Worksheet E Part I
- Return to Cost Report Summary
- Form E001
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 4
FOUNTAIN INN CONVALESCENT HOME
FOUNTAIN INN, SC 29644
FOUNTAIN INN, SC 29644
Medicare Provider Number: 425168
Cost report status: Settled Without Audit
[Record Code 1221334 - 2010]
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| CALCULATION OF REIMBURSEMENT SETTLEMENT TITLE FOR XVIII | Provider CCN: 425168 | PERIOD: FROM 10/01/2015 TO 06/30/2016 |
WORKSHEET E PART I | ||
| PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT | |||||
| 1 | Inpatient PPS amount (see instructions) | ### | 1 | ||
| 2 | Nursing and Allied Health Education Activities (pass through payments) | 2 | |||
| 3 | Subtotal (sum of lines 1 and 2) | ### | 3 | ||
| 4 | Primary payor amounts | 4 | |||
| 5 | Coinsurance | ### | 5 | ||
| 6 | Allowable bad debts (from your records) | 6 | |||
| 7 | Allowable bad debts for dual eligible beneficiaries (see instructions) | 7 | |||
| 8 | Adjusted reimbursable bad debts (see instructions) | 8 | |||
| 9 | Recovery of bad debts - for statistical records only | 9 | |||
| 10 | Utilization review | 10 | |||
| 11 | Subtotal (see instructions) | ### | 11 | ||
| 12 | Interim payments (see instructions) | ### | 12 | ||
| 13 | Tentative adjustment | 13 | |||
| 14 | Other adjustment (see instructions) OTHER ADJUSTMENT (SEE INSTRUCTIONS) | 14 | |||
| 14.50 | Demonstration payment adjustment amount before sequestration | 14.50 | |||
| 14.55 | Demonstration payment adjustment amount after sequestration | 14.55 | |||
| 14.75 | Sequestration for non-claims based amounts (see instructions) | 14.75 | |||
| 14.99 | Sequestration amount (see instructions) | ### | 14.99 | ||
| 15 | Balance due provider/program (line 11 minus line 12 and 13, plus or minus line 14) (Indicate overpayment in parentheses) (see instructions) | ### | 15 | ||
| 16 | Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 | 16 | |||
| PART B - ANCILLARY SERVICE COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES - TITLE XVIII ONLY | |||||
| 17 | Ancillary services Part B | 17 | |||
| 18 | Vaccine cost (from Wkst. D, Pt. II, line 3) | 18 | |||
| 19 | Total reasonable costs (sum of lines 17 and 18) | 19 | |||
| 20 | Medicare Part B ancillary charges (see instructions) | 20 | |||
| 21 | Cost of covered services (lesser of line 19 or line 20) | 21 | |||
| 22 | Primary payor amounts | 22 | |||
| 23 | Coinsurance and deductibles | 23 | |||
| 24 | Allowable bad debts (from your records) | 24 | |||
| 24.01 | Allowable bad debts for dual eligible beneficiaries (see instructions) | 24.01 | |||
| 24.02 | Reimbursable bad debts (see instructions) | 24.02 | |||
| 25 | Subtotal (sum of lines 21 and 24, minus lines 22 and 23) | 25 | |||
| 26 | Interim payments (see instructions) | 26 | |||
| 27 | Tentative adjustment | 27 | |||
| 28 | Other Adjustments (Specify __) (see instructions) | 28 | |||
| 28.50 | Demonstration payment adjustment amounts before sequestration | 28.50 | |||
| 28.55 | Demonstration payment adjustment amounts after sequestration | 28.55 | |||
| 28.99 | Sequestration amount (see instructions) | 28.99 | |||
| 29 | Balance due provider/program (line 25 minus line 26, 27 and plus or minus line 28) (indicate overpayments in parentheses) (see instructions) | 29 | |||
| 30 | Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 | 30 | |||
| FORM CMS-2540-10 (06/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4130) | |||||
| 06-21 | Rev. 10 | ||||