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{"sheet":"Instructions ","index":0,"n_rows":61,"n_cols":3,"rows_kept":61,"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,"RHC Exhibit A must be submitted by all hospitals claiming services from Medicaid-Certified Hospital-Based Rural Health Clinics.  This is the charges/visits for all services meeting the DSH examination uninsured definition."]
[null,null,"RHC EXHIBIT A REQUIRED DATA FIELDS"]
[null,"a.","Claim Type"]
[null,"b.","Hospital's Medicaid Number"]
[null,"c.","Medicaid-Certified RHC Medicaid Number"]
[null,"d.","Patient Identification Number"]
[null,"e.","Patient Name"]
[null,"f.","From Date of Service"]
[null,"g.","To Date of Service"]
[null,"h.","Service Indicator (Medicaid-Certified RHC)"]
[null,"i.","Revenue Code"]
[null,"j.","Revenue Code Charges"]
[null,"k.","RHC Visits"]
[null,"l.","All payments received on the claim for services provided from the admit date through the present"]
[null,"m.","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,"RHC Exhibit B must be submitted by all hospitals claiming services from Medicaid-Certified Hospital-Based Rural Health Clinics.  This is the cash-based patient payments (cash-based self-pay payments)."]
[null,null,"RHC EXHIBIT B REQUIRED DATA FIELDS"]
[null,"a.","Claim Type"]
[null,"b.","Hospital's Medicaid Number"]
[null,"c.","Medicaid-Certified RHC Medicaid Number"]
[null,"d.","Patient Identification Number"]
[null,"e.","Patient Name"]
[null,"f.","From Date of Service"]
[null,"g.","To Date of Service"]
[null,"h.","Date of Cash Collection"]
[null,"i.","Amount of Cash Collections"]
[null,"j.","Indicate if Collection is a 1011 Payment"]
[null,"k.","Insurance Status at Time of Service  (Must Enter \"Insured\" or \"Uninsured\")"]
[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,"RHC Exhibit C is required only if you are submitting Out-Of-State Medicaid Rural Health Clinic 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 (Out-of-State Medicaid FFS, Out-of-State Medicaid Crossover etc..)"]
[null,null,"RHC 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.","Medicaid-Certified RHC Medicaid Number"]
[null,"f.","Patient Identification Number"]
[null,"g.","Patient Name"]
[null,"h.","From Date of Service"]
[null,"i.","To Date of Service"]
[null,"j.","Service Indicator (Medicaid-Certified RHC)"]
[null,"k.","Revenue Code"]
[null,"l.","Revenue Code Charges"]
[null,"m.","RHC Visits"]
[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":"Ex A - RHC Uninsured Charges","index":1,"n_rows":2,"n_cols":13,"rows_kept":2,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Claim Type (A)","Hospital's Medicaid # (B)","Rural Health Clinic Medicaid # (C)","Patient Identifier Code (D)","Name (E)","Date of Service From Date (F)","Date of Service To Date (G)","Service Indicator (RHC) (H)","Revenue Code (I)","Total Charges for Services Provided (J)","Visits (K)","Total Payments for Services Provided  (L)","Claim Status (Exhausted or Non-Covered Service , if applicable) (M)"]
["RHC Uninsured Charges",{"$nulls":6},"Medicaid-Certified RHC"]

{"sheet":"Ex B - RHC Self-Pay Pmt (CASH)","index":2,"n_rows":2,"n_cols":12,"rows_kept":2,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Claim Type (A)","Hospital's Medicaid # (B)","Rural Health Clinic Medicaid # (C)","Patient Identifier Code (D)","Name (E)","Dates of Service From Date (F)","Dates of Service To Date (G)","Date of Cash Collection (H)","Amount of Cash Collections (I)","Indicate if Collection is a 1011 Payment (J)","Insurance Status When Services Were Provided (Insured or Uninsured) (K)","Claim Status (Exhausted or Non-Covered Service, if applicable) (L)"]
["RHC Self Pay Payments"]

{"sheet":"Ex C - RHC OOS Medicaid","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)","Rural Health Clinic Medicaid # (E)","Patient Identifier Code (F)","Name (G)","From Date of Service (H)","To Date of Service (I)","Service Indicator  (J)","Revenue Code (K)","Total Charges for Services Provided (L)","Visits (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","Mississippi Medicaid",{"$nulls":7},"Medicaid-Certified RHC"]
["Out-of-State Crossover","Medicare","Texas Medicaid"]