SNFData - 075306 - 01/2001 - Worksheet S-7, Part III

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INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3514.3, REV 7

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PILGRIM MANOR
CROMWELL, CT 06416

Medicare Provider Number: 075306

Cost report status: Settled Without Audit

[Record Code 15990 - 1996]

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PPS STATISTICAL DATA				PROVIDER NO: 075306		PERIOD: FROM 02/01/2000 TO 01/31/2001			WORKSHEET S-7 Part III
TRANSITION PERIOD: [ ] YEAR # 1 [ ] YEAR # 2 [ ] YEAR # 3 [ ] YEAR # 4 - 100% Federal Case Mix Rate
	HIPPS CODE GROUP	FACILITY SPECIFIC RATE	SERVICES PRIOR TO 10/01		SERVICES AFTER 9/30		SUBTOTAL		YR 1: Col. 9 = Col. 7 X 25% Col. 10 = Col. 8 X 75%
			FEDERAL CASE MIX RATE	DAYS	FEDERAL CASE MIX RATE	DAYS	FEDERAL CASE MIX (Col. 3 X 4, PLUS Col . 5 X 6)	FACILITY SPECIFIC (Col. 4 + 6 X Col. 2)	YR 1: Col. 9 = Col. 7 X 25% Col. 10 = Col. 8 X 75%
									YR 2: Col. 9 = Col. 7 X 50% Col. 10 = Col. 8 X 50%
									YR 2: Col. 9 = Col. 7 X 50% Col. 10 = Col. 8 X 50%
									YR 3: Col. 9 = Col. 7 X 75% Col. 10 = Col. 8 X 25%
									YR 3: Col. 9 = Col. 7 X 75% Col. 10 = Col. 8 X 25%
	1	2	3	4	5	6	7	8	9	10
1	RUC		###		###						1
2	RUB		###	###	###		###		###		2
3	RUA		###	###	###	###	###		###		3
4	RVC		###		###						4
5	RVB		###	###	###	###	###		###		5
6	RVA		###	###	###	###	###		###		6
7	RHC		###	###	###	###	###		###		7
8	RHB		###	###	###	###	###		###		8
9	RHA		###	###	###	###	###		###		9
10	RMC		###	###	###		###		###		10
11	RMB		###	###	###	###	###		###		11
12	RMA		###	###	###	###	###		###		12
13	RLB		###		###						13
14	RLA		###		###						14
15	SE3		###		###						15
16	SE2		###	###	###	###	###		###		16
17	SE1		###		###						17
18	SSC		###		###						18
19	SSB		###	###	###		###		###		19
20	SSA		###		###						20
21	CC2		###		###						21
22	CC1		###	###	###	###	###		###		22
23	CB2		###	###	###		###		###		23
24	CB1		###		###						24
25	CA2		###	###	###		###		###		25
26	CA1		###	###	###		###		###		26
27	IB2		###		###						27
28	IB1		###	###	###		###		###		28
29	IA2		###		###						29
30	IA1		###	###	###		###		###		30
31	BB2		###		###						31
32	BB1		###		###						32
33	BA2		###		###						33
34	BA1		###		###						34
35	PE2		###		###						35
36	PE1		###	###	###		###		###		36
37	PD2		###		###						37
38	PD1		###		###						38
39	PC2		###		###						39
40	PC1		###		###						40
41	PB2		###		###						41
42	PB1		###		###						42
43	PA2		###		###						43
44	PA1		###	###	###		###		###		44
45	Default Rate		###	###	###	###	###		###		45
46	TOTAL			###		###	###		###		46