,"RECLASSIFICATIONS  ",{"$nulls":4},"FROM ___________"]
[{"$nulls":4}," ___________",null,"TO ___________"]
[]
[null,"EXPLANATION OF ","CODE",null,"INCREASE",null,null,"DECREASE"]
[null,"RECLASSIFICATION ENTRY","(1)","COST CENTER","LINE NO.","AMOUNT(2)","COST CENTER","LINE NO.","AMOUNT(2)"]
[null,null,"1","2","3","4","5","6","7"]
[1,{"$nulls":8},1]
[2,{"$nulls":8},2]
[3,{"$nulls":8},3]
[4,{"$nulls":8},4]
[5,{"$nulls":8},5]
[6,{"$nulls":8},6]
[7,{"$nulls":8},7]
[8,{"$nulls":8},8]
[9,{"$nulls":8},9]
[10,{"$nulls":8},10]
[11,{"$nulls":8},11]
[12,{"$nulls":8},12]
[13,{"$nulls":8},13]
[14,{"$nulls":8},14]
[15,{"$nulls":8},15]
[16,{"$nulls":8},16]
[17,{"$nulls":8},17]
[18,{"$nulls":8},18]
[19,{"$nulls":8},19]
[20,{"$nulls":8},20]
[21,{"$nulls":8},21]
[22,{"$nulls":8},22]
[23,{"$nulls":8},23]
[24,{"$nulls":8},24]
[25,{"$nulls":8},25]
[26,{"$nulls":8},26]
[27,{"$nulls":8},27]
[28,{"$nulls":8},28]
[29,{"$nulls":8},29]
[30,"TOTAL RECLASSIFICATIONS(Sum of Col. 4",{"$nulls":7},30]
[null,"must equal Col. 7)"]
{"$rows_empty":18}
[null,"(1) A letter (A,B, etc.) must be entered on each line to identify each reclassification entry."]
[null,"(2) Transfer to Worksheet A. column 4, line as appropriate."]
["FORM CMS-2088-92  (12-1992)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 1805)"]
[]
["18-308",{"$nulls":8},"Rev. 7"]

{"sheet":"A3","index":6,"n_rows":68,"n_cols":10,"rows_kept":68,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",null,null,"FORM CMS 2088-92",{"$nulls":5},"1890 (Cont.)"]
["ADJUSTMENTS TO EXPENSES",null,null,"PROVIDER NO.:",null,"PERIOD:",null,"   WORKSHEET A-3"]
[{"$nulls":5},"FROM ____________"]
[null,null,null,"____________",null,"TO _______________"]
[{"$nulls":5},"  EXPENSE CLASSIFICATION ON"]
[{"$nulls":5},"  WORKSHEET A TO/FROM WHICH"]
[null,"DESCRIPTION (1)",null,null,null,"  THE AMOUNT IS TO BE ADJUSTED"]
[null,null,"BASIS (2)","AMOUNT",null,"COST CENTER",null,"LINE NO."]
[null,null,1,2,null,"                3",null,"4"]
[1,"Payments received from",{"$nulls":6},1]
[null,"specialists","B"]
[2,"Investment income ",{"$nulls":6},2]
[null,"(chapter 2)"]
[3,"Trade, quantity and time discounts","B",{"$nulls":5},3]
[null,"(chapter 8)"]
[4,"Refunds and rebates of expenses","B",{"$nulls":5},4]
[null,"(chapter 8)"]
[5,"Laundry and linen service",null,null,null," Laundry and Linen Service",null,"7",5]
[6,"Cafeteria--employees,",{"$nulls":6},6]
[null,"guests, etc.",null,null,null,"     Cafeteria",null,"9"]
[7,"Sale of medical and surgical",null,null,null,"Central Services and ",null,null,7]
[null,"supplies to other than patients",null,null,null,"Supply",null,"10"]
[8,"Sale of workshop products",{"$nulls":6},8]
[null,"or services"]
[9,"Coffee shops and canteen",{"$nulls":6},9]
[10,"Vending Machines",{"$nulls":6},10]
[11,"Rental of building or office",{"$nulls":6},11]
[null,"space to others"]
[12,"Sale of scrap, waste,",{"$nulls":6},12]
[null,"etc.(Chapter 23)"]
[13,"Related organization transactions","Supp. Wks",{"$nulls":5},13]
[null,"(chapter 10)","A-3-1"]
[14,"Provider-based physician ","Supp. Wks.",{"$nulls":5},14]
[null,"adjustment","A-8-2"]
[15,"Respiratory Therapy limit","Supp. Wks.",{"$nulls":5},15]
[null,"adjustment","A-8-4"]
[16,"Physical therapy limit","Supp. Wks.",{"$nulls":5},16]
[null,"adjustment","A-8-3"]
[17,"Respiratory Therapy limit","Supp. Wks.",{"$nulls":5},17]
[null,"adjustment","A-8-5"]
["17.1","Physical therapy limit","Supp. Wks.",{"$nulls":5},"17.1"]
[null,"adjustment","A-8-5"]
["17.2","Occupational therapy limit","Supp. Wks.",{"$nulls":5},"17.2"]
[null,"adjustment","A-8-5"]
["17.3","Speech pathology limit","Supp. Wks.",{"$nulls":5},"17.3"]
[null,"adjustment","A-8-5"]
[18,"Other (Specify) (3)",{"$nulls":6},18]
[19,"Other (Specify) (3)",{"$nulls":6},19]
[20,"Capital Related Costs-Buildings ",null,null,null,"Capital Related Costs",null,null,20]
[null,"and fixtures","A",null,null,"Buildings & Fixtures",null,"1"]
[21,"Capital Related Costs- Movable",null,null,null,"Capital Related Costs",null,null,21]
[null,"Equipment","A",null,null,"Movable Equipment",null,"2"]
[22,"TOTAL (Sum of lines 1-21) ",{"$nulls":6},22]
[null,"(Transfer to Worksheet A, col.6, line 65)"]
[]
[null,"(1) Include amounts not already applied against expenses included on Worksheet A, column 3"]
[]
[null,"(2) Basis for adjustment (SEE INSTRUCTIONS)."]
[null,"    A.  Costs -- if cost, including applicable overhead, can be determined."]
[null,"    B. Amount Received -- if cost cannot be determined."]
[]
[null,"(3) Additional adjustments may be made on subscripts of this line."]
[null," "]
[null,"Chapter references are to CMS Pub.15-I"]
[]
["FORM CMS-2088-92  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 1806)"]
[]
["Rev. 3",{"$nulls":8},"18-309"]

{"sheet":"A31","index":7,"n_rows":71,"n_cols":39,"rows_kept":71,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",{"$nulls":18},"FORM CMS 2088-92",{"$nulls":18},"08-99"]
[{"$nulls":13},"PROVIDER NO:",{"$nulls":8},"PERIOD:",{"$nulls":8},"SUPPLEMENTAL"]
["STATEMENT OF COSTS OF SERVICES",{"$nulls":21},"FROM ___________",{"$nulls":8},"WORKSHEET A-3-1"]
["FROM RELATED ORGANIZATIONS",{"$nulls":12},"___________",{"$nulls":8},"TO ___________"]
["A. Are there any costs included in Worksheet A which resulted from transactions with related"]
["   organizations as defined in CMS Pub. 15-I, chapter 10?"]
[]
[{"$nulls":7},"[   ]  Yes  (If \"Yes,\" complete Parts B and C)"]
[{"$nulls":7},"[   ]  No"]
["B. Costs incurred and adjustments required as a result of transactions with related organizations:"]
[{"$nulls":33}," Net"]
[null,null,null,"Location and amount included on Worksheet A, Column 5",{"$nulls":23},"Amount",{"$nulls":5},"Adjustments"]
[{"$nulls":27},"Allowable",{"$nulls":5},"(Col 3 minus"]
["Line No.",{"$nulls":5},"Cost Center",{"$nulls":14}," Amount",{"$nulls":5},"In Cost",{"$nulls":5},"Col 4)"]
[1,{"$nulls":5},"2",{"$nulls":14},"3",{"$nulls":5},"4",{"$nulls":5},"5"]
[1]
[2]
[3]
[4]
[5,null,"TOTALS (Sum of lines 1-4) "]
[null,null,"(Transfer col. 5, line 5 to "]
[null,null,"Worksheet A-3, line 13)"]
["C. Interrelationship to related organization(s):"]
["The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security"]
["Act, requires that you furnish the information requested under Part C of this worksheet."]
[]
["This information is used by the Centers for Medicare and Medicaid Services and its intermediaries in"]
["determining that the costs applicable to services, facilities and supplies furnished by"]
["organizations related to you by common ownership or control, represent reasonable costs as"]
["determined under section 1861 of the Social Security Act.  If you do not provide all or any"]
["part of the requested information, the cost report is considered incomplete and not acceptable"]
["for purposes of claiming reimbursement under title XVIII."]
[]
[{"$nulls":24},"  Related Organization(s)"]
[{"$nulls":13},"Percentage",{"$nulls":12},"Percentage"]
[null,"Symbol",{"$nulls":4},"Name",{"$nulls":6},"of",{"$nulls":4},"Name",{"$nulls":7},"of",{"$nulls":6}," Type of"]
[null,"  (1)",{"$nulls":11},"    Ownership",{"$nulls":12},"Ownership",{"$nulls":6}," Business"]
[null,null,"1",null,null,null,2,{"$nulls":6},3,{"$nulls":4},4,{"$nulls":7},5,{"$nulls":7},"  6"]
["1"]
["2"]
["3"]
[4]
["5"]
[]
[null,"(1) Use the following symbols to indicate interrelationship to related organizations:"]
[]
[null,null,null,"A. Individual has financial interest (stockholder, partner, etc.) in both related"]
[null,null,null,"    organization and in provider."]
[null,null,null,"B. Corporation, partnership or other organization has financial interest in provider."]
[null,null,null,"C. Provider has financial interest in corporation, partnership, or other organization."]
[null,null,null,"D. Director, officer, administrator or key person of provider or relative of such"]
[null,null,null,"     person has financial interest in related organization."]
[null,null,null,"E. Individual is director, officer, administrator or key person of provider and"]
[null,null,null,"    related organization."]
[null,null,null,"F. Director, officer, administrator or key person of related organization or relative"]
[null,null,null,"     of such person has financial interest in provider."]
[null,null,null,"G. Other (financial or non-financial) specify __________________________________________________"]
{"$rows_empty":11}
["FORM CMS-2088-92  (12-1992)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 1807)"]
[]
["18-310",{"$nulls":37},"Rev. 3"]

{"sheet":"B","index":8,"n_rows":84,"n_cols":10,"rows_kept":84,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["12-04",null,null,"FORM CMS 2088-92",{"$nulls":5},"1890 (Cont.)"]
[{"$nulls":4},"PROVIDER NO:",null,"PERIOD:",null,"  WORKSHEET B"]
[null,"COST ALLOCATION",{"$nulls":4},"FROM ___________",null,"  Page 1 of 3"]
[null,"GENERAL SERVICE COSTS",null,null," ____________",null,"TO ___________"]
[null,null,"Net Expenses ","          Capital Related"]
[null,null,"(from Wkst.A,","Buildings &","Movable","Employee","Subtotal","Administrative","Maintenance"]
[null," COST CENTERS"," Col.7)","Fixtures","Equipment","Benefits","(cols. 0-4)","& General","& Repairs"]
[null,null,"0","1","2","3","3A",4,"5"]
[null,"Gen. Service Cost Ctrs."," "," "]
[1,"Cap. Rel. Costs--Bldg.&Fixt."," "," ",{"$nulls":5},1]
[2,"Cap. Rel. Costs--Movable Eqp.",{"$nulls":7},2]
[3,"Employee Benefits",{"$nulls":7},3]
[4,"Administrative and General",{"$nulls":7},4]
[5,"Maintenance and Repairs",{"$nulls":7},5]
[6,"Operation of Plant",{"$nulls":7},6]
[7,"Laundry and Linen Service",{"$nulls":7},7]
[8,"Housekeeping",{"$nulls":7},8]
[9,"Cafeteria",{"$nulls":7},9]
[10,"Central Services and Supply",{"$nulls":7},10]
[11,"Medical Records and Library",{"$nulls":7},11]
[12,"Prof. Educ. & Training(1)",{"$nulls":7},12]
[13,{"$nulls":8},13]
[14,{"$nulls":8},14]
[null,"REIMBURSABLE COST CTRS."]
[null,"CORF"]
[15,"Skilled Nursing Care",{"$nulls":7},15]
[16,"Physical Therapy",{"$nulls":7},16]
[17,"Speech Pathology",{"$nulls":7},17]
[18,"Occupational Therapy",{"$nulls":7},18]
[19,"Respiratory Therapy",{"$nulls":7},19]
[20,"Medical Social Services",{"$nulls":7},20]
[21,"Psychological Services",{"$nulls":7},21]
[22,"Prosthetic and Orthotic Devices",{"$nulls":7},22]
[23,"Drugs and Biologicals",{"$nulls":7},23]
[24,"Supplies Charged to Patients",{"$nulls":7},24]
[25,"DME-Sold",{"$nulls":7},25]
[26,"DME-Rented",{"$nulls":7},26]
[27,{"$nulls":8},27]
[null,"CMHC"]
[29,"Drugs and Biologicals",{"$nulls":7},29]
[30,"Occupational Therapy",{"$nulls":7},30]
[31,"Psychiatric/Psychological Service",{"$nulls":7},31]
[32,"Individual Therapy",{"$nulls":7},32]
[33,"Group Therapy",{"$nulls":7},33]
[34,"Individualized Activity Therapies",{"$nulls":7},34]
[35,"Family Counseling",{"$nulls":7},35]
[36,"Diagnostic Services",{"$nulls":7},36]
[37,"Patient Training & Education",{"$nulls":7},37]
[38,{"$nulls":8},38]
[null,"OTHER PROVIDERS"]
[40,"Physical Therapy",{"$nulls":7},40]
[41,"Speech Pathology",{"$nulls":7},41]
[42,"Occupational Therapy",{"$nulls":7},42]
[43,{"$nulls":8},43]
[null,"NON-REIM. COST CENTERS"]
[45,"Sheltered Workshops",{"$nulls":7},45]
[46,"Recreational Programs",{"$nulls":7},46]
[47,"Resident Day Camps",{"$nulls":7},47]
[48,"Preschool Programs",{"$nulls":7},48]
[49,"Diagnostic Clinics",{"$nulls":7},49]
[50,"Home Employment Programs",{"$nulls":7},50]
[51,"Equipment Loan Service",{"$nulls":7},51]
[52,"Physicians' Private Office",{"$nulls":7},52]
[53,"Fundraising",{"$nulls":7},53]
[54,"Coffee Shops &Canteen",{"$nulls":7},54]
[55,"Research",{"$nulls":7},55]
[56,"Investment Property",{"$nulls":7},56]
[57,"Advertising",{"$nulls":7},57]
[58,"Franchise & Other Ass'mt",{"$nulls":7},58]
[59,"Prof. Ed. & Training(2)",{"$nulls":7},59]
[60,{"$nulls":8},60]
[null,"CMHC NON-REIMBURSABLE "]
[61,"Meals and Transportation",{"$nulls":7},61]
[62,"Activity Therapies",{"$nulls":7},62]
[63,"Psychosocial Programs",{"$nulls":7},63]
[64,"Vocational Training",{"$nulls":7},64]
[65,"Negative Cost Center",{"$nulls":7},65]
[66,"TOTAL",{"$nulls":7},66]
[null,"(1) Approved Educational Activity"]
[null,"(2) Not an  Approved Educational Activity"]
[]
["FORM CMS-2088-92  (12-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)"]
[]
["Rev. 7",{"$nulls":8},"18-311"]

{"sheet":"B_2","index":9,"n_rows":83,"n_cols":9,"rows_kept":83,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",null,null,"FORM CMS 2088-92",{"$nulls":4},"12-04"]
[null,null,null,"PROVIDER NO:",null,"PERIOD:",null,"  WORKSHEET B"]
[null,"COST ALLOCATION",null,null,null,"FROM ____________",null,"  Page 2 of 3"]
[null,"GENERAL SERVICE COSTS",null," ___________",null,"TO ____________"]
[null,null,"Operation ","Laundry",null,null,"Medical","Medical "]
[null,null,"of","and Linen","House-",null,"Supplies","Records"]
[null," COST CENTERS","Plant","Services","keeping","Cafeteria",null,"Library"]
[null,null,"6","7","8","9","10","11"]
[null,"Gen. Service Cost Ctrs."," "," "]
[1,"Cap. Rel. Costs--Bldg.&Fixt."," "," ",{"$nulls":4},1]
[2,"Cap. Rel. Costs--Movable Eqp.",{"$nulls":6},2]
[3,"Employee Benefits",{"$nulls":6},3]
[4,"Administrative and General",{"$nulls":6},4]
[5,"Maintenance and Repairs",{"$nulls":6},5]
[6,"Operation of Plant",{"$nulls":6},6]
[7,"Laundry and Linen Service",{"$nulls":6},7]
[8,"Housekeeping",{"$nulls":6},8]
[9,"Cafeteria",{"$nulls":6},9]
[10,"Central Services and Supply",{"$nulls":6},10]
[11,"Medical Records and Library",{"$nulls":6},11]
[12,"Prof. Educ. & Training(1)",{"$nulls":6},12]
[13,{"$nulls":7},13]
[14,{"$nulls":7},14]
[null,"REIMBURSABLE COST CTRS."]
[null,"CORF"]
[15,"Skilled Nursing Care",{"$nulls":6},15]
[16,"Physical Therapy",{"$nulls":6},16]
[17,"Speech Pathology",{"$nulls":6},17]
[18,"Occupational Therapy",{"$nulls":6},18]
[19,"Respiratory Therapy",{"$nulls":6},19]
[20,"Medical Social Services",{"$nulls":6},20]
[21,"Psychological Services",{"$nulls":6},21]
[22,"Prosthetic and Orthotic Devices",{"$nulls":6},22]
[23,"Drugs and Biologicals",{"$nulls":6},23]
[24,"Supplies Charged to Patients",{"$nulls":6},24]
[25,"DME-Sold",{"$nulls":6},25]
[26,"DME-Rented",{"$nulls":6},26]
[27,{"$nulls":7},27]
[null,"CMHC"]
[29,"Drugs and Biologicals",{"$nulls":6},29]
[30,"Occupational Therapy",{"$nulls":6},30]
[31,"Psychiatric/Psychological Service",{"$nulls":6},31]
[32,"Individual Therapy",{"$nulls":6},32]
[33,"Group Therapy",{"$nulls":6},33]
[34,"Individualized Activity Therapies",{"$nulls":6},34]
[35,"Family Counseling",{"$nulls":6},35]
[36,"Diagnostic Services",{"$nulls":6},36]
[37,"Patient Training & Education",{"$nulls":6},37]
[38,{"$nulls":7},38]
[null,"OTHER PROVIDERS"]
[40,"Physical Therapy",{"$nulls":6},40]
[41,"Speech Pathology",{"$nulls":6},41]
[42,"Occupational Therapy",{"$nulls":6},42]
[43,{"$nulls":7},43]
[null,"NON-REIM. COST CENTERS"]
[45,"Sheltered Workshops",{"$nulls":6},45]
[46,"Recreational Programs",{"$nulls":6},46]
[47,"Resident Day Camps",{"$nulls":6},47]
[48,"Preschool Programs",{"$nulls":6},48]
[49,"Diagnostic Clinics",{"$nulls":6},49]
[50,"Home Employment Programs",{"$nulls":6},50]
[51,"Equipment Loan Service",{"$nulls":6},51]
[52,"Physicians' Private Office",{"$nulls":6},52]
[53,"Fundraising",{"$nulls":6},53]
[54,"Coffee Shops &Canteen",{"$nulls":6},54]
[55,"Research",{"$nulls":6},55]
[56,"Investment Property",{"$nulls":6},56]
[57,"Advertising",{"$nulls":6},57]
[58,"Franchise & Other Ass'mt",{"$nulls":6},58]
[59,"Prof. Ed. & Training(2)",{"$nulls":6},59]
[60,{"$nulls":7},60]
[null,"CMHC NON-REIMBURSABLE "]
[61,"Meals and Transportation",{"$nulls":6},61]
[62,"Activity Therapies",{"$nulls":6},62]
[63,"Psychosocial Programs",{"$nulls":6},63]
[64,"Vocational Training",{"$nulls":6},64]
[65,"Negative Cost Center",{"$nulls":6},65]
[66,"TOTAL",{"$nulls":6},66]
[null,"(1) Approved Educational Activity"]
[null,"(2) Not an  Approved Educational Activity"]
["FORM CMS-2088-92  (12-1992)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)"]
[]
["18-312",{"$nulls":7},"Rev. 7"]

{"sheet":"B_3","index":10,"n_rows":84,"n_cols":9,"rows_kept":84,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["12-04",null,null,"FORM CMS 2088-92",{"$nulls":4},"1890 (Cont.)"]
[null,null,null,"PROVIDER NO:",null,"PERIOD:",null,"  WORKSHEET B"]
[null,"COST ALLOCATION",null,null,null,"FROM _____________",null,"  Page 3 of 3"]
[null,"GENERAL SERVICE COSTS",null," ____________",null,"TO ____________"]
[null,null,"Prof."]
[null,null,"Education"]
[null,null,"and"]
[null," COST CENTERS","Training",{"$nulls":4},"Total"]
[null,null,"12","13","14","15","16","17"]
[null,"Gen. Service Cost Ctrs."," "," "]
[1,"Cap. Rel. Costs--Bldg.&Fixt."," "," ",{"$nulls":4},1]
[2,"Cap. Rel. Costs--Movable Eqp.",{"$nulls":6},2]
[3,"Employee Benefits",{"$nulls":6},3]
[4,"Administrative and General",{"$nulls":6},4]
[5,"Maintenance and Repairs",{"$nulls":6},5]
[6,"Operation of Plant",{"$nulls":6},6]
[7,"Laundry and Linen Service",{"$nulls":6},7]
[8,"Housekeeping",{"$nulls":6},8]
[9,"Cafeteria",{"$nulls":6},9]
[10,"Central Services and Supply",{"$nulls":6},10]
[11,"Medical Records and Library",{"$nulls":6},11]
[12,"Prof. Educ. & Training(1)",{"$nulls":6},12]
[13,{"$nulls":7},13]
[14,{"$nulls":7},14]
[null,"REIMBURSABLE COST CTRS."]
[null,"CORF"]
[15,"Skilled Nursing Care",{"$nulls":6},15]
[16,"Physical Therapy",{"$nulls":6},16]
[17,"Speech Pathology",{"$nulls":6},17]
[18,"Occupational Therapy",{"$nulls":6},18]
[19,"Respiratory Therapy",{"$nulls":6},19]
[20,"Medical Social Services",{"$nulls":6},20]
[21,"Psychological Services",{"$nulls":6},21]
[22,"Prosthetic and Orthotic Devices",{"$nulls":6},22]
[23,"Drugs and Biologicals",{"$nulls":6},23]
[24,"Supplies Charged to Patients",{"$nulls":6},24]
[25,"DME-Sold",{"$nulls":6},25]
[26,"DME-Rented",{"$nulls":6},26]
[27,{"$nulls":7},27]
[null,"CMHC"]
[29,"Drugs and Biologicals",{"$nulls":6},29]
[30,"Occupational Therapy",{"$nulls":6},30]
[31,"Psychiatric/Psychological Service",{"$nulls":6},31]
[32,"Individual Therapy",{"$nulls":6},32]
[33,"Group Therapy",{"$nulls":6},33]
[34,"Individualized Activity Therapies",{"$nulls":6},34]
[35,"Family Counseling",{"$nulls":6},35]
[36,"Diagnostic Services",{"$nulls":6},36]
[37,"Patient Training & Education",{"$nulls":6},37]
[38,{"$nulls":7},38]
[null,"OTHER PROVIDERS"]
[40,"Physical Therapy",{"$nulls":6},40]
[41,"Speech Pathology",{"$nulls":6},41]
[42,"Occupational Therapy",{"$nulls":6},42]
[43,{"$nulls":7},43]
[null,"NON-REIM. COST CENTERS"]
[45,"Sheltered Workshops",{"$nulls":6},45]
[46,"Recreational Programs",{"$nulls":6},46]
[47,"Resident Day Camps",{"$nulls":6},47]
[48,"Preschool Programs",{"$nulls":6},48]
[49,"Diagnostic Clinics",{"$nulls":6},49]
[50,"Home Employment Programs",{"$nulls":6},50]
[51,"Equipment Loan Service",{"$nulls":6},51]
[52,"Physicians' Private Office",{"$nulls":6},52]
[53,"Fundraising",{"$nulls":6},53]
[54,"Coffee Shops &Canteen",{"$nulls":6},54]
[55,"Research",{"$nulls":6},55]
[56,"Investment Property",{"$nulls":6},56]
[57,"Advertising",{"$nulls":6},57]
[58,"Franchise & Other Ass'mt",{"$nulls":6},58]
[59,"Prof. Ed. & Training(2)",{"$nulls":6},59]
[60,{"$nulls":7},60]
[null,"CMHC NON-REIMBURSABLE "]
[61,"Meals and Transportation",{"$nulls":6},61]
[62,"Activity Therapies",{"$nulls":6},62]
[63,"Psychosocial Programs",{"$nulls":6},63]
[64,"Vocational Training",{"$nulls":6},64]
[65,"Negative Cost Center",{"$nulls":6},65]
[66,"TOTAL",{"$nulls":6},66]
[null,"(1) Approved Educational Activity"]
[null,"(2) Not an  Approved Educational Activity"]
["FORM CMS-2088-92 (12-1992)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)"]
[]
["Rev. 7",{"$nulls":7},"18-313"]

{"sheet":"B-1","index":11,"n_rows":85,"n_cols":10,"rows_kept":85,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",null,null,"FORM CMS 2088-92",{"$nulls":5},"12-04"]
[{"$nulls":4},"PROVIDER NO:",null,"PERIOD:",null,"  WORKSHEET B-1"]
[null,"COST ALLOCATION",{"$nulls":4},"FROM ____________",null,"  Page 1 of 3"]
[null,"(STATISTICAL BASIS)",null,null," ____________",null,"TO ____________"]
[null,null,null,"          Capital Related"]
[null,null,null,"Buildings &","Movable","Employee",null,"Administrative","Maintenance"]
[null," COST CENTERS",null,"Fixtures","Equipment","Benefits",null,"& General","& Repairs"]
[null,null,null,"(Square ","(Square ","(Gross ","Reconcil-","(Accum.","(Square "]
[null,null,null,"Feet)","Feet)","Salaries)","iation","Cost)","Feet)"]
[null,null,"0","1","2","3","4A","4","5"]
[null,"Gen. Service Cost Ctrs."," "," "]
[1,"Cap. Rel. Costs--Bldg.&Fixt."," "," ",{"$nulls":5},1]
[2,"Cap. Rel. Costs--Movable Eqp.",{"$nulls":7},2]
[3,"Employee Benefits",{"$nulls":7},3]
[4,"Administrative and General",{"$nulls":7},4]
[5,"Maintenance and Repairs",{"$nulls":7},5]
[6,"Operation of Plant",{"$nulls":7},6]
[7,"Laundry and Linen Service",{"$nulls":7},7]
[8,"Housekeeping",{"$nulls":7},8]
[9,"Cafeteria",{"$nulls":7},9]
[10,"Central Services and Supply",{"$nulls":7},10]
[11,"Medical Records and Library",{"$nulls":7},11]
[12,"Prof. Educ. & Training(1)",{"$nulls":7},12]
[13,{"$nulls":8},13]
[14,{"$nulls":8},14]
[null,"REIMBURSABLE COST CTRS."]
[null,"CORF"]
[15,"Skilled Nursing Care",{"$nulls":7},15]
[16,"Physical Therapy",{"$nulls":7},16]
[17,"Speech Pathology",{"$nulls":7},17]
[18,"Occupational Therapy",{"$nulls":7},18]
[19,"Respiratory Therapy",{"$nulls":7},19]
[20,"Medical Social Services",{"$nulls":7},20]
[21,"Psychological Services",{"$nulls":7},21]
[22,"Prosthetic and Orthotic Devices",{"$nulls":7},22]
[23,"Drugs and Biologicals",{"$nulls":7},23]
[24,"Supplies Charged to Patients",{"$nulls":7},24]
[25,"DME-Sold",{"$nulls":7},25]
[26,"DME-Rented",{"$nulls":7},26]
[27,{"$nulls":8},27]
[null,"CMHC"]
[29,"Drugs and Biologicals",{"$nulls":7},29]
[30,"Occupational Therapy",{"$nulls":7},30]
[31,"Psychiatric/Psychological Service",{"$nulls":7},31]
[32,"Individual Therapy",{"$nulls":7},32]
[33,"Group Therapy",{"$nulls":7},33]
[34,"Individualized Activity Therapies",{"$nulls":7},34]
[35,"Family Counseling",{"$nulls":7},35]
[36,"Diagnostic Services",{"$nulls":7},36]
[37,"Patient Training & Education",{"$nulls":7},37]
[38,{"$nulls":8},38]
[null,"OTHER PROVIDERS"]
[40,"Physical Therapy",{"$nulls":7},40]
[41,"Speech Pathology",{"$nulls":7},41]
[42,"Occupational Therapy",{"$nulls":7},42]
[43,{"$nulls":8},43]
[null,"NON-REIM. COST CENTERS"]
[45,"Sheltered Workshops",{"$nulls":7},45]
[46,"Recreational Programs",{"$nulls":7},46]
[47,"Resident Day Camps",{"$nulls":7},47]
[48,"Preschool Programs",{"$nulls":7},48]
[49,"Diagnostic Clinics",{"$nulls":7},49]
[50,"Home Employment Programs",{"$nulls":7},50]
[51,"Equipment Loan Service",{"$nulls":7},51]
[52,"Physicians' Private Office",{"$nulls":7},52]
[53,"Fundraising",{"$nulls":7},53]
[54,"Coffee Shops &Canteen",{"$nulls":7},54]
[55,"Research",{"$nulls":7},55]
[56,"Investment Property",{"$nulls":7},56]
[57,"Advertising",{"$nulls":7},57]
[58,"Franchise & Other Ass'mt",{"$nulls":7},58]
[59,"Prof. Ed. & Training(2)",{"$nulls":7},59]
[60,{"$nulls":8},60]
[null,"CMHC NON-REIMBURSABLE "]
[61,"Meals and Transportation",{"$nulls":7},61]
[62,"Activity Therapies",{"$nulls":7},62]
[63,"Psychosocial Programs",{"$nulls":7},63]
[64,"Vocational Training",{"$nulls":7},64]
[65,"Negative Cost Center",{"$nulls":7},65]
[66,"Cost to be Allocated",{"$nulls":7},66]
[67,"Unit Cost Multiplier",{"$nulls":7},67]
[null,"(1) Approved Educational Activity",null,"(2) Not an  Approved Educational Activity"]
["FORM CMS-2088-92  (12-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)"]
[]
["18-314",{"$nulls":8},"Rev. 7"]

{"sheet":"B-1_2","index":12,"n_rows":86,"n_cols":9,"rows_kept":86,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",null,null,"FORM CMS 2088-92",{"$nulls":4},"1890 (Cont.)"]
[null,null,null,"PROVIDER NO:",null,"PERIOD:",null,"WORKSHEET B-1"]
[null,"COST ALLOCATION",null,null,null,"FROM ____________",null,"  Page 2 of 3"]
[null,"(STATISTICAL BASIS)",null," ___________",null,"TO _____________"]
[null,null,"Operation ","Laundry",null,null,"Medical","Medical "]
[null,null,"of","and Linen","House-",null,"Supplies","Records"]
[null," COST CENTERS","Plant","Services","keeping","Cafeteria",null,"Library"]
[null,null,"(Square","(Pounds of","(Hrs. of","Meals","(Costed","(Time"]
[null,null,"Feet)","Laundry)","Service)","Served)","Requisitions)","Spent)"]
[null,null,"6","7","8","9","10","11"]
[null,"Gen. Service Cost Ctrs."," "," "]
[1,"Cap. Rel. Costs--Bldg.&Fixt."," "," ",{"$nulls":4},1]
[2,"Cap. Rel. Costs--Movable Eqp.",{"$nulls":6},2]
[3,"Employee Benefits",{"$nulls":6},3]
[4,"Administrative and General",{"$nulls":6},4]
[5,"Maintenance and Repairs",{"$nulls":6},5]
[6,"Operation of Plant",{"$nulls":6},6]
[7,"Laundry and Linen Service",{"$nulls":6},7]
[8,"Housekeeping",{"$nulls":6},8]
[9,"Cafeteria",{"$nulls":6},9]
[10,"Central Services and Supply",{"$nulls":6},10]
[11,"Medical Records and Library",{"$nulls":6},11]
[12,"Prof. Educ. & Training(1)",{"$nulls":6},12]
[13,{"$nulls":7},13]
[14,{"$nulls":7},14]
[null,"REIMBURSABLE COST CTRS."]
[null,"CORF"]
[15,"Skilled Nursing Care",{"$nulls":6},15]
[16,"Physical Therapy",{"$nulls":6},16]
[17,"Speech Pathology",{"$nulls":6},17]
[18,"Occupational Therapy",{"$nulls":6},18]
[19,"Respiratory Therapy",{"$nulls":6},19]
[20,"Medical Social Services",{"$nulls":6},20]
[21,"Psychological Services",{"$nulls":6},21]
[22,"Prosthetic and Orthotic Devices",{"$nulls":6},22]
[23,"Drugs and Biologicals",{"$nulls":6},23]
[24,"Supplies Charged to Patients",{"$nulls":6},24]
[25,"DME-Sold",{"$nulls":6},25]
[26,"DME-Rented",{"$nulls":6},26]
[27,{"$nulls":7},27]
[null,"CMHC"]
[29,"Drugs and Biologicals",{"$nulls":6},29]
[30,"Occupational Therapy",{"$nulls":6},30]
[31,"Psychiatric/Psychological Service",{"$nulls":6},31]
[32,"Individual Therapy",{"$nulls":6},32]
[33,"Group Therapy",{"$nulls":6},33]
[34,"Individualized Activity Therapies",{"$nulls":6},34]
[35,"Family Counseling",{"$nulls":6},35]
[36,"Diagnostic Services",{"$nulls":6},36]
[37,"Patient Training & Education",{"$nulls":6},37]
[38,{"$nulls":7},38]
[null,"OTHER PROVIDERS"]
[40,"Physical Therapy",{"$nulls":6},40]
[41,"Speech Pathology",{"$nulls":6},41]
[42,"Occupational Therapy",{"$nulls":6},42]
[43,{"$nulls":7},43]
[null,"NON-REIM. COST CENTERS"]
[45,"Sheltered Workshops",{"$nulls":6},45]
[46,"Recreational Programs",{"$nulls":6},46]
[47,"Resident Day Camps",{"$nulls":6},47]
[48,"Preschool Programs",{"$nulls":6},48]
[49,"Diagnostic Clinics",{"$nulls":6},49]
[50,"Home Employment Programs",{"$nulls":6},50]
[51,"Equipment Loan Service",{"$nulls":6},51]
[52,"Physicians' Private Office",{"$nulls":6},52]
[53,"Fundraising",{"$nulls":6},53]
[54,"Coffee Shops &Canteen",{"$nulls":6},54]
[55,"Research",{"$nulls":6},55]
[56,"Investment Property",{"$nulls":6},56]
[57,"Advertising",{"$nulls":6},57]
[58,"Franchise & Other Ass'mt",{"$nulls":6},58]
[59,"Prof. Ed. & Training(2)",{"$nulls":6},59]
[60,{"$nulls":7},60]
[null,"CMHC NON-REIMBURSABLE "]
[61,"Meals and Transportation",{"$nulls":6},61]
[62,"Activity Therapies",{"$nulls":6},62]
[63,"Psychosocial Programs",{"$nulls":6},63]
[64,"Vocational Training",{"$nulls":6},64]
[65,"Negative Cost Center",{"$nulls":6},65]
[66,"Cost to be Allocated",{"$nulls":6},66]
[67,"Unit Cost Multiplier",{"$nulls":6},67]
[null,"(1) Approved Educational Activity",null,"(2) Not an  Approved Educational Activity"]
[]
["FORM CMS-2088-92  (12-1992)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)"]
[]
["Rev. 3",{"$nulls":7},"18-315"]

{"sheet":"B-1_3","index":13,"n_rows":86,"n_cols":9,"rows_kept":86,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",null,null,"FORM CMS 2088-92",{"$nulls":4},"08-99"]
[null,null,null,"PROVIDER NO:",null,"PERIOD:",null,"WORKSHEET B-1"]
[null,"COST ALLOCATION",null,null,null,"FROM _____________",null,"  Page 3 of 3"]
[null,"(STATISTICAL BASIS)",null," ____________",null,"TO ____________"]
[]
[null,null,"Prof.Educ."]
[null,null,"& Training"]
[null,null,"(Assigned"]
[null," COST CENTERS","Time)"]
[null,null,"12","13","14","15","16","17"]
[null,"Gen. Service Cost Ctrs."," "," "]
[1,"Cap. Rel. Costs--Bldg.&Fixt."," "," ",{"$nulls":4},1]
[2,"Cap. Rel. Costs--Movable Eqp.",{"$nulls":6},2]
[3,"Employee Benefits",{"$nulls":6},3]
[4,"Administrative and General",{"$nulls":6},4]
[5,"Maintenance and Repairs",{"$nulls":6},5]
[6,"Operation of Plant",{"$nulls":6},6]
[7,"Laundry and Linen Service",{"$nulls":6},7]
[8,"Housekeeping",{"$nulls":6},8]
[9,"Cafeteria",{"$nulls":6},9]
[10,"Central Services and Supply",{"$nulls":6},10]
[11,"Medical Records and Library",{"$nulls":6},11]
[12,"Prof. Educ. & Training(1)",{"$nulls":6},12]
[13,{"$nulls":7},13]
[14,{"$nulls":7},14]
[null,"REIMBURSABLE COST CTRS."]
[null,"CORF"]
[15,"Skilled Nursing Care",{"$nulls":6},15]
[16,"Physical Therapy",{"$nulls":6},16]
[17,"Speech Pathology",{"$nulls":6},17]
[18,"Occupational Therapy",{"$nulls":6},18]
[19,"Respiratory Therapy",{"$nulls":6},19]
[20,"Medical Social Services",{"$nulls":6},20]
[21,"Psychological Services",{"$nulls":6},21]
[22,"Prosthetic and Orthotic Devices",{"$nulls":6},22]
[23,"Drugs and Biologicals",{"$nulls":6},23]
[24,"Supplies Charged to Patients",{"$nulls":6},24]
[25,"DME-Sold",{"$nulls":6},25]
[26,"DME-Rented",{"$nulls":6},26]
[27,{"$nulls":7},27]
[null,"CMHC"]
[29,"Drugs and Biologicals",{"$nulls":6},29]
[30,"Occupational Therapy",{"$nulls":6},30]
[31,"Psychiatric/Psychological Service",{"$nulls":6},31]
[32,"Individual Therapy",{"$nulls":6},32]
[33,"Group Therapy",{"$nulls":6},33]
[34,"Individualized Activity Therapies",{"$nulls":6},34]
[35,"Family Counseling",{"$nulls":6},35]
[36,"Diagnostic Services",{"$nulls":6},36]
[37,"Patient Training & Education",{"$nulls":6},37]
[38,{"$nulls":7},38]
[null,"OTHER PROVIDERS"]
[40,"Physical Therapy",{"$nulls":6},40]
[41,"Speech Pathology",{"$nulls":6},41]
[42,"Occupational Therapy",{"$nulls":6},42]
[43,{"$nulls":7},43]
[null,"NON-REIM. COST CENTERS"]
[45,"Sheltered Workshops",{"$nulls":6},45]
[46,"Recreational Programs",{"$nulls":6},46]
[47,"Resident Day Camps",{"$nulls":6},47]
[48,"Preschool Programs",{"$nulls":6},48]
[49,"Diagnostic Clinics",{"$nulls":6},49]
[50,"Home Employment Programs",{"$nulls":6},50]
[51,"Equipment Loan Service",{"$nulls":6},51]
[52,"Physicians' Private Office",{"$nulls":6},52]
[53,"Fundraising",{"$nulls":6},53]
[54,"Coffee Shops &Canteen",{"$nulls":6},54]
[55,"Research",{"$nulls":6},55]
[56,"Investment Property",{"$nulls":6},56]
[57,"Advertising",{"$nulls":6},57]
[58,"Franchise & Other Ass'mt",{"$nulls":6},58]
[59,"Prof. Ed. & Training(2)",{"$nulls":6},59]
[60,{"$nulls":7},60]
[null,"CMHC NON-REIMBURSABLE "]
[61,"Meals and Transportation",{"$nulls":6},61]
[62,"Activity Therapies",{"$nulls":6},62]
[63,"Psychosocial Programs",{"$nulls":6},63]
[64,"Vocational Training",{"$nulls":6},64]
[65,"Negative Cost Center",{"$nulls":6},65]
[66,"Cost to be Allocated",{"$nulls":6},66]
[67,"Unit Cost Multiplier",{"$nulls":6},67]
[null,"(1) Approved Educational Activity",null,"(2) Not an  Approved Educational Activity"]
[]
["FORM CMS-2088-92  (12-1992)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)"]
[]
["18-316",{"$nulls":7},"Rev. 3"]

{"sheet":"C","index":14,"n_rows":60,"n_cols":12,"rows_kept":60,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["12-02",{"$nulls":4},"FORM CMS 2088-92",{"$nulls":5},"1890 (Cont.)"]
["APPORTIONMENT OF PATIENT SERVICE COSTS",{"$nulls":5},"PROVIDER NO:",null,"PERIOD:",null,"  WORKSHEET C"]
[{"$nulls":8},"FROM __________",null,"  Page 1 of 2"]
[{"$nulls":6},"_________",null,"TO ___________"]
[{"$nulls":4},"RATIO OF COST",{"$nulls":5},"TITLE XVIII"]
[{"$nulls":4},"TO CHARGES",null,null,"TITLE XVIII",null,"REASONABLE","COST NET OF"]
[{"$nulls":4},"(Col. 1 line .01,",null,null,"CHARGES","TITLE XVIII","COST","APPLICABLE "]
[null,"CORF REIMBURSABLE SERVICE",null,null,"divided by Col. 1,","TITLE XVIII","ALL OTHER","ON OR AFTER ","COSTS ON ","REDUCTION","REASONABLE"]
[null,"COST CENTERS",null,"TOTALS","line .02)","(See Instructions)","(See Instructions)","1/1/98","AFTER 1/1/98","AMOUNT ","COST REDUCTION"]
[null,null,null,"1","2","3","4",5,6,7,8]
[15,"Skilled Nursing Care",".01",{"$nulls":8},15]
[null,null,".02"]
[16,"Physical Therapy",".01",{"$nulls":8},16]
[null,null,".02"]
[17,"Speech Pathology",".01",{"$nulls":8},17]
[null,null,".02"]
[18,"Occupational Therapy",".01",{"$nulls":8},18]
[null,null,".02"]
[19,"Respiratory Therapy",".01",{"$nulls":8},19]
[null,null,".02"]
[20,"Medical Social Services",".01",{"$nulls":8},20]
[null,null,".02"]
[21,"Psychological Services",".01",{"$nulls":8},21]
[null,null,".02"]
[22,"Prosthetic and Orthotic Devices",".01",{"$nulls":8},22]
[null,null,".02"]
[23,"Drugs and Biologicals",".01",{"$nulls":8},23]
[null,null,".02"]
[24,"Supplies Charged to Patients",".01",{"$nulls":8},24]
[null,null,".02"]
[25,"DME-Sold",".01",{"$nulls":8},25]
[null,null,".02"]
[26,"DME-Rented",".01",{"$nulls":8},26]
[null,null,".02"]
[27,null,".01",{"$nulls":8},27]
[null,null,".02"]
[28,"TOTAL(Line 15 through 27)",".01",{"$nulls":8},28]
[null,null,".02"]
[]
[null,"CORF Providers--See instructions for amounts to transfer to Worksheet D, Part I."]
{"$rows_empty":17}
["FORM CMS-2088-92  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1809)"]
[]
["Rev. 6",{"$nulls":10},"18-317"]

{"sheet":"C_2","index":15,"n_rows":60,"n_cols":12,"rows_kept":60,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",{"$nulls":4},"FORM CMS 2088-92",{"$nulls":5},"12-02"]
["APPORTIONMENT OF PATIENT SERVICE COSTS",{"$nulls":5},"PROVIDER NO:",null,"PERIOD:",null,"  WORKSHEET C"]
[{"$nulls":8},"FROM __________",null,"  Page 2 of 2"]
[{"$nulls":6},"_________",null,"TO ___________"]
[{"$nulls":7},"TITLE XVIII","TITLE XVIII"]
[{"$nulls":4},"RATIO OF COST",null,null,"CHARGES","COSTS ON OR",null,"TITLE XVIII"]
[{"$nulls":4},"TO CHARGES",null,null,"ON OR AFTER","AFTER 8/1/00,","REASONABLE","COSTS PRIOR"]
[{"$nulls":4},"(Col. 1 line a,",null,null,"8/1/00, 1/1/02,","1/1/02, 1/1/03, or","COST","TO 8/1/00, 1/1/02,"]
[null,"CMHC REIMBURSABLE SERVICE",null,null,"divided by Col. 1,","TITLE XVIII","ALL OTHER","1/1/03, or 1/1/04","1/1/04","REDUCTION","1/1/03, or 1/1/04"]
[null,"COST CENTERS",null,"TOTALS","line b.","(See Instructions)","(See Instructions)","(See Instructions)","(See Instructions)","AMOUNT ","(See Instructions)"]
[null,null,null,"1","2","3","4",5,6,7,8]
[29,"Drugs and Biologicals",".01",{"$nulls":8},29]
[null,null,".02"]
[30,"Occupational Therapy",".01",{"$nulls":8},30]
[null,null,".02"]
[31,"Psychiatric/Psychological Services",".01",{"$nulls":8},31]
[null,null,".02"]
[32,"Individual Therapy",".01",{"$nulls":8},32]
[null,null,".02"]
[33,"Group Therapy",".01",{"$nulls":8},33]
[null,null,".02"]
[34,"Individualized Activity Therapy",".01",{"$nulls":8},34]
[null,null,".02"]
[35,"Family Counseling",".01",{"$nulls":8},35]
[null,null,".02"]
[36,"Diagnostic Services",".01",{"$nulls":8},36]
[null,null,".02"]
[37,"Patient Training & Education",".01",{"$nulls":8},37]
[null,null,".02"]
[38,null,".01",{"$nulls":8},38]
[null,null,".02"]
[39,"TOTAL (Lines 29 through 38)",".01",{"$nulls":8},39]
[null,null,".02"]
[]
[{"$nulls":4},"RATIO OF COST",{"$nulls":5},"TITLE XVIII"]
[{"$nulls":4},"TO CHARGES",null,null,"TITLE XVIII","TITLE XVIII","REASONABLE","COSTS NET OF"]
[null,"OTHER OUTPATIENT THERAPY",null,null,"(Col. 1 line .01,",null,null,"CHARGES","COSTS ","COST","APPLICABLE "]
[null,"PROVIDERS",null,null,"divided by Col. 1,","TITLE XVIII","ALL OTHER","ON OR AFTER ","ON OR AFTER ","REDUCTION","REASONABLE"]
[null,null,null,"TOTALS","line .02)","(See Instructions)","(See Instructions)","1/1/1998","1/1/1998","AMOUNT ","COST REDUCTION"]
[null,null,null,"1","2","3","4",5,6,7,8]
[40,"Physical Therapy",".01",{"$nulls":8},40]
[null,null,".02"]
[41,"Speech Pathology",".01",{"$nulls":8},41]
[null,null,".02"]
[42,"Occupational Therapy",".01",{"$nulls":8},42]
[null,null,".02"]
[43,null,".01",{"$nulls":8},43]
[null,null,".02"]
[44,"TOTAL (Lines 40 through 43)",".01",{"$nulls":8},44]
[null,null,".02"]
[]
[null,"CMHC Providers--Transfer the amount entered in column 8, line 39 to Worksheet D, line 1."]
[null,"Other Outpatient Therapy Providers--Transfer the amount entered in column 8, line 44 to Worksheet D, line 1."]
[]
[]
[]
[]
["FORM CMS-2088-92  (12-2002)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1809)"]
[]
["18-318",{"$nulls":10},"Rev. 6"]

{"sheet":"D","index":16,"n_rows":67,"n_cols":14,"rows_kept":67,"cut":false,"hidden":false,"merged":[[6,10,6,11]],"flags":["formulas_cached_only"]}
["12-04",{"$nulls":4},"FORM CMS 2088-92",{"$nulls":7},"1890 (Cont.)"]
["CALCULATION OF REIMBURSEMENT",{"$nulls":4},"PROVIDER NO.:",null,null,"PERIOD:",null,null,null,"WORKSHEET D"]
["SETTLEMENT  FOR OUTPATIENT",{"$nulls":4},"______________",null,null,"FROM ________"]
["REHABILITATION SERVICES-TITLE XVIII",{"$nulls":7},"TO __________"]
[null,null,"CORF",null,null,"OPT",{"$nulls":5},"CMHC"]
["PART I - COMPUTATION OF REIMBURSEMENT SETTLEMENT"]
[null,"DESCRIPTION",{"$nulls":8},1,null,1.01]
[1,"Cost of provider services (see instructions)",{"$nulls":11},1]
[1.01,"CMHC PPS payments including outlier payments",{"$nulls":11},1.01]
[1.02,"1996 CMHC specific payment to cost ratio (obtain this ratio from your intermediary) ",{"$nulls":11},1.02]
[1.03,"Line 1, column 1.01 times 1.02",{"$nulls":11},1.03]
[1.04,"Line 1.01 divided by line 1.03",{"$nulls":11},1.04]
[1.05,"CMHC transitional corridor payment",{"$nulls":11},1.05]
[1.1,"Cost of CORF services prior to 1/1/1998 (see instructions)",{"$nulls":11},1.1]
[2,"Adjustment for the cost of services covered by Workers' Compensation, and",{"$nulls":11},2]
[null,"other primary payers (see instructions)"]
[3,"Subtotal (line 1 plus line 1.1 minus line 2) (For CMHCs see instructions)",{"$nulls":11},3]
[4,"Deductibles billed to program patients. (Do not include coinsurance)",{"$nulls":11},4]
[5,"Total amount reimbursable to provider prior to application of Lesser of",{"$nulls":11},5]
[null,"reasonable cost or customary charges (line 3 minus line 4)"]
[6,"Excess of reasonable cost over customary charges (see instructions)",{"$nulls":11},6]
[7,"Subtotal (line 5 minus line 6)",{"$nulls":11},7]
[8,"80 percent of costs (line 7 x 80 percent)",{"$nulls":11},8]
[9,"Coinsurance billed to program patients (see instructions)",{"$nulls":11},9]
[10,"Net cost for comparison (line 7 minus line 9)",{"$nulls":11},10]
[11,"Reimbursable bad debts (see instructions)",{"$nulls":11},11]
[11.01,"Reimbursable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":11},11.01]
[12,"TOTAL COST-- (line 11 plus the lesser of line 8 or line 10 )",{"$nulls":11},12]
[13,"Recovery of unreimbursed cost under the lesser of cost or",{"$nulls":11},13]
[null,"charges (from Worksheet D-1, Part I, line 3)"]
[14,"80% of recovery of unreimbursed cost under the lesser",{"$nulls":11},14]
[null,"of cost or charges (line 13 X 80 percent)"]
[15,"Total cost (line 12 plus line 14 ) (see instructions)",{"$nulls":11},15]
[16,"Sequestration adjustment (see Instructions)",{"$nulls":11},16]
[16.5,"Other Adjustments (see instructions) (specify)",{"$nulls":11},16.5]
[17,"Adjusted total cost (line 15 minus the sum of lines 16 and 16.5) (see instructions)",{"$nulls":11},17]
[18,"Interim Payments",{"$nulls":11},18]
[18.5,"Tentative settlement (For intermediary use only)",{"$nulls":11},18.5]
[19,"Balance due Provider/Program (line 17 minus line 18) (Indicate overpayment in brackets)",{"$nulls":11},19]
[]
[null,"NOTE: FOR CORF SERVICES RENDERED PRIOR TO JANUARY 1, 1998 CORFS COMPLETE LINE 22.1 ONLY AS THESE"]
[null,"SERVICES ARE NOT SUBJECT TO THE LESSER OF REASONABLE COSTS OR CUSTOMARY CHARGES,"]
[null,"BUT ARE REIMBURSED BASED ON REASONABLE COSTS.  FOR CORF RENDERED ON OR AFTER JANUARY 1,"]
[null,"1998, COMPLETE LINE 21 THROUGH 29 AS THESE SERVICES AS SUBJECT TO LCC."]
[]
["PART II -COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES",{"$nulls":11},1]
[20,"Reasonable cost of services",{"$nulls":11},20]
[21,"Cost of services (from Part I, line 1) (from Part I, line 1, column 1 for CMHCs) (see instructions)",{"$nulls":11},21]
[21.1,"Cost of services (from Part I, line 1.1 for CORFs) (see instructions)",{"$nulls":11},21.1]
[22,"TOTAL charges for medicare services",{"$nulls":11},22]
[22.1,"TOTAL CORF charges for medicare services prior to 1/1/1998 ",{"$nulls":11},22.1]
[23,"Customary Charges",{"$nulls":11},23]
[24,"Aggregate amount actually collected from patients liable for payment for services on a charge basis.",{"$nulls":11},24]
[25,"Amounts that would have been realized from patients liable for payment for services on a charge",{"$nulls":11},25]
[null,"basis had such payment been made in accordance with 42 CFR 413.13(e)"]
[26,"Ratio of line 24 to line 25 (not to exceed 1.000000)",{"$nulls":11},26]
[27,"Total customary charges (line 22 x line 26)",{"$nulls":11},27]
[27.1,"Total customary CORF charges prior to 1/1/1998 (line 22.1 x line 26)",{"$nulls":11},27.1]
[28,"Excess of customary charges over reasonable cost (Complete",{"$nulls":11},28]
[null,"only if line 27 exceeds line 21) (see instructions)"]
[29,"Excess of reasonable cost over customary charges (Complete",{"$nulls":11},29]
[null,"only if line 21 exceeds line 27) (see instructions)"]
[]
["FORM CMS-2088-92  (12-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15 - II, SEC."]
["1810, 1810.1 AND 1810.2)"]
[]
["Rev. 7",{"$nulls":12},"18-319"]

{"sheet":"G","index":17,"n_rows":67,"n_cols":7,"rows_kept":67,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",null,"FORM CMS 2088-92",null,null,null,"12-04"]
[null,"STATEMENT OF REVENUES","PROVIDER NO:","PERIOD:"]
[null,"AND EXPENSES","____________","FROM ____________","WORKSHEET G"]
[null,null,null,"TO ____________"]
[]
[]
[]
[]
[1,"Total patient revenues  ",{"$nulls":4},1]
[2,"Less: Allowances and discounts on patients' accounts",{"$nulls":4},2]
[3,"Net patient revenues (Line 1 minus line 2)",{"$nulls":4},3]
[4,"Less: total operating expenses ",{"$nulls":4},4]
[5,"Net income from service to patients (Line 3 minus line 4)",{"$nulls":4},5]
[null,"Other income:"]
[6,"Grants , gifts, and income designated by ",{"$nulls":4},6]
[null,"donor for specific expenses"]
[7,"Payments received from specialists",{"$nulls":4},7]
[8,"Investment income on unrestricted funds",{"$nulls":4},8]
[9,"Trade , quantity ,time and other discounts on purchases",{"$nulls":4},9]
[10,"Rebates and refunds of expenses",{"$nulls":4},10]
[11,"Income from laundry and linen service",{"$nulls":4},11]
[12,"Income from cafeteria - employees , guests, etc.",{"$nulls":4},12]
[13,"Sale of medical supplies to other than patients ",{"$nulls":4},13]
[14,"Sale of workshop products or services",{"$nulls":4},14]
[15,"Coffee shops and canteen",{"$nulls":4},15]
[16,"Vending machines",{"$nulls":4},16]
[17,"Rental of building or office space to others",{"$nulls":4},17]
[18,"Sale of scrap, waste, etc.",{"$nulls":4},18]
[19,"Sale of medical records and abstracts",{"$nulls":4},19]
[20,"Other(Specify)",{"$nulls":4},20]
[21,"Other(Specify)",{"$nulls":4},21]
[22,"Other(Specify)",{"$nulls":4},22]
[23,"Total other income (Sum of lines 6-22)",{"$nulls":4},23]
[24,"Total (Line 5 plus line 23)",{"$nulls":4},24]
[null,"Other expenses :"]
[25,"Fund raising ",{"$nulls":4},25]
[26,"Gift, coffee shops, and canteen",{"$nulls":4},26]
[27,"Investment property",{"$nulls":4},27]
[28,"Other(Specify)",{"$nulls":4},28]
[29,"Other(Specify)",{"$nulls":4},29]
[30,"Other(Specify)",{"$nulls":4},30]
[31,"Total other expenses (Sum of lines 25 - 30)",{"$nulls":4},31]
[32,"Net income (or loss) for the period (line 24 minus line 31)",{"$nulls":4},32]
{"$rows_empty":21}
["FORM CMS-2088-92  (12-1992)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15 - II, SEC. 1812)"]
[]
["18-320",{"$nulls":5},"Rev. 7"]

{"sheet":"A82","index":18,"n_rows":49,"n_cols":70,"rows_kept":49,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":27},"FORM CMS 2088-92",{"$nulls":40},"1890 (Cont.)"]
["This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim ",{"$nulls":61},"FORM APPROVED"]
["payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).",{"$nulls":61},"OMB NO. 0938-0037"]
[{"$nulls":27},"PROVIDER NO:",{"$nulls":13},"PERIOD:",{"$nulls":18},"SUPPLEMENTAL"]
[{"$nulls":4},"PROVIDER-BASED PHYSICIANS ADJUSTMENTS",{"$nulls":36},"FROM ___________",{"$nulls":17},"WORKSHEET A-8-2"]
[{"$nulls":27},"____________",{"$nulls":13},"TO _____________"]
[{"$nulls":9},"Cost Center/",{"$nulls":41}," Physician/",{"$nulls":12},"      5 Percent of"]
[" Wkst A",{"$nulls":8}," Physician",{"$nulls":11}," Total",{"$nulls":5},"   Professional",{"$nulls":7},"     Provider",{"$nulls":7},"      RCE",{"$nulls":7},"  Provider",{"$nulls":6},"   Unadjusted",{"$nulls":6},"Unadjusted"]
["Line No.",{"$nulls":8}," Identifier",{"$nulls":10},"Remuneration",{"$nulls":6},"    Component",{"$nulls":7},"  Component",{"$nulls":7},"   Amount",{"$nulls":6}," Component Hours",{"$nulls":7},"      RCE Limit",{"$nulls":6}," RCE Limit"]
[null," 1",{"$nulls":8},"  2",{"$nulls":11},"3",{"$nulls":6},"  4",{"$nulls":7}," 5",null,null,null,6,{"$nulls":7},7,{"$nulls":10},"8",null,null,null,9]
{"$rows_empty":11}
["TOTAL"]
[{"$nulls":21},"Cost of",{"$nulls":4},"Provider",{"$nulls":8},"Physician",{"$nulls":7},"Provider"]
[{"$nulls":9},"Cost Center/",{"$nulls":10},"Memberships",{"$nulls":5},"Component",{"$nulls":8},"Cost of",{"$nulls":7},"Component"]
[" Wkst A",{"$nulls":8}," Physician",{"$nulls":10},"& Continuing",{"$nulls":5},"Share of",{"$nulls":8},"Malpractice",{"$nulls":7},"Share of",{"$nulls":7},"Adjusted",{"$nulls":7}," RCE"]
["Line No.",{"$nulls":8}," Identifier",{"$nulls":10}," Education",{"$nulls":5},"Col 12",{"$nulls":8},"Insurance",{"$nulls":7},"Col 14",{"$nulls":7},"RCE Limit",{"$nulls":6},"Disallowance",{"$nulls":6},"Adjustment"]
[null,"10",{"$nulls":8},"  11",{"$nulls":11},"12",{"$nulls":6},"  13",{"$nulls":7},"14",{"$nulls":6},"  15",{"$nulls":7}," 16",{"$nulls":7},"17",{"$nulls":5},"  18"]
{"$rows_empty":11}
["TOTAL"]
{"$rows_empty":7}
["FORM CMS-2088-92-A-8-2  (12-1992)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 1813)"]
[]
["Rev. 3",{"$nulls":68},"18-321"]

{"sheet":"A83","index":19,"n_rows":102,"n_cols":14,"rows_kept":102,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",{"$nulls":5},"FORM CMS 2088-92",{"$nulls":6},"08-99"]
["REASONABLE  COST  DETERMINATION  FOR  PHYSICAL",{"$nulls":4},"(COMPLETE THIS WORKSHEET",null,"  PROVIDER  NO:",null," PERIOD:",null,null,"WORKSHEET  A-8-3"]
["THERAPY  SERVICES  FURNISHED  BY OUTSIDE  SUPPLIERS",{"$nulls":4},"FOR SERVICES PROVIDED",null,null,null,"  FROM: ___________",null,null,"PARTS  I, II & III"]
[{"$nulls":5},"PRIOR TO APRIL 10, 1998)",null,"  ___________",null,"  TO: ___________"]
[]
[null,"   PART  I  -  GENERAL  INFORMATION"]
[1," Total number of weeks worked (During which outside suppliers (excluding aides) worked)",{"$nulls":11},1]
[2," Line 1 multiplied by 15 hours per week",{"$nulls":11},2]
[3," Number of unduplicated days on which supervisor or therapist was on provider site (See Instructions)",{"$nulls":11},3]
[4," Number of unduplicated days on which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (See instructions)",{"$nulls":11},4]
[5," Number of unduplicated offsite visits - supervisors or therapists (See Instructions)",{"$nulls":11},5]
[6," Number of unduplicated offsite visits - therapy assistants (Include only visits made by therapy assistant and on which supervisor and/or",{"$nulls":11},6]
[null,"   therapist was not present during the visit(s)) (See Instructions)"]
[7," Standard travel expense rate",{"$nulls":11},7]
[8," Optional travel expense rate per mile",{"$nulls":11},8]
[{"$nulls":8},"Supervisors","Therapists","Assistants",null,"Aides"]
[{"$nulls":8},"1 ","2",3,null,"4"]
[9," Total hours worked",{"$nulls":11},9]
[10," A H S E A   (See Instructions)",{"$nulls":11},10]
[11," Standard Travel Allowance (Cols. 1 and 2, one-half of col. 2, line 10; col. 3, one-half of col 3, line 10)",{"$nulls":11},11]
[12," Number of travel hours - Provider site - (see instructions)",{"$nulls":11},12]
[12.01," Number of travel hours - Provider offsite - (see instructions)",{"$nulls":11},12.01]
[13," Number of miles driven - Provider site - (see instructions)",{"$nulls":11},13]
[13.01," Number of miles driven - Provider offsite - (see instructions)",{"$nulls":11},13.01]
[]
[null,"   PART  II  -  SALARY  EQUIVALENCY  COMPUTATION"]
[14," Supervisors  (Column 1, line 9 times column 1, line 10)",{"$nulls":11},14]
[15," Therapists  (Column 2, line 9 times column 2, line 10)",{"$nulls":11},15]
[16," Assistants  (Column 3, line9 times column 3, line10)",{"$nulls":11},16]
[17," Subtotal Allowance Amount  (Sum of lines 14-16)",{"$nulls":11},17]
[18," Aides  (Column 4, line 9 times column 4, line 10)",{"$nulls":11},18]
[19," Total Allowance Amount  (Sum of lines 17 and 18)",{"$nulls":11},19]
[null,"If the sum of columns 1-3, line 9, is greater than line 2, make no entries on lines 20 and 21 and enter on line 22 the"]
[null,"amount from line 19.  Otherwise complete lines 20 - 22."]
[20," Weighted average rate excluding aides  (Line 17 divided by the sum of columns 1-3, line 9)",{"$nulls":11},20]
[21," Weighted allowance excluding aides  (Line 2 times line 20)",{"$nulls":11},21]
[22," Total Salary Equivalency  (Line 19 or sum of lines 18 plus 21)",{"$nulls":11},22]
[]
[null,"   PART  III  -  STANDARD  TRAVEL  ALLOWANCE  AND  STANDARD  TRAVEL  EXPENSE  COMPUTATION  -  PROVIDER  SITE"]
[null,"   Standard Travel Allowance"]
[23," Therapists  (Line 3 times column 2, line 11)",{"$nulls":11},23]
[24," Assistants  (Line 4 times column3, line 11)",{"$nulls":11},24]
[25," Subtotal  (Sum of lines 23 and 24)",{"$nulls":11},25]
[26," Standard Travel Expense  (Line 7 times sum of lines 3 and 4)",{"$nulls":11},26]
[27," Total Standard Travel Allowance and Standard Travel Expense at the Provider Site (Sum of lines 25 and 26)",{"$nulls":11},27]
["FORM CMS-2088-92-A-8-3  (11-1998)  (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1814 - 1814.3)"]
[]
["18-322",{"$nulls":12},"Rev. 3"]
["08-99",{"$nulls":4},"FORM CMS 2088-92",{"$nulls":7},"1890 (Cont.)"]
["REASONABLE  COST  DETERMINATION  FOR  PHYSICAL",{"$nulls":4},"(COMPLETE THIS WORKSHEET",null,"  PROVIDER  NO.:",null," PERIOD:",null,null,"WORKSHEET  A-8-3"]
["THERAPY  SERVICES  FURNISHED  BY OUTSIDE  SUPPLIERS",{"$nulls":4},"FOR SERVICES PROVIDED",null,null,null,"  FROM: ___________",null,null,"PARTS  IV, V & VI"]
[{"$nulls":5},"PRIOR TO APRIL 10, 1998)",null,"   ____________",null,"  TO: ___________"]
[]
[null,"   PART  IV  -  STANDARD  TRAVEL  ALLOWANCE  AND  STANDARD  TRAVEL  EXPENSE  COMPUTATION  - SERVICES  OUTSIDE  PROVIDER  SITE"]
[null,"   Standard Travel Expense"]
[28," Therapists  (Line 5 times column 2, line 11)",{"$nulls":11},28]
[29," Assistants  (Line 6 times column 3, line 11)",{"$nulls":11},29]
[30," Subtotal  (Sum of lines 28 and 29)",{"$nulls":11},30]
[31," Standard Travel Expense  (Line 7 times the sum of lines 5 and 6)",{"$nulls":11},31]
[null,"   Optional Travel Allowance and Optional Travel Expense"]
[32," Therapists  (Sum of columns 1 and 2, line 12.01 times column 2, line 10)",{"$nulls":11},32]
[33," Assistants  (Column 3, line 12.01 times column 3, line 10)",{"$nulls":11},33]
[34," Subtotal  (Sum of lines 32 and 33)",{"$nulls":11},34]
[35," Optional Travel Expense  (Line 8 times the sum of columns 1-3, line 13.01)",{"$nulls":11},35]
[null,"   Total Travel Allowance and Travel Expense - Offsite Services;  Complete one of the following three lines 36, 37, or 38, as appropriate."]
[36," Standard Travel Allowance and Standard Travel Expense  (Sum of lines 30 and 31 - See Instructions)",{"$nulls":11},36]
[37," Optional Travel Allowance and Standard Travel Expense  (Sum of lines 34 and 31 - See Instructions)",{"$nulls":11},37]
[38," Optional Travel Allowance and Optional Travel Expense  (Sum of lines 34 and 35 - See Instructions)",{"$nulls":11},38]
[]
[null,"   PART  V  -  OVERTIME  COMPUTATION"]
[null,"                                       Description",{"$nulls":6},"Therapists","Assistants","Aides",null,"Total"]
[{"$nulls":8},"1","2"," 3",null,"4"]
[39," Overtime hours worked during cost reporting period  (If column 4, line 39, is zero or equal to",{"$nulls":11},39]
[null,"   or greater than 2,080, do not complete lines 40-47 and enter zero in each column of line 48)"]
[40," Overtime rate  (Multiply the amounts in columns 2-4, line 10  ( A H S E A )  times 1.5)",{"$nulls":11},40]
[41," Total overtime  (Including base and overtime allowance)  (Multiply line 39 times line 40)",{"$nulls":11},41]
[null,"   Calculation of Limit"]
[42," Percentage of overtime hours by category  (Divide the hours in each column on line 39 by the",{"$nulls":11},42]
[null," total  overtime worked - column 4, line 39)"]
[43," Allocation of provider's standard workyear for one full-time employee times the percentages",{"$nulls":11},43]
[null,"   on line 42.  (See Instructions)"]
[null,"   Determination of Overtime Allowance"]
[44," Adjusted hourly salary equivalency amount  ( A H S E A )  (From Part I, Columns 2-4, line 10)",{"$nulls":11},44]
[45," Overtime cost limitation  (Line 43 times line 44)",{"$nulls":11},45]
[46," Maximum overtime cost  (Enter the lessor of line 41 or line 45)",{"$nulls":11},46]
[47," Portion of overtime already included in hourly computation at the A H S E A ",{"$nulls":11},47]
[null," (Multiply line 39 times line 44)"]
[48," Overtime allowance  (Line 46 minus 47 - if negative enter zero)(Column 4, sum of cols 1-3)",{"$nulls":11},48]
[]
[null,"   PART  VI  -  COMPUTATION  OF   THERAPY  LIMITATION  AND  EXCESS  COST  ADJUSTMENT"]
[49," Salary equivalency amount  (from Part II, line 22)",{"$nulls":11},49]
[50," Travel allowance and expense - provider site  (from Part III, line 27)",{"$nulls":11},50]
[51," Travel allowance and expense - offsite services  (from Part IV, lines 36, 37 or 38)",{"$nulls":11},51]
[52," Overtime allowance  (from Part V, col. 4, line 48)",{"$nulls":11},52]
[53," Equipment cost  (See Instructions)",{"$nulls":11},53]
[54," Supplies  (See Instructions)",{"$nulls":11},54]
[55," Total allowance  (Sum of lines 49-54)",{"$nulls":11},55]
[56," Total cost of outside supplier services  (from your records)",{"$nulls":11},56]
[57," Excess over limitation  (line 56 minus line 55 - if negative, enter zero -- See Instructions) (Transfer amount to Wkst. A-3, line 16)",{"$nulls":11},57]
["FORM CMS-2088-92-A-8-3  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1814.4 - 1814.6)"]
[]
["Rev. 3",{"$nulls":12},"18-323"]

{"sheet":"A84","index":20,"n_rows":103,"n_cols":11,"rows_kept":103,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",null,null,"FORM CMS 2088-92",{"$nulls":6},"08-99"]
["REASONABLE  COST  DETERMINATION  FOR  RESPIRATORY",null,"(COMPLETE THIS WORKSHEET",null,null,"  PROVIDER  NO.:",null,"  PERIOD:",null,"WORKSHEET  A-8-4"]
["THERAPY  SERVICES  FURNISHED  BY OUTSIDE  SUPPLIERS",null,"FOR SERVICES PROVIDED",{"$nulls":4},"    FROM: ___________",null,"PARTS  I  &  II"]
[null,null,"PRIOR TO APRIL 10, 1998)",null,null,"  ___________",null,"    TO: ___________"]
[]
[null,"PART  I  -  GENERAL  INFORMATION"]
[1," Total number of weeks worked  (During which outside suppliers  (excluding aides and trainees)  worked)",{"$nulls":8},1]
[2," Line 1 multiplied by 15 hours per week",{"$nulls":8},2]
[null," Number of unduplicated days on which the following category, as appropriate, has the highest   A  H  S  E  A   on the provider site  ( See Instructions ):"]
[3," Registered Therapist",{"$nulls":8},3]
[4," Certified Therapist",{"$nulls":8},4]
[5," Nonregistered, Noncertified Therapist",{"$nulls":8},5]
[6," Standard travel expense rate",{"$nulls":8},6]
[null,null,null,"Supervisors",null,null,"Therapists"]
[{"$nulls":4},"Nonregistered",null,null,"Nonregistered"]
[null,"Description","Registered","Certified","Noncertified","Registered","Certified","Noncertified","Aides","Trainees"]
[null,null,"1","2","3","4","5","6","7","8"]
[7," Total Hours Worked",{"$nulls":8},7]
[8," A H S E A  (See Instructions)",{"$nulls":8},8]
[9,"Standard Travel Allowance (Enter in cols 1, 2, or 3,  one-half of",{"$nulls":8},9]
[null,"the amounts on line 8, columns 4, 5 or 6 respectively. Enter in"]
[null,"cols. 4, 5 or 6 one-half of the amounts on line 8, columns 4, 5 or 6"]
[null,"respectively.)"]
[]
[null," PART  II  -  SALARY  EQUIVALENCY  COMPUTATION"]
["10"," Supervisory Registered Therapist  (Col 1, line 7 times col 1, line 8)",{"$nulls":8},"10"]
["11"," Supervisory Certified Therapist  (Col 2, line 7 times col 2, Line 8)",{"$nulls":8},"11"]
["12"," Supervisory Non-Registered, Non-Certified Therapist  (Col 3, line 7 times col 3, line 8)",{"$nulls":8},"12"]
["13"," Registered Therapists  (Col 4, line 7 times col 4, line 8)",{"$nulls":8},"13"]
["14"," Certified Therapists  (Col 5, line 7 times col 5, line 8)",{"$nulls":8},"14"]
["15"," Non-Registered, Non-Certified Therapists  (Col 6, line 7 times col 6, line 8)",{"$nulls":8},"15"]
["16"," Subtotal Allowance Amount (Sum of lines 10-15)",{"$nulls":8},"16"]
["17"," Aides  (Col 7, line 7 times col 7, line 8)",{"$nulls":8},"17"]
["18"," Trainees  (Col 8, line 7 times col 8, line 8)",{"$nulls":8},"18"]
["19"," Total Allowance Amount  (Sum of lines 16-18)",{"$nulls":8},"19"]
[null," If the sum of cols 1-6, line 7, is greater than line 2, make no entries on lines 20 and 21 and enter on line 22 the amount from line 19."]
[null,"   Otherwise, complete lines 20-22."]
["20"," Weighted average rate excluding aides and trainees  (Line 16 divided by the sum of cols 1-6, line 7)",{"$nulls":8},"20"]
["21"," Weighted allowance excluding aides and trainees  (Line 2 times line 20)",{"$nulls":8},"21"]
["22"," Total Salary Equivalency  (Line 19 or sum of lines 17, 18 and 21)",{"$nulls":8},"22"]
{"$rows_empty":7}
[" FORM CMS 2088-92-A-8-4  (11-1998)  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1815 - 1815.2 ) "]
[]
["18-324",{"$nulls":9},"Rev. 3"]
["08-99",null,null,"FORM CMS 2088-92",{"$nulls":6},"1890 (Cont.)"]
["REASONABLE  COST  DETERMINATION  FOR  RESPIRATORY",null,"(COMPLETE THIS WORKSHEET",null,null,"  PROVIDER  NO.:",null,"  PERIOD:",null,"WORKSHEET  A-8-4"]
["THERAPY  SERVICES  FURNISHED  BY OUTSIDE  SUPPLIERS",null,"FOR SERVICES PROVIDED",{"$nulls":4},"    FROM: ___________",null,"PARTS  III,  IV  &  V"]
[null,null,"PRIOR TO APRIL 10, 1998)",null,null,"  ___________",null,"    TO: ___________"]
[]
[null," PART III  -  STANDARD  TRAVEL  ALLOWANCE  AND  STANDARD  TRAVEL  EXPENSE  COMPUTATION"]
["23"," Registered Therapists (Line 3 times col 4, line 9)",{"$nulls":8},"23"]
["24"," Certified Therapists (Line 4 times col 5, line 9)",{"$nulls":8},"24"]
["25"," Non-Registered, Non-Certified Therapists (Line 5 times col 6, line 9)",{"$nulls":8},"25"]
["26"," Subtotal (Sum of lines 23-25)",{"$nulls":8},"26"]
["27"," Standard Travel Expense (Line 6 times sum of lines 3-5)",{"$nulls":8},"27"]
["28"," Total Standard Travel Allowance and Standard Travel Expense (Sum of lines 26 and 27)",{"$nulls":8},"28"]
[]
[null," PART IV  -  OVERTIME  COMPUTATION"]
[{"$nulls":5},"Therapists"]
[{"$nulls":6},"Nonregistered"]
[null,"Description",null,null,"Registered","Certified","Noncertified","Aides","Trainees"," Total "]
[{"$nulls":4},"1","2","3","4","5","6"]
["29"," Overtime hours worked during cost reporting period  ( If col 6, line 29, ",{"$nulls":8},"29"]
[null,"  is zero, or equal to or greater than 2,080, do not complete lines 30"]
[null,"  through 37 and enter zero in each column of line 38 )"]
["30"," Overtime rate ( Multiply the amounts in cols 4-8, line 8 (the AHSEA)",{"$nulls":8},"30"]
[null,"  times 1.5 )"]
["31"," Total overtime (Including base and overtime allowance)",{"$nulls":8},"31"]
[null," (Multiply line 29 times line 30)"]
[null," Calculation  of  Limitation"]
["32"," Percentage of overtime hours by category (Divide the hours in each",{"$nulls":7},"100%","32"]
[null," column on line 29 by the total overtime worked - column 6, line 29)"]
["33"," Allocation of provider's standard workyear for one full-time employee",{"$nulls":8},"33"]
[null," times the percentage on line 32.  (See Instructions)"]
[null," Determination  of  Overtime  Allowance"]
["34"," Adjusted hourly salary equivalency amount (AHSEA) ",{"$nulls":8},"34"]
[null," (From Part I, cols. 4-8, line 8)"]
["35"," Overtime cost limitation (Line 33 times line 34)",{"$nulls":8},"35"]
["36"," Maximum overtime cost (Enter the lessor of line 31 or 35)",{"$nulls":8},"36"]
["37"," Portion of overtime already included in hourly computation at the ",{"$nulls":8},"37"]
[null,"  A H S E A.  (Multiply line 29 times line 34)"]
["38"," Overtime allowance (Line 36 minus line 37 - if negative enter zero)",{"$nulls":8},"38"]
[null,"  (Col. 6, sum of cols. 1 - 5)"]
[]
[null," PART  V  -  COMPUTATION  OF  RESPIRATORY  THERAPY  LIMITATION  AND  EXCESS  COST  ADJUSTMENT "]
["39"," Salary equivalency amount (from Part II, line 22)",{"$nulls":8},"39"]
["40"," Travel allowance and expense (from Part III, line 28)",{"$nulls":8},"40"]
["41"," Overtime allowance (from Part IV, col 6, line 38)",{"$nulls":8},"41"]
["42"," Equipment cost (See Instructions)",{"$nulls":8},"42"]
["43"," Supplies (See Instructions)",{"$nulls":8},"43"]
["44"," Total allowance ( Sum of lines 39 - 43)",{"$nulls":8},"44"]
["45"," Total cost of outside supplier services (from your records)",{"$nulls":8},"45"]
["46"," Excess over limitation ( line 45 minus line 44, - if negative, enter zero - See Instructions) (Transfer to amount Wkst. A-3, line 15) ",{"$nulls":8},"46"]
[]
[" FORM CMS 2088-92-A-8-4  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1815.3 - 1815.5 )"]
[]
["Rev. 3",{"$nulls":9},"18-325"]

{"sheet":"A85","index":21,"n_rows":147,"n_cols":9,"rows_kept":147,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["1890 (Cont.)",null,"FORM CMS 2088-92",{"$nulls":5},"08-99"]
["REASONABLE COST DETERMINATION FOR THERAPY SERVICES",null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET A-8-5"]
["FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998",{"$nulls":4},"FROM: ___________",null,"  PARTS  I &  II"]
[null,null,null,"___________",null,"TO: ___________"]
["Check applicable box:",null," [    ]  Respiratory    [    ]  Physical    [    ]  Occupational   [    ]  Speech Pathology"]
[]
[null,"PART I - GENERAL INFORMATION"]
[1," Total number of weeks worked (during which outside (excluding aides worked)",{"$nulls":6},1]
[2," Line 1 multiplied by 15 hours per week",{"$nulls":6},2]
[3," Number of unduplicated days on which supervisor or therapist was on provider site (see instructions)",{"$nulls":6},3]
[4," Number of unduplicated days on which therapy assistant was on provider site but neither supervisor nor therapist was",{"$nulls":6},4]
[null,"  on provider site (see instructions)"]
[5," Number of unduplicated offsite visits - supervisors or therapists (see instructions)",{"$nulls":6},5]
[6," Number of unduplicated offsite visits - therapy assistants (include only visits made by therapy assistant and on which",{"$nulls":6},6]
[null,"  supervisor and/or therapist was not present during the visit(s)) (see instructions)"]
[7," Standard travel expense rate",{"$nulls":6},7]
[8," Optional travel expense rate per mile",{"$nulls":6},8]
[null,null,null,"Supervisors","Therapists","Assistants","Aides","Trainees"]
[null,null,null,"1","2","3","4","5"]
[9," Total hours worked",{"$nulls":6},9]
[10," AHSEA (see instructions)",{"$nulls":6},10]
[11," Standard Travel Allowance (columns 1 and 2, one-half of column 2,",{"$nulls":6},11]
[null,"  line 10; column 3, one-half of column 3, line 10)"]
[12," Number of travel hours - Provider on site - (see instructions)",{"$nulls":6},12]
[12.01," Number of travel hours - Provider offsite - (see instructions)",{"$nulls":6},12.01]
[13," Number of miles driven - Provider on site - (see instructions)",{"$nulls":6},13]
[13.01," Number of miles driven - Provider offsite - (see instructions)",{"$nulls":6},13.01]
[]
[null,"PART II - SALARY EQUIVALENCY COMPUTATION"]
[14," Supervisors (column 1, line 9 times column 1, line 10)",{"$nulls":6},14]
[15," Therapists (column 2, line 9 times column 2, line 10)",{"$nulls":6},15]
[16," Assistants (column 3, line 9 times column 3, line10)",{"$nulls":6},16]
[17," Subtotal Allowance Amount (sum of lines 14-16)",{"$nulls":6},17]
[18," Aides (column 4, line 9 times column 4, line 10)",{"$nulls":6},18]
[19," Trainees (column 5, line 9 times column 5, line 10)",{"$nulls":6},19]
[20," Total Allowance Amount (see instructions)",{"$nulls":6},20]
[null,"  If the sum of columns 1 and 2 for respiratory therapy or columns 1-3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2, "]
[null,"  make no entries on lines 21 and 22 and enter on line 23 the amount from line 20.  Otherwise complete lines 21-23."]
[21," Weighted average rate excluding aides and trainees (see instructions)",{"$nulls":6},21]
[22," Weighted allowance excluding aides and trainees (see instructions)",{"$nulls":6},22]
[23," Total salary equivalency (see instructions)",{"$nulls":6},23]
[]
[]
[]
[]
[]
["FORM CMS-2088-92-A-8-5  (11-1998)  (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1816 - 1816.2)"]
[]
["18-326",{"$nulls":7},"Rev. 3"]
["08-99",null,"FORM CMS 2088-92",{"$nulls":5},"1890 (Cont.)"]
["REASONABLE COST DETERMINATION FOR THERAPY SERVICES",null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET A-8-5"]
["FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998",{"$nulls":4},"FROM: ___________",null,"  PARTS III & IV"]
[null,null,null,"____________",null,"TO: ___________"]
["Check applicable box:",null," [    ]  Respiratory    [    ]  Physical    [    ]  Occupational   [    ]  Speech Pathology"]
[]
[null,"PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE"]
["   Standard Travel Allowance"]
[24," Therapists (line 3 times column 2, line 11)",{"$nulls":6},24]
[25," Assistants (line 4 times column 3, line 11)",{"$nulls":6},25]
[26," Subtotal (sum of lines 24 and 25)",{"$nulls":6},26]
[27," Standard Travel Expense (line 7 times sum of lines 3 and 4)",{"$nulls":6},27]
[28," Total Standard Travel Allowance and Standard Travel Expense at the Provider Site (sum of lines 26 and 27)",{"$nulls":6},28]
["   Optional Travel Allowance and Optional Travel Expense"]
[29," Therapists (sum of columns 1 and 2, line 12 times column 2, line 10)",{"$nulls":6},29]
[30," Assistants (column 3, line 10 times column 3, line 12)",{"$nulls":6},30]
[31," Subtotal (sum of lines 29 and 30)",{"$nulls":6},31]
[32," Optional travel expense (line 8 times the sum of columns 1-3, line 13)",{"$nulls":6},32]
[33," Standard travel allowance and standard travel expense (line 28)",{"$nulls":6},33]
[34," Optional travel allowance and standard travel expense (sum of lines 27 and 30)",{"$nulls":6},34]
[35," Optional travel allowance and optional travel expense (sum of lines 31 and 32)",{"$nulls":6},35]
[]
[null,"PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE"]
["   Standard Travel Expense"]
[36," Therapists (line 5 times column 2, line 11)",{"$nulls":6},36]
[37," Assistants (line 6 times column 3, line 11)",{"$nulls":6},37]
[38," Subtotal (sum of lines 36 and 37)",{"$nulls":6},38]
[39," Standard Travel Expense (line 7 times the sum of lines 5 and 6)",{"$nulls":6},39]
["   Optional Travel Allowance and Optional Travel Expense"]
[40," Therapists (sum of columns 1 and 2, line 12.01 times column 2, line 10)",{"$nulls":6},40]
[41," Assistants (column 3, line 12.01 times column 3, line 10)",{"$nulls":6},41]
[42," Subtotal (sum of lines 40 and 41)",{"$nulls":6},42]
[43," Optional Travel Expense (line 8 times the sum of columns 1-3, line 13.01)",{"$nulls":6},43]
["   Total Travel Allowance and Travel Expense - Offsite Services; Complete one of the following"]
["   three lines 44, 45, or 46, as appropriate."]
[44," Standard Travel Allowance and Standard Travel Expense (sum of lines 38 and 39 - see instructions)",{"$nulls":6},44]
[45," Optional Travel Allowance and Standard Travel Expense (sum of lines 39 and 42 - see instructions)",{"$nulls":6},45]
[46," Optional Travel Allowance and Optional Travel Expense (sum of lines 42 and 43 - see instructions)",{"$nulls":6},46]
{"$rows_empty":8}
["FORM CMS-2088-92-A-8-5  (11-1998)  (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1816.3 - 1816.4)"]
[]
["Rev. 3",{"$nulls":7},"18-327"]
["1890 (Cont.)",null,"FORM CMS 2088-92",{"$nulls":5},"08-99"]
["REASONABLE COST DETERMINATION FOR THERAPY SERVICES",null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET A-8-5"]
["FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998",{"$nulls":4},"FROM: ___________",null,"  PARTS V & VI"]
[null,null,null,"___________",null,"TO: ___________"]
["Check applicable box:",null," [    ]  Respiratory    [    ]  Physical    [    ]  Occupational   [    ]  Speech Pathology"]
[]
[null,"PART V - OVERTIME COMPUTATION"]
[null,null,null,"Therapists","Assistants","Aides","Trainees","Total"]
[null,null,null,"1","2","3","4","5"]
[47," Overtime hours worked during reporting period (if column 5, ",{"$nulls":6},47]
[null," line 47, is zero or equal to or greater than 2,080, do not complete "]
[null," lines 48-55 and enter zero in each column of line 56)"]
[48," Overtime rate (see instructions)",{"$nulls":6},48]
[49," Total overtime (including base and overtime allowance) (multiply",{"$nulls":6},49]
[null," line 47 times line 48)"]
["      CALCULATION OF LIMIT"]
[50," Percentage of overtime hours by category (divide the hours in each",{"$nulls":6},50]
[null," column on line 47 by the total overtime worked - column 5, line 47)"]
[51," Allocation of provider's standard workyear for one full-time ",{"$nulls":6},51]
[null," employee times the percentages on line 50) (see instructions)"]
["      DETERMINATION OF OVERTIME ALLOWANCE"]
[52," Adjusted hourly salary equivalency amount (see instructions)",{"$nulls":6},52]
[53," Overtime cost limitation (line 51 times line 52)",{"$nulls":6},53]
[54," Maximum overtime cost (enter the lessor of line 49 or line 53)",{"$nulls":6},54]
[55," Portion of overtime already included in hourly computation at the AHSEA (multiply line 47 times line 52)",{"$nulls":6},55]
[56," Overtime allowance (line 54 minus line 55 - if negative enter zero) (column 5, sum of columns 1-4)",{"$nulls":6},56]
[]
[null,"PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT"]
[57," Salary equivalency amount (from Part II, line 23)",{"$nulls":6},57]
[58," Travel allowance and expense - provider site (from Part III, lines 33, 34, or 35))",{"$nulls":6},58]
[59," Travel allowance and expense - provider offsite services (from Part IV, lines 44, 45, or 46)",{"$nulls":6},59]
[60," Overtime allowance (from Part V, column 5, line 56)",{"$nulls":6},60]
[61," Equipment cost (see instructions)",{"$nulls":6},61]
[62," Supplies (see instructions)",{"$nulls":6},62]
[63," Total allowance (sum of lines 57-62)",{"$nulls":6},63]
[64," Total cost of outside supplier services (from your records)",{"$nulls":6},64]
[65," Excess over limitation (line 64 minus line 63 - if negative, enter zero -- See Instructions) (Transfer amount to Wkst. A-3, line 17, 17.1, 17.2 or 17.3 as applicable)",{"$nulls":6},65]
{"$rows_empty":9}
["FORM CMS-2088-92-A-8-5  (11-1998)  (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1816.5 - 1816.6)"]
[]
["18-328",{"$nulls":7},"Rev. 3"]