Worksheet E, Part III
- Return to Cost Report Summary
- Form E003
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3634.3, REV 16
SIEMON S LAKEVIEW MANOR ESTATES
SOMERSET, PA 15501
SOMERSET, PA 15501
Medicare Provider Number: 395398
Cost report status: Settled Without Audit
[Record Code 128541 - 1996]
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| CALCULATION OF REIMBURSEMENT SETTLEMENT | PROVIDER NO: 395398 |
PERIOD: FROM 07/01/2000 TO 06/30/2001 |
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 | |||