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[]
["Calculation of Low Income Utilization Revenue (LIUR) Percentage"]
[]
["Hospital Name:"]
["Medicaid #:"]
["FYE:"]
[]
["CALCULATION  OF  REVENUE  FRACTION:"]
[]
["   Medicaid Inpatient Reimbursement (Exclude DSH payments)"]
["   Plus: Medicaid Outpatient Reimbursement"]
["   Plus: State or Local Subsidy"]
[]
["   NET  LOW  INCOME  PATIENT  REVENUE",{"$nulls":5},0,"(1)"]
[]
["   Net Patient Revenue"]
["   Plus: State or Local Subsidy"]
[]
["   NET  PATIENT  REVENUE",{"$nulls":5},0,"(2)"]
[]
[]
["    REVENUE  FRACTION   (1) / (2)",{"$nulls":5},{"$error":"#DIV/0!"},"(3)"]
[]
[]
["CALCULATION  OF  FREE  CARE  FRACTION:"]
[]
["   Inpatient Free Care Charges (Gross)"]
["   Less: Inpatient State or Local Subsidy"]
[]
["   NET  INPATIENT  FREE  CARE  CHARGES",{"$nulls":5},0,"(4)"]
[]
["   TOTAL  INPATIENT  CHARGES (GROSS)",{"$nulls":6},"(5)"]
[]
["   FREE  CARE  FRACTION   (4) / (5)",{"$nulls":5},{"$error":"#DIV/0!"},"(6)"]
[]
[]
["CALCULATION  OF  LIUR  PERCENTAGE"]
["   Revenue Fraction  (3)",{"$nulls":5},{"$error":"#DIV/0!"}]
["   Plus: Free Care Fraction  (6)",{"$nulls":5},{"$error":"#DIV/0!"}]
[]
["   LIUR  PERCENTAGE",{"$nulls":5},{"$error":"#DIV/0!"}]
[]
[]
["NOTE:  LIUR percentage must exceed 25% in order for hospital to qualify for DSH under the LIUR criteria"]