{"text_format":"2","workbook":"xls","n_sheets":8,"sheets":["Instructions ","Exhibit A - Uninsured Charges","Exhibit B - Self-Pay Pmt (CASH)","Exhibit C - OOS Medicaid FFS","Exhibit C - OOS Medicaid MCO","Exhibit C - OOS FFS Crossover","Exhibit C - OOS MCO Crossover","Exhibit C - Other Mcd Eligible"],"not_rendered":{"charts":0,"images":0,"macros":0,"external_links":0,"defined_names":0,"comments":27,"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":"Instructions ","index":0,"n_rows":64,"n_cols":3,"rows_kept":64,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["General Instructions for Submitting Patient Detail that Supports the Services Reported on the DSH Survey:"]
[]
[null,null,"For all data reported on the DSH survey that is supported by internally-generated data:"]
["1.",null,"When running the internal reports for the DSH examination, please be sure that all applicable data elements are included.  These required data elements are listed as the headings in the Excel templates in this document.  If these data elements are not included, the data is considered incomplete, and will not be accepted for the DSH examination.  You may include additional column data fields as you see fit, as long as the necessary data fields are also included."]
[null,null,"**  Please do not alter column headings!  These column headings will be used to summarize patient detail into reports that can be reviewed for the DSH examination."]
[]
[]
[null,null,"Exhibit A must be submitted by all hospitals.  This is the charges/days for all services meeting the DSH examination uninsured definition."]
[null,null,"EXHIBIT A REQUIRED DATA FIELDS"]
[null,"a.","Claim Type"]
[null,"b.","Hospital's Medicaid Number"]
[null,"c.","Patient Identification Number (PCN)"]
[null,"d.","Patient Name"]
[null,"e.","Admit Date"]
[null,"f.","Discharge Date"]
[null,"g.","Service Indicator (inpatient/outpatient)"]
[null,"h.","Revenue Code"]
[null,"i.","Revenue Code Charges"]
[null,"j.","Routine Days of Care"]
[null,"k.","All payments received on the claim for services provided from the admit date through the present"]
[null,"l.","If the uninsured claim is being claimed as uninsured due to exhausted benefits or meeting lifetime/annual maximums, please enter \"Exhausted\" in this column.  If it is being claimed because it is not a covered service under the insurance package enter \"Non-Covered Service\" (it must be a covered service under the Medicaid state plan).  If neither apply, leave this field blank."]
[]
[null,null,"Exhibit B must be submitted by all hospitals.  This is the cash-based patient payments (cash-based self-pay payments)."]
[null,null,"EXHIBIT B REQUIRED DATA FIELDS"]
[null,"a.","Claim Type"]
[null,"b.","Hospital's Medicaid Number"]
[null,"c.","Patient Identification Number (PCN)"]
[null,"d.","Patient Name"]
[null,"e.","Admit Date"]
[null,"f.","Discharge Date"]
[null,"g.","Date of Cash Collection"]
[null,"h.","Amount of Cash Collections"]
[null,"i.","Indicate if Collection is a 1011 Payment"]
[null,"j.","Service Indicator (inpatient/outpatient)"]
[null,"k.","Total Hospital Charges for Services Provided"]
[null,"l.","Total Physician Charges for Services Provided"]
[null,"m.","Total Other Non-Hospital Charges for Services Provided"]
[null,"n.","Insurance Status at Time of Service  (Must Enter \"Insured\", \"Uninsured\", \"Exhausted\", \"Non-Covered Service\")"]
[null,"o.","If the uninsured claim is being claimed as uninsured due to exhausted benefits or meeting lifetime/annual maximums, please enter \"Exhausted\" in this column.  If it is being claimed because it is not a covered service under the insurance package enter \"Non-Covered Service\" (it must be a covered service under the Medicaid state plan).  If neither apply, leave this field blank."]
[null,"p.","Calculated Hospital Collections  IF(N) = \"Uninsured\" or (O)=\"Exhausted\" or (O)=\"Non-Covered Service\", (K)/((K)+(L)+(M))*(H), 0)"]
[]
[null,null,"Exhibit C is required only if you are submitting Out-Of-State Medicaid data that isn't supported by a state-provided or MCO-provided report.  If state data or MCO reports are used, this Exhibit is not necessary.  Otherwise, you must submit an Exhibit C for each type of data (OOS Medicare Crossover, OOS Medicaid MCO, etc..)"]
[null,null,"EXHIBIT C - REQUIRED DATA FIELDS (not all are applicable to all payer types - for example, Medicare payments will only apply to crossover data)"]
[null,"a.","Claim Type"]
[null,"b.","Primary Payor"]
[null,"c.","Secondary Payor"]
[null,"d.","Hospital Medicaid Number"]
[null,"e.","Patient Identification Number (PCN)"]
[null,"f.","Patient's Medicaid Recipient Number"]
[null,"g.","Patient Name"]
[null,"h.","Admit Date"]
[null,"i.","Discharge Date"]
[null,"j.","Service Indicator (inpatient/outpatient)"]
[null,"k.","Revenue Code"]
[null,"l.","Revenue Code Charges"]
[null,"m.","Routine Days of Care"]
[null,"n.","Medicare Payments (all payments received for the services provided from the admit date through the present)"]
[null,"o.","Medicaid Payments (all payments received for the services provided from the admit date through the present)"]
[null,"p.","Other Third Party Liability Payments including patient payments and private insurance (all payments received for the services provided from the admit date through the present)"]
[null,"q.","Self-Pay payments   (all payments received for the services provided from the admit date through the present)"]
[null,"r.","Total Payments received on the claim (sum of all payments listed above)"]
[]
[]
["2.",null,"Please input any internally-generated DSH survey data into the templates.  Then submit the completed template to Myers and Stauffer with the DSH Survey Submission documentation.  Internally-generated DSH survey data must be submitted using this Excel template (either .xls or .xlsx).  If this is not possible, the data must be submitted as a CSV (.csv) file using either the TAB or | (pipe symbol above the ENTER key).  The data will not be accepted if not in one of these formats."]

{"sheet":"Exhibit A - Uninsured Charges","index":1,"n_rows":2,"n_cols":12,"rows_kept":2,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Claim Type (A)","Hospital's Medicaid Provider # (B)","Patient Identifier Code (PCN) (C)","Name (D)","Admit Date (E)","Discharge Date (F)","Service Indicator (Inpatient / Outpatient) (G)","Revenue Code (H)","Total Charges for Services Provided (I)","Routine Days of Care (J)","Total Payments for Services Provided  (K)","Claim Status (Exhausted or Non-Covered Service, if applicable) (L)"]
["Uninsured Charges"]

{"sheet":"Exhibit B - Self-Pay Pmt (CASH)","index":2,"n_rows":2,"n_cols":16,"rows_kept":2,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Claim Type (A)","Hospital's Medicaid Provider # (B)","Patient Identifier Code (PCN) (C)","Name (D)","Admit Date (E)","Discharge Date (F)","Date of Cash Collection (G)","Amount of Cash Collections (H)","Indicate if Collection is a 1011 Payment (I)","Service Indicator (Inpatient / Outpatient) (J)","Total Hospital Charges for Services Provided (K)","Total Physician Charges for Services Provided (L)","Total Other Non-Hospital Charges for Services Provided (M)","Insurance Status When Services Were Provided (Insured or Uninsured) (N)","Claim Status (Exhausted or Non-Covered Service, if applicable) (O)","Calculated Hospital Uninsured Collections If (N)=\"Uninsured\" or (O)=\"Exhausted\" or \"Non-Covered Service\", (K)/((K)+(L)+(M))*(H), 0)"]
["Self Pay Payments"]

{"sheet":"Exhibit C - OOS Medicaid FFS","index":3,"n_rows":3,"n_cols":18,"rows_kept":3,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Claim Type (A)","Primary Payor (B)","Secondary Payor (C)","Hospital's Medicaid # (D)","Patient Identifier Code (PCN) (E)","Patient's Medicaid Recipient # (F)","Name (G)","Admit Date (H)","Discharge Date (I)","Service Indicator (Inpatient / Outpatient) (J)","Revenue Code (K)","Total Charges for Services Provided (L)","Routine Days of Care (M)","Total Medicare Payments for Services Provided (N)","Total Medicaid Payments for Services Provided (O)","Total Third Party Liability Payments for Services Provided (P)","Self-Pay Payments (Q)","Sum of All Payments Received on Claim (N)+(O)+(P)+(Q)"]
["Out-of-State Medicaid","Illinois Medicaid"]
["Out-of-State Medicaid","Kansas Medicaid"]

{"sheet":"Exhibit C - OOS Medicaid MCO","index":4,"n_rows":2,"n_cols":18,"rows_kept":2,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Claim Type (A)","Primary Payor (B)","Secondary Payor (C)","Hospital's Medicaid # (D)","Patient Identifier Code (PCN) (E)","Patient's Medicaid Recipient # (F)","Name (G)","Admit Date (H)","Discharge Date (I)","Service Indicator (Inpatient / Outpatient) (J)","Revenue Code (K)","Total Charges for Services Provided (L)","Routine Days of Care (M)","Total Medicare Payments for Services Provided (N)","Total Medicaid Payments for Services Provided (O)","Total Third Party Liability Payments for Services Provided (P)","Self-Pay Payments (Q)","Sum of All Payments Received on Claim (N)+(O)+(P)+(Q)"]
["Out-of-State MCO","Illinois Medicaid MCO"]

{"sheet":"Exhibit C - OOS FFS Crossover","index":5,"n_rows":2,"n_cols":18,"rows_kept":2,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Claim Type (A)","Primary Payor (B)","Secondary Payor (C)","Hospital's Medicaid # (D)","Patient Identifier Code (PCN) (E)","Patient's Medicaid Recipient # (F)","Name (G)","Admit Date (H)","Discharge Date (I)","Service Indicator (Inpatient / Outpatient) (J)","Revenue Code (K)","Total Charges for Services Provided (L)","Routine Days of Care (M)","Total Medicare Payments for Services Provided (N)","Total Medicaid Payments for Services Provided (O)","Total Third Party Liability Payments for Services Provided (P)","Self-Pay Payments (Q)","Sum of All Payments Received on Claim (N)+(O)+(P)+(Q)"]
["Out-of-State Crossover","Medicare","Kansas Medicaid"]

{"sheet":"Exhibit C - OOS MCO Crossover","index":6,"n_rows":2,"n_cols":18,"rows_kept":2,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Claim Type (A)","Primary Payor (B)","Secondary Payor (C)","Hospital's Medicaid # (D)","Patient Identifier Code (PCN) (E)","Patient's Medicaid Recipient # (F)","Name (G)","Admit Date (H)","Discharge Date (I)","Service Indicator (Inpatient / Outpatient) (J)","Revenue Code (K)","Total Charges for Services Provided (L)","Routine Days of Care (M)","Total Medicare Payments for Services Provided (N)","Total Medicaid Payments for Services Provided (O)","Total Third Party Liability Payments for Services Provided (P)","Self-Pay Payments (Q)","Sum of All Payments Received on Claim (N)+(O)+(P)+(Q)"]
["Out-of-State MCO Crossover","Medicare","Kansas Medicaid"]

{"sheet":"Exhibit C - Other Mcd Eligible","index":7,"n_rows":2,"n_cols":18,"rows_kept":2,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Claim Type (A)","Primary Payor (B)","Secondary Payor (C)","Hospital's Medicaid # (D)","Patient Identifier Code (PCN) (E)","Patient's Medicaid Recipient # (F)","Name (G)","Admit Date (H)","Discharge Date (I)","Service Indicator (Inpatient / Outpatient) (J)","Revenue Code (K)","Total Charges for Services Provided (L)","Routine Days of Care (M)","Total Medicare Payments for Services Provided (N)","Total Medicaid Payments for Services Provided (O)","Total Third Party Liability Payments for Services Provided (P)","Self-Pay Payments (Q)","Sum of All Payments Received on Claim (N)+(O)+(P)+(Q)"]
["Other Medicaid Eligibles","Medicaid"]