bcbsa 2552 10 test case - rwhc resources/bcbsa_testcase.pdf · 7 skilled nursing facility 34,218...

BCBSA

2552‐10

Test Case

07-11 FORM CMS-2552-10 4090 (Cont.)This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim FORM APPROVEDpayments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g). OMB NO. 0938-0050

HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN: PERIOD: WORKSHEET S,COMPLEX COST REPORT CERTIFICATION FROM 10/1/2010 PARTS I, II & IIIAND SETTLEMENT SUMMARY 14-0635 TO 9/30/2011PART I - COST REPORT STATUSProvider use only 1. [X] Electronically filed cost report Date: Time:

2. [ ] Manually submitted cost report 9/12/2011 8:513. [ ] If this is an amended report enter the number of times the provider resubmitted this cost report4 [F] Medicare Utilization. Enter "F" for full or "L" for low.

Contractor 5. [ ] Cost Report Status 6. Date Received:_________ 10. NPR Date:__________use only (1) As Submitted 7. Contractor No.:________ 11. Contractor's Vendor Code: ___________

(2) Settled without audit 8. [ ] Initial Report for this Provider CCN 12. [ ] If line 4, column 1 is 4: Enter number of (3) Settled with audit 9. [ ] Final Report for this Provider CCN times reopened = 0-9. (4) Reopened (5) Amended

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 OTHERWISEILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.

CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)

I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically filed or manually submitted costreport and the Balance Sheet and Statement of Revenue and Expenses prepared by East Side Medical Center # 14-0635{Provider Name(s) and Number(s)}for the cost reporting period beginning 10/1/2010 and ending 9/30/2011 and to the best of my knowledge and belief, it is a true, correctand complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further 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 compliance with such laws and regulations.

(Signed)________________________________________________ Officer or Administrator of Provider(s) ______________________________________________ Title ______________________________________________ Date

PART III - SETTLEMENT SUMMARY TITLE XVIII

TITLE V PART A PART B HIT TITLE XIX

1 2 3 4 5

1 HOSPITAL 5,574,583 564,939 178,095 1

2 SUBPROVIDER - IPF (177,445) 4,373 2

3 SUBPROVIDER - IRF 71,639 12,643 3

4 SUBPROVIDER (OTHER) 4

5 SWING BED - SNF 3,222 220 5

6 SWING BED - NF 6

7 SKILLED NURSING FACILITY 34,218 62,516 7

8 NURSING FACILITY 8

9 HOME HEALTH AGENCY (29,463) 180 9

10 HEALTH CLINIC - RHC 32,983 10

11 HEALTH CLINIC - FQHC (24,208) 11

OUTPATIENT REHABILITATION

12 PROVIDER (CMHC) (15) 12

200 TOTAL 5,476,754 653,631 178,095 200

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 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4003.1-4003.3)

Rev. 2 40-503

4090 (Cont.) FORM CMS-2552-10 12-10HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN: PERIOD: WORKSHEET S-2COMPLEX IDENTIFICATION DATA FROM 10/1/2010 Part I

14-0635 TO 9/30/2011Hospital and Hospital Health Care Complex Address:

1 Street: 100 Main Street P.O. Box: 12 City: Chicago State: IL Zip Code: 60611 County: Cook 2

Hospital and Hospital-Based Component Identification: Payment SystemProvider CBSA Provider Date (P, T, O, or N)

Component Component Name Number Number Type Certified V XVIII XIX0 1 2 3 4 5 6 7 8

3 Hospital Hospital 14-0635 16974 1 04/01/1970 N P N 34 Subprovider- IPF PYCH 14-S635 16974 4 04/01/1970 N P N 45 Subprovider- IRF IRF 14-T635 16974 5 04/01/1970 N P N 56 Subprovider- (Other) 67 Swing Beds-SNF S/B SNF 14-U635 16974 04/01/1970 N P N 78 Swing Beds-NF 89 Hospital-Based SNF SNF 14-5481 16974 04/01/1970 N P N 9

10 Hospital-Based NF 1011 Hospital-Based OLTC 1112 Hospital-Based HHA HHA 14-7105 16974 04/01/1970 N P N 1213 Separately Certified ASC ASC 14-C423 16974 04/01/1985 N O N 1314 Hospital-Based Hospice Hospice 14-1590 16974 04/01/1985 1415 Hospital-Based Health Clinic-RHC RHC 14-3400 16974 10/01/1994 N O N 1516 Hospital-Based Health Clinic-FQHC FQHC 14-1890 16974 10/01/1994 N O N 1617 Hospital-Based (CMHC) CMHC 14-1410 16974 7/01/2002 N O N 17

17.10 Other (CORF) CORF 14-4860 16974 7/01/2002 N O N18 Renal Dialysis Renal 14-3510 16974 7/01/2002 1819 Other 19

20 Cost Reporting Period (mm/dd/yyyy) FROM 10/1/2010 TO 9/30/2011 2021 Type of Control (see instructions) 4 21

Inpatient PPS Information 1 222 Does this facility qualify for and receive disproportionate share hospital payment in accordance with 42 CFR §412.106, or low income payment in accordance with 42 CFR §412.624 (e)(2)? 22

In column 1, enter "Y" for yes and "N" for no. Is this facility subject to 42 CFR §412.06 (c )(2) (Pickle amendment hospital)? In column 2, enter "Y" for yes or "N" for no. Y N23 Which method is used to determine Medicaid days on lines 24 and/or 25 below ? In column 1, enter 1 if date of admission, 2 if census days, or 3 if date of discharge. 23

Is the method of identifying the days in this cost reporting period different from the method used in the prior cost reporting period? In column 2, enter "Y" for yes or "N" for no. 2 N

In-State In-State Out-of State Out-of State Medicaid OtherMedicaid Medicaid Medicaid Medicaid HMO Medicaid

If line 22 is "yes", and this provider is an IPPS hospital enter the in-state Medicaid paid days in col. 1, in-state paid days eligible days paid days eligible days days daysMedicaid eligible days in col. 2 out-of-state Medicaid paid days in col. 3, out-of-state Medicaid eligible days 1 2 3 4 5 6

24 in col. 4, Medicaid HMO days in col. 5, and other Medicaid days in col. 6. 13,500 750 100 1 135 25 24If line 22 is "yes", and this provider is an IRF then, enter the in-state Medicaid paid days in col. 1, in-stateMedicaid 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. 717 2 5 2 35 2 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. 1 2627 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. 1 27

FORM CMS-2552-10 (12-10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)

40-504 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN: PERIOD: WORKSHEET S-2COMPLEX IDENTIFICATION DATA FROM 10/1/2010 Part I (CONT.)

14-0635 TO 9/30/201135 If this is a sole community hospital (SCH), enter the number of periods SCH status in effect in the cost reporting period. 3536 Enter the applicable SCH dates: Beginning:_______________ Ending: ______________ 3637 If this is a Medicare dependent hospital (MDH), enter the number of periods MDH status in effect in the cost reporting period. 3738 Enter applicable beginning and ending dates of MDH status. Subscript line 38 for number of periods in excess of one and enter subsequent dates. Beginning:_______________ Ending: ______________ 38

V XVIII XIX Prospective Payment System (PPS)-Capital 1 2 3

45 Does your facility qualify and receive Capital payment for disproportionate share in accordance with 42 CFR 412.320? (see instructions) Y 4546 If you are eligible for the special exceptions payment pursuant to 42 CFR 412.348(g)? If yes, Worksheet L, Part III N 4647 Is this a new hospital under 42 CFR §412.300 PPS capital? Enter "Y for yes and "N" for no. N 4748 Is the facility electing full federal capital payment? Enter "Y" for yes and "N" for no in column 2. 48

Teaching Hospitals 1 2 356 Is this a hospital involved in training residents in approved GME programs ? Enter "Y" for yes or "N" for no. Y 5657 If line 56 is yes, is this the first cost reporting period during which residents in approved GME programs trained at this facility? Enter "Y" for yes or "N" for no in column 1. 57

If column 1 is "Y" did residents start training in the first month of this cost reporting period? Enter "Y" for yes or "N" for no in column 2. If column 2 is "Y", complete Worksheet E-4. If column 2 is "N", complete Worksheet D, Part III & IV and D-2, Part II, if applicable. N

58 If line 56 is yes, did this facility elect cost reimbursement for physicians' services as defined in CMS Pub. 15-1, section 2148? 58 If yes, complete Worksheet D-5. N

59 Are costs claimed on line 100 of Worksheet A? If yes, complete Worksheet D-2, Part I. Y 5960 Are you claiming nursing school and/or allied health costs for a program that meets the provider-operated criteria under §413.85? Enter "Y" for yes or "N" for no.( see instructions) Y 60

DirectY/N IME Average GME Average 61

61 Did your facility receive additional FTE slots under section 5503? Enter "Y" for yes or "N" for no. If "Y", effective for portions of cost reporting periods beginningon or after July, 2011 enter the average number of primary care FTE residents for IME in column 2 and direct GME in column 3, from the hospital’s 3 most recentcost reports ending and submitted before March 23, 2010. (see instructions) Y 125.24 132.75

ACA Provisions Affecting the Health Resources and Services Administration (HRSA)62 Enter the number of FTE residents that your hospital trained in this cost reporting period for which your hospital received HRSA (PCRE). (see instructions) 1.35 62

62.01 Enter the number of FTE residents that rotated from a Teaching Health Center (THC) into your hospital during in this cost reporting period of HRSA (THC) program. (see instructions) 0.45 62.01

Teaching Hospitals that Claim Residents in Non-Provider Settings63 Has your facility trained residents in non-provider settings during this cost reporting period? Enter "Y" for yes or "N" for no, if yes, complete lines 64-67). (see instructions) Y 63

Unweighted Unweighted RatioFTEs FTEs (col. 1/

Section 5504 of the ACA Base Year FTE Residents in Nonprovider settings--This base year is your cost reporting period that begins on or after July 1, 2009 and before June 30, 2010. Nonprovider Sit in Hospital (col. 1 + col. 2))64 Enter in column 1 the number of unweighted non-primary care resident FTEs attributable to rotations occurring in all non-provider settings. Enter in column 2 the number 64

of unweighted non-primary care resident FTEs that trained in your hospital. Enter in column 3 the ratio of (column 1 divided by (column 1 + column 2)). (see instructions) 1.24 20 0.058380 Unweighted Unweighted \

FTEs FTEs (col. 3/65 Enter in column 1 the program name. Enter in column 2 the program code, enter in column 3 the number of Program Name Program Code Nonprovider Site in Hospital (col. 3 + col. 4))

unweighted primary care resident FTEs attributable to rotations occurring in all non-provider settings. Family Medicine 1350 0.75 25 0.029126 65Enter in column 4 the number of unweighted primary care resident FTEs that trained in your hospital. Familty Medicine 1351 1.24 30 0.039693 65.01 Enter in column 5 the ratio of (column 3 divided by (column 3 + column 4)). (see instructions) Pediatrics 2000 0.24 25 0.009509 65.02

Preventative Medicine 2150 0.14 20 0.006951 65.03 Internal Medicine/Family Medicine 2755 0.50 30 0.016393 65.04

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)

Rev. 2 40-505

HOSPITAL AND HOSPITAL HEALTH CARE DRAFTHOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN : PERIOD WORKSHEET S-2COMPLEX IDENTIFICATION DATA FROM 10/1/2010 PART I (CONT.)

14-0635 TO 9/30/2011Unweighted Unweighted Ratio

FTEs FTEs (col. 1/Section 5504 of the ACA Current Year FTE Residents in Nonprovider settings--Effective for cost reporting periods beginning on or after July 1, 2010 Nonprovider Sit in Hospital (col. 1 + col. 2))

66 Enter in column 1 the number of unweighted non-primary care resident FTEs attributable to rotations occurring in all non-provider settings. Enter in column 2 the number 66of unweighted non-primary care resident FTEs that trained in your hospital. Enter in column 3 the ratio of (column 1 divided by (column 1 + column 2)). (see instructions) 1.54 20 0.071495

Unweighted Unweighted RatioFTEs FTEs (col. 3/

67 Enter in column 1 the program name. Enter in column 2 the program code, enter in column 3 the number of Program Name Program Code Nonprovider Site in Hospital (col. 3 + col. 4)) 67unweighted primary care resident FTEs attributable to rotations occurring in all non-provider settings. Family Medicine 1350 1.25 25 0.047619 67Enter in column 4 the number of unweighted primary care resident FTEs that trained in your hospital. Familty Medicine 1351 1.45 30 0.046105 67.01 Enter in column 5 the ratio of (column 3 divided by (column 3 + column 4)). (see instructions) Pediatrics 2000 0.35 25 0.013807 67.02

Preventative Medicine 2150 0.25 20 0.012346 67.03 Internal Medicine/Family Medicine 2755 0.50 30 0.016393 67.04

Inpatient Psychiatric Facility PPS 1 2 370 Is this facility an Inpatient Psychiatric Facility (IPF), or does it contain an IPF subprovider? Enter "Y" for yes or "N" for no. Y 7071 If line 70 yes: 71

Column 1: Did the facility have a teaching program in the most recent cost report filed on or before November 15, 2004? Enter "Y" for yes or "N" for no. Column 2: Did this facility train residents in a new teaching program in accordance with 42 CFR §412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no. Column 3: If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions) If this cost reporting period covers the beginning of the fourth year, enter 4 in column 3, or if the subsequent academic years of the new teaching program in existence, enter 5. (see instructions) N Y 1

Inpatient Rehabilitation Facility PPS75 Is this facility an Inpatient Rehabilitation Facility (IRF), or does it contain an IRF subprovider? Enter "Y" for yes and "N" for no. Y 7576 If line 75 yes: 76

Column 1: Did the facility have a teaching program in the most recent cost reporting period ending on or before November 15, 2004? Enter "Y" for yes or "N" for no. Column 2: Did this facility train residents in a new teaching program in accordance with 42 CFR §412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no. Column 3: If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions) If this cost reporting period covers the beginning of the fourth year, enter 4 N N in column 3, or if the subsequent academic years of the new teaching program in existence, enter 5. (see instructions)

Long Term Care Hospital PPS80 Is this a Long Term Care Hospital (LTCH)? Enter "Y" for yes or "N" for no. N 80

TEFRA Providers85 Is this a new hospital under 42 CFR 413.40(f)(1)(i) TEFRA? Enter "Y" for yes, and "N" for no. N 8586 Did this facility establish a new Other subprovider (excluded unit) under 42 CFR §413.40(f)(1)(ii)? Enter "Y" for yes, and "N" for no. N 86

V XIX Title V and XIX Inpatient Services 1 2

90 Does this facility have title V and/or XIX inpatient hospital services? Enter "Y" for yes, and "N" for no in applicable column. N Y 9091 Is this hospital reimbursed for title V and/or XIX through the cost report either in full or in part? Enter "Y" for yes, and "N" for no in the applicable column. N 9192 Are title XIX NF patients occupying title XVIII SNF beds (dual certification)? (see instructions) Enter "Y" for yes, and "N" for no in the applicable column. N N 9293 Does this facility operate an ICF\MR facility for purposes of title V and XIX? Enter "Y" for yes, and "N" for no in the applicable column. N N 9394 Does title V or title XIX reduce capital cost? Enter "Y" for yes or "N" for no in the applicable column. N N 9495 If line 94 is "Y", enter the reduction percentage in the applicable column. 9596 Does title V or title XIX reduce operating cost? Enter "Y" for yes or "N" for no in the applicable column. N N 9697 If line 96 is "Y", enter the reduction percentage in the applicable column. 97


40-506 Rev. 2

07-11HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN : PERIOD WORKSHEET S-2COMPLEX IDENTIFICATION DATA FROM 10/1/2010 PART I (CONT.)

14-0635 TO 9/30/2011Rural Providers

105 Does this hospital qualify as a Critical Access Hospital (CAH)? N 105106 If this facility qualifies as an CAH, has it elected the all-inclusive method of payment for outpatient services? (see instructions) 106107 Column 1: 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 in column 1. (see 107

instructions) If yes, the GME elimination would not be on Worksheet B, Part I, column 26 and the program would be cost reimbursed. If yes complete Worksheet D-2, Part II. Column 2: 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 instructions)

108 Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42 CFR 412.113(c). N 108Physical Occupational Speech Respiratory

109 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 each therapy. 109Miscellaneous Cost Reporting Information

115 Is this an all-inclusive rate provider? Enter "Y" for yes or "N" for no in column 1. If yes, enter the method used (A, B, or E only) in column 2. N 115116 Is this facility classified as a referral center? Enter "Y" for yes or "N" for no. N 116117 Is this facility legally-required to carry malpractice insurance? Enter "Y" for yes or "N" for no. Y 117118 Is the malpractice insurance a claims-made or occurrence policy? Enter 1 if the policy is claim- made. Enter 2 if the policy is occurrence. 2 118119 What is the liability limit for the malpractice insurance policy? Enter in column 1 the monetary limit per lawsuit. Enter in column 2 the monetary limit per policy year. 119

2,000,000 100,000,000 Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in ACA §3121as amended by the Medicaid Extender Act (MMEA) §108 ? Enter in column 1 "Y" for yes N N

120 or "N" for no. Is this a rural hospital with <100 beds that qualifies for the Outpatient Hold Harmless provision in ACA §3121? Enter in column 2 "Y" for yes or "N" for no. 120121 Did this facility incur and report costs for implantable devices charged to patient? Enter in column 1 "Y" for yes or "N" for no. Y 121

Transplant Center Information125 Does this facility operate a transplant center? Enter "Y" for yes or "N" for no. If yes, enter certification date(s) (mm/dd/yyyy) below. Y 125126 If this is a Medicare certified kidney transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 10/1/1993 126127 If this is a Medicare certified heart transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 127128 If this is a Medicare certified liver transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 10/1/2002 128129 If this is a Medicare certified lung transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 129130 If this is a Medicare certified pancreas transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 130131 If this is a Medicare certified intestinal transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 131132 If this is a Medicare certified islet transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 132133 If this is a Medicare certified other transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2. 133134 If this is an organ procurement organization (OPO), enter the OPO number in column 1 and termination date, if applicable, in column 2. 14P123 134

All Providers 1 2140 Are there any related organization or home office costs as defined in CMS Pub. 15-1, chapter 10? Enter "Y" for yes or "N" for no in column 1. 140

If yes, and home office costs are claimed, enter in column 2 the home office chain number. (see instructions) Y HO-1466

If this facility is part of a chain organization, enter on lines 141 through 143 the name and address of the home office and enter the home office contractor name and contractor number.

141 Name: Health East Contractor's Name: J-3 Contractor Contractor's Number: 03301 141

142 Street: 225 N Michigan P. O. Box: 142143 City: Chicago State: IL Zip Code: 60601 143144 Are provider based physicians' costs included in Worksheet A? Y 144145 If costs for renal services are claimed on Worksheet A, are the y costs for inpatient services only? Enter "Y" for yes or "N" for no. N 145146 Has the cost allocation methodology changed from the previously filed cost report? Enter "Y" for yes or "N" for no in column 1. (See CMS Pub. 15-2, section 4020) 146

If yes, enter the approval date (mm/dd/yyyy) in column 2. N147 Was there a change in the statistical basis? Enter "Y" for yes or "N" for no. N 147148 Was there a change in the order of allocation? Enter "Y" for yes or "N" for no. N 148149 Was the change to the simplified cost finding method? Enter "Y" for yes or "N" for no. 149

FORM CMS-2552-10 (Draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1)

Rev. 2 40-507

07-11HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN : PERIOD WORKSHEET S-2COMPLEX IDENTIFICATION DATA FROM 10/1/2010 PART I (CONT.)

14-0635 TO 9/30/2011 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.)

Part A Part B1 2

155 Hospital N N 155156 Subprovider - IPF N N 156157 Subprovider - IRF N N 157158 Subprovider - Other 158159 SNF N N 159160 HHA N N 160

161 CMHC N 161

Multicampus 165 Is this hospital part of a multicampus hospital that has one or more campuses in different CBSAs? Enter "Y" for yes and "N" for no. N 165

166 If line 165 is yes, for each campus enter the name in column 0, county in column 1, state in column 2, zip in column 3, CBSA in column 4, FTE/Campus in column 5. 166 Name County State Zip Code CBSA FTE/Campus

0 1 2 3 4 5

Health Information Technology (HIT) incentive in the American Recovery and Reinvestment Act167 Is this provider a meaningful user under §1886 (n)? Enter "Y" for yes or "N" for no. Y 167168 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) 168169 If this provider is a meaningful user (line 167 is "Y") and is not a CAH (line 105 is "N"), enter the transition factor. (see instructions) 1.00 169


40-508 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN: PERIOD: WORKSHEET S-2REIMBURSEMENT QUESTIONNAIRE FROM 10/1/2010 Part II

14-0635 TO 9/30/2011General Instruction: For all column 1 responses enter in column 1, "Y" for Yes or "N" for No

For all the dates responses the format will be (mm/dd/yyyy)

Completed by All Hospitals, Provider Organization and Operation1 2

Y/N Date1 Has the Provider changed ownership immediately prior to the beginning of the cost reporting period? 1

If column 1 is "Y", enter the date of the change in column 2. (see instructions) N1 2 3

Y/N Date V/I2 Has the provider terminated participation in the Medicare Program? 2

If column 1 is yes enter in column 2 the date of termination and in column 3, "V" for voluntayr or "I" for involuntary N3 Is the provider involved in business transactions, including management contracts, with individuals or entities 3

(e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers, medical staff, management personnel, or members of the board of directors through ownership, control, or family and other similar relationships? (see instructions) Y

Financial Data and Reports1 2 3

Y/N Type Date4 Column 1: Were the financial statements prepared by a Certified Public Accountant? 4

Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter date available in column 3. (see instructions) If no, see instructions. Y A 11/15/2011

5 Are the cost report total expenses and total revenues different from those on the filed financial statements? 5 If yes, submit reconciliation. Y

1 2Approved Educational Activities Y/N Legal Oper.

6 Column 1: Are costs claimed for nursing school? 6 Column 2: If yes, is the provider is the legal operator of the program? Y Y

7 Are costs claimed for allied health programs? If yes, see instructions. Y 78 Were nursing school and/or allied health programs approved and/or renewed during the cost reporting period? 8

If yes, see instructions. N9 Are costs claimed for Intern-Resident programs claimed on the current cost report? If yes, see instructions. Y 9

10 Was an Intern-Resident program initiated or renewed in the current cost reporting period? If yes, see instructions. Y 1011 Are GME costs directly assigned to cost centers other than I & R in an Approved Teaching Program on Worksheet A? 11

If yes, see instructions. N

Bad Debts1

Y/N12 Is the provider seeking reimbursement for bad debts? If yes, see instructions. Y 1213 If line 12 is yes, did the provider's bad debt collection policy change during this cost reporting period? If yes, submit copy. N 1314 If line 12 is yes, were patient deductibles and/or co-payments waived? If yes, see instructions. N 14

Bed Complement15 Did total beds available change from the prior cost reporting period? If yes, see instructions. Y 15

Y/N Date Y/N DatePS&R Data 1 2 3 4

16 Was the cost report prepared using the PS&R Report only? If either column 1 or 3 is yes, enter the 15 paid-through date of the PS&R Report used in columns 2 and 4. (see instructions) Y 12/31/2011 Y 12/31/2011

17 Was the cost report prepared using the PS&R Report for totals and the provider's records for allocation? 16 If either coumn 1 or 3 is yes, enter the paid-through date in columns 2 and 4. (see instructions) N N

18 If line 16 or 17 is yes, were adjustments made to PS&R Report data for additional claims that have been 17 billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions. Y Y

19 If line 16 or 17 is yes, were adjustments made to PS&R Report data for corrections of other 18 PS&R Report information? If yes, see instructions. Y Y

20 If line 16 or 17 is yes, were adjustments made to PS&R Report data for Other? 19 Describe the other adjustments: _________________________________ N N

21 Was the cost report prepared only using the provider's records? If yes, see instructions. N N 20

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4004.2)

Rev. 2 40-509

Part A Part B

4090 (Cont.) 0 07-11HOSPITAL AND HOSPITAL HEALTH CARE PROVIDER CCN: PERIOD: WORKSHEET S-2REIMBURSEMENT QUESTIONNAIRE FROM 10/1/2010 Part II

14-0635 TO 9/30/2011General Instruction: For all column 1 responses enter in column 1, "Y" for Yes or "N" for No

For all the dates responses the format will be (mm/dd/yyyy)

COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY (EXCEPT CHILDRENS HOSPITALS)

Capital Related Cost22 Have assets been relifed for Medicare purposes? If yes, see instructions. 2223 Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost reporting period? 23

If yes, see instructions.24 Were new leases and/or amendments to existing leases entered into during this cost reporting period? If yes, see instructions. 2425 Have there been new capitalized leases entered into during the cost reporting period? If yes, see instructions. 2526 Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period? If yes, see instructions. 2627 Has the provider's capitalization policy changed during the cost reporting period? If yes, see instructions. 27

Interest Expense28 Were new loans, mortgage agreements or letters of credit entered into during the cost reporting period? If yes, see instructions. 2829 Did the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund) treated as a funded depreciation 29

account? If yes, see instructions.30 Has existing debt been replaced prior to its scheduled maturity with new debt? If yes, see instructions. 3031 Has debt been recalled before scheduled maturity without issuance of new debt? If yes, see instructions. 31

Purchased Services32 Have changes or new agreements occurred in patient care services furnished through contractual arrangements with suppliers of services? 32

If yes, see instructions.33 If line 32 is yes, were the requirements of Sec. 2135.2 applied pertaining to competitive bidding? 33

If no, see instructions.

Provider-Based Physicians34 Has debt been recalled before scheduled maturity without issuance of new debt? If yes, see instructions. 3435 If line 34 is yes, were there new agreements or amended existing agreements with the provider-based physicians during the cost 35

reporting period? If yes, see instructions.

1 2Home Office Costs Y/N Date

36 Are Home Office Cost claimed on the cost report? 3637 If line 36 is "Y", has a home office cost statement been prepared by the home office? If "Y" see instructions. 3738 If line 36 "Y", is the fiscal year end of the home office different from that of the provider? 38

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. 3940 If line 36 is "Y", does the provider render services to the home office? If "Y" see instructions. 40

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4004.2)

40-510 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX PROVIDER CCN: PERIOD WORKSHEET S-3,STATISTICAL DATA FROM 10/1/2010 PART I

14-0635 TO 9/30/2011

Worksheet A Total Total Employees Total

Line No. of Bed Days CAH Title Title All Interns & On Nonpaid Title Title AllComponent Number Beds Available Hours Title V XVIII XIX Patients Residents Payroll Workers Title V XVIII XIX Patients

1 2 3 4 5 6 7 8 9 10 11 12 13 14 151 Hospital Adults & Peds. (columns 5, 1

6, 7 and 8 exclude Swing Bed,Observation Bed and Hospice days) 30 360 131,760 34,400 14,009 113,950 1,989 680 5,820

2 HMO 1,000 31 23 HMO IPF 182 34 HMO IRF 197 45 Hospital Adults & Peds. Swing Bed SNF 156 156 56 Hospital Adults & Peds.Swing Bed NF 250 67 Total Adults and Peds. (exclude 7

observation beds) (see instructions) 360 131,760 34,556 14,009 114,356 8 Intensive Care Unit 31 15 5,490 812 386 3,144 89 Coronary Care Unit 32 15 5,490 791 186 3,245 9

10 Burn Intensive Care Unit 33 5 1,830 89 64 1,117 1011 Surgical Intensive Care Unit 1112 Other Special Care 1213 Nursery 43 387 3,000 1314 Total (see instructions) 395 144,570 - - 36,248 15,032 124,862 171.00 1,447.00 - 1,989 680 5,820 1415 CAH visits 1516 Subprovider - IPF 40 50 18,300 1,630 11,738 2.00 33.00 85 250 1617 Subprovider - IRF 41 45 16,470 2,939 750 10,103 2.00 30.00 96 240 1718 Subprovider - Other 1819 Skilled Nursing Facility 44 45 16,470 3,904 4,500 30.00 1920 Nursing Facility 2021 Other Long Term Care 2122 Home Health Agency 101 13,780 26,824 37.44 2223 ASC (Distinct Part) 2324 Hospice (Distinct Part) 116 15 5,490 1,169 300 2,023 0.50 12.00 2425 CMHC 99 30 15 80 13.00 25

25.10 CORF 99.10 75 18 367 25.126 RHC/FQHC (RHC) 88 3,200 6,905 0.50 3.10 26

26.25 RHC/FQHC (FQHC) 89 1,500 3,000 0.50 3.10 26.25 27 Total (sum of lines 13-25) 550 176.50 1608.64 2728 Observation Bed Days 650 2,700 2829 Ambulance Trips 20 2930 Employee discount days (see instruction) 100 3031 Employee discount days -IRF 23 3132 Labor & delvery days (see instructions) 65 135 3233 LTCH non-covered days 33


Rev. 2 40-511

Full Time Equivalents Discharges I/P Days / O/P Visits / Trips

4090 (Cont.) FORM CMS-2552-10 07-11HOSPITAL WAGE INDEX INFORMATION PROVIDER CCN: PERIOD: WORKSHEET S-3,

FROM 10/1/2010 PART II

14-0635 TO 9/30/2011

PART II - WAGE DATAWorksheet Reclass. Adjusted Paid Hours Average

A of Salaries Salaries Related Hourly WageLine Amount (from (col. 2 ± to Salaries (col. 4 ÷

Number Reported Wkst. A-6) col. 3) in col. 4 col. 5)1 2 3 4 5 6

SALARIES

1 Total salaries (see instructions) 22,506,820 22,506,820 650,000 34.63 1

2 Non-physician anesthetist Part A - 2

3 Non-physician anesthetist Part B 189,020 189,020 5,500 34.37 3

4 Physician-Part A 547,066 547,066 4,500 121.57 4

5 Physician-Part B 833,137 833,137 23,000 36.22 5

6 Non-physician-Part B 20,000 20,000 700 28.57 6

7 Interns & residents (in an approved program) 405,792 405,792 14,000 28.99 7

8 Home office personnel - 8

9 SNF 91,200 91,200 4,500 20.27 9

10 Excluded area salaries (see instructions) 3,267,295 21,979 3,289,274 145,500 22.61 10

OTHER WAGES & RELATED COSTS

11 Contract labor (see instructions) 350,000 350,000 7,000 50.00 11

12 Management and administrative services - 12

13 Contract labor: physician-Part A - 13

14 Home office salaries & wage-related costs - 14

15 Home office: physician Part A - 15

16 Teaching physician salaries (see instructions) - 16

WAGE-RELATED COSTS 17 Wage-related costs (core) Wkst S-3, Part IV line 24 3,000,000 3,000,000 17

18 Wage-related costs (other)Wkst S-3, Part IV line 25 622,514 622,514 18

19 Excluded areas 45,215 45,215 19

20 Non-physician anesthetist Part A - 20

21 Non-physician anesthetist Part B - 21

22 Physician Part A 24,707 24,707 22

23 Physician Part B - 23

24 Wage-related costs (RHC/FQHC) 7,000 7,000 24

25 Interns & residents (in an approved program) - 25

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.2 - 4005.3)

46-512 Rev. 2

12-10 FORM CMS-2552-10 4090 (Cont.)HOSPITAL WAGE INDEX INFORMATION PROVIDER CCN: PERIOD: WORKSHEET S-3,

FROM 10/1/2010 PART II & III

14-0635 TO 9/30/2011PART II - WAGE DATA

Worksheet Reclass. Adjusted Paid Hours Average

A of Salaries Salaries Related Hourly Wage

Line Amount (from (col. 2 ± to Salaries (col. 4 ÷

Number Reported Wkst. A-6) col. 3) in col. 4 col. 5)

1 2 3 4 5 6

OVERHEAD COSTS - DIRECT SALARIES

26 Employee Benefits 100,000 100,000 3,000 33.33 26

27 Administrative & General 544,536 28,863 573,399 17,000 33.73 27

28 Administrative & General under contract (see inst.) - 28

29 Maintenance & Repairs - 29

30 Operation of Plant 92,048 92,048 4,000 23.01 30

31 Laundry & Linen Service 342,419 342,419 11,000 31.13 31

32 Housekeeping 474,999 474,999 15,000 31.67 32

33 Housekeeping under contract (see instructions) 35,000 35,000 2,000 17.50 33

34 Dietary 669,663 (25,181) 644,482 22,000 29.29 34

35 Dietary under contract (see instructions) 10,000 10,000 750 13.33 35

36 Cafeteria 350,000 350,000 12,000 29.17 36

37 Maintenance of Personnel 25,354 25,354 1,200 21.13 37

38 Nursing Administration 628,966 628,966 21,000 29.95 38

39 Central Services and Supply 259,831 259,831 7,000 37.12 39

40 Pharmacy 149,103 149,103 5,000 29.82 40

41 Medical Records & Medical Records Library 157,706 157,706 4,500 35.05 41

42 Social Service 51,132 (2,170) 48,962 2,000 24.48 42

43 Other General Service - 43

PART III - HOSPITAL WAGE INDEX SUMMARY

1 Net salaries (see instructions) 20,556,805 - 20,556,805 605,050 33.98 1

2 Excluded area salaries (see instructions) 3,358,495 21,979 3,380,474 150,000 22.54 2

3 Subtotal salaries (line 1 minus line 2) 17,198,310 (21,979) 17,176,331 455,050 37.75 3

4 Subtotal other wages & related costs (see inst.) 350,000 350,000 7,000 50.00 4

5 Subtotal wage-related costs (see inst.) 3,647,221 - 3,647,221 - 21.23% 56 Total (sum of lines 3 thru 5) 21,195,531 (21,979) 21,173,552 462,050 45.83 67 Total overhead cost (see instructions 3,890,757 1,512 3,892,269 127,450 30.54 7

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.2 - 4005.3)

Rev. 2 40-513

4090 (Cont.) FORM CMS-2552-10 12-10HOSPITAL WAGE RELATED COSTS PROVIDER CCN: PERIOD: WORKSHEET S-3,

FROM 10/1/2010 PART IV

14-0635 TO 9/30/2011

PART IV - Wage Related Cost

Part A - Core List

AmountReported

RETIREMENT COST

1 401K Employer Contributions 241,541 1

2 Tax Sheltered Annuity (TSA) Employer Contribution 10,405 2

3 Qualified and Non-Qualified Pension Plan Cost 145,708 3

4 Prior Year Pension Service Cost 35,201 4

PLAN ADMINISTRATIVE COSTS (Paid to External Organization):

5 401K/TSA Plan Administration fees 10,000 5

6 Legal/Accounting/Management Fees-Pension Plan 5,784 6

7 Employee Managed Care Program Administration Fees 35,488 7

HEALTH AND INSURANCE COST

8 Health Insurance (Purchased or Self Funded) 524,125 8

9 Prescription Drug Plan 75,846 9

10 Dental, Hearing and Vision Plan 35,478 10

11 Life Insurance (If employee is owner or beneficiary) 125,478 11

12 Accident Insurance (If employee is owner or beneficiary) 25,484 12

13 Disability Insurance (If employee is owner or beneficiary) 114,578 13

14 Long-Term Care Insurance (If employee is owner or beneficiary) 54,875 14

15 Workers' Compensation Insurance 57,489 15

16 Retirement Health Care Cost (Only current year, not the extraordinary accrual required by FASB 106. Non cumulative portion) 395,784 16

TAXES

17 FICA-Employers Portion Only 457,125 1718 Medicare Taxes - Employers Portion Only 257,401 18

19 Unemployment Insurance 123,546 19

20 State or Federal Unemployment Taxes 125,478 20

OTHER

21 Executive Deferred Compensation 100,186 21

22 Day Care Cost and Allowances 40,000 22

23 Tuition Reimbursement 3,000 23

24 Total Wage Related cost (Sum of lines 1 -23) 3,000,000 24

Part B Other than Core Related Cost

25 Other Wage Related (Office Rental) 622,514 25


40-514 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)HOSPITAL CONTRACT LABOR AND BENEFIT COST PROVIDER CCN: PERIOD: WORKSHEET S-3,

FROM 10/1/2010 PART V14-0635 TO 9/30/2011

PART V - Contract Labor and Benefit Cost

Hospital and Hospital-Based Component Identification:Contract Benefit

Component Labor Cost0 1 2

1 Total facility's contract labor and benefit cost 405,681 59,280 12 Hospital 300,000 50,000 23 Subprovider- IPF 25,410 1,254 34 Subprovider- IRF 35,147 2,548 45 Subprovider- (Other) 56 Swing Beds-SNF 67 Swing Beds-NF 78 Hospital-Based SNF 89 Hospital-Based NF 9

10 Hospital-Based OLTC 1011 Hospital-Based HHA 45,124 5,478 1112 Separately Certified ASC 1213 Hospital-Based Hospice 1314 Hospital-Based Health Clinic RHC 1415 Hospital-Based Health Clinic FQHC 1516 Hospital-Based-CMHC 1617 Renal Dialysis 1718 Other 18


Rev. 2 40-515

4090 (Cont.) FORM CMS-2552-10 07-11HOSPITAL-BASED HOME HEALTH AGENCY PROVIDER CCN: PERIOD: WORKSHEET S-4STATISTICAL DATA 14-0635 FROM 10/1/2010

HHA CCN : TO 9/30/201114-7105

HOME HEALTH AGENCY STATISTICAL DATA County: Cook

Title Title Title DESCRIPTION V XVIII XIX Other Total

1 2 3 4 51 Home Health Aide Hours 5,364 350 5714 12 Unduplicated Census Count (see instructions) 350.00 200.00 550.00 2

HOME HEALTH AGENCY - NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)

Enter the number of hours inyour normal work week 40.0 Staff Contract Total

1 2 33 Administrator and Assistant Administrator(s) 1.00 1.00 34 Directors and Assistant Director(s) 2.00 2.00 45 Other Administrative Personnel 4.00 4.00 56 Direct Nursing Service 16.29 16.29 67 Nursing Supervisor 1.00 1.00 78 Physical Therapy Service 3.00 2.5 5.50 89 Physical Therapy Supervisor 0.75 0.75 9

10 Occupational Therapy Service 1.00 1.00 1011 Occupational Therapy Supervisor - 1112 Speech Pathology Service 0.50 0.50 1213 Speech Pathology Supervisor - 1314 Medical Social Service 0.85 0.85 1415 Medical Social Service Supervisor 0.05 0.05 1516 Home Health Aide 12.00 12.00 1617 Home Health Aide Supervisor 1.00 1.00 1718 Other (specify) - 18

HOME HEALTH AGENCY CBSA CODES1

19 Enter in column 1 the number of CBSAs where you provided services during the cost reporting period. 3 19

20 List those CBSA code(s) in column 1 serviced during this cost reporting period (line 20 contains the first code). 14060 20

16580 20.01

16974 20.02

PPS ACTIVITY DATA

Without With LUPA PEP only TotalOutliers Outliers Episodes Episodes (cols. 1-4)

1 2 3 4 521 Skilled Nursing Visits 4,740 304 488 548 6,080 2122 Skilled Nursing Visit Charges 240,536 15,428 24,764 27,808 308,536 2223 Physical Therapy Visits 2,696 172 276 312 3,456 2324 Physical Therapy Visit Charges 136,804 8,728 14,004 15,832 175,368 2425 Occupational Therapy Visits 316 20 32 36 404 2526 Occupational Therapy Visit Charges 16,032 1,016 1,624 1,828 20,500 2627 Speech Pathology Visits 148 8 16 16 188 2728 Speech Pathology Visit Charges 7,512 404 812 812 9,540 2829 Medical Social Service Visits 244 16 24 28 312 2930 Medical Social Service Visit Charges 12,380 812 1,216 1,420 15,828 3031 Home Health Aide Visits 2,604 168 268 300 3,340 3132 Home Health Aide Visit Charges 132136 8524 13600 15224 169,484 3233 Total visits (sum of lines 21, 23, 25, 27, 29, and 31) 10,748 688 1,104 1,240 13,780 3334 Other Charges - 3435 Total Charges (sum of lines 22, 24, 26, 28, 30, 32, and 34) 545400 34912 56020 62924 699,256 3536 Total Number of Episodes (standard/non outlier) 508 664 60 1,232 3637 Total Number of Outlier Episodes 36 4 40 3738 Total Non-Routine Medical Supply Charges 3734 239 384 431 4,788 38

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4006)

40-516 Rev. 2

Full Episodes

07-11 FORM CMS-2552-10 4090 (Cont.)HOSPITAL RENAL DIALYSIS DEPARTMENT PROVIDER CCN: PERIOD: WORKSHEET S-5STATISTICAL DATA 14-0635 FROM 10/1/2010

TO 9/30/2011RENAL DIALYSIS STATISTICS

Outpatient Training HomeHemo- CAPD Hemo- CAPD

DESCRIPTION Regular High Flux dialysis CCPD dialysis CCPD1 2 3 4 5 6

1 Number of patients in program at 1 end of cost reporting period 65 16 6 143

2 Number of times per week patient 2 receives dialysis 3.00 3.00 3.00 3.00

3 Average patient dialysis time including setup 6.20 38.00 6.00 34 CAPD exchanges per day 45 Number of days in year dialysis furnished 261 261 56 Number of stations 2 1 67 Treatment capacity per day per station 4 2 78 Utilization (see instructions) 65.37% 64.37% 89 Average times dialyzers re-used 2.00 1.00 9

10 Percentage of patients re-using dialyzers 40% 10

TRANSPLANT INFORMATION11 Number of patients on transplant list 10 1112 Number of patients transplanted during the cost reporting period 5 12

EPOETIN13 Net costs of Epoetin furnished to all maintenance dialysis patients by the provider. 1700 1314 Epoetin amount from Worksheet A for Home Dialysis program 1415 Number of EPO units furnished relating to the renal dialysis department 30 1516 Number of EPO units furnished relating to the home dialysis department 24 16

ARANESP17 Net costs of ARANESP furnished to all maintenance dialysis patients by the provider. 2800 1718 ARANESP amount from Worksheet A for Home Dialysis program 1819 Number of ARANESP units furnished relating to the renal dialysis department 10 1920 Number of ARANESP units furnished relating to the home dialysis department 15 20

PHYSICIAN PAYMENT METHOD (enter "X" if method(s) is applicable)21 MCP___X____ INITIAL METHOD__________ 21


Rev. 2 40-517

4090 (12-10) FORM CMS-2552-10 07-11HOSPITAL-BASED COMMUNITY MENTAL HEALTH CLINIC PROVIDER CCN: PERIOD: WORKSHEET S-6

PROVIDER STATISTICAL DATA 14-0635 FROM 10/1/2010

COMPONENT CNN: TO 9/30/2011

14-1410

COMMUNITY MENTAL HEALTH & OTHER OUTPATIENT REHABILITATION PROVIDER- NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)

Check [x] CMHC [ ] OOT

Applicable [ ] CORF [ ] OSP

Box [ ] OPT

Enter the number of hours in your normal workweek 37.5

Total

Staff Contract (col. 1 + col. 2)

1 2 3

1 Administrator and Assistant Administrator(s) - 1

2 Director(s) and Assistant Director(s) 1.00 1.00 2

3 Other Administrative Personnel - 3

4 Direct Nursing Service - 4

5 Nursing Supervisor 2.50 2.50 5

6 Physical Therapy Service - 6

7 Physical Therapy Supervisor - 7

8 Occupational Therapy Service 0.50 0.50 8

9 Occupational Therapy Supervisor 1.50 1.50 9

10 Speech Pathology Service - 10

11 Speech Pathology Supervisor - 11

12 Medical Social Service - 12

13 Medical Social Service Supervisor - 13

14 Respiratory Therapy Service - 14

15 Respiratory Therapy Supervisor - 15

16 Psychiatric/Psychological Service 3.00 3.00 16

17 Psychiatric/Psychological Service Supervisor 0.25 0.25 17

18 Other (specify) - 18


40-518 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)PROSPECTIVE PAYMENT FOR SNF PROVIDER CNN: PERIOD: WORKSHEET S-7

STATISTICAL DATA FROM 10/1/2010

14-0635 TO 9/30/2011

If this facility contains a hospital-based SNF, were all patients under managed care or was there no Medicare

1 utilization? Enter "Y" for yes in column 1 and do not complete the rest of this worksheet. N 1

Does this hospital have an agreement under either section 1883 or section 1913 for swing beds? Enter "Y" for

2 yes or "N" for no in column 1. If yes, enter the agreement date (mm/dd/yyyy) in column 2. Y 10/1/1983 2

SNF Swing Bed SNF TOTAL

GROUP Days Days (sum of col. 2 + 3)

1 2 3 4

3 RUX 20 1 21 3

4 RUL 20 12 32 4

5 RVX 10 10 5

6 RVL 5 5 6

7 RHX 4 4 7

8 RHL - - 8

9 RMX 21 21 9

10 RML 10 45 55 10

11 RLX 7 7 11

12 RUC 7 7 12

13 RUB 18 18 13

14 RUA 20 20 14

15 RVC 20 20 15

16 RVB 4 4 16

17 RVA 2 2 17

18 RHC 28 2 30 18

19 RHB 45 45 19

20 RHA 2 2 20

21 RMC 15 15 21

22 RMB 5 5 22

23 RMA 27 27 23

24 RLB 40 15 55 24

25 RLA 10 10 25

26 ES3 47 47 26

27 ES2 46 46 27

28 ES1 43 14 57 28

29 HE2 29 29 29

30 HE1 48 48 30

31 HD2 33 1 34 31

32 HD1 47 47 32

33 HC2 49 49 33

34 HC1 57 2 59 34

35 HB2 45 45 35

36 HB1 60 60 36

37 LE2 36 6 42 37

38 LE1 86 86 38

39 LD2 93 93 39

40 LD1 121 8 129 40

41 LC2 84 84 41

42 LC1 97 97 42

43 LB2 109 109 43

44 LB1 62 62 44

45 CE2 100 1 101 45

46 CE1 180 180 46

47 CD2 210 210 47

48 CD1 131 131 48

49 CC2 89 89 49

50 CC1 25 25 50

51 CB2 25 25 51

52 CB1 25 25 52

53 CA2 25 25 53

54 CA1 - 54


Rev. 2 40-5194090 (Cont.) FORM CMS-2552-10 07-11PROSPECTIVE PAYMENT FOR SNF PROVIDER CNN: PERIOD: WORKSHEET S-7 STATISTICAL DATA FROM 10/1/2010 (CONT.)

14-0635 TO 9/30/2011SNF Swing Bed SNF TOTAL

GROUP Days Days (sum of col. 2 + 3)1 2 3 4

55 SE3 165 7 172 5556 SE2 214 214 5657 SE1 180 180 5758 SSC 178 8 186 5859 SSB 201 201 5960 SSA 207 207 6061 IB2 206 206 6162 IB1 25 25 6263 IA1 23 23 6364 IA2 15 15 6465 BB2 12 12 6566 BB1 31 31 6667 BA2 8 8 6768 BA1 6 6 6869 PE2 5 5 6970 PE1 3 3 7071 PD2 8 8 7172 PD1 12 12 7273 PC2 14 14 7374 PC1 15 15 7475 PB2 12 12 7576 PB1 9 9 7677 PA2 7 7 7778 PA1 4 4 78

199 AAA 2 34 36 199200 TOTAL 3904 156 4060 200

CBSA at CBSA on/afterBeginning of October 1 of the

Cost Reporting Cost ReportingPeriod Period (if applicable)

SNF SERVICES 1 2 Enter in column 1 the SNF CBSA code, or 5 character non-CBSA code if a rural facility, in effect at the beginning of the cost

201 reporting period. Enter in column 2 the code in effect on or after October 1 of the cost reporting period (if applicable). 16974 201 A notice published in the Federal Register Volume 68, No. 149 August 4, 2003 provided for an increase in the RUG payments beginning 10/01/2003. Congress expected this increase to be used for direct patient care and related expenses. For lines 202 through 207: Enter in column 1 the amount of the expense for each category. Enter in column 2 the percentage of total expenses for each category to total SNF revenue from Worksheet G-2, Part I, line 7, column 3. In column 3, enter "Y" or "N" for no if the spending reflects increases associated with direct patient care and related expenses for each category. (see instructions)

Associated withDirect Patient Care

Expenses Percentage and Related Expenses?1 2 3

202 Staffing 91,200 40.43% Y 202203 Recruitment 7,500 3.32% Y 203204 Retention of employees 0.00% N 204205 Training 5,000 2.22% N 205206 Other (Performance Bonus) 6,000 2.66% N 206207 Total SNF revenue (Worksheet G-2, Part I, line 7, column 3) 225,571 207


40-520 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)PROVIDER-BASED RURAL HEALTH CLINIC/ PROVIDER CCN: PERIOD: WORKSHEET S-8

FEDERALLY QUALIFIED HEALTH CENTER 14-0635 FROM 10/1/2010

PROVIDER STATISTICAL DATA COMPONENT CNN: TO 9/30/2011

14-3400

Check [X] RHC

Applicable Box: [ ] FQHC

Clinic Address and Identification:

1 Street: 100 MAIN STREET 1

2 City: CHICAGO State: IL Zip Code: 60611 County: COOK 2

3 Designation (for FQHCs only) - Enter "R" for rural or "U" for urban 3

Source of Federal Funds: Grant Award Date

1 2

4 Community Health Center (Section 330(d), PHS Act) $27,000 1/01/2011 4

5 Migrant Health Center (Section 329(d), PHS Act) 5

6 Health Services for the Homeless (Section 340(d), PHS Act) 6

7 Appalachian Regional Commission 7

8 Look-Alikes 8

9 Other (specify) 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 10

other operations in column 2.(Enter in subscripts of line 12 the type of other operation(s) and the operating hours.) N

Facility hours of operations (1)

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Type Operation from to from to from to from to from to from to from to

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

11 Clinic 0700 1600 0700 1600 0700 1600 0700 1600 0700 2000 1100 1500 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? N 12

13 Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)? If yes, enter in column 2 the 13

number of providers included in this report. List the names of all providers and numbers below. N

14 Provider name: _______________________________________________ CCN number: ________________ 14

Y/N V XVIII XIX

1 2 3 4

15 Have you provided all or substantially all GME cost? Enter "Y" for yor "N" for no in column 1 15

If yes, enter in columns 2, 3 and 4 the number of program visits performed by Intern & Residents for titles V,

XVIII, and XIX, as applicable. (see instructions) N

Two columns


Rev. 2 40-521

4090 (Cont.) FORM CMS-2552-10 07-11HOSPICE IDENTIFICATION DATA PROVIDER CCN 14-0635 PERIOD: WORKSHEET S-9,

FROM 10/1/2010 PARTS I & IIHOSPICE NO.: 14-1590 TO 9/30/2011

PART I - ENROLLMENT DAYS

Title XVIIISkilled Title XIX TotalNursing Nursing All (sum of

Enrollment Days Title XVIII Title XIX Facility Facility Other cols. 1, 2 & 5)1 2 3 4 5 6

1 Continuous Home Care 20 20 40 1

2 Routine Home Care 260 220 480 2

3 Inpatient Respite Care 50 10 60 3

4 General Inpatient Care 40 40 4

5 Total Hospice Days 370 - - - 250 620 5

PART II - CENSUS DATATitle XVIII

Skilled Title XIX TotalNursing Nursing All (sum of

Title XVIII Title XIX Facility Facility Other cols. 1, 2 & 5)1 2 3 4 5 6

6 Number of Patients Receiving Hospice Care 10 6 16 67 Total Number of Unduplicated Continuous 7

Care Hours Billable to Medicare 9898 Average Length of Stay (line 5/line 6) 37.00 41.67 38.75 89 Unduplicated Census Count 8 6 14 9

NOTE: Parts I & II, columns 1 and 2 also include the days reported in columns 3 and 4 .

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4011)

40-522 Rev. 2

Unduplicated Days

07-11 FORM CMS-2552-10 4090 (Cont.)HOSPITAL UNCOMPENSATED AND INDIGENT PROVIDER CCN PERIOD: WORKSHEET S-10CARE DATA FROM 10/1/2010

14-0635 TO 9/30/2011

Uncompensated and indigent care cost computation 1

1 Cost to charge ratio (Worksheet C, Part I line 200 column 3 divided by line 200 column 8) 0.712609 1

Medicaid (see instructions for each line)

2 Net revenue from Medicaid 4,500,000 2

3 Did you receive DSH or supplemental payments from Medicaid? Y 3

4 If line 3 is yes, does line 2 include all DSH or supplemental payments from Medicaid? N 4

5 If line 4 is no, enter DSH or supplemental payments from Medicaid 250,000 5

6 Medicaid charges 5,000,000 6

7 Medicaid cost (line 1 times line 6) 3,563,045 7

8 Difference between net revenue and costs for Medicaid program (line 2 plus line 5 minus line 7) 1,186,955 8

State Children's Health Insurance Program (SCHIP) (see instructions for each line)

9 Net revenue from stand-alone SCHIP 75,000 9

10 Stand-alone SCHIP charges 67,000 10

11 Stand-alone SCHIP cost (line 1 times line 10) 47,745 11

12 Difference between net revenue and costs for stand-alone SCHIP (line 9 minus line 11) 27,255 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) 30,000 13

14 Charges for patients covered under state or local indigent care program (Not included in lines 6 or 10) 35,000 14

15 State or local indigent care program cost (line 1 times line 14) 24,941 15

16 Difference between net revenue and costs for state or local indigent care program (line 13 minus line 15) 5,059 16Uncompensated care (see instructions for each line)

17 Private grants, donations, or endowment income restricted to funding charity care 30,000 17

18 Government grants, appropriations or transfers for support of hospital operations 20,000 18

19 Total unreimbursed cost for Medicaid , SCHIP and state and local indigent care programs (sum of lines 8, 12 and 16) 1,219,269 19

Uninsured Insured Total

patients patients (col. 1 + col. 2)

1 2 3

20 Total initial obligation of patients approved for charity care (at full charges excluding

non-reimbursable cost centers) for the entire facility 3,000,000 750,000 3,750,000 20

21 Cost of initial obligation of patients approved for charity care (line 1 times line 20) 2,137,827 534,457 2,672,284 21

22 Partial payment by patients approved for charity care 250,000 150,000 400,000 22

23 Cost of charity care (line 21 minus line 22) 1,887,827 384,457 2,272,284 23

1

Does the amount in line 20, column 2 include charges for patient days beyond a length of stay limit imposed on patients covered24 by Medicaid or other indigent care program? Y 24

25 If line 24 is "yes," charges for patient days beyond an indigent care program's length of stay limit 100,000 25

26 Total bad debt expense for the entire hospital complex (see instructions) 200,000 26

27 Medicare bad debts for the entire hospital complex (see instructions) 27320 27

28 Non-Medicare and Non-Reimbursable bad debt expense (line 26 minus line 27) 172,680 28

29 Cost of non-Medicare bad debt expense (line 1 times line 28) 123,053 29

30 Cost of non-Medicare uncompensated care (line 23 column 3 plus line 29) 2,395,337 30

31 Total unreimbursed and uncompensated care cost (line 19 plus line 30) 3,614,606 31


Rev. 2 40-523

4090 (Cont.) FORM CMS-2552-10 07-11RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES PROVIDER CCN: PERIOD: WORKSHEET A

FROM 10/1/201014-0635 TO 9/30/2011

RECLASSIFIED NET EXPENSESCOST CENTER DESCRIPTIONS TOTAL RECLASSIFI- TRIAL BALANCE FOR ALLOCATION

(omit cents) SALARIES OTHER (col. 1 + col. 2) CATIONS (col. 3 ± col. 4) ADJUSTMENTS (col. 5 ± col. 6)1 2 3 4 5 6 7

GENERAL SERVICE COST CENTERS 1 00100 Capital Related Costs-Buildings and Fixtures 999,999 999,999 (176,864) 823,135 823,135 12 00200 Capital Related Costs-Movable Equipment 216,751 216,751 443,883 660,634 660,634 23 00300 Other Capital Related Costs 45,610 45,610 (45,610) - - 34 00400 Employee Benefits 100,000 650,000 750,000 750,000 750,000 45 00500 Administrative and General 544,536 34,522 579,058 32,775 611,833 (74,241) 537,592 56 00600 Maintenance and Repairs - - - 67 00700 Operation of Plant 92,048 1,134,640 1,226,688 1,226,688 (48,684) 1,178,004 78 00800 Laundry and Linen Service 342,419 169,775 512,194 512,194 512,194 89 00900 Housekeeping 474,999 382,999 857,998 857,998 857,998 9

10 01000 Dietary 669,663 1,312,103 1,981,766 (25,181) 1,956,585 (20,185) 1,936,400 1011 01100 Cafeteria 350,000 600,000 950,000 950,000 (511,400) 438,600 1112 01200 Maintenance of Personnel 25,354 12,000 37,354 37,354 (28,318) 9,036 1213 01300 Nursing Administration 628,966 116,777 745,743 745,743 745,743 1314 01400 Central Services and Supply 259,831 991,046 1,250,877 1,250,877 (28,560) 1,222,317 1415 01500 Pharmacy 149,103 978,543 1,127,646 1,127,646 (19,765) 1,107,881 1516 01600 Medical Records & Medical Records Library 157,706 98,324 256,030 256,030 (6,146) 249,884 1617 01700 Social Service 51,132 3,693 54,825 (2,170) 52,655 52,655 1718 Other General Service (specify) - - - 1819 01900 Nonphysician Anesthetists - 189,020 189,020 (189,020) - 1920 02000 Nursing School 656,199 570,105 1,226,304 1,226,304 (745,206) 481,098 2021 02100 Intern & Res. Service-Salary & Fringes (Approved) 405,792 34,943 440,735 440,735 440,735 2122 02200 Intern & Res. Other Program Costs (Approved) 120,000 33,398 153,398 153,398 153,398 2223 02300 Paramedical Ed. Program (specify) - 92,243 92,243 (11,132) 81,111 23

INPATIENT ROUTINE SERVICE COST CENTERS 30 03000 Adults and Pediatrics (General Routine Care) 4,873,668 1,067,482 5,941,150 5,941,150 5,941,150 3031 03100 Intensive Care Unit 308,163 101,978 410,141 410,141 410,141 3132 03200 Coronary Care Unit 406,653 159,852 566,505 566,505 566,505 3233 03300 Burn Intensive Care Unit 247,402 101,308 348,710 348,710 348,710 3334 03400 Surgical Intensive Care Unit - - - 3435 Other Special Care (specify) - - - 3540 04000 Subprovider - IPF 363,302 124,317 487,619 487,619 487,619 4041 04100 Subprovider - IRF 406,653 159,852 566,505 566,505 566,505 4142 04200 Subprovider (specify) - - - 4243 04300 Nursery 171,814 58,994 230,808 230,808 230,808 4344 04400 Skilled Nursing Facility 91,200 23,409 114,609 114,609 114,609 4445 04500 Nursing Facility - - - 4546 04600 Other Long Term Care - - - 46


40-524 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES PROVIDER CCN: PERIOD: WORKSHEET A

FROM 10/1/201014-0635 TO 9/30/2011

RECLASSIFIED NET EXPENSESCOST CENTER DESCRIPTIONS TOTAL RECLASSIFI- TRIAL BALANCE FOR ALLOCATION

(omit cents) SALARIES OTHER (col. 1 + col. 2) CATIONS (col. 3 ± col. 4) ADJUSTMENTS (col. 5 ± col. 6)1 2 3 4 5 6 7

ANCILLARY SERVICE COST CENTERS 50 05000 Operating Room 1,287,551 824,304 2,111,855 (80,000) 2,031,855 2,031,855 5051 05100 Recovery Room 286,074 33,423 319,497 319,497 319,497 5152 05200 Delivery Room and Labor Room 250,014 154,487 404,501 404,501 404,501 5253 05300 Anesthesiology 266,144 256,525 522,669 (109,020) 413,649 (115,480) 298,169 5354 05400 Radiology-Diagnostic 1,200,448 863,421 2,063,869 (92,243) 1,971,626 (399,398) 1,572,228 5455 05500 Radiology-Therapeutic 389,994 203,879 593,873 593,873 (64,980) 528,893 5556 05600 Radioisotope 54,950 163,068 218,018 218,018 218,018 5657 05700 Computed Tmography (CT) Scan 125,400 45,789 171,189 171,189 171,189 5758 05800 Magnetic Resonance Imaging (MRI) 67,450 36,541 103,991 103,991 103,991 5859 05900 Cardiac Catheterization 150,002 175,000 325,002 325,002 325,002 5960 06000 Laboratory 1,487,957 209,691 1,697,648 (29,331) 1,668,317 (300,960) 1,367,357 60

60.01 06001 Blood Lab 45,000 12,000 57,000 57,000 57,000 60.01 61 06100 PBP Clinical Laboratory Services-Program Only 70,682 70,682 70,682 70,682 6162 06200 Whole Blood & Packed Red Blood Cells 72,325 74,959 147,284 147,284 147,284 6263 06300 Blood Storing, Processing, & Trans. - 29,331 29,331 29,331 6364 06400 Intravenous Therapy 48,897 53,477 102,374 102,374 102,374 6465 06500 Respiratory Therapy 506,334 104,549 610,883 610,883 610,883 6566 06600 Physical Therapy 233,117 6,115 239,232 (9,903) 229,329 229,329 6667 06700 Occupational Therapy 76,000 34,551 110,551 110,551 110,551 6768 06800 Speech Pathology 65,000 25,777 90,777 90,777 90,777 6869 06900 Electro cardiology 106,042 43,099 149,141 149,141 149,141 6970 07000 Electroencephalography 116,022 42,139 158,161 158,161 158,161 7071 07100 Medical Supplies Charged to Patients - - - 7172 07200 Implantable Devices Charged to Patients - - - 7273 07300 Drugs Charged to Patients - - - 7374 07400 Renal Dialysis 424,139 670,579 1,094,718 16,412 1,111,130 1,111,130 7475 07500 ASC (Non-Distinct Part) 148,545 52,734 201,279 201,279 201,279 7576 Other Ancillary (specify) - - - 76

OUTPATIENT SERVICE COST CENTERS 88 08800 Rural Health Clinic (RHC) 279,936 141,382 421,318 421,318 421,318 8889 08900 Federally Qualified Health Center (FQHC) 88,500 17,690 106,190 106,190 106,190 8990 09000 Clinic 238,461 61,538 299,999 299,999 299,999 9091 09100 Emergency 754,774 459,848 1,214,622 1,214,622 1,214,622 9192 09200 Observation Beds 9293 Other Outpatient Service (specify) - - - 93


Rev. 2 40-525

07-11 FORM CMS-2552-10 4090 (Cont.)RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES PROVIDER CCN: PERIOD: WORKSHEET A

FROM 10/1/2010

14-0635 TO 9/30/2011

RECLASSIFIED NET EXPENSES

COST CENTER DESCRIPTIONS TOTAL RECLASSIFI- TRIAL BALANCE FOR ALLOCATION

(omit cents) SALARIES OTHER (col. 1 + col. 2) CATIONS (col. 3 ± col. 4) ADJUSTMENTS (col. 5 ± col. 6)

1 2 3 4 5 6 7OTHER REIMBURSABLE COST CENTERS

94 09400 Home Program Dialysis - - - 9495 09500 Ambulance Services 50,000 50,000 50,000 50,000 9596 09600 Durable Medical Equipment-Rented 47,000 47,000 47,000 47,000 9697 09700 Durable Medical Equipment-Sold 39,000 39,000 39,000 39,000 9799 09900 Outpatient Rehabilitation Provider (CMHC) 235,465 174,854 410,319 410,319 410,319 99

99.10 09910 Outpatient Rehabilitation Provider (CORF) 216,629 74,273 290,902 290,902 290,902 99.10

100 10000 Intern-Resident Service (not appvd. tchng. prgm.) 816,546 816,546 816,546 816,546 100

101 10100 Home Health Agency 794,256 249,674 1,043,930 20842 1,064,772 1,064,772 101

SPECIAL PURPOSE COST CENTERS

105 10500 Kidney Acquisition 74026 196947 270,973 270,973 270,973 105

106 10600 Heart Acquisition - - - 106

107 10700 Liver Acquisition 65,148 135,478 200,626 200,626 200,626 107

108 10800 Lung Acquisition - - - 108

109 10900 Pancreas Acquisition - - - 109

110 11000 Intestinal Acquisition - - - 110

111 11100 Islet Acquisition - - - 111112 Other Organ Acquisition (specify) - - - 112113 11300 Interest Expense 225321 225,321 -225321 - - 113114 11400 Utilization Review-SNF 48224 5110 53,334 -28863 24,471 -24471 - 114115 11500 Ambulatory Surgical Center (Distinct Part) - - - 115116 11600 Hospice 81,937 77,190 159,127 159,127 159,127 116117 Other Special Purpose (specify) - - - 117118 SUBTOTALS (sum of lines 1-117) 22,181,364 17,111,060 39,292,424 - 39,292,424 (2,587,946) 36,704,478 118

NONREIMBURSABLE COST CENTERS 190 19000 Gift, Flower, Coffee Shop, & Canteen 200,000 132,247 332,247 332,247 332,247 190191 19100 Research 125,456 78,950 204,406 204,406 204,406 191192 19200 Physicians' Private Offices 37,136 37,136 37,136 37,136 192193 19300 Nonpaid Workers - - - 193194 Other Nonreimbursable (specify) - - - 194200 TOTAL (sum of lines 118-199) 22,506,820 17,359,393 39,866,213 - 39,866,213 (2,587,946) 37,278,267 200


40-526 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)COMPUTATION OF RATIO OF COSTS TO CHARGES PROVIDER CCN: PERIOD: WORKSHEET C

FROM 10/1/2010 PART I

14-0635 TO 9/30/2011

Total Cost Charges

(from Wkst. Therapy RCE Total TEFRA PPS

COST CENTER DESCRIPTIONS B, Part I, Limit Total Dis- Total (col. 6 Cost or Inpatient Inpatient

col. 24) Adj. Costs allowance Costs Inpatient Outpatient + col. 7) Other Ratio Ratio Ratio

1 2 3 4 5 6 7 8 9 10 11INPATIENT ROUTINE SERVICE COST CENTERS

30 Adults and Pediatrics (General Routine Care) 10,835,697 10,835,697 10,835,697 17,470,396 17,470,396 3031 Intensive Care Unit 583,552 583,552 583,552 946,850 946,850 3132 Coronary Care Unit 772,423 772,423 772,423 629,821 629,821 3233 Burn Intensive Care Unit 491,062 491,062 491,062 409,384 409,384 3334 Surgical Intensive Care Unit - - - - 3436 Other Special Care (specify) - - - - 3640 Subprovider IPF 652,500 652,500 652,500 759,228 759,228 4041 Subprovider IRF 792,011 792,011 792,011 350,000 350,000 4142 Subprovider (Specify) - - - - 4243 Nursery 328,692 328,692 328,692 - 4344 Skilled Nursing Facility 324,677 324,677 324,677 897,609 897,609 4445 Nursing Facility - - - - 4546 Other Long Term Care - - - - 46

ANCILLARY SERVICE COST CENTERS50 Operating Room 2,437,138 2,437,138 2,437,138 2,875,965 491,718 3,367,683 0.723684 0.723684 0.723684 5051 Recovery Room 403,851 403,851 403,851 570,420 570,420 0.707989 0.707989 0.707989 5152 Labor Room and Delivery Room 531,674 531,674 531,674 523,827 523,827 1.014980 1.014980 1.014980 5253 Anesthesiology 668,964 668,964 3,480 672,444 758,459 251,089 1,009,548 0.662637 0.662637 0.666084 5354 Radiology-Diagnostic 1,866,822 1,866,822 17,874 1,884,696 875,944 1,166,705 2,042,649 0.913922 0.913922 0.922672 5455 Radiology-Therapeutic 592,784 592,784 592,784 857,456 117,734 975,190 0.607865 0.607865 0.607865 5556 Radioisotope 251,514 251,514 251,514 285,471 113,846 399,317 0.629860 0.629860 0.629860 5657 Computed Tomography (CT) Scan 307,582 307,582 307,582 302,500 125,000 427,500 0.719490 0.719490 0.719490 5758 Magnetic Resonance Imaging (MRI) 176,633 176,633 176,633 185,241 16,058 201,299 0.877466 0.877466 0.877466 5859 Cardiac Catheterization 375,683 375,683 375,683 345,879 50,321 396,200 0.948216 0.948216 0.948216 5960 Laboratory 1,563,471 1,563,471 1,563,471 1,658,749 956,624 2,615,373 0.597800 0.597800 0.597800 60

60.01 Blood Lab 77,445 77,445 77,445 60,000 30,000 90,000 0.860500 0.860500 0.860500 61 PBP Clinical Laboratory Services-Prgm. Only 70,682 70,682 70,682 65,789 28,416 94,205 0.750300 0.750300 0.750300 6162 Whole Blood & Packed Red Blood Cells 164,606 164,606 164,606 176,247 59,373 235,620 0.698608 0.698608 0.698608 6263 Blood Storing, Processing, & Trans. 31,829 31,829 31,829 44,621 44,621 0.713319 0.713319 0.713319 6364 Intravenous Therapy 110,003 110,003 110,003 125,789 12,507 138,296 0.795417 0.795417 0.795417 6465 Respiratory Therapy 703,162 703,162 703,162 1,400,000 24,851 1,424,851 0.493499 0.493499 0.493499 6566 Physical Therapy 307,121 307,121 307,121 257,845 233,805 491,650 0.624674 0.624674 0.624674 6667 Occupational Therapy 190,188 190,188 190,188 108,683 108,683 1.749933 1.749933 1.749933 6768 Speech Pathology 119,079 119,079 119,079 140,000 140,000 0.850564 0.850564 0.850564 68

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4023)

Rev. 2 40-563

Costs

4090 (Cont.) FORM CMS-2552-10 07-11COMPUTATION OF RATIO OF COSTS TO CHARGES PROVIDER CCN: PERIOD: WORKSHEET C

FROM 10/1/2010 PART I (CONT.)14-0635 TO 9/30/2011

Total Cost Charges(from Wkst. Therapy RCE Total TEFRA PPS

COST CENTER DESCRIPTIONS B, Part I, Limit Total Dis- Total (col. 6 Cost or Inpatient Inpatientcol. 24) Adj. Costs allowance Costs Inpatient Outpatient + col. 7) Other Ratio Ratio Ratio

1 2 3 4 5 6 7 8 9 10 1169 Electrocardiology 165076 165,076 165076 150796 28729 179,525 0.919515 0.919515 0.919515 6970 Electroencephalography 177,155 177,155 177,155 204478 5949 210,427 0.841883 0.841883 0.841883 7071 Medical Supplies Charged to Patients 660,345 660,345 660,345 800000 700000 1,500,000 0.440230 0.440230 0.440230 7172 Implantable Devices Charged to Patients 531,605 531,605 531,605 454789 404773 859,562 0.618460 0.618460 0.618460 7273 Drugs Charged to Patients 782,464 782,464 782,464 1000125 515014 1,515,139 0.516431 0.516431 0.516431 7374 Renal Dialysis 1,271,435 1,271,435 1,271,435 568,254 549,067 1,117,321 1.137932 1.137932 1.137932 7475 ASC (Non-Distinct Part) 297,889 297,889 297,889 35,000 440,000 475,000 0.627135 0.627135 0.627135 7576 Other Ancillary (specify) - - - - 76

OUTPATIENT SERVICE COST CENTERS88 Rural Health Clinic (RHC) 688,473 688,473 688,473 1,930,057 1,930,057 8889 Federally Qualified Health Center (FQHC) 154,618 154,618 154,618 12,578 209,422 222,000 8990 Clinic 427,581 427,581 427,581 52,412 397,588 450,000 0.950180 0.950180 0.950180 9091 Emergency 1,280,532 1,280,532 1,280,532 120,000 976,586 1,096,586 1.167744 1.167744 1.167744 9192 Observation Beds (see instructions) 250,020 250,020 250,020 - 300,000 300,000 0.833400 0.833400 0.833400 9293 Other Outpatient Service (specify) - - - - 93

OTHER REIMBURSABLE COST CENTERS 094 Home Program Dialysis - - - - 9495 Ambulance Services 52,169 52,169 52,169 39,557 24,948 64,505 0.808759 0.808759 0.808759 9596 Durable Medical Equipment-Rented 47,820 47,820 47,820 75,000 75,000 0.637600 0.637600 0.637600 9697 Durable Medical Equipment-Sold 39,680 39,680 39,680 60,000 60,000 0.661333 0.661333 0.661333 9799 Outpatient Rehabilitation Provider (CMHC) 450,526 450,526 450,526 254,876 254,876 99

99.10 Outpatient Rehabilitation Provider (CORF) 338,775 338,775 338,775 829,993 829,993 ####100 Intern-Resident Service (not appvd. tchng. prgm.) 831,944 831,944 831944 - 100101 Home Health Agency 1,146,041 1,146,041 1,630,625 1,630,625 101

SPECIAL PURPOSE COST CENTERS105 Kidney Acquisition 324,224 324,224 254,875 254,875 105106 Heart Acquisition - - - 106107 Liver Acquisition 300,907 300,907 259,874 259,874 107108 Lung Acquisition - - - 108109 Pancreas Acquisition - - - 109110 Intestinal Acquisition - - - 110111 Islet Acquisition - - - 111112 Other Organ Acquisition (specify) - - - 112115 Ambulatory Surgical Center (Distinct Part) - - 115116 Hospice 231655 231,655 432,000 390,268 822,268 116117 Other Special Purpose (specify) - 117200 Subtotal (see instructions) 36,181,779 - 36,181,779 21,354 34,200,306 36,886,373 13,887,275 50,773,648 200201 Less Observation Beds 250,020 250,020 250,020 201202 Total (see instructions) 35,931,759 35,931,759 33,950,286 36,886,373 13,887,275 50,773,648 202


40-563 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)APPORTIONMENT OF INPATIENT ROUTINE PROVIDER CCN: PERIOD: WORKSHEET D,

SERVICE CAPITAL COSTS FROM 10/1/2010 PART I

14-0635 TO 9/30/2011

Check [ ] Title V [X] PPS

applicable [X] Title XVIII, Part A [ ] TEFRA

boxes [ ] Title XIX

Reduced Inpatient

Capital Capital Program

Related Cost Related Per Capital

(from Wkst. Swing Cost Total Diem Inpatient Cost

B, Part II, Bed (col. 1 - Patient (col. 3 / Program (col. 5

Cost Center Description col. 26) Adjustment col. 2) Days col. 4) days x col. 6)

1 2 3 4 5 6 7

(A) INPATIENT ROUTINE

SERVICE COST CENTERS

30 Adults & Pediatrics 30

(General Routine Care) 602,785 1,907 600,878 116,650 5.15 34,400 177,160

31 Intensive Care Unit 10,029 10,029 3,144 3.19 812 2,590 31

32 Coronary Care Unit 24,018 24,018 3,245 7.40 791 5,853 32

33 Burn Intensive Care Unit 6,456 6,456 1,117 5.78 89 514 33

34 Surgical Intensive Care Unit - 34

35 Other Special Care Unit (specify) - 35

40 Subprovider IPF 38,461 38,461 11,738 3.28 1,630 5,346 40

41 Subprovider IRF 16,061 16,061 10,103 1.59 2,939 4,673 41

42 Subprovider (Other) - 42

43 Nursery 10,168 10,168 3,000 3.39 - 43

44 Skilled Nursing Facility 24,958 24,958 4,500 5.55 3,904 21,667 44

45 Nursing Facility 45

200 Total (lines 30-199) 732,936 731,029 153,497 44,565 217,803 200

(A) Worksheet A line numbers

NOTE IF PPS

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4024 - 4024.1)

Rev. 2 40-567

4090 (Cont.) FORM CMS-2552-10 07-11APPORTIONMENT OF INPATIENT ANCILLARY PROVIDER CCN: 14-0635 PERIOD: WORKSHEET D,SERVICE CAPITAL COSTS FROM 10/1/2010 PART II

COMPONENT NO.:____________ TO 9/30/2011Check [ ] Title V [x] Hospital [ ] Subprovider (Othe [x] PPSapplicable [x] Title XVIII, Part A [ ] IPF [ ] TEFRAboxes [ ] Title XIX [ ] IRF

CapitalRelated Cost Ratio of Cost Capital(from Wkst. Total Charges to Charges Inpatient Costs

Cost Center Description B, Part II, (from Wkst. C, (col .1 ÷ Program (col. 3 x col. 26) Part I, col. 8) col. 2) Charges col. 4)

1 2 3 4 5 (A) ANCILLARY SERVICE COST CENTERS

50 Operating Room 95,836 3,367,683 0.028458 716,479 20,390 5051 Recovery Room 19,759 570,420 0.034639 77,565 2,687 5152 Delivery Room and Labor Room 29,455 523,827 0.056230 - - 5253 Anesthesiology 17,595 1,009,548 0.017429 157,599 2,747 5354 Radiology-Diagnostic 55,929 2,042,649 0.027381 332,735 9,111 5455 Radiology-Therapeutic 8,731 975,190 0.008953 190,143 1,702 5556 Radioisotope 7,974 399,317 0.019969 125,610 2,508 5657 Computed Tomography (CT) Scan 56,139 427,500 0.131319 25,125 3,299 5758 Magnetic Resonance Imaging (MRI) 30,699 201,299 0.152504 30,145 4,597 5859 Cardiac Catheterization 16,945 396,200 0.042769 25,478 1,090 6060 Laboratory 41,776 2,615,373 0.015973 660,777 10,555 60

#### Blood Lab 9,202 90,000 0.102244 12,547 1,283 60.01 61 PBP Clinical Laboratory Services-Prgm. Only 6162 Whole Blood & Packed Red Blood Cells 6,035 235,620 0.025613 50,000 1,281 6263 Blood Storing, Processing, & Transfusing 597 44,621 0.013379 13,833 185 6364 Intravenous Therapy 1,238 138,296 0.008952 50,391 451 6465 Respiratory Therapy 19,321 1,424,851 0.013560 461,432 6,257 6566 Physical Therapy 31,178 491,650 0.063415 138,455 8,780 6667 Occupational Therapy 32,692 108,683 0.300801 16,414 4,937 6768 Speech Pathology 8,387 140,000 0.059907 25,000 1,498 6869 Electrocardiology 2,693 179,525 0.015001 29,520 443 6970 Electroencephalography 3,402 210,427 0.016167 29,889 483 7071 Medical Supplies Charged to Patients 22,756 1,500,000 0.015171 550,000 8,344 7172 Implantable Devices Charged to Patients 18,321 859,562 0.021314 414,487 8,834 7273 Drugs Charged to Patients 7,184 1,515,139 0.004741 592,970 2,811 7374 Renal Dialysis 37,516 1,117,321 0.033577 10,128 340 7475 ASC (Non-Distinct Part) 13,626 475,000 0.028686 - - 7576 Other Ancillary (specify) - - - - 7688 Rural Health Clinic (RHC) 57,318 1,930,057 0.029698 - - 8889 Federally Qualified Health Center (FQHC) 9,325 222,000 0.042005 - - 8990 Clinic 21,077 450,000 0.046838 11,857 555 9091 Emergency 7,319 1,096,586 0.006674 53,098 354 9192 Observation Beds 13,953 300,000 0.046510 - - 9293 Other Outpatient Service (specify) - - - - 93

OTHER REIMBURSABLE COST CENTERS94 Home Program Dialysis - - - - 9495 Ambulance Services 9596 Durable Medical Equipment-Rented 106 75,000 0.001413 - - 9697 Durable Medical Equipment-Sold 88 60,000 0.001467 - - 9798 Other Reimbursable (specify) - - 98

200 Total (sum of lines 50 through 199) 704,172 25,193,344 4,801,677 105,522 200



40-568 Rev. 2

DRAFT FORM CMS-2552-10 4090 (Cont.)APPORTIONMENT OF INPATIENT ROUTINE PROVIDER CCN: PERIOD: WORKSHEET D,SERVICE OTHER PASS THROUGH COSTS FROM 10/1/2010 PART III

14-0635 TO 9/30/2011Check [ ] Title V [x] PPSapplicable [x] Title XVIII, Part A [ ] TEFRAboxes [ ] Title XIX

All Swing-Bed Inpatient Other Adjustment Total Costs Per Program

Medical Amount (sum of cols. Total Diem Inpatient Pass thruNursing Allied Health Education (see 1 through 3, Patient (col. 5 ÷ Program Cost

Cost Center Description School Cost Cost instructions) minus col. 4) Days col. 6) Days (col. 7 x col. 8)1 2 3 4 5 6 7 8 9

(A) INPATIENT ROUTINE SERVICE COST CENTERS

30 Adults & Pediatrics 30 (General Routine Care) 289,362 915 288,447 116,650 2.47 34,400 84,968

31 Intensive Care Unit 21,635 21,635 3,144 6.88 812 5,587 31

32 Coronary Care Unit 21,635 21,635 3,245 6.67 791 5,276 32

33 Burn Intensive Care Unit 16,226 16,226 1,117 14.53 89 1,293 33

34 Surgical Intensive Care Unit - - 34

35 Other Special Care Unit (specify) - - 35

40 Subprovider IPF 1,623 1,623 11,738 0.14 1,630 228 40

41 Subprovider IRF 16,226 16,226 10,103 1.61 2,939 4,732 41

42 Subprovider (Other) - - 42

43 Nursery 10,817 10,817 3,000 3.61 - - 43

44 Skilled Nursing Facility 2704 2,704 4500 0.60 3904 2,342 44

45 Nursing Facility 45

200 Total (sum of lines 30-199) 380,228 - - 379,313 153,497 44,565 104,426 200



Rev. 2 40-569

4090 (Cont.) FORM CMS-2552-10 07-11APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY PROVIDER CC14-0635 PERIOD: WORKSHEET D,SERVICE OTHER PASS THROUGH COSTS FROM 10/1/2010 PART IV

COMPONENT NO.:____________ TO 9/30/2011Check [ ] Title V [x] Hospital [ ] Subprovider (Other) [ ] ICF/MR [x] PPSapplicable [x] Title XVIII, Part A [ ] IPF [ ] SNF [ ] TEFRAboxes [ ] Title XIX [ ] IRF [ ] NF

All TotalNon Other Outpatient

Physician Medical Total cost CostCost Center Description Anesthetist Nursing Allied Education (sum of col. 1 (sum of col. 2,

Cost School Health Cost thru col. 4) 3 and 4)1 2 3 4 5 6

(A) ANCILLARY SERVICE COST CENTERS50 Operating Room 43,269 - 43,269 43,269 5051 Recovery Room 5,409 - 5,409 5,409 5152 Delivery Room and Labor Room 16,226 - 16,226 16,226 5253 Anesthesiology - - - - 5354 Radiology-Diagnostic - 73,291 73,291 73,291 5455 Radiology-Therapeutic - 7,461 7,461 7,461 5556 Radioisotope - 7,022 7,022 7,022 5657 Computed Tomography (CT) Scan - - - - 5758 Magnetic Resonance Imaging (MRI) - - - - 5859 Cardiac Catheterization - - - - 5960 Laboratory - - - - 60

60.01 Blood Lab - - - - 61 PBP Clinical Laboratory Services-Prgm. Only 6162 Whole Blood & Packed Red Blood Cells - - - - 6263 Blood Storing, Processing, & Tranfusing - - - - 6364 Intravenous Therapy - - - - 6465 Respiratory Therapy - - - - 6566 Physical Therapy - - - - 6667 Occupational Therapy 5,409 - 5,409 5,409 6768 Speech Pathology 3,245 - 3,245 3,245 6869 Electrocardiology - - - - 6970 Electroencephalography - - - - 7071 Medical Supplies Charged To Patients - - - - 7172 Implantable Devices Charged to Patients - - - - 7273 Drugs Charged to Patients - - - - 7374 Renal Dialysis - - - - 7475 ASC (Non-Distinct Part) - - - - 75

76 Other Ancillary (specify) - - - - 76

OUTPATIENT SERVICE COST CENTERS

88 Rural Health Clinic (RHC) 40,565 - 40,565 40,565 88

89 Federally Qualified Health Center (FQHC) 2,704 - 2,704 2,704 89

90 Clinic 18,930 - 18,930 18,930 90

91 Emergency 2,704 - 2,704 2,704 91

92 Observation Beds 6,698 - - 6,698 6,698 92

93 Other Outpatient Service (specify) - - - - 93

OTHER REIMBURSABLE COST CENTERS

94 Home Program Dialysis - - 94

95 Ambulance Services 95

96 Durable Medical Equipment-Rented - - 96

97 Durable Medical Equipment-Sold - - 97

98 Other Reimbursable (specify) - - 98

200 Total (sum of lines 50 through 199) - 145,159 87,774 - 232,933 232,933 200



40-570 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY PROVIDER CC14-0635 PERIOD: WORKSHEET D,

SERVICE OTHER PASS THROUGH COSTS FROM 10/1/2010 PART IV (Cont.)

COMPONENT NO.:____________ TO 9/30/2011

Check [ ] Title V [x] Hospital [ ] Subprovider (Other) [ ] ICF/MR [x] PPS

applicable [x] Title XVIII, Part A [ ] IPF [ ] SNF [ ] TEFRA

boxes [ ] Title XIX [ ] IRF [ ] NF

Inpatient Outpatient

Outpatient Program Program

Total Ratio Ratio Pass Pass

Charges of Cost of Cost Inpatient Through Outpatient Through

Cost Center Description (from Wkst. C, to Charges to Charges Program Costs Program CostsPart I, col. 8) (col. 5 ÷ col. 7) (col. 6 ÷ col. 7) Charges (col. 8 x col. 10 Charges (col. 9 x col. 12)

7 8 9 10 11 12 13

(A) ANCILLARY SERVICE COST CENTERS

50 Operating Room 3,367,683 0.012848 0.012848 716,479 9,205 11,463 147 50

51 Recovery Room 570,420 0.009482 0.009482 77,565 735 989 9 51

52 Delivery Room and Labor Room 523,827 0.030976 0.030976 - - - - 52

53 Anesthesiology 1,009,548 - - 157,599 - 46,401 - 53

54 Radiology-Diagnostic 2,042,649 0.035880 0.035880 332,735 11,939 38,208 1,371 54

55 Radiology-Therapeutic 975,190 0.007651 0.007651 190,143 1,455 13,277 102 55

56 Radioisotope 399,317 0.017585 0.017585 125,610 2,209 1,548 27 56

57 Computed Tmography (CT) Scan 427,500 - - 25,125 - 1,254 - 57

58 Magnetic Resonance Imaging (MRI) 201,299 - - 30,145 - 1,254 - 58

59 Cardiac Catheterization 396,200 - - 25,478 - 13,103 - 59

60 Laboratory 2,615,373 - - 660,777 - 5,063 - 60

60.01 Blood Lab 90,000 - - 12,547 - - -

61 PBP Clinical Laboratory Services-Prgm. Only 61

62 Whole Blood & Packed Red Blood Cells 235,620 - - 50,000 - - - 62

63 Blood Storing, Processing, & Tranfusing 44,621 - - 13,833 - - - 6364 Intravenous Therapy 138,296 - - 50,391 - - - 6465 Respiratory Therapy 1,424,851 - - 461,432 - 2,179 - 6566 Physical Therapy 491,650 - - 138,455 - - - 6667 Occupational Therapy 108,683 0.049769 0.049769 16,414 817 - - 6768 Speech Pathology 140,000 0.023179 0.023179 25,000 579 - - 6869 Electrocardiology 179,525 - - 29,520 - 6,176 - 6970 Electroencephalography 210,427 - - 29,889 - 5,014 - 7071 Medical Supplies Charged To Patients 1,500,000 - - 550,000 - 16,121 - 7172 Implantable Devices Charged to Patients 859,562 - - 414,487 - 5,000 - 7273 Drugs Charged to Patients 1,515,139 - - 592,970 - 11,907 - 7374 Renal Dialysis 1,117,321 - - 10,128 - - - 7475 ASC (Non-Distinct Part) 475,000 - - - - - - 7576 Other Ancillary (specify) - - - - - 76

OUTPATIENT SERVICE COST CENTERS88 Rural Health Clinic (RHC) 1,930,057 0.021018 0.021018 - - - - 8889 Federally Qualified Health Center (FQHC) 222,000 0.012180 0.012180 - - - - 8990 Clinic 450,000 0.042067 0.042067 11,857 499 5,611 236 9091 Emergency 1,096,586 0.002466 0.002466 53,098 131 40,262 99 9192 Observation Beds 300,000 0.022327 0.022327 - - 73,000 1,630 9293 Other Outpatient Service (specify) - - - - - 93

OTHER REIMBURSABLE COST CENTERS94 Home Program Dialysis - - - - - 9495 Ambulance Services 9596 Durable Medical Equipment-Rented 75,000 - - - - 987 - 96

97 Durable Medical Equipment-Sold 60,000 - - - - 1,362 - 97

98 Other Reimbursable (specify) - - - - 98200 Total (sum of lines 50 through 199) 25,193,344 4,801,677 27,569 300,179 3,621 200



Rev. 2 40-571

4090 (Cont.) FORM CMS-2552-10 07-11APPORTIONMENT OF MEDICAL, OTHER PROVIDER CCN: PERIOD: WORKSHEET D,HEALTH SERVICES AND VACCINE COST 14-0635 FROM 10/1/2010 PARTS V

COMPONENT CCN.: TO 9/30/2011__________________

Check [ ] Title V - O/P [x] Hospital [ ] Subprovider (Other) [ ] Swing Bed SNFApplicable [x] Title XVIII, Part B [ ] IPF [ ] SNF [ ] Swing Bed NFBoxes [ ] Title XIX - O/P [ ] IRF [ ] NF [ ] ICF/MRPART V - APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS

PROGRAM CHARGES PROGRAM COSTCost to Cost Cost Cost Cost Charge Services Services Not Services Services Not

Cost Center Description Ratio From PPS Subject To Subject To PPS Subject To Subject To Worksheet C, Services Ded. & Coin. Ded. & Coin. Services Ded. & Coin. Ded. & Coin.Part I, col. 9 (see inst.) (see inst.) (see inst.) (see inst.) (see inst.) (see inst.)

1 2 3 4 5 6 7(A) ANCILLARY SERVICE COST CENTERS

50 Operating Room 0.723684 11,463 8,296 - - 5051 Recovery Room 0.707989 989 700 - - 5152 Delivery & Labor Room 1.014980 - - - 5253 Anesthesiology 0.662637 46,401 30,747 - - 5354 Radiology-Diagnostic 0.913922 38,208 34,919 - - 5455 Radiology-Therapeutic 0.607865 13,277 8,071 - - 5556 Radioisotope 0.629860 1,548 975 - - 5657 Computed Tomography (CT) Scan 0.719490 1,254 902 - - 5758 Magnetic Resonance Imaging (MRI) 0.877466 1,254 1,100 - - 5859 Cardiac Catheterization 0.948216 13,103 12,424 - - 5960 Laboratory 0.597800 5,063 3,027 - - 60

60.01 Blood Lab 0.860500 - - - ####61 PBP Clinic Laboratory Services-Prgm. Only 0.750300 - 6162 Whole Blood & Packed Red Blood Cells 0.698608 - - - 6263 Blood Storing, Processing, & Transfusing 0.713319 - - - 6364 Intravenous Therapy 0.795417 - - - 6465 Respiratory Therapy 0.493499 2,179 1,075 - - 6566 Physical Therapy 0.624674 - - - 6667 Occupational Therapy 1.749933 - - - 6768 Speech Pathology 0.850564 - - - 6869 Electrocardiology 0.919515 6,176 5,679 - - 6970 Electroencephalography 0.841883 5,014 4,221 - - 7071 Medical Supplies Charged To Patients 0.440230 16,121 2,000 7,097 880 - 7172 Implantable Devices Charged to Patients 0.618460 5,000 3,092 - - 7273 Drugs Charged to Patients 0.516431 11,907 2,500 6,149 - 1,291 7374 Renal Dialysis 1.137932 - - - 7475 ASC (Non-Distinct Part) 0.627135 - - - 7576 Other Ancillary (specify) - - - - 76

OUTPATIENT SERVICE COST CENTERS88 Rural Health Clinic (RHC) - - - - 8889 Federally Qualified Health Center (FQHC) - - - - 8990 Clinic 0.950180 5,611 5,331 - - 9091 Emergency 1.167744 40,262 47,016 - - 9192 Observation Bed 0.833400 73,000 60,838 - - 9293 Other Outpatient Service (specify) - - - - 93

OTHER REIMBURSABLE COST CENTERS94 Home Program Dialysis - - - 9495 Ambulance 0.808759 - 9596 Durable Medical Equipment-Rented 0.637600 987 629 - - 9697 Durable Medical Equipment-Sold 0.661333 1,362 901 - - 9798 Other Reimbursable Cost Center - - - - 98

200 Subtotal (see instructions) 300,179 2,000 2,500 243,189 880 1,291 200201 Less PBP Clinic Lab. Services-Program 201

Only Charges - - - - - - 202 Net Charges (line 200 ± line 201 ) 300,179 2,000 2,500 243,189 880 1,291 202

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4024.5)

40-572 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)COMPUTATION OF INPATIENT PROVIDER CCN: COMPONENT CNN.: PERIOD: WORKSHEET D-1,OPERATING COST FROM 10/1/2010 PART I

14-0635 __________________ TO 9/30/2011Check [ ] Title V - I/P [x ] Hospital [ ] SUBPROVIDER (other) [ ] IC [x ] PPSapplicable [x ] Title XVIII, Part A [ ] IPF [ ] SNF [ ] TEFRAboxes [ ] Title XIX - I/P [ ] IRF [ ] NF [ ] OtherPART I - ALL PROVIDER COMPONENTS

INPATIENT DAYS1 Inpatient days (including private room days and swing-bed days, excluding newborn) 117,056 12 Inpatient days (including private room days, excluding swing-bed and newborn days) 116,650 23 Private room days (excluding swing-bed and observation bed days) 3,500 34 Semi-private room days (excluding swing-bed and observation bed days) 113,150 45 Total swing-bed SNF type inpatient days (including private room days) through December 31 of the cost reporting period 100 56 Total swing-bed SNF type inpatient days (including private room days) after December 31 of the cost reporting period (if 6

calendar year, enter 0 on this line) 56 7 Total swing-bed NF type inpatient days (including private room days) through December 31 of the cost reporting period 150 78 Total swing-bed NF type inpatient days (including private room days) after December 31 of the cost reporting period (if 8

calendar year, enter 0 on this line) 100 9 Total inpatient days including private room days applicable to the Program (excluding swing-bed and newborn days) 34,400 9

10 Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) through December 31 of the 10 cost reporting period (see instructions). 56

11 Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) after December 31 of the 11 cost reporting period (if calendar year, enter 0 on this line) 100

12 Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) through December 31 of 12 the cost reporting period.

13 Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) after December 31 of the 13 cost reporting period (if calendar year, enter 0 on this line)

14 Medically necessary private room days applicable to the Program ( excluding swing-bed days) 511 1415 Total nursery days (title V or XIX only) 1516 Nursery days (title V or XIX only) 16

SWING BED ADJUSTMENT17 Medicare rate for swing-bed SNF services applicable to services through December 31 of the cost reporting period 96.00 1718 Medicare rate for swing-bed SNF services applicable to services after December 31 of the cost reporting period 104.00 1819 Medicaid rate for swing-bed NF services applicable to services through December 31 of the cost reporting period 70.50 1920 Medicaid rate for swing-bed NF services applicable to services after December 31 of the cost reporting period 82.75 2021 Total general inpatient routine service cost (see instructions) 10,835,697 2122 Swing-bed cost applicable to SNF type services through December 31 of the cost reporting period (line 5 x line 17) 9,600 2223 Swing-bed cost applicable to SNF type services after December 31 of the cost reporting period (line 6 x line 18) 5,824 2324 Swing-bed cost applicable to NF type services through December 31 of the cost reporting period (line 7 x line 19) 10,575 2425 Swing-bed cost applicable to NF type services after December 31 of the cost reporting period (line 8 x line 20) 8,275 2526 Total swing-bed cost (see instructions) 34,274 2627 General inpatient routine service cost net of swing-bed cost (line 21 minus line 26) 10,801,423 27

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT28 General inpatient routine service charges (excluding swing-bed charges) 17,470,396 2829 Private room charges (excluding swing-bed charges) 1,363,058 2930 Semi-private room charges (excluding swing-bed charges) 16,107,338 3031 General inpatient routine service cost/charge ratio (line 27 ÷ line 28) 0.618270 3132 Average private room per diem charge (line 29 ÷ line 3) 389.45 3233 Average semi-private room per diem charge (line 30 ÷ line 4) 142.35 3334 Average per diem private room charge differential (line 32 minus line 33)(see instructions) 247.10 3435 Average per diem private room cost differential (line 34 x line 31) 152.77 3536 Private room cost differential adjustment (line 3 x line 35) 534,695 3637 General inpatient routine service cost net of swing-bed cost and private room cost differential (line 27 minus line 36) 10,266,728 37


Rev. 2 40-573

4090 (Cont.) FORM CMS-2552-10 07-11COMPUTATION OF INPATIENT PROVIDER CCN: COMPONENT CCN.: PERIOD: WORKSHEET D-1,OPERATING COST FROM 10/1/2010 PART II

14-0635 ______________ TO 9/30/2011Check [ ] Title V - I/P [x ] Hospital [ ] SUBPROVI [x ] PPSapplicable [x ] Title XVIII, Part A [ ] IPF [ ] TEFRAboxes [ ] Title XIX - I/P [ ] IRF [ ] OtherPART II - HOSPITAL AND SUBPROVIDERS ONLY

PROGRAM INPATIENT OPERATING COST BEFORE PASS THROUGH COST ADJUSTMENTS 1

38 Adjusted general inpatient routine service cost per diem (see instructions) 92.60 3839 Program general inpatient routine service cost (line 9 x line 38) 3,185,440 3940 Medically necessary private room cost applicable to the Program (line 14 x line 35) 4041 Total Program general inpatient routine service cost (line 39 + line 40) 3,185,440 41

AverageTotal Total Per Diem Program Program Cost

Inpatient Cost Inpatient Days (col. 1 ÷ col. 2) Days (col. 3 x col. 4)1 2 3 4 5

42 Nursery (title V & XIX only) 42 Intensive Care Type Inpatient Hospital Units

43 Intensive Care Unit 583,552 185.61 812 150,715 4344 Coronary Care Unit 772,423 238.03 791 188,282 4445 Burn Intensive Care Unit 491,062 439.63 89 39,127 4546 Surgical Intensive Care Unit - 4647 Other Special Care Unit (specify) - 47

148 Program inpatient ancillary service cost (Wkst. D-3, col. 3, line 200) 3,094,826 4849 Total Program inpatient costs (sum of lines 41 through 48) (see instructions) 6,658,390 49

PASS THROUGH COST ADJUSTMENTS50 Pass through costs applicable to Program inpatient routine services (from Wkst. D, sum of Parts I and III) 283,241 5051 Pass through costs applicable to Program inpatient ancillary services (from Wkst. D, sum of Parts II and IV) 133,091 5152 Total Program excludable cost (sum of lines 50 and 51) 416,332 5253 Total Program inpatient operating cost excluding capital related, nonphysician anesthetist, and medical education costs 53

(line 49 minus line 52) 6,242,058

TARGET AMOUNT AND LIMIT COMPUTATION54 Program discharges 5455 Target amount per discharge 5556 Target amount (line 54 x line 55) 5657 Difference between adjusted inpatient operating cost and target amount (line 56 minus line 53) 5758 Bonus payment (see instructions) 5859 Lesser of lines 53/54 or 55 from the cost reporting period ending 1996, updated and compounded by the market basket. 59 60 Lesser of lines 53/54 or 55 from prior year cost report, updated by the market basket. 6061 If line 53/54 is less than the lower of lines 55, 59 or 60 enter the lesser of 50% of the amount by which operating costs 61

(line 53) are less than expected costs (lines 54 x 60), or 1 % of the target amount (line 56), otherwise enter zero. (see instructions)

62 Relief payment (see instructions) 6263 Allowable Inpatient cost plus incentive payment (see instructions) 63

PROGRAM INPATIENT ROUTINE SWING BED COST64 Medicare swing-bed SNF inpatient routine costs through December 31 of the cost reporting period (See instructions) 64

(title XVIII only) 5,376 65 Medicare swing-bed SNF inpatient routine costs after December 31 of the cost reporting period (See instructions) 65

(title XVIII only) 10,400 66 Total Medicare swing-bed SNF inpatient routine costs ( line 64 plus line 65) (title XVIII only). For CAH (see instructions) 15,776 6667 Title V or XIX swing-bed NF inpatient routine costs through December 31 of the cost reporting period (line 12 x line 19) 6768 Title V or XIX swing-bed NF inpatient routine costs after December 31 of the cost reporting period (line 13 x line 20) 6869 Total title V or XIX swing-bed NF inpatient routine costs ( line 67 + line 68) 69


40-574 Rev. 1

-

3,144 3,245 1,117

-

07-11 CMS FORM-2552-10 4090 (Cont.)COMPUTATION OF INPATIENT PROVIDER CCN: COMPONENT CCN.:PERIOD: WORKSHEET D-1,OPERATING COST FROM 10/1/2010 PARTS III & IV

14-0635 _________________ TO 9/30/2011Check [ ] Title V - I/P [x ] Hospital [ ] SUBPROVIDER (other) [ ] ICF/M [x ] PPSapplicable [x ] Title XVIII, Part A [ ] IPF [ ] SNF [ ] TEFRAboxes [ ] Title XIX - I/P [ ] IRF [ ] NF [ ] OtherPART III - SKILLED NURSING FACILITY, OTHER NURSING FACILITY, AND ICF/MR ONLY

70 Skilled nursing facility/other nursing facility/ICF/MR routine service cost (line 37) 70

71 Adjusted general inpatient routine service cost per diem (line 70 ÷ line 2) 71

72 Program routine service cost (line 9 x line 71) 72

73 Medically necessary private room cost applicable to Program (line 14 x line 35) 73

74 Total Program general inpatient routine service costs (line 72 + line 73) 74

75 Capital-related cost allocated to inpatient routine service costs (from Worksheet B, Parts II, column 26, line 45) 75

76 Per diem capital-related costs (line 75 ÷ line 2) 76

77 Program capital-related costs (line 9 x line 76) 77

78 Inpatient routine service cost (line 70 minus line 73) 78

79 Aggregate charges to beneficiaries for excess costs (from provider records) 79

80 Total Program routine service costs for comparison to the cost limitation (line 78 minus line 79) 80

81 Inpatient routine service cost per diem limitation 81

82 Inpatient routine service cost limitation (line 9 x line 81) 82

83 Reasonable inpatient routine service costs (see instructions) 83

84 Program inpatient ancillary services (see instructions) 84

85 Utilization review - physician compensation (see instructions) 85

86 Total Program inpatient operating costs (sum of lines 83 through 85) 86

PART IV - COMPUTATION OF OBSERVATION BED PASS THROUGH COST

87 Total observation bed days (see instructions) 2700 87

88 Adjusted general inpatient routine cost per diem (line 27 ÷ line 2) 92.60 88

89 Observation bed cost (line 87 x line 88) (see instructions) 250,020 89

COMPUTATION OF OBSERVATION BED PASS THROUGH COSTTotal Observation Bed

Routine Observation Pass Through CostCost Bed Cost (col. 3 x col. 4)

Cost (from line 27) col. 1 ÷ col. 2 (from line 89) (see instructions)1 2 3 4 5

90 Capital-related cost 602,785 10,801,423 0.055806 250,020 13,953 90

91 Nursing School 289,362 10,801,423 0.026789 250,020 6,698 91

92 Allied Health 92

93 Other Medical Education 93

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4025.3 - 4025.4)

Rev. 2 40-575

4090 (Cont.) FORM CMS-2552-10 07-11INPATIENT ANCILLARY SERVICE PROVIDER CCN: PERIOD: WORKSHEET D-3COST APPORTIONMENT 14-0635 FROM 10/1/2010

COMPONENT CCN.: TO 9/30/2011_______________

Check [ ] Title V [x] Hospital [ ] Subprovider (other) [ ] Swing-Bed SNF [x ] PPSApplicable [x] Title XVIII, Part A [ ] IPF [ ] SNF [ ] Swing-Bed NF [ ] TEFRABoxes [ ] Title XIX [ ] IRF [ ] NF [ ] ICF/MR [ ] Other

Ratio of Cost Inpatient Inpatient Program CostsCOST CENTER DESCRIPTION To Charges Program Charges (col. 1 x col. 2)

1 2 3INPATIENT ROUTINE SERVICE COST CENTERS

30 Adults and Pediatrics (General Routine Care) 7,894,920 3031 Intensive Care Unit 244,543 3132 Coronary Care Unit 153,525 3233 Burn Intensive Care Unit 32,619 3334 Surgical Intensive Care Unit 3435 Other Special Care (specify) 3540 Subprovider IPF 4041 Subprovider IRF 4142 Subprovider (Specify) 4243 Nursery 43

ANCILLARY SERVICE COST CENTERS50 Operating Room 0.723684 716,479 518,504 5051 Recovery Room 0.707989 77,565 54,915 5152 Delivery Room and Labor Room 1.014980 - 5253 Anesthesiology 0.666084 157,599 104,974 5354 Radiology-Diagnostic 0.922672 332,735 307,005 5455 Radiology-Therapeutic 0.607865 190,143 115,581 5556 Radioisotope 0.629860 125,610 79,117 5657 Computed Tomography (CT) Scan 0.719490 25,125 18,077 5758 Magnetic Resonance Imaging (MRI) 0.877466 30,145 26,451 5859 Cardiac Catheterization 0.948216 25,478 24,159 5960 Laboratory 0.597800 660,777 395,012 60

#### Blood Lab 0.860500 12,547 10,797 ####61 PBP Clinical Laboratory Services-Prgm. Only 0.750300 65,789 49,361 6162 Whole Blood & Packed Red Blood Cells 0.698608 50,000 34,930 6263 Blood Storing, Processing, & Trans. 0.713319 13,833 9,867 6364 Intravenous Therapy 0.795417 50,391 40,082 6465 Respiratory Therapy 0.493499 461,432 227,716 6566 Physical Therapy 0.624674 138,455 86,489 6667 Occupational Therapy 1.749933 16,414 28,723 6768 Speech Pathology 0.850564 25,000 21,264 6869 Electrocardiology 0.919515 29,520 27,144 6970 Electroencephalography 0.841883 29,889 25,163 7071 Medical Supplies Charged to Patients 0.440230 550,000 242,127 7172 Implantable Devices Charged to Patients 0.618460 414,487 256,344 7273 Drugs Charged to Patients 0.516431 592,970 306,228 7374 Renal Dialysis 1.137932 10,128 11,525 7475 ASC (Non-Distinct Part) 0.627135 - 7576 Other Ancillary (specify) - - 76

OUTPATIENT SERVICE COST CENTERS88 Rural Health Clinic (RHC) 0 - 8889 Federally Qualified Health Center (FQHC) 0 - 8990 Clinic 0.95018 11,857 11,266 9091 Emergency 1.167744 53,098 62,005 9192 Observation Beds (see instructions) 0.833400 - 9293 Other Outpatient Service (specify) 93

OTHER REIMBURSABLE COST CENTERS94 Home Program Dialysis - 9495 Ambulance Services 9596 Durable Medical Equipment-Rented 0.637600 - 9697 Durable Medical Equipment-Sold 0.661333 - 9798 Other Reimbursable (specify) - - 98

200 Total (sum of lines 50-94 and 96-98) 4,867,466 3,094,826 200201 Less PBP Clinic Laboratory Services-Program only charges (line 61) 65789 201202 Net Charges (line 200 minus line 201) 4,801,677 202

(A) Worksheet A liine numbers

FORM CMS-2552-10 (12-10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4027)

40-578 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)COMPUTATION OF ORGAN ACQUISITION PROVIDER CCN: PERIOD: WORKSHEET D-4,

COSTS AND CHARGES 14-0635 FROM 10/1/2010 PART I

OPO CNN.: TO 9/30/2011

14P123

Check [ ] HEART [ ] LIVER [ ] PANCREAS [ ] ISLET

Applicable Box [x] KIDNEY [ ] LUNG [ ] INTESTINE [ ] OTHER (specify)

PART I - COMPUTATION OF ORGAN ACQUISITION COSTS (INPATIENT ROUTINE AND ANCILLARY SERVICES)

Computation of Inpatient Inpatient Organ

Routine Service Costs Routine Organ Per Diem Costs Acquisition Cost

Applicable to Organ Acquistion Charges (from Wkst. D-1,Part II Days (col. 2 x col. 3)

1 D 2 3 4

1 Adults and Pediatrics 110,801 38 92.60 395 36,577 1

2 Intensive Care 66,428 43 185.61 110 20,417 2

3 Coronary Care 44 238.03 - 3

4 Burn Intensive Care Unit 45 439.63 - 4

5 Surgical Intensive Care Unit 46 - - 5

6 Other Special Care (specify) 47 - - 6

7 TOTAL (sum of lines 1-6) 177,229 505 56,994 7

Computation of Ancillary Ratio of Cost/ Organ Organ

Service Cost Applicable Charges Acquisition Acquisition

to Organ Acquisition (from Ancillary Ancillary

Wkst. C) Charges Costs

C 1 2 3

8 Operating Room 50 0.723684 21,090 15,262 8

9 Recovery Room 51 0.707989 5,340 3,781 9

10 Delivery Room & Labor Room 52 1.014980 - 10

11 Anesthesiology 53 0.662637 5,000 3,313 11

12 Radiology-Diagnostic 54 0.913922 10,725 9,802 12

13 Radiology-Theraputic 55 0.607865 - 13

14 Radioisotope 56 0.629860 - 14

15 Computed Tomography (CT) Scan 57 0.719490 - - 15

16 Magnetic Resonance Imaging (MRI) 58 0.877466 - 16

17 Cardiac Catheterization 59 0.948216 - 17

18 Laboratory 60 0.597800 9712 5,806 18

18.01 Blood Lab 60.01 0.860500 -

19 PBP Clinical Laboratory Services-Program Only 61 0.750300 3,950 2,964 19

20 Whole Blood & Packed Red Blood Cells 62 0.698608 - 20

21 Blood Storage, Processing, & Transfusing 63 0.713319 - 21

22 IV Therapy 64 0.795417 - 22

23 Respiratory Therapy 65 0.493499 - 23

24 Physical Therapy 66 0.624674 - 24

25 Occupational Therapy 67 1.749933 - 25

26 Speech Pathology 68 0.850564 - 26

27 Electrocardiology 69 0.919515 440 405 27

28 Electroencephalography 70 0.841883 - 28

29 Medical Supplies Charged to Patients 71 0.440230 1,890 832 29

30 Implantable Devices Charged to Patients 72 0.618460 - 30

31 Drugs Charged to Patients 73 0.516431 - 31

32 Renal Dialysis 74 1.137932 1,221 1,389 32

33 ASC (non-distinct part) 75 0.627135 - 33

34 Other Ancillary (specify) 76 - - 34

35 Rural Health Clinic (RHC) 88 - - 35

36 Federally Qualified Health Center (FQHC) 89 - - 36

37 Clinic 90 0.950180 - 35

38 Emergency Room 91 1.167744 - 36

39 Observation Beds 92 0.833400 - 37

40 Other Outpatient Service (specify) 93 - - 38

41 TOTAL (sum of lines 8-40) 59,368 43,554 40

C = Worksheet C line numbers D = Worksheet D-1 line numbers


Rev. 2 40-579

4090 (Cont.) FORM CMS-2552-10 07-11COMPUTATION OF ORGAN ACQUISITION PROVIDER CCN: PERIOD: WORKSHEET D-4,

COSTS AND CHARGES 14-0635 FROM 10/1/2010 PART II

OPO CNN.: TO 9/30/2011

14P123



PART II - COMPUTATION OF ORGAN ACQUISITION COSTS (OTHER THAN INPATIENT ROUTINE AND

ANCILLARY SERVICES COSTS)

Average Cost Organ

Computation of the Cost of Inpatient Per Day Acquisition

Services of Interns and Residents Not (from Wkst. D-2, Organ Costs

In Approved Teaching Program Part I, col. 4) Acquisition Days (col. 1 x col. 2)

D 1 2 3

42 Adults & Pediatrics (General routine care) 2 2.20 395 869 42

43 Intensive Care Unit 3 23.82 110 2,620 43

44 Coronary Care Unit 4 23.07 - - 44

45 Burn Intensive Care Unit 5 67.03 - - 45

46 Surgical Intensive Care Unit 6 - - - 46

47 Other Special Care (specify) 7 - - - 47

48 TOTAL (sum of lines 42 through 47) 505 3,489 48

Computation of the Cost of Ratio of Cost Organ

Outpatient Services of Interns Organ To Charges Acquisition

and Residents Not In Approved Charges from Wkst. D-2, Costs

Teaching Program (see instructions) Part I, col. 4) (col. 1 x col. 2)

1 D 2 3

49 Rural Health Clinic (RHC) 21 - - 44

50 Federally Qualified Health Center (FQHC) 22 - - 45

51 Clinic 23 0.221851 - 46

52 Emergency 24 0.022760 - 47

53 Observation Beds 25 0.083193 - 48

54 Other Outpatient Service (specify) 26 - - 49

55 TOTAL (sum of lines 49 through 54) - - 50

D = Worksheet D-2, Part I, line numbers


40-580 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)COMPUTATION OF ORGAN ACQUISITION PROVIDER CCN: PERIOD: WORKSHEET D-4,

COSTS AND CHARGES 14-0635 FROM 10/1/2010 PARTS III & IV

OPO CNN.: TO 9/30/2011

14P123



PART III - SUMMARY OF COSTS AND CHARGES

Cost Charges

Part A Part B Part A Part B

1 2 3 4

56 Routine and Ancillary from Part I 100,548 236,597 56

57 Interns and Residents (inpatient) 3,489 57

58 Interns and Residents (outpatient) - 58

59 Direct Organ Acquisition (see instructions) 324,224 324,224 59

60 Cost of Services of Teaching Physicians (Wkst. D-5, Part II) 60

61 Total (sum of lines 56 thru 60) 428,261 560,821 61

62 Total Usable Organs (see instructions) 46 62

63 Medicare Usable Organs (see instructions) 35 63

64 Ratio of Medicare Usable Organs to Total Usable 64

Organs (line 63 ÷ line 62) 0.760870

65 Medicare Cost/Charges (see instructions) 325,851 426,712 65

66 Revenue for Organs Sold 241,058 241,058 66

67 Subtotal (line 65 minus line 66) 84,793 185,654 67

68 Organs Furnished Part B 82,500 82,500 82,500 82,500 68

69 Net Organ Acquisition Cost and Charges (see instructions) 2,293 82,500 103,154 82500 69

PART IV - STATISTICS

Living Related Cadaveric Revenue

1 2 3

70 Organs Excised in ProvideR (1) 12 31 70

71 Organs Purchased from Other Transplant Hospitals (2) 71

72 Organs Purchased from Non-Transplant Hospitals 72

73 Organs Purchased from OPOs 6 73

74 Total (sum of lines 70 thru 73) 18 31 74

75 Organs Transplanted 18 22 219,520 75

76 Organs Sold to Other Hospitals 2 21,538 76

77 Organs Sold to OPOs 77

78 Organs Sold to Transplant Hospitals 78

79 Organs Sold to Military or VA Hospitals 79

80 Organs Sold Outside the U.S. 80

81 Organs Sent Outside the U.S. (no revenue received) - 81

82 Organs Used for Research 4 82

83 Unusable/Discarded Organs 3 83

84 Total (sum of lines 75 through 83 should equal line 74) 18 31 84

(1) Organs procured outside your center by a procurement team from your center are not to be included in the count.

(2) Organs procured outside your center by a procurement team are included in the count.


Rev. 2 40-581

4090 (Cont.) CMS FORM-2552-10 07-11CALCULATION OF REIMBURSEMENT PROVIDER CCN: PERIOD: WORKSHEET E,

SETTLEMENT 14-0635 FROM 10/1/2010 PART A

COMPONENT CCN : TO 9/30/2011

________________

Check [x] Hospital

Applicable Box [ ] Subprovider (other)

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS

1 DRG Amounts Other than Outlier Payments 6,242,792 1

2 Outlier payments for discharges. (see instructions) 200,000 2

3 Managed Care Simulated Payments 5,703,696 3

4 Bed days available divided by number of days in the cost reporting period (see instructions) 387.57 4

Indirect Medical Education Adjustment

5 FTE count for allopathic and osteopathic programs for the most recent cost reporting period ending on or 5

before 12/31/1996.(see instructions) 130.00

6 FTE count for allopathic and osteopathic programs which meet the criteria for an add-on to the cap for new programs in 6

in accordance with 42 CFR 413.79(e)

7 MMA Section 422 reduction amount to the IME cap as specified under 42 CFR §412.105(f)(1)(iv)(B)(1) 25.00 7

7.01 ACA Section 5503 reduction amount to the IME cap as specified under 42 CFR § 412.105(f)(1)(iv)(B)(2) 7.01

If the cost report straddles July 1, 2011 then see instructions. 10.00

8 Adjustment (increase or decrease) to the FTE count for allopathic and osteopathic programs for affiliated programs in accordance 8

with 42 CFR 413.75(b), 413.79(c)(2)(iv) and Vol. 64 Federal Register, May 12, 1998, page 26340 and Vol. 67 Federal Register,

page 50069, August 1, 2002. 8.00

8.01 The amount of increase if the hospital was awarded FTE cap slots under section 5503 of the ACA. 8.01

If the cost report straddles July 1, 2011 then see instructions. 20.00

8.02 The amount of increase if the hospital was awarded FTE cap slots from a closed teaching hospital under 8.02

section 5506 of ACA. (see instructions)

9 Sum of lines 5 plus 6 minus lines (7 and 7.01) plus/minus lines (8, 8,01 and 8,02) (see instructions) 123.00 9

10 FTE count for allopathic and osteopathic programs in the current year from your records 150.00 10

11 FTE count for residents in dental and podiatric programs. 16.00 11

12 Current year allowable FTE (see instructions) 139.00 12

13 Total allowable FTE count for the prior year. 145.00 13

14 Total allowable FTE count for the penultimate year if that year ended on or after September 30, 1997, otherwise enter zero. 125.00 14

15 Sum of lines 12 through 14 divided by 3. 136.33 15

16 Adjustment for residents in initial years of the program 3.00 16

17 Adjusment for residents displaced by program or hospital closure 1718 Adjusted rolling average FTE count 139.33 18

19 Current year resident to bed ratio (line 18 divided by line 4). 0.359496 19

20 Prior year resident to bed ratio (see instructions) 0.382000 20

21 Enter the lesser of lines 19 or 20 (see instructions) 0.359496 21

22 IME payment adjustment (see instructions) 2,136,068 22

Indirect Medical Education Adjustment for the Add-on for Section 422 of the MMA

23 Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 Sec. 412.105 (f)(1)(iv)(C ). 25.00 23

24 IME FTE Resident Count Over Cap (see instructions) 27.00 24

25 If the amount on line 24 is greater than -0-, then enter the lower of line 23 or line 24 (see instructions) 25.00 25

26 Resident to bed ratio (divide line 25 by line 4) 0.064504 26

27 IME payments adjustment. (see instructions) 0.016922 27

28 IME Adjustment (see instructions) 202,158 28

29 Total IME payment ( sum of lines 22 and 28) 2,338,226.00 29

Disproportionate Share Adjustment

30 Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions) 0.2555 30

31 Percentage of Medicaid patient days to total days reported on Worksheet S-2, Part I, line 24. (see instructions) 0.1164 31

32 Sum of lines 30 and 31 0.3719 32

33 Allowable disproportionate share percentage (see instructions) 0.1990 33

34 Disproportionate share adjustment (see instructions) 1,242,316 34


40-584 Rev. 2

07-11 CMS FORM-2552-10 4090 (Cont.)CALCULATION OF REIMBURSEMENT PROVIDER CCN: PERIOD: WORKSHEET E,

SETTLEMENT 14-0635 FROM 10/1/2010 PART A (Cont.)

COMPONENT NO.: TO 9/30/2011

________________

Check [x] Hospital [ ] IPF

Applicable Box [ ] IRF [ ] Subprovider (other)

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS

Additional payment for high percentage of ESRD beneficiary discharges Period 5/1 - 12/31 Period 1/1 - 4/30

1 1.01

40 Total Medicare discharges on Worksheet S-3, Part I excluding discharges for MS-DRGs 652, 682, 683, 40

684 and 685 (see instructions) 500

41 Total ESRD Medicare discharges excluding MS-DRGs 652, 682, 683, 684 an 685. (see instructions) 40 12 41

42 Divide line 41 by line 40 (if less than 10%, you do not qualify for adjustment) 10.40% 42

43 Total Medicare ESRD inpatient days excluding MS-DRGs 652, 682, 683, 684 an 685. (see instructions) 500 43

44 Ratio of average length of stay to one week (line 43 divided by line 41 divided by 7 days) 1.373626 44

45 Average weekly cost for dialysis treatments (see instructions) 405.44 417.60 45

46 Total additional payment (line 45 times line 43 times line 41) 29,161 46

47 Subtotal (see instructions) 10,052,495 47

48 Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only.(see instructions) 48

49 Total payment for inpatient operating costs SCH and MDH only (see instructions) 10,052,495 49

50 Payment for inpatient program capital (from Worksheet L, Parts I, II, as applicable) 179,228 50

51 Exception payment for inpatient program capital (Worksheet L, Part III, see instructions) - 51

52 Direct graduate medical education payment (from Worksheet E-4, line 49 see instructions). 3,430,845 52

53 Nursing and Allied Health Managed Care payment 32,458 53

54 Special add-on payments for new technologies 20,000 54

55 Net organ acquisition cost (Worksheet D-4 Part III, col. 1, line 62) 84,415 55

56 Cost of teaching physicians (Worksheet D-5, Part II, col. 3, line 19) 56

57 Routine service other pass through costs 97,124 57

58 Ancillary service other pass through costs Worksheet D, Part IV, col. 13 line 200) 27,569 58

59 Total (sum of amounts on lines 49 through 58) 13,924,134 59

60 Primary payer payments 165,000 60

61 Total amount payable for program beneficiaries (line 59 minus line 60) 13,759,134 61

62 Deductibles billed to program beneficiaries 467,380 62

63 Coinsurance billed to program beneficiaries 18,347 63

64 Allowable bad debts (see instructions) 27,000 64

65 Adjusted reimbursable bad debts (see instructions) 18,900 65

66 Allowable bad debts for dual eligible beneficiaries (see instructions) 5,000 66

67 Subtotal (line 61 plus line 65 minus lines 62 and 63) 13,292,307 67

68 Credits received from manufacturers for replaced devices applicable to MS-DRG (see instructions) 24,789 68

69 Outlier payments reconciliation (136,048) 69

70 Other adjustments (specify) (see instructions) 70

71 Amount due provider (line 67 minus lines 68 plus/minus lines 69 & 70) 13,131,470 71

72 Interim payments 7,556,887 72

73 Tentative settlement (for fiscal intermediary use only) 73

74 Balance due provider (Program) (lines 71 minus the sum of lines 72 and 73 ) 5,574,583 74

75 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2 75

TO BE COMPLETED BY CONTRACTOR

90 Original outlier amount from Worksheet E, Part A line 2 200,000 90

91 Original capital outlier from Worksheet L, Part I, line 2 24,567 91

92 Operating outlier amount (see instructions) (100,000) 92

93 Capital outlier reconciliation amount (see instructions) (10,000) 93

94 The rate used to calculate the Time Value of Money 7.4% 94

95 Time Value of Money for operating expenses(see instructions) (23,680) 95

96 Time Value of Money for capital related expenses (see instructions) (2,368) 96


Rev. 2 40-585

4090 (Cont.) FORM CMS-2552-10 07-11CALCULATION OF PROVIDER CCN: PERIOD: WORKSHEET E,

REIMBURSEMENT SETTLEMENT 14-0635 FROM 10/1/2010 PART B

COMPONENT CCN : TO 9/30/2011

___________________

Check applicable box [x] Hospital [ ] IPF [ ] IRF [ ] Subprovider(Other) [ ] SNFPART B - MEDICAL AND OTHER HEALTH SERVICES

1 Medical and other services (see instructions) 2,171 1

2 Medical and other services reimbursed under OPPS (see instructions). 239,568 2

3 PPS payments 193,564 3

4 Outlier payment (see instructions) 25,213 4

5 Enter the hospital specific payment to cost ratio.(see instructions) 5

6 Line 2 times line 5. 6

7 Sum of lines line 3 plus line 4 divided by line 6. 7

8 Transitional corridor payment (see instructions) 8

9 Ancillary Service Other Pass Through Costs from Worksheet D, Part IV, column 13, line 200 3,621 9

10 Organ acquisitions 139,500 10

11 Total cost (sum of lines 1 and 10)(see instructions) 141,671 11

COMPUTATION OF LESSER OF COST OR CHARGES

Reasonable charges

12 Ancillary service charges 4,500 12

13 Organ acquisition charges (from Worksheet D-4, Part III, line 62, col. 4) 139,500 13

14 Total reasonable charges (sum of lines 12 and 13) 144,000 14

Customary charges

15 Aggregate amount actually collected from patients liable for payment for services on a charge basis 15

16 Amounts that would have been realized from patients liable for payment for services on a charge 16

basis had such payment been made in accordance with 42 CFR 413.13(e)

17 Ratio of line 15 to line 16 (not to exceed 1.000000) 17

18 Total customary charges (see instructions) 144,000 18

19 Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see instructions) 2,329 19

20 Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see instructions) - 20

21 Lesser of cost or charges (line 11 minus line 20) (for CAH, see instructions) 141,671 21

22 Interns and residents (see instructions) 120,599 22

23 Cost of teaching physicians (see instructions, 42 CFR 415.160 and CMS Pub. 15-1, §2148) 23

24 Total prospective payment (sum of lines 3, 4, 8 and 9) 222,398 24

COMPUTATION OF REIMBURSEMENT SETTLEMENT

25 Deductibles and coinsurance (see instructions) 49,000 25

26 Deductibles and Coinsurance relating to amount on line 24 (see instructions) 19,000 26

27 Subtotal {(lines 21 and 24 - the sum of lines 25 and 26) plus the sum of lines 22 and 23}(see instructions) 416,668 27

28 Direct graduate medical education payments (from Worksheet E-4, line 50) 442,940 28

29 ESRD direct medical education costs (from Worksheet E-4, line 36) - 29

30 Subtotal (sum of lines 27 through 29) 859,608 30

31 Primary payer payments 3,000 31

32 Subtotal (line 30 minus line 31) 856,608 32

ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)

33 Composite rate ESRD (from Worksheet I-5, line 11) 800 33

34 Allowable bad debts (see instructions) 1,500 34

35 Adjusted reimbursable bad debts (see instructions) 1,050 35

36 Allowable bad debts for dual eligible beneficiaries (see instructions) 750 36

37 Subtotal (sum of lines 32, 33, and 34 or 35) (line 35 hospital and subprovider only) 858,458 37

38 MSP-LCC reconciliation amount from PS&R 20,000 38

39 Other adjustments (specify) (see instructions) 39

40 Subtotal (line 37 plus or minus lines 39 minus 38) 838,458 40

41 Interim payments 273,519 41

42 Tentative settlement (for contractors use only) 42

43 Balance due provider/program (line 40 minus the sum of lines 41, and 42) 564,939 43

44 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2 44


40-586 Rev.1

07-11 FORM CMS-2552-10 4090 (Cont.)CALCULATION OF PROVIDER CCN: PERIOD: WORKSHEET E,REIMBURSEMENT SETTLEMENT 14-0635 FROM 10/1/2010 PART B (Cont.)

COMPONENT NO.: TO 9/30/2011___________________

Check applicable box [x] Hospital [ ] IPF [ ] IRF [ ] Subprovider(Other) [ ] SNFPART B - MEDICAL AND OTHER HEALTH SERVICES

TO BE COMPLETED BY CONTRACTOR90 Original outlier amount (see instructions) 20,214 9091 Outlier reconciliation amount (see instructions) 4,875 9192 The rate used to calculate the Time Value of Money 7.4% 9293 Time Value of Money (see instructions) 124 9394 Total (sum of lines 91 and 93) 4,999 94


Rev. 2 40-587

4090 (Cont.) FORM CMS-2552-10 07-11ANALYSIS OF PAYMENTS TO PROVIDERS PROVIDER CCN: PERIOD: WORKSHEET E-1,FOR SERVICES RENDERED 14-0635 FROM 10/1/2010 PART I

COMPONENT CCN : TO 9/30/2011_______________

Check [x] Hospital [ ] Subprovider (Other) InpatientApplicable [ ] IPF [ ] SNF Part A Part BBox [ ] IRF [ ] Swing-Bed SNF mm/dd/yyyy Amount mm/dd/yyyy Amount

Description 1 2 3 41 Total interim payments paid to provider 7,121,387 273,519 1.002 Interim payments payable on individual bills, either submitted or to be submitted to the intermediary 2.00

for services rendered in the cost reporting period. If none, write "NONE" or enter a zero3 List separately each retroactive .01 11/28/2010 514,000 3.01

lump sum adjustment amount based .02 12/30/2010 228,000 3.02on subsequent revision of the Program to .03 2/28/2011 308,500 3.03interim rate for the cost reporting period. Provider 0 3Also show date of each payment. .05 3.05If none, write "NONE" or enter a zero. (1) .50 9/30/2011 615,000 3.50

.51 3.51Provider to .52 3.52Program .53 3.53

.54 3.54Subtotal (sum of lines 3.01- 3.49 minus sum of lines 3.50-3.98) .99 435,500 3.99

4 Total interim payments (sum of lines 1, 2, and 3.99) 4.00(transfer to Wkst. E or Wkst. E-3, lineand column as appropriate) 7,556,887 273,519 TO BE COMPLETED BY CONTRACTOR

5 List separately each tentative settlement Program to .01 5.01payment after desk review. Also show Provider .02 5.02date of each payment. .03 5.03If none, write "NONE" or enter a zero. (1) .50 5.50

Provider to .51 5.51Program .52 5.52

Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50 -5.98) .99 5.996 Determined net settlement amount (balance Program to provider .01 6.01

due) based on the cost report. (1) Provider to program .02 6.027 Total Medicare program liability (see instructions) 7.008 Name of Contractor: J-3 Contractor Contractor Number 03301 6/2/2011 8.00

(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 repaymenteven though total repayment is not accomplished until a later date.

FORM CMS-2552-10 (12-10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4031)

40-588 Rev. 2

7-11 CMS FORM-2552-10 4090 (Cont.)CALCULATION OF REIMBURSEMENT PROVIDER CCN: PERIOD: WORKSHEET E-1,

SETTLEMENT FOR HIT 14-0635 FROM 10/1/2010 PART II

COMPONENT CCN.: TO 9/30/2011

________________

Check [x] Hospital

Applicable Box

DATA COLLECTION NEEDED FOR THE HIT CALCULATION

1 Total hospital discharges as defined in AARA §4102 from Wkst S-3, Part I, line 14, column 15 5,820 1

2 Medicare days from Wkst S-3, Part I, column 6 sum of lines 1, and 8-12 36,092 2

3 Medicare HMO days from Wkst S-3, Part I, column 6. line 2 1,000 3

4 Total inpatient bed days from S-3, Part I column 8 sum of lines 1 and 8-12 121,456 4

5 Total hospital charges from Wkst C, Part I, column 8 line 200 50,773,648 5

6 Total hospital charity care charges from Wkst S-10, column 3 line 20 3,750,000 6

7 CAH only - The reasonable cost incurred for the purchase of certified HIT technology Worksheet S-2, Part I line 168 7

8 Calculation of the HIT incentive payment (see instruction) 967,547 8

INPATIENT HOSPITAL SERVICES UNDER PPS & CAH

30 Initial payment 789,452 30

31 Other Adjustment (specify) 31

32 Balance due provider (line 8 minus line 30 ± 31) 178,095 34


Rev. 2 40-589

4090(Cont.) FORM CMS-2552-10 07-11CALCULATION OF REIMBURSEMENT PROVIDER CCN: PERIOD: WORKSHEET E-2 SETTLEMENT - SWING BEDS 14-0635 FROM 10/1/2010

COMPONENT CCN : TO 9/30/201114-U635

Check [ ] Title V [x] Swing Bed - SNFApplicable [x] Title XVIII [ ] Swing Bed - NFBoxes [ ] Title XIX

PART A PART BCOMPUTATION OF NET COST OF COVERED SERVICES 1 2

1 Inpatient routine services - swing bed-SNF (see instructions) 14,976 12 Inpatient routine services - swing bed-NF (see instructions) 23 Ancillary services (from Wkst. D-3, column 3, line 200 for Part A, and sum of Wkst. D, Part V, 3

columns 5 and 7, line 203). For CAH Wkst. E, Part B (see instructions)4 Per diem cost for interns and residents not in approved teaching program (see instructions) 2.20 45 Program days 156 125 56 Interns and residents not in approved teaching program (see instructions) 275 67 Utilization review - physician compensation - SNF optional method only 78 Subtotal (sum of lines 1 through 3 plus lines 6 and 7) 14,976 275 89 Primary payer payments (see instructions) 500 9

10 Subtotal (line 8 minus line 9) 14,476 275 1011 Deductibles billed to program patients (exclude amounts applicable to physician professional 11

services) 1,254 12 Subtotal (line 10 minus line 11) 13,222 275 1213 Coinsurance billed to program patients (from provider records) (exclude coinsurance for 13

physician professional services)14 80% of Part B costs (line 12 x 80%) 220 1415 Subtotal (enter the lesser of line 12 minus line 13, or line 14) 13,222 220 1516 Other adjustments (see instructions) (specify) 1617 Reimbursable bad debts (see instructions) 1718 Reimbursable bad debts for dual eligible beneficiaries (see instructions) 1819 Total (sum of lines 15 and 17, plus/minus line 16) 13,222 220 1920 Interim payments 10,000 2021 Tentative settlement (for fiscal contractor use only) 2122 Balance due provider/program (line 19 minus the sum of lines 20 and 21) 3,222 220 2223 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, 23

section 115.2


40590 Rev. 2

4090 (Cont.) FORM CMS-2552-10 07-11CALCULATION OF MEDICARE REIMBURSEMENT PROVIDER CCN: PERIOD: WORKSHEET E-3,

SETTLEMENT IPF PPS 14-0635 FROM 10/1/2010 PART II

COMPONENT CCN :TO 9/30/2011

14-S635

[ ] Hospital

PART II - MEDICARE PART A SERVICES - IPF PPS [x] Subprovider

1 Net Federal IPF PPS Payments (excluding outlier, ECT, and medical education payments) 120,000 12 Net IPF PPS Outlier Payments 5,000 23 Net IPF PPS ECT Payments 2,000 34 Unweighted intern and resident FTE count in the most recent cost report filed on or before November 15, 2004. (see instructions) 45 New Teaching program adjustment. (see instructions) 56 Current year's unweighted FTE count of I&R other than FTEs in the first 3 years of a "new teaching program". (see inst.) 0 67 Current year's unweighted I&R FTE count for residents within the first 3 years of a "new teaching program". (see inst.) 5 78 Intern and resident count for IPF PPS medical education adjustment (see instructions) 5 89 Average Daily Census (see instructions) 32.158904 9

10 Medical Education Adjustment Factor {((1 + (line 8/line 9)) raised to the power of .5150 -1}. 0.077264 1011 Medical Education Adjustment (line 1 multiplied by line 10). 9,272 1112 Adjusted Net IPF PPS Payments (sum of lines 1, 2, 3 and 11) 136,272 1213 Nursing and Allied Health Managed Care payment (see instruction) 13

14 Organ acquisition 14

15 Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 19) (see instructions) 15

16 Subtotal (see instructions) 136,272 1617 Primary payer payments 5,479 17

18 Subtotal (line 16 less line 17). 130,793 1819 Deductibles 8,900 19

20 Subtotal (line 18 minus line 19) 121,893 2021 Coinsurance 1,200 21

22 Subtotal (line 20 minus line 21) 120,693 2223 Allowable bad debts (exclude bad debts for professional services) (see instructions) 500 2324 Adjusted reimbursable bad debts (see instructions) 350 2425 Allowable bad debts for dual eligible beneficiaries (see instructions) 100 25

26 Subtotal (sum of lines 22 and 24) 121,043 26

27 Direct graduate medical education payments (from Worksheet E-4, line 49) 27

28 Other pass through costs (see instructions) 1,512 28

29 Outlier payments reconciliation 2930 Other adjustments (see instructions) (specify 30

31 Total amount payable to the provider (see instructions) 122,555 31



34 Balance due provider/program (line 31 minus the sum lines 32 and 33) (177,445) 34

35 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 35


50 Original outlier amount from Worksheet E-3, Part II, line 2 5000 50

51 Outlier reconciliation amount (see instructions) 51

52 The rate used to calculate the Time Value of Money 52

53 Time Value of Money (see instructions) 53


40-592 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)CALCULATION OF MEDICARE REIMBURSEMENT PROVIDER CCN: PERIOD: WORKSHEET E-3,

SETTLEMENT UNDER IRF PPS 14-0635 FROM 10/1/2010 PART III

COMPONENT NO.: TO 9/30/201114-T635 [ ] Hospital

PART III - MEDICARE PART A SERVICES - IRF PPS [x] Subprovider

1 Net Federal PPS Payment (see instructions) 323,000 12 Medicare SSI ratio (IRF PPS only) (see instructions) 0.2345 23 Inpatient Rehabilitation LIP Payments (see instructions) 42,828 34 Outlier Payments 15,000 45 Unweighted intern and resident FTE count in the most recent cost reporting period ending 5

on or prior to November 15, 2004. (see inst.)6 New Teaching program adjustment. (see instructions) 67 Current year's unweighted FTE count of I&R other than FTEs in the first 3 years of a "new teaching program". (see inst.) 78 Current year's unweighted I&R FTE count for residents within the first 3 years of a "new teaching program". (see inst.) 89 Intern and resident count for IRF PPS medical education adjustment (see instructions) 9

10 Average Daily Census (see instructions) 27.679452 1011 Medical Education Adjustment Factor {((1 + (line 9/line 10)) raised to the power of .6876 -1}. 1112 Medical Education Adjustment (line 1 multiplied by line 11). 1213 Total PPS Payment (sum of lines 1, 3, 4 and 12) 380,828 1314 Nursing and Allied Health Managed Care payment (see instruction) 14

15 Organ acquisition 15

16 Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 19) (see instructions) 16

17 Subtotal (see instructions) 380,828 1718 Primary payer payments 5,479 18

19 Subtotal (line 17 less line 18). 375,349 1920 Deductibles 8,900 20

21 Subtotal (line 19 minus line 20) 366,449 2122 Coinsurance 1,200 22

23 Subtotal (line 21 minus line 22) 365,249 2324 Allowable bad debts (exclude bad debts for professional services) (see instructions) 500 2425 Adjusted reimbursable bad debts (see instructions) 350 2526 Allowable bad debts for dual eligible beneficiaries (see instructions) 50 26

27 Subtotal (sum of lines 23 and 25) 365,599 27

28 Direct graduate medical education payments (from Worksheet E-4, line 49) 28

29 Other pass through costs (see instructions) 6,040 29

30 Outlier payments reconciliation 30

31 Other adjustments (see instructions) (specify) 31

32 Total amount payable to the provider (see instructions) 371,639 32



35 Balance due provider/program (line 32 minus the sum lines 33 and 34) 71,639 35

36 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 36


50 Original outlier amount from Worksheet E-3, Part III line 4 15000 50

51 Outlier reconciliation amount (see instructions) 51

52 The rate used to calculate the Time Value of Money 52

53 Time Value of Money (see instructions) 53


Rev. 2 40-593

07-11 FORM CMS-2552-10 4090 (Cont.)CALCULATION OF REIMBURSEMENT PROVIDER CCN: PERIOD: WORKSHEET E-3,SETTLEMENT ______________ FROM _________ PART V

COMPONENT CCN : TO ______________________

Check [ ] HospitalApplicable [ ] SubproviderBox

PART V - MEDICARE PART A SERVICES - COST REIMBURSEMENT

1 Inpatient services 12 Nursing and Allied Health Managed Care payment (see instruction) 23 Organ acquisition 34 Subtotal (sum of lines 1 thru 3) 45 Primary payer payments 56 Total cost (line 5 less line 6) . For CAH (see instructions) 6

COMPUTATION OF LESSER OF COST OR CHARGESReasonable charges

7 Routine service charges 78 Ancillary service charges 89 Organ acquisition charges, net of revenue 9

10 Total reasonable charges 10Customary charges

11 Aggregate amount actually collected from patients liable for payment for services on a charge basis 1112 Amounts that would have been realized from patients liable for payment for services on 12

a charge basis had such payment been made in accordance with 42 CFR 413.13(e)13 Ratio of line 11 to line 12 (not to exceed 1.000000) 1314 Total customary charges (see instructions) 1415 Excess of customary charges over reasonable cost (complete only if line 14 exceeds line 6) (see instructions) 1516 Excess of reasonable cost over customary charges (complete only if line 6 exceeds line 14) (see instructions) 1617 Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 19) (see instructions) 17

COMPUTATION OF REIMBURSEMENT SETTLEMENT18 Direct graduate medical education payments (from Worksheet E-4, line 49) 1819 Cost of covered services (sum of lines 6, 17 and 18) 1920 Deductibles (exclude professional component) 2021 Excess reasonable cost (from line 16) 2122 Subtotal (line 19 minus sum of lines 20 and 21) 2223 Coinsurance 2324 Subtotal (line 22 minus line 23) 2425 Allowable bad debts (exclude bad debts for professional services) (see instructions) 2526 Adjusted reimbursable bad debts (see instructions) 2627 Allowable bad debts for dual eligible beneficiaries (see instructions) 2728 Subtotal (sum of lines 24 and 25 or 26(line 26 hospital and subprovider only)) 2829 Other adjustments (see instructions) (specify) 2930 Subtotal (line 28, plus or minus lines 29) 3031 Interim payments 3132 Tentative settlement (for contractor use only) 3233 Balance due provider/program (line 30 minus the sum of lines 31, and 32) 3334 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 34


Rev. 2 40-595

4090 (Cont.) FORM CMS-2552-10 12-10CALCULATION OF REIMBURSEMENT PROVIDER CCN: PERIOD: WORKSHEET E-3,SETTLEMENT 14-0635 FROM 10/1/2010 PART VI

COMPONENT CCN .: TO 9/30/201114-5481

PART VI - TITLE XVIII SNF PPS ONLY

1PROSPECTIVE PAYMENT AMOUNT (SEE INSTRUCTIONS)

1 Resource Utilization Group Payment (RUGS) 629,144 12 Routine service other pass through costs 2,342 23 Ancillary service other pass through costs 2,641 34 Subtotal (sum of lines 1 through 3) 634,127 4

COMPUTATION OF NET COST OF COVERED SERVICES 5 Medical and other services - 56 Deductible 2,700 67 Coinsurance 3,200 78 Allowable bad debts (see instructions) 700 89 Reimbursable bad debts for dual eligible beneficiaries (see instructions) 100 9

10 Allowable reimbursable bad debts (see instructions) 520 1011 Utilization review 24,471 1112 Subtotal (Sum of lines 4, 5 minus 6 & 7 plus 10 and 11)(see Instructions) 653,218 1213 Inpatient primary payer payments 3,000 1314 Other adjustments (see instructions) (specify) 1415 Subtotal (line 12 minus 13 ± lines 14 650,218 1516 Interim payments 616,000 1617 Tentative settlement (for fiscal contractor use only) 1718 Balance due provider/program (line 15 minus the sum of lines 16 and 17) 34,218 1819 Protested amounts (nonallowable cost report items) in accordance with CMS 19

Pub. 15-2, section 115.2


40-596 Rev. 2

4090 (Cont.) FORM CMS-2552-10 07-11DIRECT GRADUATE MEDICAL EDUCATION (GME) PROVIDER CCN: PERIOD: WORKSHEET E-4,

& ESRD OUTPATIENT DIRECT MEDICAL FROM 10/1/2010

EDUCATION COSTS 14-0635 TO 9/30/2011

Check [ ] Title V

Applicable [x] Title XVIII

Box [ ] Title XIX

COMPUTATION OF TOTAL DIRECT GME AMOUNT

1 Unweighted resident FTE count for allopathic and osteopathic programs for cost reporting periods ending on or before December 31, 1996. 135.00 1

2 Unweighted FTE resident cap add-on for new programs per 42 CFR 413.79(e)(1) (see instructions) 8.00 2

3 Amount of r eduction to Direct GME c ap u nder s ection 422 of MMA 25.00 3

3.01 Direct GME cap reduction amount under ACA §5503 in accordance with CFR §413.79 (m). (see instructions 3.01

for cost reporting periods straddling 7/1/2011) 5.00 4 Adjustment (plus or minus) to the FTE cap for allopathic and osteopathic programs due to a Medicare GME 4

affiliation agreement (42 CFR §413.75(b) and § 413.79 (f))

4.01 ACA Section 5503 increase to the Direct GME FTE Cap (see instructions for cost reporting periods straddling 7/1/2011) 10.00 4.01

4.02 ACA Section 5506 number of additional direct GME FTE cap slots (see instructions for cost reporting periods straddling 7/1/2011) 4.02

5 FTE adjusted cap (line 1 plus line 2 minus line 3 and 3.01 plus or minus line 4 plus line 4.01 plus line 4.02 plus applicable subscripts 123.00 5

6 Unweighted resident FTE count for allopathic and osteopathic programs for the current year from your records (see instructions) 155.00 6

7 Enter the lesser of line 5 or line 6 123.00 7

Primary Care Other Total

1 2 3

8 Weighted FTE count for physicians in an allopathic and osteopathic program for the current year. 130.00 20.00 150.00 8

9 If line 6 is less than 5 enter the amount from line 8, otherwise multiply line 8 times the result 9

of line 5 divided by the amount on line 6. 103.16 15.87 119.03

10 Weighted dental and podiatric resident FTE count for the current year 16.00 10

11 Total weighted FTE count 103.16 31.87 11

12 Total weighted resident FTE count for the prior cost reporting year (see instructions) 160.00 27.00 12

13 Total weighted resident FTE count for the penultimate cost reporting year (see instructions) 145.00 30.00 13

14 Rolling average FTE count (sum of lines 11 through 13 divided by 3). 136.05 29.62 14

15 Adjustment for residents in initial years of new programs 1.00 2.00 15

16 Adjustment for residents displaced by program or hospital closure 16

17 Adjusted rolling average FTE count 137.05 31.62 17

18 Per resident amount 75,000.00 70,000.00 18

19 Approved amount for resident costs 10,278,750 2,213,400 12,492,150 19

20 Additional unweighted allopathic and osteopathic direct GME FTE resident cap slots received under 42 Sec. 413.79(c )(4) 15.00 20

21 GME FTE weighted Resident count over Cap (see instructions) 32.00 21

22 Allowable additional direct GME FTE Resident Count (see instructions) 11.90 22

23 Enter the locality adjustment national average per resident amount (see instructions) 65,000 23

24 Multiply line 22 time line 23 773,500 24

25 Total direct GME amount (sum of lines 19 and 24) 13,265,650 25

COMPUTATION OF PROGRAM PATIENT LOAD Inpatient Part A Managed care

26 Inpatient Days 40,661 1,379 26

27 Total Inpatient Days 143,297 143,297 27

28 Ratio of inpatient days to total inpatient days 0.283753 0.009623 28

29 Program direct GME amount 3,764,168 127,655 29

30 Reduction for nursing/allied health 18,038 30

31 Net Program direct GME amount 3,873,785 31

DIRECT MEDICAL EDUCATION COSTS FOR ESRD COMPOSITE RATE - TITLE XVIII ONLY (NURSING SCHOOL AND PARAMEDICAL EDUCATION COSTS)

32 Renal dialysis direct medical education costs (from Worksheet B, Part I, sum of columns 20 and 23, lines 71 and 94) - 32

33 Renal dialysis and home dialysis total charges (Worksheet C, Part I, column 8, sum of lines 74 and 94) 1,117,321 33

34 Ratio of direct medical education costs to total charges (line 32 ÷ line 33) - 34

35 Medicare outpatient ESRD charges (see instructions) - 35

36 Medicare outpatient ESRD direct medical education costs (line 34 x line 35) - 36

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4034)

40-598 Rev. 2

07-11 FORM CMS-2552-09 4090 (Cont.)DIRECT GRADUATE MEDICAL EDUCATION (GME) PROVIDER CCN: PERIOD: WORKSHEET E-4,

& ESRD OUTPATIENT DIRECT MEDICAL FROM 10/1/2010 (Cont.)

EDUCATION COSTS 14-0635 TO 9/30/2011

Check [ ] Title V

Applicable [x] Title XVIII

Box [ ] Title XIX

APPORTIONMENT BASED ON MEDICARE REASONABLE COST - TITLE XVIII ONLY

Part A Reasonable Cost

37 Reasonable cost (see instructions) 8,049,436 37

38 Organ acquisition costs (Worksheet D-4, Part III, column 1, line 62) 84,415 38

39 Cost of teaching physicians (Worksheet D-5, Part II, column 3, line 19) 39

40 Primary payer payments (see instructions) 180,847 40

41 Total Part A reasonable cost (sum of lines 37 through 39 minus line 40) 7,953,004 41

Part B Reasonable Cost

42 Reasonable cost (see instructions) 1,044,777 42

43 Primary payer payments (see instructions) 18,000 43

44 Total Part B reasonable cost (line 42 minus line 43) 1,026,777 44

45 Total reasonable cost (sum of lines 41 and 44) 8,979,781 45

46 Ratio of Part A reasonable cost to total reasonable cost (line 41 ÷ line 45) 0.885657 46

47 Ratio of Part B reasonable cost to total reasonable cost (line 44 ÷ line 45) 0.114343 47

ALLOCATION OF MEDICARE DIRECT GME COSTS BETWEEN PART A AND PART B

48 Total program GME payment (line 31) 3,873,785 48

49 Part A Medicare GME payment (line 46 x 48)(Title XVIII only)(see instructions) 3,430,845 49

50 Part B Medicare GME payment (line 47 x 48) (title XVIII only) (see instructions) 442,940 50

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4034)

Rev. 2 40-599

4090 (Cont.) FORM CMS-2552-10 07-11BALANCE SHEET PROVIDER CCN: PERIOD: WORKSHEET G

(If you are nonproprietary and do not maintain fund-type FROM 10/1/2010

accounting records, complete the General Fund column only) 14-0635 TO 9/30/2011

SpecificAssets General Purpose Endowment Plant

(Omit cents) Fund Fund Fund Fund

1 2 3 4CURRENT ASSETS

1 Cash on hand and in banks 1,224,020 1

2 Temporary investments 3,262,024 2

3 Notes receivable 3

4 Accounts receivable 4,844,075 4

5 Other receivables 9,400 5

6 Allowances for uncollectible notes and 6

accounts receivable (461,290)

7 Inventory 540,380 7

8 Prepaid expenses 59,400 8

9 Other current assets 925,500 9

10 Due from other funds 10

11 Total current assets (sum of lines 1-10) 10,403,509 11FIXED ASSETS

12 Land 297,537 12

13 Land improvements 303,545 13

14 Accumulated depreciation (212,552) 14

15 Buildings 16,171,147 15

16 Accumulated depreciation (2,755,090) 16

17 Leasehold improvements 17

18 Accumulated depreciation 18

19 Fixed equipment 3,000,000 19

20 Accumulated depreciation (1,500,000) 20

21 Automobiles and trucks 21


23 Major movable equipment 2,067,706 23


25 Minor equipment depreciable 25


27 HIT designated Assets 1,000,000 27


29 Minor equipment-nondepreciable 29

30 Total fixed assets (sum of lines 12-29) 18,092,043 30OTHER ASSETS

31 Investments 31

32 Deposits on leases 32

33 Due from owners/officers 33

34 Other assets 3,493,398 34

35 Total other assets (sum of lines 31-34) 3,493,398 35

36 Total assets (sum of lines 11, 30, and 35) 31,988,950 36


40-600 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)BALANCE SHEET PROVIDER CCN: PERIOD: WORKSHEET G

(If you are nonproprietary and do not maintain fund-type FROM 10/1/2010 (CONT.)

accounting records, complete the General Fund column only) 14-0635 TO 9/30/2011

Liabilities and Fund Specific

Balances General Purpose Endowment Plant

(Omit cents) Fund Fund Fund Fund

1 2 3 4

CURRENT LIABILITIES

37 Accounts payable 878,000 37

38 Salaries, wages, and fees payable 1,057,236 38

39 Payroll taxes payable 246,884 39

40 Notes and loans payable (short term) 275,000 40

41 Deferred income 41

42 Accelerated payments 42

43 Due to other funds 43

44 Other current liabilities 378,400 44

45 Total current liabilities (sum of 45

lines 37 thru 44) 2,835,520

LONG TERM LIABILITIES

46 Mortgage payable 7,000,000 46

47 Notes payable 99,370 47

48 Unsecured loans 415,225 48

49 Other long term liabilities 49

50 Total long term liabilities (sum of 50

lines 46 thru 49) 7,514,595

51 Total liabilities (sum of lines 45 and 50) 10,350,115 51

CAPITAL ACCOUNTS

52 General fund balance 21,638,835 52

53 Specific purpose fund 53

54 Donor created - endowment fund 54

balance - restricted

55 Donor created - endowment fund 55

balance - unrestricted

56 Governing body created - endowment 56

fund balance

57 Plant fund balance - invested in plant 57

58 Plant fund balance - reserve for plant 58

improvement, replacement, and expansion

59 Total fund balances (sum of lines 52 thru 58) 21,638,835 59

60 Total liabilities and fund balances (sum of 60

lines 51 and 59) 31,988,950

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4040)Rev. 2 40-601

07-11 FORM CMS-2552-10 4090 (Cont.)STATEMENT OF CHANGES IN FUND BALANCES PROVIDER CCN: PERIOD: WORKSHEET G-1

FROM 10/1/201014-0635 TO 9/30/2011

GENERAL FUND SPECIFIC PURPOSE FUND ENDOWMENT FUND PLANT FUND1 2 3 4 5 6 7 8

1 Fund balances at beginning of period 16,007,202 12 Net income (loss) (from Wkst. G-3, line 31) 5,566,633 23 Total (sum of line 1 and line 2) 21,573,835 34 Additions (credit adjustments) (specify) 45 Capital investment 95,000 56 67 78 89 9

10 Total additions (sum of lines 4-9) 95,000 1011 Subtotal (line 3 plus line 10) 21,668,835 1112 Deductions (debit adjustments) (specify) 1213 Capital Withdrawl 30,000 1314 1415 1516 1617 1718 Total deductions (sum of lines 12-17) 30,000 1819 Fund balance at end of period per balance 19

sheet (line 11 minus line 18) 21,638,835


40-602 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)STATEMENT OF PATIENT REVENUES PROVIDER CCN: PERIOD: WORKSHEET G-2,AND OPERATING EXPENSES FROM 10/1/2010 PARTS I & II

14-0635 TO 9/30/2011

PART I - PATIENT REVENUES

INPATIENT OUTPATIENT TOTALREVENUE CENTER

1 2 3GENERAL INPATIENT ROUTINE CARE SERVICES

1 Hospital 17,470,396 17,470,396 12 Subprovider IPF 759,228 759,228 23 Subprovider IRF 350,000 350,000 34 Subprovider (Other) - 45 Swing bed - SNF 50,000 50,000 56 Swing bed - NF - 67 Skilled nursing facility 225,571 225,571 78 Nursing facility - 89 Other long term care - 9

10 Total general inpatient care services (sum of lines 1-9) 18,855,195 18,855,195 10INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICES

11 Intensive care unit 946,850 946,850 1112 Coronary care unit 629,821 629,821 1213 Burn intensive care unit 409,384 409,384 1314 Surgical intensive care unit - 1415 Other special care (specify) - 1516 Total intensive care type inpatient hospital services (sum of 16

of lines 11-15) 1,986,055 1,986,055 17 Total inpatient routine care services (sum of lines 10 and 16) 20,841,250 20,841,250 1718 Ancillary services 14,077,645 7,022,354 21,099,999 1819 Outpatient services 184,990 1,883,596 2,068,586 1920 Rural Health Clinic (RHC) 1,930,057 1,930,057 2121 Federally Qualified Health Center (FQHC) 209,422 209,422 2222 Home health agency 1,630,625 1,630,625 2023 Ambulance 39,557 24,948 64,505 2324 Outpatient rehabilitation providers 620,571 620,571 2425 ASC - 2526 Hospice 432,000 390,268 822,268 2627 Other (specify) 2728 Total patient revenues (sum of lines 17-27 ) (transfer column 3 to 28

Worksheet G-3, line 1) 35,575,442 13,711,841 49,287,283

PART II - OPERATING EXPENSES1 2

27 Operating expenses (per Wkst. A, column 3, line 200) 39,866,213 2728 Add (specify) 2829 2930 3031 3132 3233 3334 Total additions (sum of lines 28-33) - 3435 Deduct (specify) 3536 3637 3738 3839 3940 Total deductions (sum of lines 35-39) - 4041 Total operating expenses (sum of lines 27 and 34 minus line 40) (transfer to Worksheet G-3, line 4) 39,866,213 41


4090 (Cont.) FORM CMS-2552-10 07-11STATEMENT OF REVENUES PROVIDER CCN: PERIOD: WORKSHEET G-3

AND EXPENSES FROM 10/1/2010

14-0635 TO 9/30/2011

Description

1 Total patient revenues (from Wkst. G-2, Part I, column 3, line 26) 49,287,283 1

2 Less contractual allowances and discounts on patients' accounts 5,342,449 2

3 Net patient revenues (line 1 minus line 2) 43,944,834 3

4 Less total operating expenses (from Wkst. G-2, Part II, line 41) 39,866,213 4

5 Net income from service to patients (line 3 minus line 4) 4,078,621 5

OTHER INCOME

6 Contributions, donations, bequests, etc 6

7 Income from investments 7

8 Revenues from telephone and telegraph service 59,700 8

9 Revenue from television and radio service 9,364 9

10 Purchase discounts 19,884 10

11 Rebates and refunds of expenses 3,011 11

12 Parking lot receipts 23,133 12

13 Revenue from laundry and linen service 13

14 Revenue from meals sold to employees and guests 511,400 14

15 Revenue from rental of living quarters 28,318 15

16 Revenue from sale of medical and surgical supplies to other than patients 8,676 16

17 Revenue from sale of drugs to other than patients 19,765 17

18 Revenue from sale of medical records and abstracts 6,146 18

19 Tuition (fees, sale of textbooks, uniforms, etc.) 745,206 19

20 Revenue from gifts, flowers, coffee shops, and canteen 16,189 20

21 Rental of vending machines 11,689 21

22 Rental of hospital space 22

23 Governmental appropriations 23

24 Other (sale of scrap $24,097 Misc. $5,242) 29,339 24

25 Total other income (sum of lines 6-24) 1,491,820 25

26 Total (line 5 plus line 25) 5,570,441 26

27 Other expenses (MC overpayments) 3,808 27

28 Total other expenses (sum of line 27 and subscripts) 3,808 28

29 Net income (or loss) for the period (line 26 minus line 28) 5,566,633 29


40-604 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS PROVIDER CCN : PERIOD: WORKSHEET I-1

14-0635 FROM 10/1/2010TO 9/30/2011

Check applicable box: [x] Renal Dialysis Department [ ] Home Program Dialysis

TOTAL FTEs per

COSTS BASIS STATISTICS 2080 Hours

1 2 3 4

1 Registered Nurses 150,000 Hours of Service 7,778 3.74 1

2 Licensed Practical Nurses - Hours of Service 2

3 Nurses Aides 26,130 Hours of Service 581 0.28 3

4 Technicians 45,000 Hours of Service 5,444 2.62 4

5 Social Workers 25,000 Hours of Service 2,778 1.34 5

6 Dieticians 16,412 Hours of Service 2,178 1.05 6

7 Physicians 160,009 Accumulated Cost 7

8 Non-patient Care Salary 18,000 Accumulated Cost 8

9 Subtotal (sum of lines 1-8) 440,551 9

10 Employee Benefits Salary 10

11 Capital Related Costs-Bldgs. & Fixtures Square Feet 11

12 Capital Related Costs-Mov. Equip. Percentage of Time 12

13 Machine Costs & Repairs 370,579 Percentage of Time 13

14 Supplies Requisitions 1415 Drugs Requisitions 1516 Other 300,000 Accumulated Cost 1617 Subtotal (sum of lines 9-16)* 1,111,130 1718 Capital Related Costs-Bldgs. & Fixtures 15315 Square Feet 1819 Capital Related Costs-Mov. Equip. 13149 Percentage of Time 1920 Employee Benefits 15023 Salary 2021 Administrative and General 20134 Accumulated Cost 2122 Maint./Repairs-Operation-Housekeeping 35919 Square Feet 2223 Medical Education Program Costs 2324 Central Services & Supplies 17477 Requisitions 2425 Pharmacy 149 Requisitions 2526 Other Allocated Costs 43139 Accumulated Cost 2627 Subtotal (sum of lines 17-26)* 1271435 2728 Laboratory (see instructions) 15094 Charges 25,250 2829 Respiratory Therapy (see instructions) 3208 Charges 6,500 2930 Other (see instructions) Charges 3031 Total costs (sum of lines 27-30) 1289737 31

* Line 17, column 1 should agree with Worksheet A, column 7 for line 71 or line 94 as appropriate, and line 27, column 1 should agree with Worksheet B, Part I, column 26 for line 71 or line 94 as appropriate.


Rev. 2 40-617

4090 (Cont.) FORM CMS-2552-10 07-11HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND PROVIDER CCN14-0635 PERIOD: WORKSHEET J-2,OTHER OUTPATIENT REHABILITATION FROM 10/1/2010 PART IPROVIDER STATISTICAL DATA COMPONENT C14-1410 TO 9/30/2011Check [x] CMHC [ ] OOTapplicable [ ] Title V [x] Title XVIII [ ] Title XIX [ ] CORF [ ] OSPboxes: [ ] OPTPART I -APPORTIONMENT OF OUTPATIENT REHABILITATION PROVIDER COST CENTERS

(From Ratio of Title V Title XVIII Title XIXWkst. J-1, Total Costs to Title V Component Title XVIII Component Title XIX Component

Part I, Component Charges Component Costs (col. 3 Component Costs (col. 3 Component Costs (col. 3col. 28) Charges (col. 1 ÷ col. 2) Charges x col. 4) Charges x col. 6) Charges x col. 8)

1 2 3 4 5 6 7 8 91 Administrative and General 12 Skilled Nursing Care 161,829 72,882 2.220425 - 23 Physical Therapy 89,771 146,876 0.611203 - 34 Occupational Therapy 36,664 48,959 0.748872 - 45 Speech Pathology 18,723 20,718 0.903707 - 56 Medical Social Services 14,324 11,350 1.262026 - 67 Respiratory Therapy 27,284 30,043 0.908165 - 78 Psychiatric/Psychological Services 30,522 75,107 0.406380 - 89 Individual Therapy - - 9

10 Group Therapy - - 1011 Individualized Activity Therapy - - 1112 Family Counseling - - 1213 Diagnostic Services - - 1314 Approved Patient Training & Education - - 1415 Prosthetic and Orthotic Devices 6,487 11,350 0.571542 - 1516 Drugs and Biologicals 9,732 20,140 0.483217 - 1617 Medical Supplies 17,885 25,147 0.711218 - 1718 Medical Appliances 14,597 22,421 0.651041 - 1819 All Others (1) - 1920 Totals (sum of lines 1-19) 427,818 484,993 - - 20

(1) Enter amount in column 1 from Worksheet J-1, Part I, column 28, line 21.

FORM CMS-2552-10(07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4054.1)

40-628 Rev. 2

07-11 FORM CMS-2552-10 4090 (Cont.)HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND PROVIDER CC14-0635 PERIOD: WORKSHEET J-2,OTHER OUTPATIENT REHABILITATION FROM 10/1/2010 PART IIPROVIDER STATISTICAL DATA COMPONENT 14-1410 TO 9/30/2011Check [x] CMHC [ ] OOTapplicable [ ] Title V [x] Title XVIII [ ] Title XIX [ ] CORF [ ] OSPboxes: [ ] OPT

PART II - APPORTIONMENT OF COST OF OUTPATIENT REHABILITATION PROVIDER SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS(From Title V Title XVIII Title XIX

Wkst. J-1, Total Ratio of Title V Component Title XVIII Component Title XIX ComponentPart I, Component Costs to Component costs (col. 3 Component costs (col. 3 Component costs (col. 3

col. 29) Charges Charges (1) Charges (2) x col. 4) Charges (2) x col. 6) Charges (2) x col. 8)1 2 3 4 5 6 7 8 9

21 Respiratory Therapy 0.493499 2122 Physical Therapy 0.624674 2223 Occupational Therapy 1.749933 2324 Speech Pathology 0.850564 2425 Medical Supplies Charged to Patients 0.44023 2526 Implantable Devices Charged to Patients 0.61846 2627 Drugs Charged to Patients 0.516431 2728 Total (sum of lines 21-28) 2829 Total component costs. Add the amount from Part I, line 20 29

and the amounts from line 28, columns 5, 7, and 9. (3) -

(1) From Worksheet C, Part I, column 9, lines as appropriate(2) Charges for columns 4, 6, and 8 are obtained from your records.(3) Transfer the amounts on line 28, columns 5, 7, and 9, as appropriate, to Worksheet J-3, line 1.


Rev. 2 40-629

4090 (Cont.) FORM CMS-2552-10 07-11HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND PROVIDER CCN: PERIOD: WORKSHEET J-3OTHER OUTPATIENT REHABILITATION 14-0635 FROM 10/1/2010PROVIDER STATISTICAL DATA COMPONENT CCN : TO 9/30/2011

14-1410Check [x] CMHC [ ] OOT

applicable [ ] Title V [x] Title XVIII [ ] Title XIX [ ] CORF [ ] OSPboxes: [ ] OPT

PROGRAMCOST

1 Cost of component services (from Worksheet J-2, Part II, line 29) - 12 PPS payments received excluding outliers 125,047 23 Outlier payments 2,514 34 Primary payer payments 15,000 45 Total reasonable cost (see instructions) 112,561 56 Total charges for program services - 6

CUSTOMARY CHARGES7 Aggregate amount actually collected from patients liable for services on a charge basis 78 Amount that would have been realized from patients liable for payment for services on a charge 8

basis had such payment been made in accordance with 42 CFR 413.13(e) 89 Ratio of line 7 to line 8 (not to exceed 1.000000) (see instructions) 1.000000 9

10 Total customary charges (see instructions) 0 1011 Excess of customary charges over reasonable cost (see instructions) 1112 Excess of reasonable cost over customary charges (see instructions) 12

COMPUTATION OF REIMBURSEMENT SETTLEMENT13 Total reasonable cost (from line 5) 112,561 1314 Part B deductible billed to program patients 12,451 1415 Net cost (line 13 minus line 14) 100,110 1516 Excess of reasonable cost over customary charges (from line 12) 1617 Subtotal (line 15 minus line 16) 100,110 1718 80 percent of costs (80% of line 17) (see instructions) 80,088 1819 Actual coinsurance billed to program patients (from provider records) - 1920 Net cost less actual billed coinsurance (line 17 minus line 19) 100,110 2021 Reimbursable bad debts (from provider records) (see instructions) 5,000 2122 2223 Reimbursable bad debts for dual eligible beneficiaries (see instructions) 500 2324 Net reimbursable amount (see instructions) 105,110 2425 Other adjustments (see instructions) (specify) 2526 Total cost (line 24 plus or minus line 25) 105,110 2627 Interim payments (see instructions) 105,125 2728 Tentative settlement (for contractor use only) 2829 Balance due component/program (line 26 minus lines 27 and 28) (15) 2930 Protested amounts (nonallowable cost report items in accordance with CMS Pub. 15-II, section 115.2) 30


40-630 Rev. 2

4090 (Cont.) FORM CMS-2552-10 07-11ALLOCATION OF OVERHEAD PROVIDER CCN: PERIOD: WORKSHEET M-2

TO RHC/FQHC SERVICES 14-0635 FROM 10/1/2010 COMPONENT CCN .: TO 9/30/2011

14-3400

Check Applicable Box: [x] RHC [ ] FQHC

VISITS AND PRODUCTIVITY

Number Minimum Greater of

of FTE Total Productivity Visits (col. 1 col. 2 or

Personnel Visits Standard (1) x col. 3) col. 4

Positions 1 2 3 4 5

1 Physicians 0.50 2,624 4200 2,100 1

2 Physician Assistants 0.60 369 2100 1,260 2

3 Nurse Practitioners 0.50 1,107 2100 1,050 3

4 Subtotal (sum of lines 1-3) 1.60 4,100 4,410 4,410 4

5 Visiting Nurse - 5

6 Clinical Psychologist 0.50 350 350 6

7 Clinical Social Worker 1.00 550 550 7

7 Medical Nutrition Therapist (FQHC only) 7

7 Diabetes Self Management Training (FQHC only) 7

8 Total FTEs and Visits (sum of lines 4-7) 3.10 5,000 5,310 8

9 Physician Services Under Agreements 1,905 1,905 9

DETERMINATION OF ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES

10 Total costs of health care services (from Worksheet M-1, column 7, line 22) 303,606 10

11 Total nonreimbursable costs (from Worksheet M-1, column 7, line 28) 31,080 11

12 Cost of all services (excluding overhead) (sum of lines 10 and 11) 334,686 12

13 Ratio of RHC/FQHC services (line 10 divided by line 12) 0.907137 13

14 Total facility overhead - (from Worksheet M-1, column 7, line 31) 86,632 14

15 Parent provider overhead allocated to facility (see instructions) 267,155 15

16 Total overhead (sum of lines 14 and 15) 353,787 16

17 Allowable GME overhead (see instructions) 17

18 Subtract line 17 from line 16 353,787 18

19 Overhead applicable to RHC/FQHC services (line 13 x line 18) 320,933 19

20 Total allowable cost of RHC/FQHC services (sum of lines 10 and 19) 624,539 20

(1) The productivity standard for physicians is 4,200 and 2,100 for physician assistants and nurse practitioners. If an exception

to the standard has been granted (Worksheet S-8, line 14 equals "Y"), column 3, lines 1thru 3 of this worksheet should contain,

at a minimum, one element that is different than the standard.


40-660 Rev. 2

07-11 FORM CMS-2552-10 4090(Cont.)CALCULATION OF REIMBURSEMENT PROVIDER CCN: PERIOD: WORKSHEET M-3

SETTLEMENT FOR RHC/FQHC SERVICES 14-0635 FROM 10/1/2010

COMPONENT NO.: TO 9/30/2011

14-3400

Check [x] RHC [ ] Title V [ ] Title XIX

Applicable Box: [ ] FQHC [x] Title XVIII

DETERMINATION OF RATE FOR RHC/FQHC SERVICES

1 Total Allowable Cost of RHC/FQHC Services (from Worksheet M-2, line 20) 624,539 1

2 Cost of vaccines and their administration (from Worksheet M-4, line 15) 49,982 2

3 Total allowable cost excluding vaccine (line 1 minus line 2) 574,557 3

4 Total Visits (from Worksheet M-2, column 5, line 8) 5,310 4

5 Physicians visits under agreement (from Worksheet M-2, column 5, line 9) 1,905 5

6 Total adjusted visits (line 4 plus line 5) 7,215 6

7 Adjusted cost per visit (line 3 divided by line 6) 79.63 7

Calculation of Limit (1)

Prior to On or after

January 1 January 1

1 2

8 Per visit payment limit (from CMS Pub. 27,Sec. 505 or your intermediary) 82.95 87.10 8

9 Rate for Program covered visits (see instructions) 79.63 79.63 9

CALCULATION OF SETTLEMENT

10 Program covered visits excluding mental health services (from intermediary records) 900 2,000 10

11 Program cost excluding costs for mental health services (line 9 x line 10) 71,667 159,260 11

12 Program covered visits for mental health services (from intermediary records) 375 125 12

13 Program covered cost from mental health services (line 9 x line 12) 29,861 9,954 13

14 Limit adjustment for mental health services (see instructions) 20,529 6,843 14

15 Graduate Medical Education Pass Through Cost (see instructions) 15

16 Total Program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3) * 92,196 166,103 16

16.01 Total Program Charges (see instructions)(from contractor's records) 16.01

16.02 Total Program Preventive Charges (see instructions)(from provider's records) 16.02

16.03 Total Program Preventive Costs ((line 16.02/line 16.01) times line 16) 16.03

16.04 Total Program Non-Preventive Costs ((line 16 minus line 16.03) times 80%) 132,882 16.04

16.05 Total Program Cost (see instructions) 73,757 132,882 16.05

17 Primary payer amounts 17

18 Less: Beneficiary deductible for RHC only (see instructions) (from contractor records) 4,575 18

19 Less: Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor records) 161,528 19

20 Net Medicare cost excluding vaccines (see instructions) 202,064 20

21 Program cost of vaccines and their administration (from Wkst. M-4, line 16) 20,919 21

22 Total reimbursable Program cost (line 20 plus line 21) 222,983 22

23 Reimbursable bad debts (see instructions) 23

24 Reimbursable bad debts for dual eligible beneficiaries (see instructions) 24

25 Other adjustments (see instructions) (specify) 25

26 Net reimbursable amount (lines 22 plus 23 plus or minus line 25 ) 222,983 26



29 Balance due component/program (line 26 minus lines 27 and 28) 32,983 29

30 Protested amounts (nonallowable cost report items) in accordance with CMS 30

Pub. 15-II, chapter I, section 115.2

(1) Lines 8 through 14: Fiscal year providers use columns 1 & 2, calendar year providers use column 2 only * For line 15, use column 2 only for graduate medical education pass through cos


Rev. 2 40-661

4090 (Cont.) FORM CMS-2552-10 07-11CALCULATION OF CAPITAL PAYMENT PROVIDER CCN: PERIOD: WORKSHEET L

14-0635 FROM 10/1/2010 COMPONENT CCN : TO 9/30/2011______________

Check [ ] Title V [x] Hospital [x] PPSApplicable [x] Title XVIII [ ] Subprovider [ ] Cost MethodBoxes [ ] Title XIXPART I - FULLY PROSPECTIVE METHOD

CAPITAL FEDERAL AMOUNT1 Capital DRG other than outlier 125,987 12 Capital DRG outlier payments 24,567 23 Total inpatient days divided by number of days in the cost reporting period (see instructions) 333.03 34 Number of interns & residents (see instructions) 164.33 45 Indirect medical education percentage (see instructions) 0.1494 56 Indirect medical education adjustment (line 1 times line 5) 18,822 67 Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, part A line 30 see instructions) 0.2555 78 Percentage of Medicaid patient days to total days reported on Worksheet S-3, Part I (see instructions) 0.1164 89 Sum of lines 7 and 8 0.3719 9

10 Allowable disproportionate share percentage (see instructions) 0.0782 1011 Disproportionate share adjustment (line 10 times line 1) 9,852 1112 Total prospective capital payments (sum of lines 1-2, and 7) 179,228 12

PART II - PAYMENT UNDER REASONABLE COST1 Program inpatient routine capital cost (see instructions) 12 Program inpatient ancillary capital cost (see instructions) 23 Total inpatient program capital cost (line 1 plus line 2) 34 Capital cost payment factor (see instructions) 45 Total inpatient program capital cost (line 3 x line 4) 5

PART III - COMPUTATION OF EXCEPTION PAYMENTS1 Program inpatient capital costs (see instructions) 12 Program inpatient capital costs for extraordinary circumstances (see instructions) 23 Net program inpatient capital costs (line 1 minus line 2) 34 Applicable exception percentage (see instructions) 45 Capital cost for comparison to payments (line 3 x line 4) 56 Percentage adjustment for extraordinary circumstances (see instructions) 67 Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6) 78 Capital minimum payment level (line 5 plus line 7) 89 Current year capital payments (from Part I, line 8, as applicable) 9

10 Current year comparison of capital minimum payment level to capital payments (line 8 less line 9) 1011 Carryover of accumulated capital minimum payment level over capital payment 11

(from prior year Worksheet L, Part III, line 14)12 Net comparison of capital minimum payment level to capital payments (line 10 plus line 11) 1213 Current year exception payment (if line 12 is positive, enter the amount on this line) 1314 Carryover of accumulated capital minimum payment level over capital payment 14

for the following period (if line 12 is negative, enter the amount on this line)15 Current year allowable operating and capital payment (see instructions) 1516 Current year operating and capital costs (see instructions) 1617 Current year exception offset amount (see instructions) 17

FORM CMS-2552-10 (07/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4064.1 - 4064.3)

40-646 Rev. 2

bcbsa 2552 10 test case - rwhc resources/bcbsa_testcase.pdf · 7 skilled nursing facility 34,218...

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