3290 (Cont.),,,,,,FORM CMS 1728-94,,,,,,08-99
REASONABLE COST DETERMINATION FOR THERAPY,,,,,,,  PROVIDER NO.:,,  PERIOD:,,WORKSHEET A-8-3,
SERVICES FURNISHED BY OUTSIDE SUPPLIERS,,,,,,,,,From:  ___________,,PARTS I - III        ,
,,,,,,,  ________________,,To: ___________,,,
Check applicable box:,,,[   ]  Physical Therapy services rendered before 4/10/98  [   ]  Occupational Therapy  [   ]  Speech Pathology,,,,,,,,,
,,,[   ]  Physical Therapy services rendered on or after 4/10/98,,,,,,,,,
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,PART I - GENERAL INFORMATION,,,,,,,,,,,
 1, Total number of weeks worked (During which outside suppliers (excluding aides) worked),,,,,,,,,,, 1
 2, Line 1 multiplied by 15 hours per week,,,,,,,,,,, 2
 3, Number of unduplicated HHA visits - supervisors or therapists (See Instructions),,,,,,,,,,, 3
 4, Number of unduplicated HHA visits - therapy assistants (Include only visits made by therapy assistants and on which,,,,,,,,,,, 4
, supervisor and/or therapist was not present during the visit) (See Instructions),,,,,,,,,,,
 5, Standard travel expense rate,,,,,,,,,,, 5
 6, Optional travel expense rate per mile,,,,,,,,,,, 6
,,,,,,,,Supervisors,Therapists,Assistants,Aides,
,,,,,,,,1,2,3,4,
 7, Total hours worked,,,,,,,,,,, 7
 8, AHSEA (See Instructions),,,,,,,,,,, 8
 9," Standard Travel Allowance (Cols 1 and 2, one-half of col 2, line 8; col 3, one-half of col 3, line 8)",,,,,,,,,,, 9
10, Number of travel hours (HHA only),,,,,,,,,,,10
11, Number of miles driven (HHA only),,,,,,,,,,,11
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,PART II - SALARY EQUIVALENCY COMPUTATIONS,,,,,,,,,,,
12," Supervisors (Col 1, line 7 times col 1, line 8)",,,,,,,,,,,12
13," Therapists (Col 2, line 7 times col 2, line 8)",,,,,,,,,,,13
14," Assistants (Col 3, line 7 times col 3, line 8)",,,,,,,,,,,14
15, Subtotal Allowance Amount (Sum of lines 12-14),,,,,,,,,,,15
16," Aides (Col 4, line 7 times col 4, line 8)",,,,,,,,,,,16
17, Total Allowance Amount (Sum of lines 15 and 16),,,,,,,,,,,17
" If the sum of cols 1-3, line 7, is greater than line 2, make no entries on lines 18 and 19",,,,,,,,,,,,
" and enter on line 20 the amount from line 17.  Otherwise, complete lines 18-20.",,,,,,,,,,,,
18," Weighted average rate excluding aides (Line 15 divided by the sum of cols 1-3, line 7)",,,,,,,,,,,18
19, Weighted allowance excluding aides (Line 2 times line 18),,,,,,,,,,,19
20, Total Salary Equivalency (Line 17 or sum of lines 16 plus 19),,,,,,,,,,,20
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,PART III - TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - HHA SERVICES,,,,,,,,,,,
,Standard Travel Allowance and Standard Travel Expense,,,,,,,,,,,
21," Therapists (Line 3 times col 2, line 9)",,,,,,,,,,,21
22," Assistants (Line 4 times col 3, line 9)",,,,,,,,,,,22
23, Subtotal (Sum of lines 21 and 22),,,,,,,,,,,23
24, Standard Travel Expense (Line 5 times sum of lines 3 and 4),,,,,,,,,,,24
, Optional Travel Allowance and Optional Travel Expense,,,,,,,,,,,
25," Therapists (Sum of cols 1 and 2, line 10 times col 2, line 8)",,,,,,,,,,,25
26," Assistants (Col 3, line 10 times col 3, line 8)",,,,,,,,,,,26
27, Subtotal (Sum of lines 25 and 26),,,,,,,,,,,27
28," Optional Travel Expense (Line 6 times sum of cols 1-3, line 11)",,,,,,,,,,,28
, Total Travel Allowance and Travel Expenses - HHA Services; Complete one of the following,,,,,,,,,,,
," three lines 29, 30 or 31, as appropriate",,,,,,,,,,,
29, Standard Travel Allowance and Standard Travel Expenses (Sum of lines 23 and 24 - See Instructions),,,,,,,,,,,29
30, Optional Travel Allowance and Standard Travel Expenses (Sum of lines 27 and 24 - See Instructions),,,,,,,,,,,30
31, Optional Travel Allowance and Optional Travel Expenses (Sum of lines 27 and 28 - See Instructions),,,,,,,,,,,31
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"FORM CMS-1728-94-A-8-3  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC 3219-3219.3) ",,,,,,,,,,,,
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32-316,,,,,,,,,,,,Rev. 7