J.1.f_Appendix_F_-_Final_Cost_Report_2013.pdf

version 3.1 This report is required by law (42 USC 1395mm and 42 USC 1995I). FORM APPROVED Failure to report can result in all interim payments made since OMB NO. 0938-0165 the beginning of the cost reporting period being deemed overpayments.

PREPAID HEALTH PLAN COST REPORT WORKSHEET S

GENERAL INFORMATION

1 Name and Address of Plan:

2 Reporting Period: Plan Number:

From:

H-xxxx To:

3 a. Type of Report: b. Bill Processing Option: c. Reimbursement Under:

[ ] Budget Forecast Select Option 1876

[ ] Interim Reports

[x ] Final Cost Report

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST

REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW

CERTIFICATION BY OFFICER OF THE PLAN

I HEREBY CERTIFY that I have examined the accompanying Statement of Reimbursable Cost, the allocation of expenses and services, and the attached Worksheets for the period from 01/00/1900 to 01/00/1900 and that to the best of my knowledge and belief they are true and correct statements prepared from the books and records of the Plan in accordance with applicable instructions, except as noted.

SIGNATURE (Officer or Administrator of the Plan) DATE

TITLE PHONE NUMBER

FORM CMS 276-08 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2302)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0165. The time required to complete this information is estimated to average as follows: (1) for HMOs/CMPs, 24 hours to complete the budget forecast, 80 hours to complete the fourth quarter and final cost reports, and 12 hours to complete the first, second, and third quarterly reports;

and (2)for HCPPs, 16 hours to complete the budget forecast, 60 hours to complete the final cost report, and 8 hours to complete the mid-year report. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HCFA, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

B7DV

Typewritten Text Appendix F

PLAN STATISTICS WORKSHEET D

PART I

Name of Plan: 0 Page 1 Plan #: H-xxxx

PERIOD FROM: 01/00/00

TO: 01/00/00

BILLS TOTAL COV MED COV MED

PROVIDER RELATION- PROCESSED TOTAL MEDICARE PRIMARY SECONDARY

NUMBER SHIP (1) BY (2) DAYS DAYS* DAYS DAYS

LIST OF PROVIDERS

1 2 3 4 5 6 7

A. Hospitals & SNF's:

1 ________________________________ ________ _ _ 0 0 0 0 2 ________________________________ ________ _ _ 0 0 0 0 3 ________________________________ ________ _ _ 0 0 0 0 4 ________________________________ ________ _ _ 0 0 0 0 5 ________________________________ ________ _ _ 0 0 0 0 6 ________________________________ ________ _ _ 0 0 0 0 7 ________________________________ ________ _ _ 0 0 0 0 8 ________________________________ ________ _ _ 0 0 0 0 9 ________________________________ ________ _ _ 0 0 0 0

10 ________________________________ ________ _ _ 0 0 0 0 11 ________________________________ ________ _ _ 0 0 0 0 12 ________________________________ ________ _ _ 0 0 0 0 13 ________________________________ ________ _ _ 0 0 0 0 14 ________________________________ ________ _ _ 0 0 0 0 15 ________________________________ ________ _ _ 0 0 0 0 16 ________________________________ ________ _ _ 0 0 0 0 17 ________________________________ ________ _ _ 0 0 0 0 18 ________________________________ ________ _ _ 0 0 0 0 19 ________________________________ ________ _ _ 0 0 0 0 20 ________________________________ ________ _ _ 0 0 0 0 21 ________________________________ ________ _ _ 0 0 0 0 22 ________________________________ ________ _ _ 0 0 0 0 23 ________________________________ ________ _ _ 0 0 0 0 24 ________________________________ ________ _ _ 0 0 0 0 25 ________________________________ ________ _ _ 0 0 0 0 26 ________________________________ ________ _ _ 0 0 0 0 27 ________________________________ ________ _ _ 0 0 0 0 28 ________________________________ ________ _ _ 0 0 0 0 29 ________________________________ ________ _ _ 0 0 0 0 30 ________________________________ ________ _ _ 0 0 0 0 31 ________________________________ ________ _ _ 0 0 0 0 32 ________________________________ ________ _ _ 0 0 0 0 33 ________________________________ ________ _ _ 0 0 0 0 34 ________________________________ ________ _ _ 0 0 0 0 35 ________________________________ ________ _ _ 0 0 0 0 36 ________________________________ ________ _ _ 0 0 0 0 37 ________________________________ ________ _ _ 0 0 0 0 38 ________________________________ ________ _ _ 0 0 0 0 39 ________________________________ ________ _ _ 0 0 0 0 40 ________________________________ ________ _ _ 0 0 0 0 41 ________________________________ ________ _ _ 0 0 0 0 42 ________________________________ ________ _ _ 0 0 0 0 43 ________________________________ ________ _ _ 0 0 0 0 44 ________________________________ ________ _ _ 0 0 0 0 45 ________________________________ ________ _ _ 0 0 0 0 46 ________________________________ ________ _ _ 0 0 0 0 47 ________________________________ ________ _ _ 0 0 0 0 48 ________________________________ ________ _ _ 0 0 0 0 49 ________________________________ ________ _ _ 0 0 0 0 50 ________________________________ ________ _ _ 0 0 0 0 51 ________________________________ ________ _ _ 0 0 0 0 52 ________________________________ ________ _ _ 0 0 0 0

* Note: Col 5 minus 6 & 7 = Non-covered

(1) (2)

O - OWNED OR CONTROLLED H - PROCESSED BY HCFA

P - PURCHASED P - PROCESSED BY PLAN

FORM HCFA 276-99

(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306)

PART 1

Name of Plan: 0 Page 2 Plan #: H-xxxx

PERIOD FROM: 01/00/00

TO: 01/00/00

BILLS TOTAL COV MED COV MED

PROVIDER RELATION- PROCESSED TOTAL MEDICARE PRIMARY SECONDARY

NUMBER SHIP (1) BY (2) VISITS VISITS* VISITS VISITS

LIST OF PROVIDERS

1 2 3 4 5 6 7

B. HHA's:

1 ________________________________ ________ _ _ 0 0 0 0 2 ________________________________ ________ _ _ 0 0 0 0 3 ________________________________ ________ _ _ 0 0 0 0 4 ________________________________ ________ _ _ 0 0 0 0 5 ________________________________ ________ _ _ 0 0 0 0 6 ________________________________ ________ _ _ 0 0 0 0 7 ________________________________ ________ _ _ 0 0 0 0 8 ________________________________ ________ _ _ 0 0 0 0 9 ________________________________ ________ _ _ 0 0 0 0

10 ________________________________ ________ _ _ 0 0 0 0 11 ________________________________ ________ _ _ 0 0 0 0 12 ________________________________ ________ _ _ 0 0 0 0 13 ________________________________ ________ _ _ 0 0 0 0 14 ________________________________ ________ _ _ 0 0 0 0 15 ________________________________ ________ _ _ 0 0 0 0 16 ________________________________ ________ _ _ 0 0 0 0 17 ________________________________ ________ _ _ 0 0 0 0 18 ________________________________ ________ _ _ 0 0 0 0 19 ________________________________ ________ _ _ 0 0 0 0 20 ________________________________ ________ _ _ 0 0 0 0 21 ________________________________ ________ _ _ 0 0 0 0 22 ________________________________ ________ _ _ 0 0 0 0 23 ________________________________ ________ _ _ 0 0 0 0 24 ________________________________ ________ _ _ 0 0 0 0 25 ________________________________ ________ _ _ 0 0 0 0

C. Other (Specify Name & Type):

1 ________________________________ ________ _ _ 0 0 0 0 2 ________________________________ ________ _ _ 0 0 0 0 3 ________________________________ ________ _ _ 0 0 0 0 4 ________________________________ ________ _ _ 0 0 0 0 5 ________________________________ ________ _ _ 0 0 0 0 6 ________________________________ ________ _ _ 0 0 0 0 7 ________________________________ ________ _ _ 0 0 0 0 8 ________________________________ ________ _ _ 0 0 0 0 9 ________________________________ ________ _ _ 0 0 0 0

10 ________________________________ ________ _ _ 0 0 0 0 11 ________________________________ ________ _ _ 0 0 0 0 12 ________________________________ ________ _ _ 0 0 0 0 13 ________________________________ ________ _ _ 0 0 0 0 14 ________________________________ ________ _ _ 0 0 0 0 15 ________________________________ ________ _ _ 0 0 0 0 16 ________________________________ ________ _ _ 0 0 0 0 17 ________________________________ ________ _ _ 0 0 0 0 18 ________________________________ ________ _ _ 0 0 0 0 19 ________________________________ ________ _ _ 0 0 0 0 20 ________________________________ ________ _ _ 0 0 0 0 21 ________________________________ ________ _ _ 0 0 0 0 22 ________________________________ ________ _ _ 0 0 0 0 23 ________________________________ ________ _ _ 0 0 0 0 24 ________________________________ ________ _ _ 0 0 0 0 25 ________________________________ ________ _ _ 0 0 0 0

* Note: Col 5 minus 6 & 7 = Non-covered

(1) (2)

O - OWNED OR CONTROLLED H - PROCESSED BY HCFA

P - PURCHASED P - PROCESSED BY PLAN

PART II

Name of Plan: 0 Page 1 Plan #: H-xxxx

PERIOD FROM: 01/00/00

TO: 01/00/00

HOW STATISTICS

TYPE OF PAYMENT PHYSICIANS TOTAL COVERED MED COVERED MED

GROUP MECHANISM PAID TOTAL MEDICARE * PRIMARY SECONDARY

LIST OF SUPPLIERS (1) (2) (2)

1 2 3 4 5 6 7

A. Physician Services:

1 ________________________________ _ _ _ 0 0 0 0 2 ________________________________ _ _ _ 0 0 0 0 3 ________________________________ _ _ _ 0 0 0 0 4 ________________________________ _ _ _ 0 0 0 0 5 ________________________________ _ _ _ 0 0 0 0 6 ________________________________ _ _ _ 0 0 0 0 7 ________________________________ _ _ _ 0 0 0 0 8 ________________________________ _ _ _ 0 0 0 0 9 ________________________________ _ _ _ 0 0 0 0

10 ________________________________ _ _ _ 0 0 0 0 11 ________________________________ _ _ _ 0 0 0 0 12 ________________________________ _ _ _ 0 0 0 0 13 ________________________________ _ _ _ 0 0 0 0 14 ________________________________ _ _ _ 0 0 0 0 15 ________________________________ _ _ _ 0 0 0 0 16 ________________________________ _ _ _ 0 0 0 0 17 ________________________________ _ _ _ 0 0 0 0 18 ________________________________ _ _ _ 0 0 0 0 19 ________________________________ _ _ _ 0 0 0 0 20 ________________________________ _ _ _ 0 0 0 0 21 ________________________________ _ _ _ 0 0 0 0 22 ________________________________ _ _ _ 0 0 0 0 23 ________________________________ _ _ _ 0 0 0 0 24 ________________________________ _ _ _ 0 0 0 0 25 ________________________________ _ _ _ 0 0 0 0 26 ________________________________ _ _ _ 0 0 0 0 27 ________________________________ _ _ _ 0 0 0 0 28 ________________________________ _ _ _ 0 0 0 0 29 ________________________________ _ _ _ 0 0 0 0 30 ________________________________ _ _ _ 0 0 0 0 31 ________________________________ _ _ _ 0 0 0 0 32 ________________________________ _ _ _ 0 0 0 0 33 ________________________________ _ _ _ 0 0 0 0 34 ________________________________ _ _ _ 0 0 0 0 35 ________________________________ _ _ _ 0 0 0 0 36 ________________________________ _ _ _ 0 0 0 0 37 ________________________________ _ _ _ 0 0 0 0 38 ________________________________ _ _ _ 0 0 0 0 39 ________________________________ _ _ _ 0 0 0 0 40 ________________________________ _ _ _ 0 0 0 0 41 Physician Groups:

42 Fee For Service 0 0 0 0 43 Capitation 0 0 0 0 44 Other 0 0 0 0 45 Individual Physicians:

46 Fee For Service 0 0 0 0 47 Capitation 0 0 0 0 48 Other 0 0 0 0

(1) (2)

A - IPA A - FEE-FOR-SERVICE

B - GROUP PRACTICE B - CAPITATION

C - STAFF C - OTHER-SPECIFY

D - INDIVIDUAL PRACTITIONERS

* Note Col 5 minus 6 & 7 = Non-covered

PART II

Name of Plan: 0 Page 2 Plan #: H-xxxx

PERIOD FROM: 01/00/00

TO: 01/00/00

HOW STATISTICS

TYPE OF PAYMENT PHYSICIANS TOTAL COVERED MED COVERED MED

GROUP MECHANISM PAID TOTAL MEDICARE* PRIMARY SECONDARY

LIST OF SUPPLIERS (1) (2) (2)

1 2 3 4 5 6 7

B. Certified Labs:

1 ________________________________ A _ _ 0 0 0 0 2 ________________________________ _ _ _ 0 0 0 0 3 ________________________________ _ _ _ 0 0 0 0 4 ________________________________ _ _ _ 0 0 0 0 5 ________________________________ _ _ _ 0 0 0 0 6 ________________________________ _ _ _ 0 0 0 0 7 ________________________________ _ _ _ 0 0 0 0 8 Certified Labs 9 Fee For Service 0 0 0 0

10 Capitation 0 0 0 0 11 Other 0 0 0 0

C. X-Ray Units:

1 ___________________________________ _ _ _ 0 0 0 0 2 ___________________________________ _ _ _ 0 0 0 0 3 ___________________________________ _ _ _ 0 0 0 0 4 ___________________________________ _ _ _ 0 0 0 0 5 ___________________________________ _ _ _ 0 0 0 0 6 ___________________________________ _ _ _ 0 0 0 0 7 ___________________________________ _ _ _ 0 0 0 0 8 X-Ray Units 9 Fee For Service 0 0 0 0

10 Capitation 0 0 0 0 11 Other 0 0 0 0

D. Others (Specify):

1 ___________________________________ _ _ _ 0 0 0 0 2 ___________________________________ _ _ _ 0 0 0 0 3 ___________________________________ _ _ _ 0 0 0 0 4 ___________________________________ _ _ _ 0 0 0 0 5 ___________________________________ _ _ _ 0 0 0 0 6 ___________________________________ _ _ _ 0 0 0 0 7 ___________________________________ _ _ _ 0 0 0 0 8 ___________________________________ _ _ _ 0 0 0 0 9 ___________________________________ _ _ _ 0 0 0 0

10 ___________________________________ _ _ _ 0 0 0 0 11 ___________________________________ _ _ _ 0 0 0 0 12 ___________________________________ _ _ _ 0 0 0 0 13 ___________________________________ _ _ _ 0 0 0 0 14 ________________________________ _ _ _ 0 0 0 0

* Note: Col 5 minus 6 & 7 = Non-covered

(1) (2)

A - IPA A - FEE-FOR-SERVICE

B - GROUP PRACTICE B - CAPITATION

C - STAFF C - OTHER-SPECIFY

D - INDIVIDUAL PRACTITIONERS

MEDICARE MEDICARE

E. MEMBERSHIP: PART A PART B

1 2 1 Total Medicare Member Months........................................................................................................................................................... 0 0 2 Medicare Secondary Liable (Employer Groups) Member Months

3 Medicare Primary Member Months (Line 1 minus Line 2)..................................................................................................................... 0 0 4 Ratio (Line 3 & Line 1).......................................................................................................................................................................... 0.0000 0.0000

(3) Part B Member Months = Total Member Months

FORM CMS 276-08

(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2306)

SUMMARY TRIAL BALANCE WORKSHEET E

Name of Plan: 0 Plan #: H-xxxx

PERIOD FROM: 01/00/00

TO: 01/00/00

A & G TRANSFER

TRIAL RECLASSIFI- ADJUSTMENTS ALLOWABLE ALLOCATION TOTALS TO

COST CENTER BALANCE CATIONS COST (WKST I, WKST, LINE

(WKST F) (WKST G) (Col 1 thru 3) Part I) (Col 4 + Col 5)

1 2 3 4 5 6 7

1 Inpatient Hospitals 0 0 0 0 0 J 2-47 2 Outpatient Hospitals 0 0 0 0 0 J 2-47 3 Skilled Nursing Facilities.......….… 0 0 0 0 0 J 52-61 4 Home Health Agencies........….…. 0 0 0 0 0 J 66-74 5 Clinics..........……….........….......… 0 0 0 0 0 K | 1 6 Physician Groups.......................… 0 0 0 0 0 K | 2-6 7 Individual Physicians.....…...….… 0 0 0 0 0 K | 7 8 Certified Labs..................…......… 0 0 0 0 0 K | 8-10 9 X-Ray Units....................……....… 0 0 0 0 0 K | 11-13

10 ESRD Facilities.........................… 0 0 0 0 0 K | 14-15 11 Durable Medical Equipment.......… 0 0 0 0 0 K | 16 12 Ambulance...............……….......… 0 0 0 0 0 K | 17 13 Pharmacy (Outpatient).......…...… 0 0 0 0 0 13a Pharmacy-Medicare Covered Rx 0 0 0 0 0 14 Emergency-Urgent Needed Svcs.. 0 0 0 0 0 K | 18 15 Mental Health Services....….…… 0 0 0 0 0 K | 19&20 16 DED+CO pd by MAC/Carrier/Inter 0 0 0 0 0 L | 18 17 Other - Medicare Bad Debts...… 0 0 0 0 0 L | 9 18 Other - Blood Deductible.....… 0 0 0 0 0 L | 12 19 Part B Cost Not Subj to Coins. 0 0 0 0 0 L | 25 20 Non-Allowable Costs 0 0 0 0 0 21 Other - (Specify)...… … .......… 0 0 0 0 0 J&K | 22 Other - (Specify)...… … .......… 0 0 0 0 0 J&K | 23 Other - (Specify)...… … .......… 0 0 0 0 0 J&K |

24 Subtotal (Sum Lines 1-23).............. 0 0 0 0 0 0

25 Plan Administration..............…..… 0 0 0 0 0 L | 3 26 Special Admin Costs................… 0 0 0 0 0 L | 6

27 Subtotal: (Sum Lns 25+26)............. 0 0 0 0 0 0

28 Admin & General Costs...…......… 0 0 0 0 0

29 Total Program Costs (24+27+28)... 0 0 0 0 0 0

(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2307)

RECLASSIFICATIONS WORKSHEET F

Name of Plan: 0 Page 1 Plan #: H-xxxx PERIOD FROM: 01/00/00

TO: 01/00/00

CC LINE AMOUNT (2)

CODE COST CENTER NUMBER

LINE EXPLANATION OF RECLASSIFICATION ENTRY (1) (Worksheet E) (WKST E) INCREASES (DECREASES) 1 2 3 4 5

1 ____________________________________________ ______ _________________________ ___________ 0 0 2 ____________________________________________ ______ _________________________ ___________ 0 0 3 ____________________________________________ ______ _________________________ ___________ 0 0 4 ____________________________________________ ______ _________________________ ___________ 0 0 5 ____________________________________________ ______ _________________________ ___________ 0 0 6 ____________________________________________ ______ _________________________ ___________ 0 0 7 ____________________________________________ ______ _________________________ ___________ 0 0 8 ____________________________________________ ______ _________________________ ___________ 0 0 9 ____________________________________________ ______ _________________________ ___________ 0 0

10 ____________________________________________ ______ _________________________ ___________ 0 0 11 ____________________________________________ ______ _________________________ ___________ 0 0 12 ____________________________________________ ______ _________________________ ___________ 0 0 13 ____________________________________________ ______ _________________________ ___________ 0 0 14 ____________________________________________ ______ _________________________ ___________ 0 0 15 ____________________________________________ ______ _________________________ ___________ 0 0 16 ____________________________________________ ______ _________________________ ___________ 0 0 17 ____________________________________________ ______ _________________________ ___________ 0 0 18 ____________________________________________ ______ _________________________ ___________ 0 0 19 ____________________________________________ ______ _________________________ ___________ 0 0 20 ____________________________________________ ______ _________________________ ___________ 0 0 21 ____________________________________________ ______ _________________________ ___________ 0 0 22 ____________________________________________ ______ _________________________ ___________ 0 0 23 ____________________________________________ ______ _________________________ ___________ 0 0 24 ____________________________________________ ______ _________________________ ___________ 0 0 25 ____________________________________________ ______ _________________________ ___________ 0 0 26 ____________________________________________ ______ _________________________ ___________ 0 0 27 ____________________________________________ ______ _________________________ ___________ 0 0 28 ____________________________________________ ______ _________________________ ___________ 0 0 29 ____________________________________________ ______ _________________________ ___________ 0 0 30 ____________________________________________ ______ _________________________ ___________ 0 0 31 ____________________________________________ ______ _________________________ ___________ 0 0 32 ____________________________________________ ______ _________________________ ___________ 0 0 33 ____________________________________________ ______ _________________________ ___________ 0 0 34 ____________________________________________ ______ _________________________ ___________ 0 0 35 ____________________________________________ ______ _________________________ ___________ 0 0 36 ____________________________________________ ______ _________________________ ___________ 0 0 37 ____________________________________________ ______ _________________________ ___________ 0 0 38 ____________________________________________ ______ _________________________ ___________ 0 0 39 ____________________________________________ ______ _________________________ ___________ 0 0 40 ____________________________________________ ______ _________________________ ___________ 0 0 41 ____________________________________________ ______ _________________________ ___________ 0 0 42 ____________________________________________ ______ _________________________ ___________ 0 0 43 ____________________________________________ ______ _________________________ ___________ 0 0 44 ____________________________________________ ______ _________________________ ___________ 0 0 45 ____________________________________________ ______ _________________________ ___________ 0 0 46 ____________________________________________ ______ _________________________ ___________ 0 0 47 ____________________________________________ ______ _________________________ ___________ 0 0 48 ____________________________________________ ______ _________________________ ___________ 0 0 49 ____________________________________________ ______ _________________________ ___________ 0 0 50 ____________________________________________ ______ _________________________ ___________ 0 0

51 Page total............................................................................. ................. ....................................................... ............................... 0 0 52 a. Subtotal from Page 2....................................................... ................. ....................................................... ............................... 0 0

b. Subtotal from Page 3....................................................... ................. ....................................................... ............................... 0 0

c. Subtotal from Page 4....................................................... ................. ....................................................... ............................... 0 0

53 Total Reclassifications (Col 4 must equal Col 5)................. ................. ....................................................... ............................... 0 0

(1) A Letter (A, B, etc.) Must Be Entered on Each Line to Identify Each Reclassification Entry. Net, must be 0 0

(2) Transfer to Worksheet E, Col. 2, lines as appropriate. ============

Summarized on Worksheet F, Page 3

(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)

Name of Plan: 0 Page 2 Plan #: H-xxxx PERIOD FROM: 01/00/00

TO: 01/00/00

CC LINE AMOUNT

CODE COST CENTER NUMBER

LINE EXPLANATION OF RECLASSIFICATION ENTRY (1) (Worksheet E) (WKST E) INCREASES (DECREASES) 1 2 3 4 5

54 ____________________________________________ ______ _________________________ ___________ 0 0 55 ____________________________________________ ______ _________________________ ___________ 0 0 56 ____________________________________________ ______ _________________________ ___________ 0 0 57 ____________________________________________ ______ _________________________ ___________ 0 0 58 ____________________________________________ ______ _________________________ ___________ 0 0 59 ____________________________________________ ______ _________________________ ___________ 0 0 60 ____________________________________________ ______ _________________________ ___________ 0 0 61 ____________________________________________ ______ _________________________ ___________ 0 0 62 ____________________________________________ ______ _________________________ ___________ 0 0 63 ____________________________________________ ______ _________________________ ___________ 0 0 64 ____________________________________________ ______ _________________________ ___________ 0 0 65 ____________________________________________ ______ _________________________ ___________ 0 0 66 ____________________________________________ ______ _________________________ ___________ 0 0 67 ____________________________________________ ______ _________________________ ___________ 0 0 68 ____________________________________________ ______ _________________________ ___________ 0 0 69 ____________________________________________ ______ _________________________ ___________ 0 0 70 ____________________________________________ ______ _________________________ ___________ 0 0 71 ____________________________________________ ______ _________________________ ___________ 0 0 72 ____________________________________________ ______ _________________________ ___________ 0 0 73 ____________________________________________ ______ _________________________ ___________ 0 0 74 ____________________________________________ ______ _________________________ ___________ 0 0 75 ____________________________________________ ______ _________________________ ___________ 0 0 76 ____________________________________________ ______ _________________________ ___________ 0 0 77 ____________________________________________ ______ _________________________ ___________ 0 0 78 ____________________________________________ ______ _________________________ ___________ 0 0 79 ____________________________________________ ______ _________________________ ___________ 0 0 80 ____________________________________________ ______ _________________________ ___________ 0 0 81 ____________________________________________ ______ _________________________ ___________ 0 0 82 ____________________________________________ ______ _________________________ ___________ 0 0 83 ____________________________________________ ______ _________________________ ___________ 0 0 84 ____________________________________________ ______ _________________________ ___________ 0 0 85 ____________________________________________ ______ _________________________ ___________ 0 0 86 ____________________________________________ ______ _________________________ ___________ 0 0 87 ____________________________________________ ______ _________________________ ___________ 0 0 88 ____________________________________________ ______ _________________________ ___________ 0 0 89 ____________________________________________ ______ _________________________ ___________ 0 0 90 ____________________________________________ ______ _________________________ ___________ 0 0 91 ____________________________________________ ______ _________________________ ___________ 0 0 92 ____________________________________________ ______ _________________________ ___________ 0 0 93 ____________________________________________ ______ _________________________ ___________ 0 0 94 ____________________________________________ ______ _________________________ ___________ 0 0 95 ____________________________________________ ______ _________________________ ___________ 0 0 96 ____________________________________________ ______ _________________________ ___________ 0 0 97 ____________________________________________ ______ _________________________ ___________ 0 0 98 ____________________________________________ ______ _________________________ ___________ 0 0 99 ____________________________________________ ______ _________________________ ___________ 0 0

100 ____________________________________________ ______ _________________________ ___________ 0 0 101 ____________________________________________ ______ _________________________ ___________ 0 0 102 ____________________________________________ ______ _________________________ ___________ 0 0 103 ____________________________________________ ______ _________________________ ___________ 0 0 104 ____________________________________________ ______ _________________________ ___________ 0 0 105 ____________________________________________ ______ _________________________ ___________ 0 0 106 ____________________________________________ ______ _________________________ ___________ 0 0 107 ____________________________________________ ______ _________________________ ___________ 0 0 108 ____________________________________________ ______ _________________________ ___________ 0 0 109 ____________________________________________ ______ _________________________ ___________ 0 0

110 Total Page 2 (Col 4 must equal Col 5)................................. ................. ....................................................... ............................... 0 0

(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry. Summarized on Worksheet F, Page 3

(2) Transfer to Worksheet E, Col. 2, lines as appropriate.

Name of Plan: 0 Page 3 Plan #: H-xxxx PERIOD FROM: 01/00/00

TO: 01/00/00

CC LINE AMOUNT

CODE COST CENTER NUMBER

LINE EXPLANATION OF RECLASSIFICATION ENTRY (1) (Worksheet E) (WKST E) INCREASES (DECREASES) 1 2 3 4 5

111 ____________________________________________ ______ _________________________ ___________ 0 0 112 ____________________________________________ ______ _________________________ ___________ 0 0 113 ____________________________________________ ______ _________________________ ___________ 0 0 114 ____________________________________________ ______ _________________________ ___________ 0 0 115 ____________________________________________ ______ _________________________ ___________ 0 0 116 ____________________________________________ ______ _________________________ ___________ 0 0 117 ____________________________________________ ______ _________________________ ___________ 0 0 118 ____________________________________________ ______ _________________________ ___________ 0 0 119 ____________________________________________ ______ _________________________ ___________ 0 0 120 ____________________________________________ ______ _________________________ ___________ 0 0 121 ____________________________________________ ______ _________________________ ___________ 0 0 122 ____________________________________________ ______ _________________________ ___________ 0 0 123 ____________________________________________ ______ _________________________ ___________ 0 0 124 ____________________________________________ ______ _________________________ ___________ 0 0 125 ____________________________________________ ______ _________________________ ___________ 0 0 126 ____________________________________________ ______ _________________________ ___________ 0 0 127 ____________________________________________ ______ _________________________ ___________ 0 0 128 ____________________________________________ ______ _________________________ ___________ 0 0 129 ____________________________________________ ______ _________________________ ___________ 0 0 130 ____________________________________________ ______ _________________________ ___________ 0 0 131 ____________________________________________ ______ _________________________ ___________ 0 0 132 ____________________________________________ ______ _________________________ ___________ 0 0 133 ____________________________________________ ______ _________________________ ___________ 0 0 134 ____________________________________________ ______ _________________________ ___________ 0 0 135 ____________________________________________ ______ _________________________ ___________ 0 0 136 ____________________________________________ ______ _________________________ ___________ 0 0 137 ____________________________________________ ______ _________________________ ___________ 0 0 138 ____________________________________________ ______ _________________________ ___________ 0 0 139 ____________________________________________ ______ _________________________ ___________ 0 0 140 ____________________________________________ ______ _________________________ ___________ 0 0 141 ____________________________________________ ______ _________________________ ___________ 0 0 142 ____________________________________________ ______ _________________________ ___________ 0 0 143 ____________________________________________ ______ _________________________ ___________ 0 0 144 ____________________________________________ ______ _________________________ ___________ 0 0 145 ____________________________________________ ______ _________________________ ___________ 0 0 146 ____________________________________________ ______ _________________________ ___________ 0 0 147 ____________________________________________ ______ _________________________ ___________ 0 0 148 ____________________________________________ ______ _________________________ ___________ 0 0 149 ____________________________________________ ______ _________________________ ___________ 0 0 150 ____________________________________________ ______ _________________________ ___________ 0 0 151 ____________________________________________ ______ _________________________ ___________ 0 0 152 ____________________________________________ ______ _________________________ ___________ 0 0 153 ____________________________________________ ______ _________________________ ___________ 0 0 154 ____________________________________________ ______ _________________________ ___________ 0 0 155 ____________________________________________ ______ _________________________ ___________ 0 0 156 ____________________________________________ ______ _________________________ ___________ 0 0 157 ____________________________________________ ______ _________________________ ___________ 0 0 158 ____________________________________________ ______ _________________________ ___________ 0 0 159 ____________________________________________ ______ _________________________ ___________ 0 0 160 ____________________________________________ ______ _________________________ ___________ 0 0 161 ____________________________________________ ______ _________________________ ___________ 0 0 162 ____________________________________________ ______ _________________________ ___________ 0 0 163 ____________________________________________ ______ _________________________ ___________ 0 0 164 ____________________________________________ ______ _________________________ ___________ 0 0 165 ____________________________________________ ______ _________________________ ___________ 0 0 166 ____________________________________________ ______ _________________________ ___________ 0 0

167 Total Page 3 (Col 4 must equal Col 5)................................. ................. ....................................................... ............................... 0 0

(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry. Summarized on Worksheet F, Page 3

(2) Transfer to Worksheet E, Col. 2, lines as appropriate.

Name of Plan: 0 Page 4 Plan #: H-xxxx PERIOD FROM: 01/00/00

TO: 01/00/00

CC LINE AMOUNT

CODE COST CENTER NUMBER

LINE EXPLANATION OF RECLASSIFICATION ENTRY (1) (Worksheet E) (WKST E) INCREASES (DECREASES) 1 2 3 4 5

168 ____________________________________________ ______ _________________________ ___________ 0 0 169 ____________________________________________ ______ _________________________ ___________ 0 0 170 ____________________________________________ ______ _________________________ ___________ 0 0 171 ____________________________________________ ______ _________________________ ___________ 0 0 172 ____________________________________________ ______ _________________________ ___________ 0 0 173 ____________________________________________ ______ _________________________ ___________ 0 0 174 ____________________________________________ ______ _________________________ ___________ 0 0 175 ____________________________________________ ______ _________________________ ___________ 0 0 176 ____________________________________________ ______ _________________________ ___________ 0 0 177 ____________________________________________ ______ _________________________ ___________ 0 0 178 ____________________________________________ ______ _________________________ ___________ 0 0 179 ____________________________________________ ______ _________________________ ___________ 0 0 180 ____________________________________________ ______ _________________________ ___________ 0 0 181 ____________________________________________ ______ _________________________ ___________ 0 0 182 ____________________________________________ ______ _________________________ ___________ 0 0 183 ____________________________________________ ______ _________________________ ___________ 0 0 184 ____________________________________________ ______ _________________________ ___________ 0 0 185 ____________________________________________ ______ _________________________ ___________ 0 0 186 ____________________________________________ ______ _________________________ ___________ 0 0 187 ____________________________________________ ______ _________________________ ___________ 0 0 188 ____________________________________________ ______ _________________________ ___________ 0 0 189 ____________________________________________ ______ _________________________ ___________ 0 0 190 ____________________________________________ ______ _________________________ ___________ 0 0 191 ____________________________________________ ______ _________________________ ___________ 0 0 192 ____________________________________________ ______ _________________________ ___________ 0 0 193 ____________________________________________ ______ _________________________ ___________ 0 0 194 ____________________________________________ ______ _________________________ ___________ 0 0 195 ____________________________________________ ______ _________________________ ___________ 0 0 196 ____________________________________________ ______ _________________________ ___________ 0 0 197 ____________________________________________ ______ _________________________ ___________ 0 0 198 ____________________________________________ ______ _________________________ ___________ 0 0 199 ____________________________________________ ______ _________________________ ___________ 0 0 200 ____________________________________________ ______ _________________________ ___________ 0 0 201 ____________________________________________ ______ _________________________ ___________ 0 0 202 ____________________________________________ ______ _________________________ ___________ 0 0 203 ____________________________________________ ______ _________________________ ___________ 0 0 204 ____________________________________________ ______ _________________________ ___________ 0 0 205 ____________________________________________ ______ _________________________ ___________ 0 0 206 ____________________________________________ ______ _________________________ ___________ 0 0 207 ____________________________________________ ______ _________________________ ___________ 0 0 208 ____________________________________________ ______ _________________________ ___________ 0 0 209 ____________________________________________ ______ _________________________ ___________ 0 0 210 ____________________________________________ ______ _________________________ ___________ 0 0 211 ____________________________________________ ______ _________________________ ___________ 0 0 212 ____________________________________________ ______ _________________________ ___________ 0 0 213 ____________________________________________ ______ _________________________ ___________ 0 0 214 ____________________________________________ ______ _________________________ ___________ 0 0 215 ____________________________________________ ______ _________________________ ___________ 0 0 216 ____________________________________________ ______ _________________________ ___________ 0 0 217 ____________________________________________ ______ _________________________ ___________ 0 0 218 ____________________________________________ ______ _________________________ ___________ 0 0 219 ____________________________________________ ______ _________________________ ___________ 0 0 220 ____________________________________________ ______ _________________________ ___________ 0 0 221 ____________________________________________ ______ _________________________ ___________ 0 0 222 ____________________________________________ ______ _________________________ ___________ 0 0 223 ____________________________________________ ______ _________________________ ___________ 0 0

224 Total Page 4 (Col 4 must equal Col 5)................................. ................. ....................................................... ............................... 0 0

(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry. Summarized on Worksheet F, Page 3

(2) Transfer to Worksheet E, Col. 2, lines as appropriate.

SUMMARY OF RECLASSIFICATIONS WORKSHEET F

Name of Plan: 0 Page 5 Plan #: H-xxxx PERIOD FROM: 01/00/00

TO: 01/00/00

SUMMARY OF RECLASSIFICATIONS

INCREASES (DECREASES) NET

CC (From Worksheet F, Pgs 1 & 2)

LINE COST CENTER DESCRIPTIONS 4 5 6

1 Inpatient Hospitals …….. ....................................................... 0 0 0 2 Outpatient Hospitals …………………………………………………………....................................................... 0 0 0 3 Skilled Nursing Facilities...................................................... ................. ....................................................... 0 0 0 4 Home Health Agencies........................................................ ................. ....................................................... 0 0 0 5 Clinics.................................................................................. ................. ....................................................... 0 0 0 6 Physician Groups................................................................. ................. ....................................................... 0 0 0 7 Individual Physicians............................................................ ................. ....................................................... 0 0 0 8 Certified Labs....................................................................... ................. ....................................................... 0 0 0 9 X-Ray Units.......................................................................... ................. ....................................................... 0 0 0

10 ESRD Facilities.................................................................... ................. ....................................................... 0 0 0 11 Durable Medical Equipment................................................. ................. ....................................................... 0 0 0 12 Ambulances......................................................................... ................. ....................................................... 0 0 0 13 Pharmacy (Outpatient)......................................................... ................. ....................................................... 0 0 0 13a Pharmacy-Medicare Covered Rx......................................... ................. ....................................................... 0 0 0 14 Emergency-Urgently Needed Svcs...................................... ................. ....................................................... 0 0 0 15 Mental Health Services........................................................ ................. ....................................................... 0 0 0 16 CO pd by MAC/Carrier/Inter ................. ....................................................... 0 0 0 16a DED pd by MAC/C/Inter 0 0 0 17 Other - Medicare Bad Debts...… ................. ....................................................... 0 0 0 18 Other - Blood Deductible.....… ................. ....................................................... 0 0 0 19 Part B Cost Not Subj to Coins. ................. ....................................................... 0 0 0 20 Non-Allowable Costs ................. ....................................................... 0 0 0 21 Other - (Specify)...…….......… ................. ....................................................... 0 0 0 22 Other - (Specify)...…….......… ................. ....................................................... 0 0 0 23 Other - (Specify)...…….......… ................. ....................................................... 0 0 0 25 Plan Administration.............................................................. ................. ....................................................... 0 0 0 26 Special Admin Costs............................................................ ................. ....................................................... 0 0 0 28 Admin & General Costs....................................................... ................. ....................................................... 0 0 0

29 Total Reclassifications (Lines 1 thru 28) (Col 6 must net to zero)......... ....................................................... 0 0 0

DIFFERENCES from total of pages 1 & 2 on page 1, Line 53…………………………………………………… 0 0 ============= ============= Must net to zero.

To Worksheet E If these differences are not Column 2 zero there is a problem!!

SUPPLEMENT TO WORKSHEET F - RECLASSIFICATIONS

Plan #: H-xxxx Period From: 01/00/00 To: 01/00/00 AD181...AN240

THIS IS A SUPPLEMENTAL WORKSHEET TO SUM UP RECLASSIFICATIONS BY COST CENTER

CCNO INCREASES (DECREASES)

1 IP Hosp 0 0

CCNO

2 OP Hosp 0 0

CCNO

3 SNF 0 0

CCNO

4 HHA 0 0

CCNO

5 Clinic 0 0

CCNO

6 Physicians Groups 0 0

CCNO

7 Ind Phy 0 0

CCNO

8 Labs 0 0

CCNO

9 Xray 0 0

CCNO

10 ESRD 0 0

CCNO

11 DME 0 0

CCNO

12 Amb 0 0

CCNO

13 Phrm 0 0

CCNO

14 Emerg 0 0

CCNO

15 Mental 0 0

CCNO

16 Ded & Coins 0 0

CCNO

17 0 0

CCNO

18 Other 0 0

CCNO

19 Nonallowable 0 0

CCNO

21 Plan Admin 0 0

CCNO

22 Spec Admin 0 0

CCNO

24 A&G 0 0

0 0

ADJUSTMENTS TO EXPENSES WORKSHEET G

Name of Plan: 0 PART I

Plan #: H-xxxx PERIOD FROM: 01/00/00 Page 1

TO: 01/00/00

BASIS Amount (2) CC LINE CC FOR (To Wkst E as COST CENTER NUMBER LINE DESCRIPTIONS ADJ (1) appropriate) (Wkst E) (Wkst E)

1 2 3 4

1 Investment income on commingled restricted & unrestricted funds................ _ 0 _____________________________ __ 2 Trade, quantity, time & other discounts on purchases..................................... _ 0 _____________________________ __ 3 Rebates & refunds of expenses....................................................................... _ 0 _____________________________ __ 4 Rental of space by suppliers............................................................................ _ 0 _____________________________ __ 5 Telephone service............................................................................................ _ 0 _____________________________ __ 6 Television & radio service................................................................................ _ 0 _____________________________ __ 7 Parking lot........................................................................................................ _ 0 _____________________________ __ 8 Home Office Costs (Attach copy of Home Office Cost Statement).......... _ 0 _____________________________ __ 9 Sale of scrap, waste, etc.................................................................................. _ 0 _____________________________ __

10 Adj. resulting from transactions with related organizations (3)......................... _ 0 _____________________________ __ 10a Adj. resulting from transactions with related organizations (3)......................... _ 0 _____________________________ __ 10b Adj. resulting from transactions with related organizations (3)......................... _ 0 _____________________________ __ 10c Adj. resulting from transactions with related organizations (3)......................... _ 0 _____________________________ __ 11 Laundry and linen service................................................................................ _ 0 _____________________________ __ 12 Cafeteria - employees, guests, etc................................................................... _ 0 _____________________________ __ 13 Rental of living quarters to employees and others........................................... _ 0 _____________________________ __ 14 Sale of medical and surgical supplies to other than patients........................... _ 0 _____________________________ __ 15 Sale of drugs to other than patients................................................................. _ 0 _____________________________ __ 16 Sale of medical records and abstracts............................................................. _ 0 _____________________________ __ 17 Nursing school (tuition, fees, uniforms, finance charges)................................ _ 0 _____________________________ __ 18 Income from vending machines....................................................................... _ 0 _____________________________ __ 19 Income from imposition of interest and finance charges.................................. _ 0 _____________________________ __ 20 Payments - Physicians' assumption of operating costs................................... _ 0 _____________________________ __ 21 Undistributed risk pool..................................................................................... _ 0 _____________________________ __ 22 Charges in excess of MAC screens................................................................. _ 0 _____________________________ __ 23 Part B coinsurance on services paid by CMS's MAC/Carriers........................ _ 0 _____________________________ __ 24 Part B coinsurance on services paid by CMS's MAC/Intermediaries............... _ 0 _____________________________ __ 25 Adjustment for physicial therapy costs in excess of limit (4)............................ _ 0 _____________________________ __ 26 Reinsurance......................................................................................