MPAPA_Exhibit_E-3.xlsx

XLSX spreadsheet 25 KB Posted

Attached to
Medicare Part A Provider Cost Report Appeals (MPAPA)
Solicitation number
HHSM-500-2013-RFP-0030
Issued by

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Exhibit E-3

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Text version

Base Year

MPAPA
Exhibit E.3
OTHER DIRECT COST BREAKDOWN
TASKSTask 1Task 2Task 3GRAND
Cost ElementAmountAmountAmountTOTAL
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Add Other Costs by Category As Appropriate$0.00

TOTAL ODCs $0.00 $0.00 $0.00 $0.00

Use Date of Submission

Option Year 1

MPAPA
Exhibit E.3
OTHER DIRECT COST BREAKDOWN
TASKSTask 1Task 2Task 3GRAND
Cost ElementAmountAmountAmountTOTAL
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Add Other Costs by Category As Appropriate$0.00

TOTAL ODCs $0.00 $0.00 $0.00 $0.00

&"Arial,Italic"(

Use Date of Submission

Option Year 2

MPAPA
Exhibit E.3
OTHER DIRECT COST BREAKDOWN
TASKSTask 1Task 2Task 3GRAND
Cost ElementAmountAmountAmountTOTAL
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Add Other Costs by Category As Appropriate$0.00

TOTAL ODCs $0.00 $0.00 $0.00 $0.00

Use Date of Submission

Option Year 3

MPAPA
Exhibit E.3
OTHER DIRECT COST BREAKDOWN
TASKSTask 1Task 2Task 3GRAND
Cost ElementAmountAmountAmountTOTAL
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Add Other Costs by Category As Appropriate$0.00

TOTAL ODCs $0.00 $0.00 $0.00 $0.00

Use Date of Submission

Option Year 4

MPAPA
Exhibit E.3
OTHER DIRECT COST BREAKDOWN
TASKSTask 1Task 2Task 3GRAND
Cost ElementAmountAmountAmountTOTAL
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Add Other Costs by Category As Appropriate$0.00

TOTAL ODCs $0.00 $0.00 $0.00 $0.00

Use Date of Submission

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