{"text_format":"2","workbook":"xls","n_sheets":28,"sheets":["CY Changes","Submission Checklist","Instructions per CMS Audit Rule","Summary cost & pymt per CMS ","Instructions per UCC (Priv-Pub)","Summary cost&pmt UCC (Priv-Pub)","Per Diems & CCRs","Crosswalk","IP Analysis Rev Codes-EIDR ","IP Analysis-Cost Report Summary","OP Analysis Rev Codes - EIDR","Medicaid OP Fee Schedule","OP Analysis-Cost Report Summary","IP OP Crossover temp-FFS,SP&PP","Medicare Fee for Service","Ambulance Computation","Psych Analysis Rev Codes-EIDR","Psych Analysis - Cost Report","Psych Crossover templet-T,S&Pre","Uninsured IP Analysis Rev Codes","Uninsured IP CR Summary","Uninsured OP Analysis Rev Codes","Uninsured OP CR Summary","Uninsured Psych Analysis Rev Co","Uninsured Psych CR Summary","RHC Computation","RHC Crossover","RHC Uninsured"],"not_rendered":{"charts":0,"images":0,"macros":0,"external_links":1,"defined_names":49,"comments":1,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"run_cost":"one","rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900","formulas":"cached_only"}

{"sheet":"CY Changes","index":0,"n_rows":19,"n_cols":2,"rows_kept":19,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,"Schedule of Uncompensated Care Cost (per CMS Audit Rule) for Small Rural Hospitals SFY 2018"]
[]
[null,"Current year changes to SFY 2018 calculation"]
[1,"Added tab labed \"Submission Checklist\""]
[]
[2,"OP Analysis by Revenue Code-EIDR tab:"]
[null,"The EIDRs for Hospital Medicaid Outpatient is now separated into the following three (3) sections:"]
[null,"     - Reportable for Cost Report"]
[null,"     - Exclude CR-Third Party Liability-Zero Pay"]
[null,"    -  Exclude CR-Items Paid on Fee Schedule"]
[]
[null,"Key the \"Reportable for Cost Report\" and \"Exclude CR-Items Paid on Fee Schedule\" Covered Charges and Interim Payments in the first and last column for each payer (Covered Charges/Interim Payments) of the Outpatient tab."]
[null,"Key the \"Exclude CR-Third Party Liability-Zero Pay\" Covered charges in the TPL No Pay charge column of each payer.  "]
[]
[3,"Other Coverage -   Key the Total Other Coverage (TPL Third Party Liability) payment amounts from sections \"Exclude CR-Third Party Liability-Zero Pay\" and \"Exclude CR-Items Paid on Fee Schedule\" on the Outpatient tab as provided.  Note TPL payment amounts are entered in total by section not by revenue code. "]
[]
[4,"Shadow Charges - Enter the zero paid Shadow charges associated with a paid Medicaid Outpatient Surgery encounter in the Shadow Charge column.  Amounts are reported from the separate EIDR Shadow Charge report (Rpt 144F) or internal records as available.  "]
[]
[5,"Crossover tabs - Clarified Medicare payment lines are to be reported NET of sequestration reductions."]

{"sheet":"Submission Checklist","index":1,"n_rows":20,"n_cols":4,"rows_kept":20,"cut":false,"hidden":false,"merged":[[0,0,0,3],[2,0,2,3],[3,0,3,3]],"flags":["formulas_cached_only"]}
["Schedule of Uncompensated Care Cost (per CMS Audit Rule) for Small Rural Hospitals SFY 2018"]
[]
["The following items must be submitted along with the electronic file \"Small Rural Hospitals UCC SFY 18 rev1 8-10-2017.  Without all items, the submission will be"]
["considered incomplete."]
[null,null,"Included","N/A"]
[]
[1,"An electronic copy of the excel file \"Small Rural Hospitals UCC SFY 18 rev1 8-10-2017.\""]
[]
[2,"Signed  - Small Rural Hospitals Disproportionate Share Hospital (DSH) Annual Qualifications & Certification SFY/FFY 2018 form."]
[]
[3,"Signed - Schedule of Uncompensated Care Cost (per CMS Audit Rule) for Small Rural Hospitals SFY 2018, rev. 8/10/17."]
[]
[4,"Signed - Schedule of Uncompensated Care Cost (Private/Public) for Small Rural Hospitals SFY 2018."]
[]
[5,"Copy of ALL Rural Health Clinic licenses covering the entire Hospital's fiscal year."]
[]
[6,"Copy of Hospital's summary by revenue code and detail Medicaid log, if using in place of EIDR.  Note: the summary log must agree to the detail log."]
[]
[7,"Report that list charges by major payors listed on old UCC form that ties to Worksheet C.  Also, list payors included in commercial insurance"]
[null,"calculation (should include:  Medicare HMO, liability claims and worker's compensation)."]

{"sheet":"Instructions per CMS Audit Rule","index":2,"n_rows":32,"n_cols":3,"rows_kept":32,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Schedule of Uncompensated Care Cost (per CMS Audit Rule) for Small Rural Hospitals SFY 2018"]
[]
["HELPFUL HINTS WHEN COMPLETING FORMS:"]
[null,"** Complete the following tabs FIRST: \"Per Diems & CCRs\", and \"Crosswalk\" "]
[null,"** Use ROUNDED dollar amounts only (no cents)"]
[null,"** If extra cost center lines are needed, add these cost center lines to the Summary Tabs.  Make sure they are tied to the Per Diems & CCR TAB, and the Crosswalk TAB. "]
[]
[]
["Complete the yellow highlighted areas on the all applicable schedules as it relates to your facility."]
[null,"*  Only complete Rural Health Clinic Schedule if the Clinic is licensed as a department of the hospital.  "]
[null,"    NOTE:  A copy of the RHC license MUST be submitted with supporting documentation."]
[]
["Please do not override formulas."]
[]
["If you currently have a Revenue Code Schedule that is used for analysis of the EIDR, it can be substituted."]
[]
["Submit all supporting documentation with schedules (i.e..  Cost report pages, Medicare PS&R, EIDR with run date different from the "]
["one provided, Provider's records is substituted for EIDR,etc.)."]
[]
[null,"*  Detailed Uninsured Patient data should be maintained by the facility and available upon request."]
[]
["NOTE:","All EIDR's should be reconciled to your facility's records to ensure accuracy of data reported through the system."]
[]
["Template changes:"]
[]
[]
[]
[]
["Reminder:",null,"If data is not available during the external audit process conducted by Myers & Stauffer, "]
[null,null,"cost will be disallowed and the facility will be responsible for reimbursing all funds received."]
[]
["If you have any questions, or need assistance with flow of the spreadsheets please do not hesitate to call Tizi D. Robinson at (225) 219-4285."]

{"sheet":"Summary cost & pymt per CMS ","index":3,"n_rows":46,"n_cols":7,"rows_kept":46,"cut":false,"hidden":false,"merged":[[2,1,2,6],[42,3,42,4],[44,0,44,1],[41,0,41,6],[3,1,3,6],[4,1,4,6]],"flags":["formulas_cached_only"]}
["Schedule of Uncompensated Care Cost (per CMS Audit Rule) for Small Rural Hospitals SFY 2018, rev. 8/3/17"]
["Yellow Highlighted Areas Are Input"]
["Hospital Name"]
["Medicaid #"]
["FYE"]
[]
[{"$nulls":4},"Input"]
["CMS Audit Rule --Medicaid Summary Sheet ","Inpatient","Inpatient Psych/Magellan/ Magellan SMO","Outpatient","Rural Health Clinic (Licensed as Hospital Services)","Hospital Based Ambulance","Totals"]
["PLEASE    DO    NOT     OVERRIDE     FORMULAS   (NOTE:   UNINSURED PATIENT DATA REQUIRES DIRECT INPUT ON SUMMARY )"]
[]
["Cost:"]
["Medicaid Inpatient Costs",0,0,null,null,null,0]
["Medicaid Outpatient/RHC Costs",null,null,0,0,null,0]
["Fee Schedule Costs, Lab + TPL No Pay Cost",null,null,0,null,null,0]
["Crossover Costs - All Plans",null,0,0,0,null,0]
["Ambulance Costs (see calculation) - All Plans",{"$nulls":4},0,0]
["              Total Costs   (1)",0,0,0,0,0,0]
[]
["Payments:"]
["    Medicaid Inpatient Payments",0,0," "," ",null,0]
["    Cost Report Outpatient/RHC Settlement",null,null,0,0,null,0]
["    Primary Payers - OP/RHC  (Per EIDR)",0,0,0,0,null,0]
["    Crossover Payments (see calculation--see (G) on templets) - All Plans",null,0,0,0,null,0]
["    Fee Schedule Payments --Lab",null," ",0,null,null,0]
["   Ambulance Payments (see calculation) - All Plans",{"$nulls":4},0,0]
["              Total Payments  (2)",0,0,0,0,0,0]
[]
["               Medicaid Shortfall/(Long fall)  (1) - (2)",0,0,0,0,0,0]
["(Hospital Internal Records)"]
["Costs of Treating Uninsured Patients (Per Provider's Records)",0,0,0,0,0,0]
["Less: Payments from Patients",0,0,0,0,0,0]
["     Net Uninsured Costs (3)",0,0,0,0,0,0]
[]
["    Total Uncompensated Care Costs  ",0,0,0,0,0,0]
["     (Medicaid Shortfall(Long fall) + Net Uninsured Costs)"]
["** Filed cost report #'s as submitted to Medicaid Intermediary to be used & updated  using more recent EIDR or Provider's logs on attached worksheets. Please submit copies of applicable CR pages, Fee Sch w/PS&R "]
["     cost calculation and uninsured log summary of charges, days & payments. "]
[]
[]
["                                                     Prepared By",null,null,"Telephone #",null,null,"E-mail address"]
["The following certification is to be completed by the hospital's CEO or CFO:"]
["Based on the above cited source reporting fiscal year end cost report, I certify that the hospital has incurred those uncompensated costs.   I certify that from a review of currently available information and to the best of my knowledge from such review,  that the hospital will incur similar uncompensated care costs constituting public expenditures during state fiscal year 2018.  Since these uncompensated care costs are public expenditures, they are eligible for Medicaid disproportionate share payments in state fiscal year 2018.   I agree to maintain all documentation to support the above calculation.  I understand that this information will be audited in accordance with CMS DSH audit & reporting rule to ensure accuracy and compliance with state and federal regulations.  I understand that in accordance with federal law and the approved state plan, the limit for State Fiscal Year 2018 disproportionate share payments will be determined based on actual hospital uncompensated costs for dates of service from July 1, 2017 through June 30, 2018.\n\n\n\n\n"]
[]
["Signature",null,null,"Title",null,null,"Date"]
[]
["E-Mail Address"]

{"sheet":"Instructions per UCC (Priv-Pub)","index":4,"n_rows":56,"n_cols":15,"rows_kept":56,"cut":false,"hidden":false,"merged":[[33,2,39,13],[41,2,44,13],[46,2,47,13],[49,2,51,13],[0,0,0,13],[29,2,31,13]],"flags":["formulas_cached_only"]}
["Schedule of Uncompensated Care Cost (Private/Public) for Small Rural Hospitals SFY 2018"]
[]
["Complete the yellow highlighted areas on all applicable schedules as it relates to your facility."]
[null,"*  Only complete Rural Health Clinic Schedule if the Clinic is licensed as a department of the hospital."]
[null,"*  Do not use the Crossover statistics for this section.  Only the Federal section of the EIDR apply to this section.  "]
[null,"    NOTE:  A copy of the RHC license MUST be submitted with supporting documentation."]
[]
["Please do not override formulas."]
[]
["If you currently have a Revenue Code Schedule that is used for analysis of the EIDR, it can be substituted."]
[]
["Submit all supporting documentation with schedules (i.e..  Cost report pages, Medicare PS&R, EIDR with run date different from "]
["the one provided, Provider's records, if substituted, etc.)."]
[]
[]
["NOTE:","All EIDR's should be reconciled to your facility's records to ensure accuracy of data reported through the system."]
[]
[]
[{"$nulls":5},"FFY 2018"]
[{"$nulls":5},"DISPROPORTIONATE SHARE HOSPITAL INSTRUCTIONS - ",{"$nulls":8}," "]
[{"$nulls":5},"COMPLETION OF UNCOMPENSATED CARE COST DATA FORM"]
[]
["The attached forms and worksheets represents your hospital's actual unaudited amount of uncompensated care cost which must be based "]
["on dates of service for the latest filed fiscal year-end cost reporting period filed in accordance with Medicare guidelines, including extensions."]
["In accordance with federal law and our approved state plan, actual SFY 2018 uncompensated care cost data will have to be utilized as the payment limit.   "]
["You will be required to provide uncompensated care cost data from cost report periods covering service dates in SFY 2018 (7/1/2017 through 6/30/2018)"]
["at a later date. This data will most likely be submitted with your subsequent years’ disproportionate "]
["share uncompensated care costs calculations.  "]
[]
[null,1,"Total cost should be obtained from the cost report, Worksheet B, Part I, Column 26, Line 118 and must exclude costs for services that are not hospital level of care, i.e., home health, hospital based skilled nursing beds, swing beds, rural health clinics that are not licensed as a hospital services, Federally Qualified Health Centers, mental health rehabilitation services (partial hospitalization), clinics not included on the hospital license, and KIDMED."]
[]
[]
[]
[null,2,"Medicaid and Medicare data are to be derived from cost report data per the latest filed fiscal year end cost report period. If this cost reporting period is not a full year (twelve month) period, data from the previous cost reporting period may be used on a pro rata basis to equate to a full year. Include the revenue associated with Medicaid fee schedule payments, which are excluded from cost report settlement data, in this calculation. Medicaid fee schedule payment data may be obtained from your log or an EIDR that corresponds to your cost reporting period. Cost associated with Medicare outpatient and Part B only services paid on a fee schedule must also be included in Medicare cost. You may determine this cost by accumulating the charges of these Medicare services and multiplying by the appropriate cost to charge ratio."]
{"$rows_empty":7}
[null,null,"To determine the cost of private insurance patients or other hospital patient care, it is advised that you run \"mock\" cost reports which isolate the charges, days and other statistics related to these patients per your patient accounting system. You must calculate private insurance costs utilizing the same methodology as used to determine Medicaid patients' costs on the CMS 2552 cost reporting forms. "]
[null,3]
[]
[]
[]
[null,4,"Self pay revenues and other patient care revenues should be obtained from your patient accounting system or general ledger on a cash basis and should also correspond to your cost reporting period."]
[]
[]
[null,null,"Your hospital must maintain all documentation to support the attached calculation. This information and the costs corresponding to SFY 2018 uncompensated costs will be audited to ensure accuracy and compliance with state and federal regulations. "]
[null,5]
[]
[]
[]
["If you have any questions, or need assistance with flow of the spreadsheets please do not hesitate to call Tizi D. Robinson"]
["at (225) 219-4285."]

{"sheet":"Summary cost&pmt UCC (Priv-Pub)","index":5,"n_rows":55,"n_cols":13,"rows_kept":55,"cut":false,"hidden":false,"merged":[[2,4,2,6],[3,4,3,6],[4,4,4,6],[48,0,48,9]],"flags":["formulas_cached_only"]}
["Schedule of Uncompensated Care Cost (Private/Public) for Small Rural Hospitals SFY 2017"]
["Yellow Highlighted Areas Are Input"]
["Hospital Name:",null,null,null,0]
["Medicaid #",null,null,null,0]
["FYE",null,null,null,"00/00/0000",null,null,null,"Input"]
[]
[{"$nulls":6},"Hospital","Rural Health Clinic(s)","Hosp. Based","Amounts incl. RHC",null,"Hospital"]
[{"$nulls":5},"Source","Amounts","Licensed as","Ambulance","& Hosp. Based",null,"Charges"]
["UCC (Private/Public) --Medicaid Summary Sheet ",{"$nulls":5},"(See Exclusions)","Hospital Service","Amounts","Ambulance"]
[null,null,"*** (Hospital Excludes: SNF, HHA, SWB, RHC (not licensed as hosp. svc), ",null,null,"B Pt I, col. 26, Ln 118,",{"$nulls":6},"Gross Charges per Cost Report [Wkst. C, Pt I, Col 8, Ln 202"]
["I.  Total Cost",null," FQHC, MH Rehab,Partial Hosp,Amblance,other non hosp level of care svcs)",null,null," RHC's Line 88-88.06 & Ambl. Ln 95",0,0,0,0,null,0,"  less line 101 (HHA) & line 88.xx (RHC)]"]
["      Less:"]
[null,"Medicaid Net Revenues(Excl. DSH Payments):",null,null,null,"MEDICAID COMPUTATION - REQUIRES COMPLETION OF ATTACHED WORKSHEETS"]
[null,null,"Inpatient Acute (Incl. NICU/PICU)",null,null,"Attached W/S",0,null,null,0,null,0,"Gross Charges per EIDR Reports"]
[null,null,"Inpatient Psychiatric",null,null,"Attached W/S",0,null,null,0,null,0,"Gross Charges per EIDR Reports"]
[null,null,"Other Coverage (Incl. IP & OP Hosp, DPP)/RHC ",null,null,"Attached W/S",0,0,null,0,null,0,"Gross Charges per EIDR Reports"]
[null,null,"Outpatient Cost Based/RHC Cost/Ambl",null,null,"Attached W/S",0,0,0,0,null,0,"Gross Charges per EIDR Reports excluding RHC"]
[null,null,"Outpatient Lab Fee Schedule",null,null,"Attached W/S",0,null,null,0,null,0,"Gross Charges per EIDR Reports"]
[]
["II.",null,"Total Medicaid Net Revenues",null,null,null,0,0,0,0,null,0,"Total Medicaid Charges"]
[]
[null,"Medicare Costs:",null,null,null,"DIRECT    INPUT    BELOW"]
[null,null,"Inpatient Acute ",null,null,"T-18, D-1, Pt II, Ln 49",0,null,null,0,null,0,"Gross Charges per PS&R Reports"]
[null,null,"Inpatient Psychiatric",null,null,"T-18, D-1, Pt II, Ln 49, IPF",0,null,null,0,null,0,"Gross Charges per PS&R Reports"]
[null,null,"Inpatient Rehab/Inpatient Swing Bed",null,null,"T-18",0,null,null,0,null,0,"Gross Charges per PS&R Reports"]
[null,null,"Outpatient Cost Based/Ambulance ",null,null,"T-18, D V, col.5, Ln 200; Ambl: D V, col. 5, Ln 95",0,null,0,0,null,0,"Gross Charges per PS&R Reports"]
[null,null,"Rural Health Clinic(s) Cost ",null,null,"T-18, M-3, Ln 16 + Ln 17",null,0,null,0,null,null,"Test using visits"]
[null,null,"Outpatient Fee Schedule",null,null,"Attached W/S",0,null,null,0,null,0,"Gross Charges per PS&R Reports"]
[]
["III.",null,"Total Medicare Costs",null,null,null,0,0,0,0,null,0,"Total Medicare Charges"]
[]
["IV.","Private Insurance Costs",null,null,null,"Provider's Records (Send support)",0,0,0,0,null,0,"Gross Charges from Provider Records"]
[]
["V.","Self Pay Net Revenue",null,null,null,"Provider's Records (Send support)",0,0,0,0,null,0,"Gross Charges from Provider Records"]
[]
["VI.","All Other Hospital Patient Care Net Revenue"]
[null,"or Cost Not Included in Above-listed"]
[null,"Revenues & Costs (Please Itemize):"]
[null,null,"Swing Beds",null,null,"T-18",0,null,null,0,null,0,"Gross Charges from Provider Records"]
[null,null,"Intensive OP / OP Day Psych",null,null,"T-18",0,null,null,0,null,0,"Gross Charges from Provider Records"]
[null,null,"SNF/Home Health/Ambulance Trips to Other Facility",null,null,"T-18",0,null,0,0,null,0,"Gross Charges from Provider Records"]
[null,null,null,"Total (All Other)",null,null,0,null,0,0,null,0]
[]
["VII.  Total - Uncompensated Care Cost",{"$nulls":5},0,0,0,0,null,0,"Reasonableness Check"]
[]
["Prepared By:",null,0,null,null,"Telephone #:",0,"E-mail Address:",0,null,null,{"$error":"#DIV/0!"}]
[]
["The following certification is to be completed by the hospital's CEO or CFO:"]
["I agree to maintain all documentation to support the above calculation.  I understand that this information will be audited by the Medicaid t intermediary as part of the regular cost report audit process to ensure accuracy and compliance with state and federal regulations.  I understand that in accordance with federal law and the approved state plan, the limit for State Fiscal Year 2018 disproportionate share payments will be determined based on actual hospital uncompensated costs for dates of service from July 1, 2017 through June 30, 2018."]
[]
[]
["Signature",{"$nulls":5},"Title",null,null,"Date"]
[]
[]
["E-Mail Address",{"$nulls":5},"Phone"]

{"sheet":"Per Diems & CCRs","index":6,"n_rows":50,"n_cols":4,"rows_kept":50,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Hospital Name",0]
["Medicaid #",0]
["FYB:","00/00/0000","FYE:","00/00/0000"]
[]
[]
[null,null,"Inpatient","Outpatient"]
["COST CENTER LINE #","COST CENTER","(W/S D-1,Pt. II)"]
[30,"Adults & Peds-Routine Charges",0]
[31,"Intensive Care",0]
[40,"Psychiatric",0]
[43,"Nursery",0]
[31.01,"Neonatal Intensive Care",0]
[31.02,"Pediatric Intensive Care",0]
[44,"Coronary Care Unit",0]
[45,"Burn Intensive Care Unit",0]
[46,"Surgical Intensive Care Unit",0]
[47,"Other Special Care Unit (Specify)",0]
[]
[null,null,"(D-3, col. 1)","(W/S D Pt V, col. 1)"]
["XX","Non Allowable Routine/Ancillary (Rev.      )",0,0]
[50,"Operating Room",0,0]
[51,"Recovery Room",0,0]
[52,"Labor & Delivery Room",0,0]
[53,"Anesthesiology",0,0]
[54,"Radiology-Diagnostic",0,0]
[55,"Radiology-Therapeutic",0,0]
[56,"Radioisotope",0,0]
[57,"C T Scan",0,0]
[58,"MRI",0,0]
[59,"Cardiac Catherization",0,0]
[60,"Laboratory",0,0]
[62,"Whole &Packed Red Bl",0,0]
[63,"Blood Storing, Proc ",0,0]
[64,"Intravenous Therapy",0,0]
[65,"Respiratory Therapy",0,0]
[66,"Physical Therapy",0,0]
[67,"Occupational Therapy",0,0]
[68,"Speech Pathology",0,0]
[69,"Electrocardiology",0,0]
[70,"Electroencephalography",0,0]
[71,"Medical Supplies ",0,0]
[72,"Implantable Devices ",0,0]
[73,"Drugs Charged ",0,0]
[74,"Renal Dialysis",0,0]
[75,"ASC",0,0]
[76.01,"Cardiology Clinic",0,0]
[90,"Clinic",0,0]
[91,"Emergency",0,0]
[92,"Observation",0,0]
[95,"Ambulance",0,0]

{"sheet":"Crosswalk","index":7,"n_rows":153,"n_cols":4,"rows_kept":153,"cut":false,"hidden":false,"merged":[[5,1,5,3]],"flags":["formulas_cached_only"]}
["Hospital Name",0]
["Medicaid #",0]
["FYB:","00/00/0000","FYE:","00/00/0000"]
[]
[]
[null,"Cost Centers"]
["Revenue Code","Inpatient","Outpatient","Psychiatric"]
[110]
[111]
[112]
[113]
[114]
[120]
[121]
[124]
[117]
[170]
[171]
[172]
[174]
[200]
[203]
[206]
[230]
[250]
[251]
[254]
[255]
[258]
[259]
[260]
[269]
[270]
[271]
[272]
[274]
[275]
[276]
[278]
[290]
[292]
[294]
[300]
[301]
[302]
[303]
[304]
[305]
[306]
[307]
[309]
[310]
[311]
[312]
[320]
[322]
[323]
[324]
[329]
[331]
[333]
[335]
[341]
[342]
[343]
[344]
[350]
[351]
[352]
[359]
[360]
[361]
[370]
[381]
[390]
[391]
[400]
[401]
[402]
[403]
[404]
[409]
[410]
[412]
[420]
[421]
[422]
[423]
[424]
[430]
[431]
[432]
[433]
[434]
[440]
[441]
[442]
[443]
[444]
[450]
[460]
[470]
[471]
[480]
[481]
[482]
[490]
[500]
[510]
[511]
[512]
[514]
[516]
[540]
[610]
[611]
[612]
[623]
[634]
[635]
[636]
[637]
[683]
[710]
[720]
[722]
[723]
[730]
[731]
[732]
[740]
[750]
[760]
[761]
[762]
[770]
[771]
[801]
[802]
[820]
[825]
[829]
[850]
[863]
[900]
[914]
[915]
[916]
[920]
[921]
[922]
[940]
[942]

{"sheet":"IP Analysis Rev Codes-EIDR ","index":8,"n_rows":157,"n_cols":25,"rows_kept":157,"cut":false,"hidden":false,"merged":[[2,7,2,8],[9,8,10,9],[9,11,10,12],[9,14,10,15],[9,17,10,18],[9,2,10,6],[10,23,10,24],[12,2,12,3],[12,5,12,6],[12,8,12,9],[12,11,12,12],[12,14,12,15],[12,23,12,24],[12,17,12,18],[9,20,10,21],[12,20,12,21]],"flags":["formulas_cached_only"]}
["Hospital Name",0]
["Medicaid #",0]
["FYB:","00/00/0000","FYE:","00/00/0000",null,"EIDR print date:",null,"00/00/0000"]
[]
["Inpatient Analysis per  EIDR/Provider's Records (Revenue Code)"]
[]
["Input","Generic Revenue code/cost center listing.  Use appropriate revenue codes/cost center for Inpatient.  If revenue code/cost center is not listed, override unused code."]
[null,"** Note: Total Columns (Charges & Payments) transfers to:  IP Analysis-Cost Report Summary tab. "]
[]
[null,null,"TRADITIONAL MEDICAID & SHARED PLANS (FFS/SP)",{"$nulls":5},"AMERIGROUP OF LOUISIANA",null,null,"AMERIHEALTH CARITAS LA",null,null,"LA HEALTHCARE CONNECTIONS",null,null,"Aetna",null,null,"United Healthcare"]
[{"$nulls":23},"TOTAL MEDICAID"]
[]
[null,null,"**  Federal **",null,null,"**  Crossover  **",null,null,"**  Allowable  **",null,null,"**  Allowable  **",null,null,"**  Allowable  **",null,null,"**  Allowable  **",null,null,"**  Allowable  **",null,null,"** Allowable **"]
["Cost Center Line #","Revenue Code","Days","Total Charges ",null,"Days","Total Charges ",null,"Days","Total Charges ",null,"Days","Total Charges ",null,"Days","Total Charges ",null,"Days","Total Charges ",null,"Days","Total Charges ",null,"Total Days","Total Charges "]
[{"$nulls":23}," (Col.  C+L+T+AB) "," (Col.  D + I + O + U) "]
["Routine: "]
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[" Allowable Subtotal",null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0]
[]
["Ancillary:","Revenue Code"]
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[0,942,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[" Allowable Subtotal",null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[]
["Noncovered:"]
["XX","001",null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX","016",null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX","024",null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX","073",null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX",103,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX",230,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX",231,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX",530,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX",572,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX",992,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["Noncovered Subtotal",null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[]
["Totals",null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["Totals per EIDR Reports",null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[]
["Difference",null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[]
["Medicaid Payments (Per EIDRs)",null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["Medicaid Other Coverage (Per EIDRs)",null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[]
["Medicare Payment - Crossover Only (Per EIDR)",{"$nulls":5},0]

{"sheet":"IP Analysis-Cost Report Summary","index":9,"n_rows":61,"n_cols":13,"rows_kept":61,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Hospital Name",null,0]
["Medicaid #",null,0]
["FYE",null,"00:00:00"]
[]
["Inpatient  Analysis per Cost Report",{"$nulls":4},"EIDR print date:","00/00/0000"]
[]
[null,null,"Beginning",null,null,"Ending"]
["For the Period:  ",null,"00/00/0000",null,null,"00/00/0000"]
[]
["Input"]
[{"$nulls":4},"MEDICAID ALL PAYORS "]
[{"$nulls":4},"FEDERAL",{"$nulls":4},"CROSSOVER"]
[null,null,"Cost to Charge Ratio",null,"Days","Charges","Cost","Payments",null,"Days","Charges","Cost","Payments"]
["COST CENTER LINE #","COST CENTER","(W/S D-1,Pt. II)",null,"EIDR","EIDR/Prov W/S","Calculated","EIDR/Prov W/S",null,"EIDR","EIDR/Prov W/S","Calculated","EIDR/Prov W/S"]
[30,"Adults & Peds-Routine Charges",0,null,0,0,0,0,null,0,0,0,0]
[31,"Intensive Care",0,null,0,0,0,0,null,0,0,0,0]
[43,"Nursery",0,null,0,0,0,0,null,0,0,0,0]
[31.01,"Neonatal Intensive Care",0,null,0,0,0,0,null,0,0,0,0]
[31.02,"Pediatric Intensive Care",0,null,0,0,0,0,null,0,0,0,0]
[40,"Psychiatric",0,null,0,0,0,0,null,0,0,0,0]
[45,"Burn Intensive Care Unit",0,null,0,0,0,0,null,0,0,0,0]
[46,"Surgical Intensive Care Unit",0,null,0,0,0,0,null,0,0,0,0]
[47,"Other Special Care Unit (Specify)",0,null,0,0,0,0,null,0,0,0,0]
[null,"Total Routine",null,null,0,0,0,0,null,0,0,0,0]
[null,null,"(D-3, col. 1)"]
["XX","Non Allowable Routine/Ancillary (Rev.      )",0,null,null,0,null,0,null,null,0,0,0]
[50,"Operating Room",0,null,null,0,0,null,null,null,0,0,0]
[51,"Recovery Room",0,null,null,0,0,null,null,null,0,0,0]
[52,"Labor & Delivery Room",0,null,null,0,0,null,null,null,0,0,0]
[53,"Anesthesiology",0,null,null,0,0,null,null,null,0,0,0]
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[58,"MRI",0,null,null,0,0,null,null,null,0,0,0]
[59,"Cardiac Catherization",0,null,null,0,0,null,null,null,0,0,0]
[60,"Laboratory",0,null,null,0,0,null,null,null,0,0,0]
[62,"Whole &Packed Red Bl",0,null,null,0,0,null,null,null,0,0,0]
[63,"Blood Storing, Proc ",0,null,null,0,0,null,null,null,0,0,0]
[64,"Intravenous Therapy",0,null,null,0,0,null,null,null,0,0,0]
[65,"Respiratory Therapy",0,null,null,0,0,null,null,null,0,0,0]
[66,"Physical Therapy",0,null,null,0,0,null,null,null,0,0,0]
[67,"Occupational Therapy",0,null,null,0,0,null,null,null,0,0,0]
[68,"Speech Pathology",0,null,null,0,0,null,null,null,0,0,0]
[69,"Electrocardiology",0,null,null,0,0,null,null,null,0,0,0]
[70,"Electroencephalography",0,null,null,0,0,null,null,null,0,0,0]
[71,"Medical Supplies ",0,null,null,0,0,null,null,null,0,0,0]
[72,"Implantable Devices ",0,null,null,0,0,null,null,null,0,0,0]
[73,"Drugs Charged ",0,null,null,0,0,null,null,null,0,0,0]
[74,"Renal Dialysis",0,null,null,0,0,null,null,null,0,0,0]
[90,"Clinic",0,null,null,0,0,null,null,null,0,0,0]
[91,"Emergency",0,null,null,0,0,null,null,null,0,0,0]
[92,"Observation",0,null,null,0,0,null,null,null,0,0,0]
[95,"Ambulance",0,null,null,0,0,null,null,null,0,0,0]
[null,"Total I/P Ancillary",0,null,null,0,0,0,null,null,0,0,0]
[]
[null,"Total Routine & Ancillary",null,null,null,0,0,0,null,null,0,0,0]
["Less:"," Non allowable XIX Charges/Cost",null,null,null,0,null,0,null,null,0]
[null,"Net I/P Cost Based Reimbursement",null,null,null,0,0,0,null,null,0,0,0]
["Add:","I/P Other Coverage",{"$nulls":5},0,{"$nulls":4},0]
[null,"Total Inpatient",{"$nulls":5},0,{"$nulls":4},0]

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[null,null,null,"Note:",null,"Generic Revenue code/cost center listing.  Use appropriate revenue codes/cost center for Outpatient.  If revenue code/cost center is not listed, override unused code.",{"$nulls":9},"Note:",null,"Generic Revenue code/cost center listing.  Use appropriate revenue codes/cost center for Outpatient.  If revenue code/cost center is not listed, override unused code.",{"$nulls":9},"Note:",null,"Generic Revenue code/cost center listing.  Use appropriate revenue codes/cost center for Outpatient.  If revenue code/cost center is not listed, override unused code.",{"$nulls":9},"Note:",null,"Generic Revenue code/cost center listing.  Use appropriate revenue codes/cost center for Outpatient.  If revenue code/cost center is not listed, override unused code."]
[null,null,null,"** Note: Total Columns (Charges & Payments) transfers to:  OP Analysis-Cost Report Summary tab. ",{"$nulls":11},"** Note: Total Columns (Charges & Payments) transfers to:  OP Analysis-Cost Report Summary tab. ",{"$nulls":11},"** Note: Total Columns (Charges & Payments) transfers to:  OP Analysis-Cost Report Summary tab. ",{"$nulls":11},"** Note: Total Columns (Charges & Payments) transfers to:  OP Analysis-Cost Report Summary tab. "]
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[0,null,740,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
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[0,null,762,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
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[0,null,920,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
[0,null,921,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
[0,null,922,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
[0,null,942,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
[" Allowable Subtotal",null,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
[]
["Noncovered:"]
["XX",null,null,null,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
["XX",null,964,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
["XX",null,990,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
["XX",null,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
["Noncovered Subtotal",null,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
[]
["Totals",null,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,0]
["Amounts per EIDR/Provider's Records",null,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0]
[]
["Difference",null,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0,null,0,0,0,null,0]
[]
["EIDR Report Type 142 ( Total from Third Party Liability (TPL) column):"]
["Outpatient Other Coverage- Cost Report (Reportable for Cost Report)"]
["Outpatient Other Coverage- TPL No Pay (Exclude CR-Third Party Liability-Zero Pay)",{"$nulls":12},0,{"$nulls":5},0,{"$nulls":5},0,{"$nulls":5},0,{"$nulls":5},0,{"$nulls":5},0,{"$nulls":4},0]
["Outpatient Other Coverage- Fee Schedule (Exclude CR-Items Paid on Fee Schedule)",{"$nulls":12},0,{"$nulls":5},0,{"$nulls":5},0,{"$nulls":5},0,{"$nulls":5},0,{"$nulls":5},0,{"$nulls":4},0]

{"sheet":"Medicaid OP Fee Schedule","index":11,"n_rows":101,"n_cols":8,"rows_kept":101,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Hospital Name",null,null,0]
["Medicaid #",null,null,0]
["Cost report period",null,null,"00:00:00"]
[]
["Medicaid Outpatient Fee Schedule and TPL No Pay",{"$nulls":4},"Note:  If revenue codes are split on the OP Analysis Rev Codes EIDR tab,"]
[{"$nulls":5},"need to insert lines and transfer applicable fee schedule data"]
[]
[null,null,null,"** Note: Total Columns (Charges, Cost & Payments) transfers to:  OP Analysis-Cost Report Summary tab. "]
[]
[null,null,null,"TOTAL MEDICAID"]
[]
[null,null,null,"**  TOTAL ALLOWABLE  **"]
["COST CENTER LINE #","CCR","Revenue Code","Total Covered Charges (per EIDR / Provider's Records)","Lab Shadow Charges and TPL No Pay (per EIDR / Provider's Records)","Total Outpatient Charges","Fee Schedule Cost","Fee Schedule Payments (per EIDR / Provider's Records)"]
[0,0,250,null,0,0,0]
[0,0,258,null,0,0,0]
[0,0,260,null,0,0,0]
[0,0,270,null,0,0,0]
[0,0,271,null,0,0,0]
[0,0,272,null,0,0,0]
[0,0,274,null,0,0,0]
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[0,0,300,0,0,0,0,0]
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[0,0,302,0,0,0,0,0]
[0,0,303,0,0,0,0,0]
[0,0,304,0,0,0,0,0]
[0,0,305,0,0,0,0,0]
[0,0,306,0,0,0,0,0]
[0,0,307,0,0,0,0,0]
[0,0,309,0,0,0,0,0]
[0,0,310,0,0,0,0,0]
[0,0,311,0,0,0,0,0]
[0,0,312,0,0,0,0,0]
[0,0,320,null,0,0,0]
[0,0,324,null,0,0,0]
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[0,0,335,null,0,0,0]
[0,0,341,null,0,0,0]
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[0,0,350,null,0,0,0]
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[0,0,360,null,0,0,0]
[0,0,370,null,0,0,0]
[0,0,390,null,0,0,0]
[0,0,391,null,0,0,0]
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[0,0,420,null,0,0,0]
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[0,0,422,null,0,0,0]
[0,0,423,null,0,0,0]
[0,0,424,null,0,0,0]
[0,0,430,null,0,0,0]
[0,0,431,null,0,0,0]
[0,0,432,null,0,0,0]
[0,0,433,null,0,0,0]
[0,0,434,null,0,0,0]
[0,0,440,null,0,0,0]
[0,0,441,null,0,0,0]
[0,0,442,null,0,0,0]
[0,0,443,null,0,0,0]
[0,0,444,null,0,0,0]
[0,0,450,null,0,0,0]
[0,0,460,null,0,0,0]
[0,0,470,null,0,0,0]
[0,0,471,null,0,0,0]
[0,0,480,null,0,0,0]
[0,0,481,null,0,0,0]
[0,0,482,null,0,0,0]
[0,0,490,null,0,0,0]
[0,0,510,null,0,0,0]
[0,0,511,null,0,0,0]
[0,0,512,null,0,0,0]
[0,0,514,null,0,0,0]
[0,0,516,null,0,0,0]
[0,0,540,null,0,0,0]
[0,0,610,null,0,0,0]
[0,0,611,null,0,0,0]
[0,0,612,null,0,0,0]
[0,0,636,null,0,0,0]
[0,0,710,null,0,0,0]
[0,0,720,null,0,0,0]
[0,0,730,null,0,0,0]
[0,0,731,null,0,0,0]
[0,0,732,null,0,0,0]
[0,0,740,null,0,0,0]
[0,0,761,null,0,0,0]
[0,0,762,null,0,0,0]
[0,0,771,null,0,0,0]
[0,0,920,null,0,0,0]
[0,0,921,null,0,0,0]
[0,0,922,null,0,0,0]
[0,0,942,null,0,0,0]
["Total Fee Schedule",null,null,0,0,0,0,0]

{"sheet":"OP Analysis-Cost Report Summary","index":12,"n_rows":51,"n_cols":7,"rows_kept":51,"cut":false,"hidden":false,"merged":[[6,4,6,6]],"flags":["formulas_cached_only"]}
["Hospital Name",null,0]
["Medicaid #",null,0]
["FYE",null,"00:00:00"]
[]
["Outpatient Analysis per Cost Report",{"$nulls":4},"EIDR print date:","00/00/0000"]
[]
[null,"Input",null,null,"MEDICAID ALL PAYORS"]
[{"$nulls":4},"TOTAL  (FEDERAL + SHADOW)"]
["COST CENTER LINE #","COST CENTER","Cost to Charge Ratio",null,"Charges","Cost","Payments"]
[null,null,"(W/S D Pt V, col. 1)",null,"EIDR/Prov W/S","(W/S D Pt V, col. 6)","EIDR/Prov W/S"]
[]
["XX","Non Allowable Routine/Ancillary (Rev.      )",null,null,0,0,0]
[50,"Operating Room",0,null,0,0,0]
[51,"Recovery Room",0,null,0,0,0]
[52,"Labor & Delivery Room",0,null,0,0,0]
[53,"Anesthesiology",0,null,0,0,0]
[54,"Radiology-Diagnostic",0,null,0,0,0]
[55,"Radiology-Therapeutic",0,null,0,0,0]
[56,"Radioisotope",0,null,0,0,0]
[57,"C T Scan",0,null,0,0,0]
[58,"MRI",0,null,0,0,0]
[59,"Cardiac Catherization",0,null,0,0,0]
[60,"Laboratory",0,null,0,0,0]
[62,"Whole &Packed Red Bl",0,null,0,0,0]
[63,"Blood Storing",0,null,0,0,0]
[64,"Intravenous Therapy",0,null,0,0,0]
[65,"Respiratory Therapy",0,null,0,0,0]
[66,"Physical Therapy",0,null,0,0,0]
[67,"Occupational Therapy",0,null,0,0,0]
[68,"Speech Pathology",0,null,0,0,0]
[69,"Electrocardiology",0,null,0,0,0]
[70,"Electroencephalography",0,null,0,0,0]
[71,"Medical Supplies ",0,null,0,0,0]
[72,"Implantable Devices ",0,null,0,0,0]
[73,"Drugs Charged ",0,null,0,0,0]
[74,"Renal Dialysis",0,null,0,0,0]
[76.01,"Cardiology Clinic",0,null,0,0,0]
[90,"Clinic",0,null,0,0,0]
[91,"Emergency",0,null,0,0,0]
[92,"Observation",0,null,0,0,0]
[95,"Ambulance",0,null,0,0,0]
[null,"Total O/P Ancillary",0,null,0,0,0]
["Less:","Non-Allowable",null,null,0]
["Less:","Fee For Service Lab + TPL No Pay",0,null,0,0,0]
["Less:","Ambulance",null,null,0,0,0]
[null,"Net O/P Cost Based Reimbursement",null,null,0,0,0]
["Add:","10% Cost Reimbursement ",null,null,null,0]
[null,"O/P Medicaid Cost Based ",null,null,null,0]
["Add: ","O/P Lump Sum Payment Adjustment",{"$nulls":4},0]
["Add:","O/P Other Coverage - TPL No Pay and Fee Schedule",{"$nulls":4},0]
[null,"Total Outpatient - Cost Based ",null,null,null,0,0]

{"sheet":"IP OP Crossover temp-FFS,SP&PP","index":13,"n_rows":46,"n_cols":6,"rows_kept":46,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["TRADITIONAL MEDICAID, SHARED PLANS & PREPAID PLANS"]
["Calculation of Crossover Costs & Payments"]
[]
["Hospital Name",0]
["Medicaid #",0]
["FYE","00:00:00"]
["COMPLETE    APPROPRIATE    COLUMN",null,"Input"]
[]
["(Note:  For N/A Column, Enter 1.00 in 1st cell)",null,"PPS",null,null,"CAH"]
["Medicare Reimbursable Costs:"]
["Total IP Medicare Hospital Reimbursable Cost (PPS/CAH)","T-18, W/S D-1, Pt II, Line 49, col. 5",0,null,null,1]
["Total OP Medicare Hospital Reimbursable Cost (PPS/CAH)","W/S E, Pt B, Ln 1 & 2",0,null,null,0]
["OP Medicare Pass-Through Hospital Reimbursable Cost  (PPS)","W/S E, Pt B, Ln 9",0]
["Medicare Fee for Service Items (PPS/CAH)","PS&R 125,135,145,855\"fee\" Chgs x RCC--calculation",0,null,null,0]
["   Total  Medicare Reimbursable Cost",null,0,"A",null,1]
["Medicare Net Payments:"]
["IP Medicare Net Payments (PPS Hospitals) ","W/S E, Pt A, Ln 71 less Ln 71.01",0]
["OP Medicare Net Payments (PPS Hospitals)","W/S E,Pt B,Ln 40 less Ln 40.01",0]
["IP Medicare Net Payments (CAH Hospitals) ","W/S E-3, Pt V, Ln 6 less Ln 30.01",null,null,null,0]
["OP Medicare Net Payments (CAH Hospitals after 101%) ","W/S E,Pt B, Ln 21 less 40.01",null,null,null,0]
["OP Fee for Service Medicare Payments (PPS/CAH)","PS&R 125,135,145,855\"fee\" net reimbursement",0,null,null,0]
["   Total Medicare Payments"," ",0,"B",null,0]
["         Medicare Payments as a % of Cost ",null,0,"B/A",null,0]
[]
[]
["Medicare IP PPS Deductibles","W/S E, Pt A, Ln 62",0]
["Medicare IP PPS Co-Insurance","W/S E, Pt A, Ln 63",0]
["Medicare OP Deductibles & Co-Insurance (PPS)","W/S E, Pt B, Ln 25",0]
["Medicare OP Deductibles & Co-Insurance (PPS)","W/S E, Pt B, Ln 26",0]
["Medicare OP Fee for Service Deductibles & Co-Insurance (PPS)","PS&R 125,135,145,855\"fee\" deduct & coinsur",0]
["   Total Deductibles & Co-Insurance",null,0,"C"]
["          Medicare Deductibles & Co-Insurance as a % of Cost",null,0,"C/A"]
[]
[]
["Medicaid Crossover Calculated Adjusted Cost","Crossover EIDR days x D-1 + Anc Chgs x RCC",0,"D",null,0]
[" x  Medicare payment %","  see above calculation",0,null,null,0]
["Estimated Medicaid/Medicare Payments"," ",0,"E",null,0]
[]
["Medicaid In-State Crossover Actual Paymnts+Other Coverage (Incl. Ambulance)","    per EIDR  actual interim pymts",0,"F"]
[]
[]
["Medicare In-State Crossover Payments","Crossover Costs above:(D) x Medicare pymt % above)",0]
["Medicaid In-State Crossover Payments","Minimum of Calculated Max. Pymts or Payment Rec'd: (E) or (F)",0]
["          Total In-State Crossover Payments",null,0,"G"]
[]
["          Net Medicaid Crossover underpymt/ (overpymt)",null,0,null,null,0]

{"sheet":"Medicare Fee for Service","index":14,"n_rows":64,"n_cols":14,"rows_kept":64,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Hospital Name",null,null,0]
["Medicare Fee for Service PS&R Analysis"]
["FYE",null,null,"00:00:00",null,null,null,"Medicare PS&R run:",null,"00/00/0000"]
[]
["Inpatient & Outpatient",null,null,"Note:  If Revenue code is not used, delete entire ROW in order that Col. L & Col. N will properly calculate."]
[]
[{"$nulls":9},"Note:  This column can be replaced with correct CR Ln #"]
["Input",{"$nulls":8},"Medicaid",null,"Medicaid",null,"Fee For"]
[{"$nulls":7},"Total",null,"Cost Report Ln #",null,"RCC",null,"Service"]
["Revenue Code",null,"PS&R 125","PS&R 135","PS&R 145","PS&R 855",null,"Charges",null,"W/S D V",null,"W/S D V",null,"Cost"]
[250,null,0,0,0,0,null,0,null,73,null,0,null,0]
[260,null,0,0,0,0,null,0,null,71,null,0,null,0]
[270,null,0,0,0,0,null,0,null,71,null,0,null,0]
[271,null,0,0,0,0,null,0,null,71,null,0,null,0]
[272,null,0,0,0,0,null,0,null,71,null,0,null,0]
[274,null,0,0,0,0,null,0,null,72,null,0,null,0]
[275,null,0,0,0,0,null,0,null,72,null,0,null,0]
[278,null,0,0,0,0,null,0,null,72,null,0,null,0]
[300,null,0,0,0,0,null,0,null,60,null,0,null,0]
[301,null,0,0,0,0,null,0,null,60,null,0,null,0]
[302,null,0,0,0,0,null,0,null,60,null,0,null,0]
[303,null,0,0,0,0,null,0,null,60,null,0,null,0]
[304,null,0,0,0,0,null,0,null,60,null,0,null,0]
[305,null,0,0,0,0,null,0,null,60,null,0,null,0]
[306,null,0,0,0,0,null,0,null,60,null,0,null,0]
[307,null,0,0,0,0,null,0,null,60,null,0,null,0]
[309,null,0,0,0,0,null,0,null,60,null,0,null,0]
[310,null,0,0,0,0,null,0,null,60,null,0,null,0]
[311,null,0,0,0,0,null,0,null,60,null,0,null,0]
[370,null,0,0,0,0,null,0,null,71,null,0,null,0]
[400,null,0,0,0,0,null,0,null,53,null,0,null,0]
[401,null,0,0,0,0,null,0,null,54,null,0,null,0]
[402,null,0,0,0,0,null,0,null,54,null,0,null,0]
[403,null,0,0,0,0,null,0,null,54,null,0,null,0]
[409,null,0,0,0,0,null,0,null,54,null,0,null,0]
[410,null,0,0,0,0,null,0,null,54,null,0,null,0]
[420,null,0,0,0,0,null,0,null,66,null,0,null,0]
[421,null,0,0,0,0,null,0,null,66,null,0,null,0]
[422,null,0,0,0,0,null,0,null,66,null,0,null,0]
[423,null,0,0,0,0,null,0,null,66,null,0,null,0]
[424,null,0,0,0,0,null,0,null,66,null,0,null,0]
[430,null,0,0,0,0,null,0,null,66,null,0,null,0]
[431,null,0,0,0,0,null,0,null,66,null,0,null,0]
[432,null,0,0,0,0,null,0,null,66,null,0,null,0]
[433,null,0,0,0,0,null,0,null,66,null,0,null,0]
[434,null,0,0,0,0,null,0,null,66,null,0,null,0]
[440,null,0,0,0,0,null,0,null,66,null,0,null,0]
[441,null,0,0,0,0,null,0,null,66,null,0,null,0]
[442,null,0,0,0,0,null,0,null,66,null,0,null,0]
[443,null,0,0,0,0,null,0,null,66,null,0,null,0]
[444,null,0,0,0,0,null,0,null,66,null,0,null,0]
[540,null,0,0,0,0,null,0,null,95,null,0,null,0]
[762,null,0,0,0,0,null,0,null,92,null,0,null,0]
[770,null,0,0,0,0,null,0,null,71,null,0,null,0]
[942,null,0,0,0,0,null,0,null,54,null,0,null,0]
["Totals:",null,0,0,0,0,null,0,{"$nulls":5},0]
[]
["Gross Reimbursement:",null,0,0,0,0,null,0]
[]
[]
["Deductibles  (PPS/CAH):",null,0,0,0,0,null,0]
[" Coinsurance (PPS/CAH):",null,0,0,0,0,null,0,{"$nulls":5},0]
["(Excludes:  MSP Payments)"]
["Net Reimbursement (PPS/CAH):",null,0,0,0,0,null,0]

{"sheet":"Ambulance Computation","index":15,"n_rows":23,"n_cols":5,"rows_kept":23,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Hospital Name",0]
["Medicaid #",0]
["FYE","00:00:00",null,"EIDR print date:","00/00/0000"]
[]
[]
[null,null,"Input"]
[" D  O       N  O  T        O   V  E  R  R  I  D  E       F  O  R  M  U  L  A  S "]
[]
[]
["Ambulance Computation per CMS DSH Audit Method"]
[]
[]
["Total Cost  ","CR W/S B Pt I, Ln 95",0]
[]
["Outpatient Cost Based:"]
["     Billed Charges","Per EIDR (Rev. 540)",0]
["     Cost to Charge Ratio (CCR)","CR W/S C Pt I, Ln 95",0]
["     Calculated Cost ",null,0]
[]
["     Reimbursable Cost",null,0]
[]
[]
["Payments","Per EIDR (Rev. 540)",0]

{"sheet":"Psych Analysis Rev Codes-EIDR","index":16,"n_rows":120,"n_cols":26,"rows_kept":120,"cut":false,"hidden":false,"merged":[[10,21,10,22],[11,21,11,22],[10,24,10,25],[6,16,6,19],[6,22,6,25],[9,15,10,16],[11,15,11,16],[11,24,11,25],[11,18,11,19],[10,18,10,19],[11,3,11,4],[10,9,10,10],[11,9,11,10],[10,3,10,7],[6,4,6,7],[6,10,6,13],[10,12,10,13],[11,12,11,13],[11,6,11,7]],"flags":["formulas_cached_only"]}
["Hospital Name",null,null,null,0,null,null,"DPP",null,null,0,null,null,"DPP",null,null,0,null,null,"DPP",null,null,0,null,null,"DPP"]
["Medicaid #",null,null,null,0,null,null,"Input",null,null,0,null,null,"Input",null,null,0,null,null,"Input",null,null,0,null,null,"Input"]
["FYE",null,null,null,"00:00:00",{"$nulls":5},"00:00:00",{"$nulls":5},"00:00:00",{"$nulls":5},"00:00:00"]
[]
["Inpatient Analysis per  EIDR Federal (Revenue Code)",null,null,null,"EIDR print date:",null,null,"00/00/0000",null,null,"EIDR print date:",null,null,"00/00/0000",null,null,"EIDR print date:",null,null,"00/00/0000",null,null,"EIDR print date:",null,null,"00/00/0000"]
[]
["Note:",null,null,null,"Generic Revenue code/cost center listing.  Use appropriate revenue codes/cost center for Inpatient.  If revenue code/cost center is not listed, override unused code.",{"$nulls":5},"Generic Revenue code/cost center listing.  Use appropriate revenue codes/cost center for Inpatient.  If revenue code/cost center is not listed, override unused code.",{"$nulls":5},"Generic Revenue code/cost center listing.  Use appropriate revenue codes/cost center for Inpatient.  If revenue code/cost center is not listed, override unused code.",{"$nulls":5},"Generic Revenue code/cost center listing.  Use appropriate revenue codes/cost center for Inpatient.  If revenue code/cost center is not listed, override unused code."]
[null,null,null,"** Note: Total Columns (Charges & Payments) transfers to:  Psych Analysis-Cost Report tab. ",{"$nulls":5},"** Note: Total Columns (Charges & Payments) transfers to:  Psych Analysis-Cost Report tab. ",{"$nulls":5},"** Note: Total Columns (Charges & Payments) transfers to:  Psych Analysis-Cost Report tab. ",{"$nulls":5},"** Note: Total Columns (Charges & Payments) transfers to:  Psych Analysis-Cost Report tab. "]
[]
[{"$nulls":15},"LA HEALTHCARE CONNECTIONS (PP)"]
[null,null,null,"MAGELLAN",{"$nulls":5},"AMERIGROUP PREPAID (PP)",null,null,"LACARE (PP)",{"$nulls":5},"AETNA (PP)",null,null,"UNITED HEALTHCARE (PP)",null,null,"TOTAL MEDICAID"]
[null,null,null,"**  Federal **",null,null,"**  Crossover  **",null,null,"**  Allowable **",null,null,"**  Allowable **",null,null,"**  Allowable **",null,null,"**  Allowable **",null,null,"**  Allowable **",null,null,"**  Allowable  **"]
["COST CENTER LINE #","See CCR Input below","Revenue Code","Days (per EIDR)","Total Charges (per EIDR)",null,"Days (per EIDR)","Total Charges (per EIDR)",null,"Days (per EIDR)","Total Charges (per EIDR)",null,"Days (per EIDR)","Total Charges (per EIDR)",null,"Days (per EIDR)","Total Charges (per EIDR)",null,"Days (per EIDR)","Total Charges (per EIDR)",null,"Days (per EIDR)","Total Charges (per EIDR)",null,"Days (per EIDR)","Total Charges (per EIDR)"]
[]
["Routine: "]
[0,null,110,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0]
[0,null,114,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0]
[0,null,114,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0]
[0,null,120,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0]
[0,null,124,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0]
[" Allowable Subtotal",null,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0,null,0,0]
[]
["Ancillary:"]
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[0,null,251,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,254,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,255,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,258,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,259,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,260,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,270,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,271,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,272,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,274,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,275,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,278,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,294,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,300,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,301,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,302,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,305,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,306,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,307,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,309,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,310,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,311,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,312,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,320,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,323,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,324,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,333,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,341,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,342,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,343,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,350,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,351,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,352,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,360,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,361,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,370,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,381,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,390,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,391,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,401,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,402,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,403,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,410,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[{"$error":"#N/A"},null,413,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,420,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,424,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,430,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,434,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,440,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,441,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,444,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,450,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,460,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,470,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,471,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,480,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,481,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,490,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,610,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,611,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,612,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,634,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,635,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,636,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,683,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,710,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,720,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,730,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,731,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,740,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,750,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,761,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,762,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,771,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,801,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,900,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,914,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,915,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,916,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,921,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[0,null,942,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[" Allowable Subtotal",null,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[]
["Noncovered:"]
["XX",null,"001",null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX",null,180,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["XX",null,985,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["Noncovered Subtotal",null,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[]
["Totals",null,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["Totals per EIDR Reports",null,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[]
["Difference",null,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
[]
["Medicaid Payments (Per EIDRs)",null,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]
["Medicaid Other Coverage (Per EIDRs)",null,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0,null,null,0]

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["Hospital Name",null,0,null,null,"DPP"]
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[]
[null,null,"Beginning",null,"Ending"]
["For the Period:  ",null,"00/00/0000",null,"00/00/0000"]
[]
[null,null,null,"TOTAL MEDICAID"]
[null,null,null,"FEDERAL",{"$nulls":4},"CROSSOVER"]
["COST CENTER LINE #","COST CENTER","Cost to Charge Ratio","Days","Charges","Cost","Payments",null,"Days","Charges","Cost","Payments"]
[null,null,"(W/S D-1  (IPF))","EIDR","EIDR/Prov W/S","Calculated","EIDR/Prov W/S",null,"EIDR","EIDR/Prov W/S","Calculated","EIDR/Prov W/S"]
[40,"Adults & Peds-Routine Charges",0,0,0,0,0,null,0,0,0,0]
[null,"Total Routine",null,0,0,0,0,null,0,0,0,0]
[null,null,"( W/S D-3  (IPF))"]
["XX","Non Allowable Routine/Ancillary (Rev.      )",0,null,0,{"$nulls":4},0,0]
[50,"Operating Room",0,null,0,0,null,null,null,0,0]
[51,"Recovery Room",0,null,0,0,null,null,null,0,0]
[52,"Labor & Delivery Room",0,null,0,0,null,null,null,0,0]
[53,"Anesthesiology",0,null,0,0,null,null,null,0,0]
[54,"Radiology-Diagnostic",0,null,0,0,null,null,null,0,0]
[55,"Radiology-Therapeutic",0,null,0,0,null,null,null,0,0]
[56,"Radioisotope",0,null,0,0,null,null,null,0,0]
[57,"C T Scan",0,null,0,0,null,null,null,0,0]
[58,"MRI",0,null,0,0,null,null,null,0,0]
[59,"Cardiac Catherization",0,null,0,0,null,null,null,0,0]
[60,"Laboratory",0,null,0,0,null,null,null,0,0]
[62,"Whole &Packed Red Bl",0,null,0,0,null,null,null,0,0]
[63,"Blood Storing, Proc ",0,null,0,0,null,null,null,0,0]
[64,"Intravenous Therapy",0,null,0,0,null,null,null,0,0]
[65,"Respiratory Therapy",0,null,0,0,null,null,null,0,0]
[66,"Physical Therapy",0,null,0,0,null,null,null,0,0]
[67,"Occupational Therapy",0,null,0,0,null,null,null,0,0]
[68,"Speech Pathology",0,null,0,0,null,null,null,0,0]
[69,"Electrocardiology",0,null,0,0,null,null,null,0,0]
[70,"Electroencephalography",0,null,0,0,null,null,null,0,0]
[71,"Medical Supplies ",0,null,0,0,null,null,null,0,0]
[72,"Implantable Devices ",0,null,0,0,null,null,null,0,0]
[73,"Drugs Charged ",0,null,0,0,null,null,null,0,0]
[74,"Renal Dialysis",0,null,0,0,null,null,null,0,0]
[75,"ASC ",0,null,0,0,null,null,null,0,0]
[90,"Clinic",0,null,0,0,null,null,null,0,0]
[91,"Emergency",0,null,0,0,null,null,null,0,0]
[92,"Observation",0,null,0,0,null,null,null,0,0]
[95,"Ambulance",0,null,0,0,null,null,null,0,0]
[null,"Total I/P Ancillary",0,null,0,0,0,null,null,0,0,0]
[]
[null,"Total Routine & Ancillary",null,null,0,0,0,null,null,0,0,0]
["Less:"," Non allowable XIX Charges/Cost",null,null,0,null,0,null,null,0]
[null,"Net I/P Cost Based Reimbursement",null,null,0,0,0,null,null,0,0,0]
["Add:","I/P Other Coverage",{"$nulls":4},0,{"$nulls":4},0]
[null,"Total Inpatient",{"$nulls":4},0,{"$nulls":4},0]

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["TRADITIONAL MEDICAID, SHARED PLANS & PREPAID PLANS"]
["Calculation of Psych Crossover Costs & Payments"]
[]
["Hospital Name",0]
["Medicaid #",0]
["FYE","00:00:00"]
[]
[null,"(IRF Worksheets)","Input"]
["Medicare Reimbursable Costs:"]
["Total IP Medicare Subprovider Reimbursable Cost","T-18 (IPF), W/S D-1, Pt II, Line 49",0]
["   Total  Medicare Reimbursable Cost",null,0,"A"]
["Medicare Net Payments:"]
["IP Medicare Subprovider Net Payments (PPS) ","W/S E-3,Pt II, Ln 31 (net of ded/coin,msp+ bad debts+1%) less Ln 31.01",0]
["IP Medicare Subprovider Net Payments (CAH) ","W/S E-3,PtII, Ln 31 (net of ded/coin,msp+ bad debts+1%) less Ln 31.01",0]
["   Total Medicare Payments"," ",0,"B"]
["         Medicare Payments as a % of Cost ",null,0,"B/A"]
[]
[]
["Medicare IP Subprovider PPS Deductibles","W/S E-3, Pt II, Ln 19",0]
["Medicare IP Subprovider PPS Co-Insurance","W/S E-3, Pt II, Ln 21",0]
["Medicare IP Subprovider CAH Deductibles","W/S E-3, Pt II, Ln 19",0]
["Medicare IP Subprovider CAH Co-Insurance","W/S E-3, Pt II, Ln 21",0]
["   Total Deductibles & Co-Insurance",null,0,"C"]
["          Medicare Deductibles & Co-Insurance as a % of Cost",null,0,"C/A"]
[]
[]
["Medicaid In-State Crossover Calculated Adjusted Cost","Crossover EIDR days x D-1 + Anc Chgs x RCC",0,"D"]
[" x  Medicare deductible and co-insurance paymt %","  see above calculation",0]
["= Maximum Medicaid In-State Crossover Payments"," ",0,"E"]
[]
["Medicaid In-State Crossover Actual Paymnts+Other Coverage (Incl. Ambulance)","    per EIDR  actual interim pymts",0,"F"]
[]
[]
["Medicare In-State Crossover Payments","Crossover Costs above:(D) x Medicare pymt %  above)",0]
["Medicaid In-State Crossover Payments","Minimum of Calculated Max. Pymts or Payment Rec'd: (E) or (F)",0]
["          Total In-State Crossover Payments",null,0,"G"]
[]
["          Net Medicaid Crossover underpymt/ (overpymt)",null,0]

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["Hospital Name",0]
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["FYB:","00/00/0000","FYE:","00/00/0000"]
[]
["Uninsured Inpatient Analysis per Provider's Records (Revenue Code)"]
[]
["Input",null,"** Note: Total Columns (Charges & Payments) transfers to:  Uninsured IP CR Summary tab. "]
[]
[]
[null,null,null,"Uninsured"]
["Cost Center Line #","See CCR Input below","Revenue Code","Days","Total Charges "]
[]
["Routine: "]
[0,null,110,null,0]
[0,null,111,null,0]
[0,null,112,null,0]
[0,null,113,null,0]
[0,null,117,null,0]
[0,null,170,null,0]
[0,null,172,null,0]
[0,null,174,null,0]
[0,null,200,null,0]
[0,null,203,null,0]
[0,null,206,null,0]
[" Allowable Subtotal",null,null,0,0]
[]
["Ancillary:","See CCR Input below","Revenue Code"]
[0,null,250,null,0]
[0,null,258,null,0]
[0,null,259,null,0]
[0,null,260,null,0]
[0,null,270,null,0]
[0,null,271,null,0]
[0,null,272,null,0]
[0,null,274,null,0]
[0,null,275,null,0]
[0,null,276,null,0]
[0,null,278,null,0]
[0,null,300,null,0]
[0,null,301,null,0]
[0,null,302,null,0]
[0,null,305,null,0]
[0,null,306,null,0]
[0,null,307,null,0]
[0,null,309,null,0]
[0,null,310,null,0]
[0,null,320,null,0]
[0,null,322,null,0]
[0,null,323,null,0]
[0,null,324,null,0]
[0,null,329,null,0]
[0,null,331,null,0]
[0,null,333,null,0]
[0,null,341,null,0]
[0,null,342,null,0]
[0,null,343,null,0]
[0,null,344,null,0]
[0,null,350,null,0]
[0,null,351,null,0]
[0,null,352,null,0]
[0,null,359,null,0]
[0,null,360,null,0]
[0,null,361,null,0]
[0,null,370,null,0]
[0,null,390,null,0]
[0,null,391,null,0]
[0,null,401,null,0]
[0,null,402,null,0]
[0,null,403,null,0]
[0,null,404,null,0]
[0,null,410,null,0]
[0,null,420,null,0]
[0,null,424,null,0]
[0,null,430,null,0]
[0,null,434,null,0]
[0,null,440,null,0]
[0,null,444,null,0]
[0,null,450,null,0]
[0,null,460,null,0]
[0,null,470,null,0]
[0,null,471,null,0]
[0,null,480,null,0]
[0,null,481,null,0]
[0,null,482,null,0]
[0,null,490,null,0]
[0,null,510,null,0]
[0,null,540,null,0]
[0,null,610,null,0]
[0,null,611,null,0]
[0,null,612,null,0]
[0,null,623,null,0]
[0,null,634,null,0]
[0,null,635,null,0]
[0,null,636,null,0]
[0,null,637,null,0]
[0,null,710,null,0]
[0,null,720,null,0]
[0,null,722,null,0]
[0,null,723,null,0]
[0,null,730,null,0]
[0,null,732,null,0]
[0,null,740,null,0]
[0,null,750,null,0]
[0,null,760,null,0]
[0,null,761,null,0]
[0,null,762,null,0]
[0,null,771,null,0]
[0,null,801,null,0]
[0,null,802,null,0]
[0,null,820,null,0]
[0,null,825,null,0]
[0,null,829,null,0]
[0,null,850,null,0]
[0,null,863,null,0]
[0,null,915,null,0]
[0,null,921,null,0]
[0,null,922,null,0]
[0,null,940,null,0]
[0,null,942,null,0]
[" Allowable Subtotal",null,null,null,0]
[]
["Noncovered:"]
["XX",null,"001",null,0]
["XX",null,"016",null,0]
["XX",null,"024",null,0]
["XX",null,"073",null,0]
["XX",null,103,null,0]
["XX",null,230,null,0]
["XX",null,960,null,0]
["XX",null,981,null,0]
["XX",null,987,null,0]
["XX",null,990,null,0]
["Noncovered Subtotal",null,null,null,0]
[]
["Totals",null,null,null,0]

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["Hospital Name",null,0]
["Medicaid #",null,0]
["FYE",null,"00:00:00"]
[]
["Uninsured Inpatient  Analysis per Cost Report"]
[]
[null,null,"Beginning",null,null,"Ending"]
["For the Period:  ",null,"00/00/0000",null,null,"00/00/0000"]
[]
["Input"]
[{"$nulls":4},"Uninsured"]
[]
[null,null,"Cost to Charge Ratio",null,"Days","Charges","Cost"]
["COST CENTER LINE #","COST CENTER","(W/S D-1,Pt. II)",null,"Provider Records","Provider Records","Calculated"]
[30,"Adults & Peds-Routine Charges",0,null,0,0,0]
[31,"Intensive Care",0,null,0,0,0]
[43,"Nursery",0,null,0,0,0]
[31.01,"Neonatal Intensive Care",0,null,0,0,0]
[31.02,"Pediatric Intensive Care",0,null,0,0,0]
[44,"Coronary Care Unit",0,null,0,0,0]
[45,"Burn Intensive Care Unit",0,null,0,0,0]
[46,"Surgical Intensive Care Unit",0,null,0,0,0]
[47,"Other Special Care Unit (Specify)",0,null,0,0,0]
[null,"Total Routine",null,null,0,0,0]
[null,null,"(D-3, col. 1)"]
["XX","Non Allowable Routine/Ancillary (Rev.      )",0,null,null,0]
[50,"Operating Room",0,null,null,0,0]
[51,"Recovery Room",0,null,null,0,0]
[52,"Labor & Delivery Room",0,null,null,0,0]
[53,"Anesthesiology",0,null,null,0,0]
[54,"Radiology-Diagnostic",0,null,null,0,0]
[55,"Radiology-Therapeutic",0,null,null,0,0]
[56,"Radioisotope",0,null,null,0,0]
[57,"C T Scan",0,null,null,0,0]
[58,"MRI",0,null,null,0,0]
[59,"Cardiac Catherization",0,null,null,0,0]
[60,"Laboratory",0,null,null,0,0]
[62,"Whole &Packed Red Bl",0,null,null,0,0]
[63,"Blood Storing, Proc ",0,null,null,0,0]
[64,"Intravenous Therapy",0,null,null,0,0]
[65,"Respiratory Therapy",0,null,null,0,0]
[66,"Physical Therapy",0,null,null,0,0]
[67,"Occupational Therapy",0,null,null,0,0]
[68,"Speech Pathology",0,null,null,0,0]
[69,"Electrocardiology",0,null,null,0,0]
[70,"Electroencephalography",0,null,null,0,0]
[71,"Medical Supplies ",0,null,null,0,0]
[72,"Implantable Devices ",0,null,null,0,0]
[73,"Drugs Charged ",0,null,null,0,0]
[74,"Renal Dialysis",0,null,null,0,0]
[90,"Clinic",0,null,null,0,0]
[91,"Emergency",0,null,null,0,0]
[92,"Observation",0,null,null,0,0]
[95,"Ambulance",0,null,null,0,0]
[null,"Total I/P Ancillary",0,null,null,0,0]
[]
[null,"Total Routine & Ancillary",null,null,null,0,0]
["Less:"," Non allowable Charges/Cost",null,null,null,0]
[null,"Net I/P Cost Based Reimbursement",null,null,null,0,0]

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["Hospital Name",0]
["Medicaid #",0]
["FYB:","00/00/0000","FYE:","00/00/0000"]
[]
["Uninsured Outpatient Analysis per  EIDR/Provider's Records (Revenue Code)"]
[]
["Input","** Note: Total Columns (Charges & Payments) transfers to:  Uninsured OP Analysis-Cost Report Summary tab. "]
[]
[]
[null,null,null,"Uninsured"]
[]
[]
["Cost Center Line #","See CCR Input below","Revenue Code","Total Charges "]
[0,null,250,0]
[0,null,258,0]
[0,null,259,0]
[0,null,260,0]
[0,null,270,0]
[0,null,271,0]
[0,null,272,0]
[0,null,274,0]
[0,null,275,0]
[0,null,276,0]
[0,null,292,0]
[0,null,300,0]
[0,null,301,0]
[0,null,302,0]
[0,null,305,0]
[0,null,306,0]
[0,null,307,0]
[0,null,309,0]
[0,null,310,0]
[0,null,320,0]
[0,null,322,0]
[0,null,323,0]
[0,null,324,0]
[0,null,329,0]
[0,null,331,0]
[0,null,333,0]
[0,null,341,0]
[0,null,342,0]
[0,null,343,0]
[0,null,344,0]
[0,null,350,0]
[0,null,351,0]
[0,null,352,0]
[0,null,359,0]
[0,null,360,0]
[0,null,361,0]
[0,null,370,0]
[0,null,390,0]
[0,null,391,0]
[0,null,401,0]
[0,null,402,0]
[0,null,403,0]
[0,null,404,0]
[0,null,410,0]
[0,null,420,0]
[0,null,424,0]
[0,null,430,0]
[0,null,434,0]
[0,null,440,0]
[0,null,444,0]
[0,null,450,0]
[0,null,460,0]
[0,null,470,0]
[0,null,471,0]
[0,null,480,0]
[0,null,481,0]
[0,null,482,0]
[0,null,490,0]
[0,null,510,0]
[0,null,540,0]
[0,null,610,0]
[0,null,611,0]
[0,null,612,0]
[0,null,623,0]
[0,null,634,0]
[0,null,635,0]
[0,null,636,0]
[0,null,637,0]
[0,null,710,0]
[0,null,720,0]
[0,null,722,0]
[0,null,723,0]
[0,null,730,0]
[0,null,731,0]
[0,null,732,0]
[0,null,740,0]
[0,null,760,0]
[0,null,761,0]
[0,null,762,0]
[0,null,771,0]
[0,null,801,0]
[0,null,802,0]
[0,null,820,0]
[0,null,825,0]
[0,null,829,0]
[0,null,850,0]
[0,null,863,0]
[0,null,915,0]
[0,null,921,0]
[0,null,922,0]
[0,null,940,0]
[0,null,942,0]
[" Allowable Subtotal",null,null,0]
[]
["Noncovered:"]
["XX",null,"001",0]
["XX",null,"016",0]
["XX",null,"024",0]
["XX",null,"073",0]
["XX",null,103,0]
["XX",null,230,0]
["XX",null,960,0]
["XX",null,981,0]
["XX",null,987,0]
["XX",null,992,0]
["Noncovered Subtotal",null,null,0]
[]
["Totals",null,null,0]

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["Hospital Name",null,0]
["Medicaid #",null,0]
["FYE",null,"00:00:00"]
[]
["Uninsured Outpatient  Analysis per Cost Report"]
[]
[null,null,"Beginning",null,null,"Ending"]
["For the Period:  ",null,"00/00/0000",null,null,"00/00/0000"]
[]
["Input"]
[{"$nulls":4},"Uninsured"]
[]
[null,null,"Cost to Charge Ratio",null,"Days","Charges","Cost"]
["COST CENTER LINE #","COST CENTER","(W/S D Pt V, col. 1)",null,"Provider Records","Provider Records","Calculated"]
["XX","Non Allowable Routine/Ancillary (Rev.      )",0,null,null,0]
[50,"Operating Room",0,null,null,0,0]
[51,"Recovery Room",0,null,null,0,0]
[52,"Labor & Delivery Room",0,null,null,0,0]
[53,"Anesthesiology",0,null,null,0,0]
[54,"Radiology-Diagnostic",0,null,null,0,0]
[55,"Radiology-Therapeutic",0,null,null,0,0]
[56,"Radioisotope",0,null,null,0,0]
[57,"C T Scan",0,null,null,0,0]
[58,"MRI",0,null,null,0,0]
[59,"Cardiac Catherization",0,null,null,0,0]
[60,"Laboratory",0,null,null,0,0]
[62,"Whole &Packed Red Bl",0,null,null,0,0]
[63,"Blood Storing, Proc ",0,null,null,0,0]
[64,"Intravenous Therapy",0,null,null,0,0]
[65,"Respiratory Therapy",0,null,null,0,0]
[66,"Physical Therapy",0,null,null,0,0]
[67,"Occupational Therapy",0,null,null,0,0]
[68,"Speech Pathology",0,null,null,0,0]
[69,"Electrocardiology",0,null,null,0,0]
[70,"Electroencephalography",0,null,null,0,0]
[71,"Medical Supplies ",0,null,null,0,0]
[72,"Implantable Devices ",0,null,null,0,0]
[73,"Drugs Charged ",0,null,null,0,0]
[74,"Renal Dialysis",0,null,null,0,0]
[76.01,"Cardiology Clinic",0,null,null,0,0]
[90,"Clinic",0,null,null,0,0]
[91,"Emergency",0,null,null,0,0]
[92,"Observation",0,null,null,0,0]
[95,"Ambulance",0,null,null,0,0]
[null,"Total O/P Ancillary",0,null,null,0,0]
[]
[null,"Total Charges",null,null,null,0,0]
["Less:"," Non allowable Charges/Cost",null,null,null,0]
["Less:","Ambulance",null,null,null,0,0]
[null,"Net O/P Cost Based Reimbursement",null,null,null,0,0]

{"sheet":"Uninsured Psych Analysis Rev Co","index":23,"n_rows":136,"n_cols":5,"rows_kept":136,"cut":false,"hidden":false,"merged":[[9,3,9,4],[6,1,7,4]],"flags":["formulas_cached_only"]}
["Hospital Name",0]
["Medicaid #",0]
["FYB:","00/00/0000","FYE:","00/00/0000"]
[]
["Uninsured Psychiatric Analysis per  EIDR/Provider's Records (Revenue Code)"]
[]
["Input","** Note: Total Columns (Charges & Payments) transfers to:  Uninsured Psychiatric Analysis-Cost Report Summary tab. "]
[]
[]
[null,null,null,"Uninsured"]
[]
[]
["Cost Center Line #","See CCR Input below","Revenue Code","Days","Total Charges "]
[]
["Routine: "]
[0,null,110,null,0]
[0,null,111,null,0]
[0,null,112,null,0]
[0,null,114,null,0]
[0,null,117,null,0]
[0,null,171,null,0]
[0,null,172,null,0]
[0,null,174,null,0]
[0,null,200,null,0]
[0,null,203,null,0]
[0,null,206,null,0]
[" Allowable Subtotal",null,null,0,0]
[]
["Ancillary:","See CCR Input below","Revenue Code"]
[0,null,250,null,0]
[0,null,258,null,0]
[0,null,259,null,0]
[0,null,260,null,0]
[0,null,270,null,0]
[0,null,271,null,0]
[0,null,272,null,0]
[0,null,274,null,0]
[0,null,275,null,0]
[0,null,276,null,0]
[0,null,278,null,0]
[0,null,300,null,0]
[0,null,301,null,0]
[0,null,302,null,0]
[0,null,305,null,0]
[0,null,306,null,0]
[0,null,307,null,0]
[0,null,309,null,0]
[0,null,310,null,0]
[0,null,320,null,0]
[0,null,322,null,0]
[0,null,323,null,0]
[0,null,324,null,0]
[0,null,329,null,0]
[0,null,331,null,0]
[0,null,333,null,0]
[0,null,341,null,0]
[0,null,342,null,0]
[0,null,343,null,0]
[0,null,344,null,0]
[0,null,350,null,0]
[0,null,351,null,0]
[0,null,352,null,0]
[0,null,359,null,0]
[0,null,360,null,0]
[0,null,361,null,0]
[0,null,370,null,0]
[0,null,390,null,0]
[0,null,391,null,0]
[0,null,401,null,0]
[0,null,402,null,0]
[0,null,403,null,0]
[0,null,404,null,0]
[0,null,410,null,0]
[0,null,420,null,0]
[0,null,424,null,0]
[0,null,430,null,0]
[0,null,434,null,0]
[0,null,440,null,0]
[0,null,444,null,0]
[0,null,450,null,0]
[0,null,460,null,0]
[0,null,470,null,0]
[0,null,471,null,0]
[0,null,480,null,0]
[0,null,481,null,0]
[0,null,482,null,0]
[0,null,490,null,0]
[0,null,510,null,0]
[0,null,540,null,0]
[0,null,610,null,0]
[0,null,611,null,0]
[0,null,612,null,0]
[0,null,634,null,0]
[0,null,635,null,0]
[0,null,636,null,0]
[0,null,637,null,0]
[0,null,710,null,0]
[0,null,720,null,0]
[0,null,722,null,0]
[0,null,723,null,0]
[0,null,730,null,0]
[0,null,731,null,0]
[0,null,740,null,0]
[0,null,750,null,0]
[0,null,760,null,0]
[0,null,761,null,0]
[0,null,762,null,0]
[0,null,771,null,0]
[0,null,801,null,0]
[0,null,802,null,0]
[0,null,820,null,0]
[0,null,825,null,0]
[0,null,829,null,0]
[0,null,850,null,0]
[0,null,863,null,0]
[0,null,915,null,0]
[0,null,921,null,0]
[0,null,922,null,0]
[0,null,940,null,0]
[0,null,942,null,0]
[" Allowable Subtotal",null,null,null,0]
[]
["Noncovered:"]
["XX",null,"001",null,0]
["XX",null,"016",null,0]
["XX",null,"024",null,0]
["XX",null,"073",null,0]
["XX",null,103,null,0]
["XX",null,230,null,0]
["XX",null,231,null,0]
["XX",null,981,null,0]
["XX",null,987,null,0]
["XX",null,992,null,0]
["Noncovered Subtotal",null,null,null,0]
[]
["Totals",null,null,null,0]

{"sheet":"Uninsured Psych CR Summary","index":24,"n_rows":59,"n_cols":7,"rows_kept":59,"cut":false,"hidden":false,"merged":[[10,4,10,6]],"flags":["formulas_cached_only"]}
["Hospital Name",null,0]
["Medicaid #",null,0]
["FYE",null,"00:00:00"]
[]
["Uninsured Psychiatric  Analysis per Cost Report"]
[]
[null,null,"Beginning",null,null,"Ending"]
["For the Period:  ",null,"00/00/0000",null,null,"00/00/0000"]
[]
["Input"]
[{"$nulls":4},"Uninsured"]
[]
[null,null,"Cost to Charge Ratio",null,"Days","Charges","Cost"]
["COST CENTER LINE #","COST CENTER","(W/S D-1,Pt. II)",null,"Provider Records","Provider Records","Calculated"]
[30,"Adults & Peds-Routine Charges",0,null,0,0,0]
[31,"Intensive Care",0,null,0,0,0]
[40,"Psychiatric",0,null,0,0,0]
[31.01,"Neonatal Intensive Care",0,null,0,0,0]
[31.02,"Pediatric Intensive Care",0,null,0,0,0]
[44,"Coronary Care Unit",0,null,0,0,0]
[45,"Burn Intensive Care Unit",0,null,0,0,0]
[46,"Surgical Intensive Care Unit",0,null,0,0,0]
[47,"Other Special Care Unit (Specify)",0,null,0,0,0]
[null,"Total Routine",null,null,0,0,0]
[null,null,"(D-3, col. 1)"]
["XX","Non Allowable Routine/Ancillary (Rev.      )",0,null,null,0]
[50,"Operating Room",0,null,null,0,0]
[51,"Recovery Room",0,null,null,0,0]
[52,"Labor & Delivery Room",0,null,null,0,0]
[53,"Anesthesiology",0,null,null,0,0]
[54,"Radiology-Diagnostic",0,null,null,0,0]
[55,"Radiology-Therapeutic",0,null,null,0,0]
[56,"Radioisotope",0,null,null,0,0]
[57,"C T Scan",0,null,null,0,0]
[58,"MRI",0,null,null,0,0]
[59,"Cardiac Catherization",0,null,null,0,0]
[60,"Laboratory",0,null,null,0,0]
[62,"Whole &Packed Red Bl",0,null,null,0,0]
[63,"Blood Storing, Proc ",0,null,null,0,0]
[64,"Intravenous Therapy",0,null,null,0,0]
[65,"Respiratory Therapy",0,null,null,0,0]
[66,"Physical Therapy",0,null,null,0,0]
[67,"Occupational Therapy",0,null,null,0,0]
[68,"Speech Pathology",0,null,null,0,0]
[69,"Electrocardiology",0,null,null,0,0]
[70,"Electroencephalography",0,null,null,0,0]
[71,"Medical Supplies ",0,null,null,0,0]
[72,"Implantable Devices ",0,null,null,0,0]
[73,"Drugs Charged ",0,null,null,0,0]
[74,"Renal Dialysis",0,null,null,0,0]
[90,"Clinic",0,null,null,0,0]
[91,"Emergency",0,null,null,0,0]
[92,"Observation",0,null,null,0,0]
[95,"Ambulance",0,null,null,0,0]
[null,"Total I/P Ancillary",0,null,null,0,0]
[]
[null,"Total Routine & Ancillary",null,null,null,0,0]
["Less:"," Non allowable Charges/Cost",null,null,null,0]
[null,"Net I/P Cost Based Reimbursement",null,null,null,0,0]

{"sheet":"RHC Computation","index":25,"n_rows":139,"n_cols":11,"rows_kept":139,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Hospital Name",0]
["Medicaid #",0,null,null,"All Payors"]
["FYE","00:00:00"]
[" D  O       N  O  T        O   V  E  R  R  I  D  E       F  O  R  M  U  L  A  S ",null,null,null,"Input"]
[]
[{"$nulls":4},"EIDR/Provider's Record dated:","00/00/0000"]
["Rural Health Clinic I   ",0,"Federal",null,"Crossover (IP &OP)"]
["Medicaid cost/Visit ","CR  W/S B-1, Pt I, col. 26 ÷ WS S-3, Pt I, Col. 8)",0,null,0]
["Medicaid visits","Traditional/Shared per EIDR/Prov. Report",null,null,0]
["Medicaid visits","AmeriGroup of Louisiana per EIDR/Prov. Report",null,null,0]
["Medicaid visits","AmeriHealth Caritas LA per EIDR/Prov. Report"]
["Medicaid visits","LA Healthcare Connections per EIDR/Prov. Report"]
["Medicaid visits","Aetna per EIDR/Prov. Report"]
["Medicaid visits","United Healthcare per EIDR/Prov. Report"]
["Total Medicaid visits","Total Medicaid Visits per EIDR/Prov.  report",0]
["Actual Cost",null,0]
["Medicaid cost/Visit (with Productivity Limit)","CR W/S M-3, Ln 3  ÷  M-3, Ln 4",0]
["Medicaid cost/Visit"," ",0]
["New reimbursement rate",null,1.1]
["Estimated reimbursement",null,0]
["Medicaid visits","EIDR/Prov.  report",0]
["Estimated reimbursement",null,0]
["Medicaid Encounter Rate ","Per DHH (RHC Section)",null,"***","((Rate*#mos)+(Rate*#mos))/12","** Note:  In order that we are in agreement,  "]
["Medicaid visits","EIDR/Prov.  report",0,null,null,"   e-mail me at:  tizi.robinson@la.gov"]
["Encounter Amount",null,0,null,null,"for appropriate rate."]
["     ***  Encounter Rates:  (Year: # mos. @ Rate; Year: # mos. @ Rate )",null,"Answer","** Note: RHC established after 6/30/2008, receive only the encounter rate.",{"$nulls":6},"Before"]
["Was the RHC established before or after 07/01/2008  -------------------------------------------------------------------------------------------->",null,"Before",{"$nulls":7},"After"]
["Greater of 110% Cost or Encounter Amount",null,0]
["Payment Summary:"]
["Encounters/Visits ","EIDR/Prov.  report",null,null,0]
["Other  ",null,null,null,0]
["Subtotal",null,null,null,0]
["Other Coverage",null,null,null,0]
["      Total Payments",null,null,null,0]
[]
["Medicare Payment - Crossover Only (Per EIDR)",null,null,null,0]
["****************************************************************************************************************************************************************************************************************************************************"]
[{"$nulls":4},"EIDR/Provider's Record dated:","00/00/0000"]
["Rural Health Clinic I I ","0000000","Federal",null,"Crossover (IP &OP)"]
["Medicaid cost/Visit ","CR  W/S B-1, Pt I, col. 26 ÷ WS S-3, Pt I, Col. 8)",0,null,0]
["Medicaid visits","Traditional/Shared per EIDR/Prov. Report",null,null,0]
["Medicaid visits","AmeriGroup of Louisiana per EIDR/Prov. Report",null,null,0]
["Medicaid visits","AmeriHealth Caritas LA per EIDR/Prov. Report"]
["Medicaid visits","LA Healthcare Connections per EIDR/Prov. Report"]
["Medicaid visits","Aetna per EIDR/Prov. Report"]
["Medicaid visits","United Healthcare per EIDR/Prov. Report"]
["Total Medicaid visits","Total Medicaid Visits per EIDR/Prov.  report",0]
["Actual Cost",null,0]
["Medicaid cost/Visit (with Productivity Limit)","CR W/S M-3, Ln 3  ÷  M-3, Ln 4",0]
["Medicaid cost/Visit",null,0]
["New reimbursement rate",null,1.1]
["Estimated reimbursement",null,0]
["Medicaid visits","EIDR/Prov.  report",0]
["Estimated reimbursement",null,0]
["Medicaid Encounter Rate ","Per DHH (RHC Section)",null,"***","((Rate*#mos)+(Rate*#mos))/12","** Note:  In order that we are in agreement,  "]
["Medicaid visits","EIDR/Prov.  report",0,null,null,"   e-mail me at:  tizi.robinson@la.gov"]
["Encounter Amount",null,0,null,null,"for appropriate rate."]
["     ***  Encounter Rates:  (Year: # mos. @ Rate; Year: # mos. @ Rate )",null,"Answer","** Note: RHC established after 6/30/2008, receive only the encounter rate."]
["Was the RHC established before or after 07/01/2008  -------------------------------------------------------------------------------------------->",null,"Before"]
["Greater of 110% Cost or Encounter Amount",null,0]
["Payment Summary:"]
["Encounters/Visits ","EIDR/Prov.  report",null,null,0]
["Other  (Community Care already offset on A-8)",null,null,null,0]
["Subtotal",null,null,null,0]
["Other Coverage",null,null,null,0]
["      Total Payments",null,null,null,0]
[]
["Medicare Payment - Crossover Only (Per EIDR)",null,null,null,0]
["****************************************************************************************************************************************************************************************************************************************************"]
[{"$nulls":4},"EIDR/Provider's Record dated:","00/00/0000"]
["Rural Health Clinic I I I ","0000000","Federal",null,"Crossover (IP &OP)"]
["Medicaid cost/Visit ","CR  W/S B-1, Pt I, col. 26 ÷ WS S-3, Pt I, Col. 8)",0,null,0]
["Medicaid visits","Traditional/Shared per EIDR/Prov. Report"]
["Medicaid visits","AmeriGroup of Louisiana per EIDR/Prov. Report"]
["Medicaid visits","AmeriHealth Caritas LA per EIDR/Prov. Report"]
["Medicaid visits","LA Healthcare Connections per EIDR/Prov. Report"]
["Medicaid visits","Aetna per EIDR/Prov. Report"]
["Medicaid visits","United Healthcare per EIDR/Prov. Report"]
["Total Medicaid visits","Total Medicaid Visits per EIDR/Prov.  report",0,null,0]
["Actual Cost",null,0,null,0]
["Medicaid cost/Visit (with Productivity Limit)","CR W/S M-3, Ln 3  ÷  M-3, Ln 4",0]
["Medicaid cost/Visit",null,0]
["New reimbursement rate",null,1.1]
["Estimated reimbursement",null,0]
["Medicaid visits","EIDR/Prov.  report",0]
["Estimated reimbursement",null,0]
["Medicaid Encounter Rate ","Per DHH (RHC Section)",0,"***","((Rate*#mos)+(Rate*#mos))/12","** Note:  In order that we are in agreement,  "]
["Medicaid visits","EIDR/Prov.  report",0,null,null,"   e-mail me at:  tizi.robinson@la.gov"]
["Encounter Amount",null,0,null,null,"for appropriate rate."]
["     ***  Encounter Rates:  (Year: # mos. @ Rate; Year: # mos. @ Rate )",null,"Answer"]
["Was the RHC established before or after 07/01/2008  -------------------------------------------------------------------------------------------->",null,"Before"]
["Greater of 110% Cost or Encounter Amount",null,0]
["Payment Summary:"]
["Encounters/Visits ","EIDR/Prov.  report",null,null,0]
["Other  (Community Care already offset on A-8)",null,null,null,0]
["Subtotal",null,null,null,0]
["Other Coverage",null,null,null,0]
["      Total Payments",null,null,null,0]
[]
["Medicare Payment - Crossover Only (Per EIDR)",null,null,null,0]
["***************************************************************************************************************************************************************************************************************************************************"]
[{"$nulls":4},"EIDR/Provider's Record dated:","00/00/0000"]
["Rural Health Clinic I V","0000000","Federal",null,"Crossover (IP &OP)"]
["Medicaid cost/Visit ","CR  W/S B-1, Pt I, col. 26 ÷ WS S-3, Pt I, Col. 8)",0,null,0]
["Medicaid visits","Traditional/Shared per EIDR/Prov. Report"]
["Medicaid visits","AmeriGroup of Louisiana per EIDR/Prov. Report"]
["Medicaid visits","AmeriHealth Caritas LA per EIDR/Prov. Report"]
["Medicaid visits","LA Healthcare Connections per EIDR/Prov. Report"]
["Medicaid visits","Aetna per EIDR/Prov. Report"]
["Medicaid visits","United Healthcare per EIDR/Prov. Report"]
["Total Medicaid visits","Total Medicaid Visits per EIDR/Prov.  report",0,null,0]
["Actual Cost",null,0,null,0]
["Medicaid cost/Visit (with Productivity Limit)","CR W/S M-3, Ln 3  ÷  M-3, Ln 4",0]
["Medicaid cost/Visit",null,0]
["New reimbursement rate",null,1.1]
["Estimated reimbursement",null,0]
["Medicaid visits","EIDR/Prov.  report",0]
["Estimated reimbursement",null,0]
["Medicaid Encounter Rate ","Per DHH (RHC Section)",0,"***","((Rate*#mos)+(Rate*#mos))/12","** Note:  In order that we are in agreement,  "]
["Medicaid visits","EIDR/Prov.  report",0,null,null,"   e-mail me at:  tizi.robinson@la.gov"]
["Encounter Amount",null,0,null,null,"for appropriate rate."]
["     ***  Encounter Rates:  (Year: # mos. @ Rate; Year: # mos. @ Rate )",null,"Answer"]
["Was the RHC established before or after 07/01/2008  -------------------------------------------------------------------------------------------->",null,"Before"]
["Greater of 110% Cost or Encounter Amount",null,0]
["Payment Summary:"]
["Encounters/Visits ","EIDR/Prov.  report",null,null,0]
["Other  (Community Care already offset on A-8)",null,null,null,0]
["Subtotal",null,null,null,0]
["Other Coverage",null,null,null,0]
["      Total Payments",null,null,null,0]
[]
["Medicare Payment - Crossover Only (Per EIDR)",null,null,null,0]
["***************************************************************************************************************************************************************************************************************************************************"]
[]
["Total Other Coverage per EIDR/Prov. (Input)","RHC I & II  & III & IV",0]
["Total Cost ","RHC I & II  & III & IV",0,null,0]
["Total Reimbursement ","RHC I & II  & III & IV",0,null,0]
[]
["Total Medicare Payment - Crossover Only (Per EIDR)",null,null,null,0]

{"sheet":"RHC Crossover","index":26,"n_rows":54,"n_cols":4,"rows_kept":54,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Traditional/Shared & Prepaid Plans"]
["Calculation of RHC(s) Crossover Costs & Payments"]
[]
["Hospital Name",0]
["Medicaid #",0]
["FYE","00:00:00"]
[null,null,"Input"]
[]
["Medicare Reimbursable Costs:"]
["Total OP Medicare RHC I Reimbursable Cost","T-18, W/S M-3, Line 16 + Ln 21",0]
["Total OP Medicare RHC II Reimbursable Cost","T-18, W/S M-3, Line 16 + Ln 21",0]
["Total OP Medicare RHC III Reimbursable Cost","T-18, W/S M-3, Line 16 + Ln 21",0]
["Total OP Medicare RHC IV Reimbursable Cost","T-18, W/S M-3, Line 16 + Ln 21",0]
["Medicare Fee for Service Items","PS&R 710\"fee\" Chgs x RCC--calculation",0]
["   Total  Medicare Reimbursable Cost",null,0,"A"]
["Medicare Net Payments:"]
["OP Medicare RHC I Net Payments ","W/S M-3, Line 26 (net of ded/coin,msp+ bad debts+ 1%) less Ln 26.01",0]
["OP Medicare RHC II Net Payments ","W/S M-3, Line 26 (net of ded/coin,msp+ bad debts+ 1%) less Ln 26.01",0]
["OP Medicare RHC III Net Payments ","W/S M-3, Line 26 (net of ded/coin,msp+ bad debts+ 1%) less Ln 26.01",0]
["OP Medicare RHC IV Net Payments ","W/S M-3, Line 26 (net of ded/coin,msp+ bad debts+ 1%) less Ln 26.01",0]
["OP Fee for Service Medicare Payments ","PS&R 710\"fee\" net reimbursement",0]
["   Total Medicare Payments"," ",0,"B"]
["         Medicare Payments as a % of Cost ",null,0,"B/A"]
[]
[]
["Medicare OP RHC I Deductibles","T-18, W/S M-3, Line 18",0]
["Medicare OP RHC II Deductibles","T-18, W/S M-3, Line 18",0]
["Medicare OP RHC III Deductibles","T-18, W/S M-3, Line 18",0]
["Medicare OP RHC IV Deductibles","T-18, W/S M-3, Line 18",0]
["Medicare OP RHC I Co-Insurance","PS&R 710\"fee\" deduct & coinsur",0]
["Medicare OP RHC II Co-Insurance","PS&R 710\"fee\" deduct & coinsur",0]
["Medicare OP RHC III Co-Insurance","PS&R 710\"fee\" deduct & coinsur",0]
["Medicare OP RHC IV Co-Insurance","PS&R 710\"fee\" deduct & coinsur",0]
["Medicare OP Deductibles & Co-Insurance",null,0]
["Medicare OP RHC I Fee for Service Deductibles & Co-Insurance","PS&R 710\"fee\" deduct & coinsur",0]
["Medicare OP RHC II Fee for Service Deductibles & Co-Insurance","PS&R 710\"fee\" deduct & coinsur",0]
["Medicare OP RHC III Fee for Service Deductibles & Co-Insurance","PS&R 710\"fee\" deduct & coinsur",0]
["Medicare OP RHC IV Fee for Service Deductibles & Co-Insurance","PS&R 710\"fee\" deduct & coinsur",0]
["   Total Deductibles & Co-Insurance",null,0,"C"]
["          Medicare Deductibles & Co-Insurance as a % of Cost",null,0,"C/A"]
[]
[]
["Medicaid In-State Crossover Calculated Adjusted Cost","Crossover EIDR/Prov days x Encounter Rate",0,"D"]
[" x  Medicare deductible and co-insurance paymt %","  see above calculation",0]
["= Maximum Medicaid In-State Crossover Payments"," ",0,"E"]
[]
["Medicaid In-State Crossover Actual Paymnts+Other Coverage (Incl. Ambulance)","    per EIDR/Prov  actual interim pymts",0,"F"]
[]
[]
["Medicare In-State Crossover Payments","Crossover Costs above:(D) x Medicare pymt % above)",0]
["Medicaid In-State Crossover Payments","Minimum of Calculated Max. Pymts or Payment Rec'd: (E) or (F)",0]
["          Total In-State Crossover Payments",null,0,"G"]
[]
["          Net Medicaid Crossover underpymt/ (overpymt)",null,0]

{"sheet":"RHC Uninsured","index":27,"n_rows":31,"n_cols":3,"rows_kept":31,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Hospital Name",0]
["Medicaid #",0]
["FYE","00:00:00"]
[" D  O       N  O  T        O   V  E  R  R  I  D  E       F  O  R  M  U  L  A  S "]
[]
[]
["Rural Health Clinic I   ","0000000","Federal"]
["Medicaid cost/Visit ","CR  W/S B-1, Pt I, col. 26 ÷ WS S-3, Pt I, Col. 8)"]
["Uninsured visits","Total Uninsured Visits per Provider reports"]
["Actual Cost",null,0]
[]
[]
["Rural Health Clinic I I  ","0000000","Federal"]
["Medicaid cost/Visit ","CR  W/S B-1, Pt I, col. 26 ÷ WS S-3, Pt I, Col. 8)"]
["Uninsured visits","Total Uninsured Visits per Provider reports"]
["Actual Cost",null,0]
[]
[]
["Rural Health Clinic I I I  ","0000000","Federal"]
["Medicaid cost/Visit ","CR  W/S B-1, Pt I, col. 26 ÷ WS S-3, Pt I, Col. 8)"]
["Uninsured visits","Total Uninsured Visits per Provider reports"]
["Actual Cost",null,0]
[]
[]
["Rural Health Clinic I V  ","0000000","Federal"]
["Medicaid cost/Visit ","CR  W/S B-1, Pt I, col. 26 ÷ WS S-3, Pt I, Col. 8)"]
["Uninsured visits","Total Uninsured Visits per Provider reports"]
["Actual Cost",null,0]
[]
[]
["Total RHC Uninsured Cost - All Clinics",null,0]