Worksheet E, Part III
- Return to Cost Report Summary
- Form E003
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3634.3, REV 16
THE MILTON & HATTIE KUTZ HOME INC
WILMINGTON, DE 19809
WILMINGTON, DE 19809
Medicare Provider Number: 085043
Cost report status: Settled Without Audit
[Record Code 113524 - 1996]
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CALCULATION OF REIMBURSEMENT SETTLEMENT | PROVIDER NO: 085043 |
PERIOD: FROM 07/01/1999 TO 06/30/2000 |
WORKSHEET E Part III |
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PART III - SNF REIMBURSEMENT UNDER PPS | |||||
SNF - SNF Medicare - Title XVIII | |||||
PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES | |||||
1 | Inpatient ancillary services - Part A - (See Instructions) | 1 | |||
2 | Interns & Residents and Medical Education cost for Title XVIII (See Instructions) | 2 | |||
3 | Total cost (Sum of lines 1 and 2) | 3 | |||
4 | Medicare inpatient ancillary charges (see instructions) | 4 | |||
5 | Intern and Resident Charges (From Provider Records) | 5 | |||
6 | Cost of covered services (lesser of line 3, or the sum of lines 4 and 5) | 6 | |||
7 | Inpatient PPS amount (see instructions) | ### | 7 | ||
8 | Primary payor amounts | 8 | |||
9 | Coinsurance | ### | 9 | ||
10 | Reimbursable bad debts (From your records) | 10 | |||
10.01 | Adjusted reimbursable bad debts for periods before 10/01/2005 (See instructions) | 10.01 | |||
10.02 | Reimbursable bad debts for dual eligible beneficiaries (See instructions) | 10.02 | |||
10.03 | Adjusted reimbursable bad debts for periods ending on & after 10/01/2005 (See instructions) | 10.03 | |||
10.04 | Recovery of reimbursable bad debts for dual eligible beneficiaries | 10.04 | |||
11 | Utilization review | 11 | |||
12 | Recovery of excess depreciation resulting from provider termination or a decrease in Program utilization. | 12 | |||
13 | Amounts applicable to prior cost reporting periods resulting from disposition 'in Program utilization. | 13 | |||
14 | Subtotal (See instructions) | ### | 14 | ||
15 | Sequestration adjustment | 15 | |||
16 | Interim payments (See instructions) | ### | 16 | ||
16.01 | Tentative adjustment (See instructions) | 16.01 | |||
16.20 | Other adjustments (See instructions) | 16.20 | |||
17 | Balance due provider/program (Line 14 minus the sum of lines 15 and 16) (Indicate overpayments in brackets) (See Instructions) | ### | 17 | ||
18 | Protested amounts (Nonallowable cost report items in accordance with CMS Pub. 15-II, section 115.2) | 18 | |||
PART B - ANCILLARY SERVICES COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES - TITLE XVIII ONLY | |||||
19 | Ancillary services Part B | 19 | |||
20 | Vaccine cost (From Wkst D, Part II, line 3) | ### | 20 | ||
21 | Intern and Resident Cost (From Worksheet D-2) | 21 | |||
22 | Total reasonable costs (Sum of lines 19 to 21) | ### | 22 | ||
23 | Medicare Part B ancillary charges (See instructions) | ### | 23 | ||
24 | Intern and Resident Charges (From Provider Records) | 24 | |||
25 | Cost of covered services (Lesser of line 22, or sum of lines 23 and 24) | ### | 25 | ||
26 | Primary payor amounts | 26 | |||
27 | Coinsurance and deductibles | 27 | |||
28 | Reimbursable bad debts (From your records) | 28 | |||
29 | Recovery of unreimbursed cost under the lesser of reasonable cost or customary charges | 29 | |||
30 | 80% of recovery of unreimbursed cost under the lesser of reasonable cost or customary charges (Line 29 times 0.80) | 30 | |||
31 | Recovery of excess depreciation resulting from provider termination or a decrease in Program utilization. | 31 | |||
32 | Other Adjustments (See instructions) Specify | 32 | |||
33 | Amounts applicable to prior cost reporting periods resulting from disposition of assets. (If minus, enter amount in brackets) | 33 | |||
34 | Subtotal (Sum of lines 25, 28, & 30, minus lines 26, 27, and 31, plus or minus line 32 and 33) | ### | 34 | ||
35 | Sequestration adjustment | 35 | |||
36 | Interim payments (See instructions) | ### | 36 | ||
36.01 | Tenative adjustment (See instructions) | 36.01 | |||
36.20 | OTHER adjustments (See instructions) | 36.20 | |||
37 | Balance due provider/program (Line 34 minus the sum of lines 35 and 36) (Indicate overpayments in brackets) (See Instructions) | ### | 37 | ||
38 | Protested amounts (Nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2) | 38 | |||