05-07,,,,,FORM CMS 1728-94,,,,,,3290 (Cont.)
REASONABLE COST DETERMINATION FOR THERAPY,,,,,,  PROVIDER NO.:,,  PERIOD:,,WORKSHEET A-8-3,
SERVICES FURNISHED BY OUTSIDE SUPPLIERS,,,,,,,,From:  ___________,,PART IV & V,
,,,,,,  ________________,,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 IV - OVERTIME COMPUTATION,,,,,,,,,,
,,,,,,,Therapists,Assistants,Aides,TOTAL,
,,Description,,,,,1,2,3,4,
32," Overtime hours worked during cost reporting period (If col 4, line 32, is zero or equal to or greater",,,,,,,,,,32
," than 2,080, do not complete lines 33-40 and enter zero in each column of line 41)",,,,,,,,,,
33," Overtime rate (Multiply the amounts in cols 2-4, line 8 (AHSEA) times 1.5)",,,,,,,,,,33
34, Total overtime (Including base and overtime allowance) (Multiply line 32 times line 33),,,,,,,,,,34
,CALCULATION OF LIMIT,,,,,,,,,,
35, Percentage of overtime hours by category (Divide the hours in each column on line 32 by the total,,,,,,,,,,35
," overtime worked - col. 4, line 32)",,,,,,,,,,
36, Allocation of provider's standard workyear for one full-time employee times the percentage on line 35),,,,,,,,,,36
, (See Instructions),,,,,,,,,,
,DETERMINATION OF OVERTIME ALLOWANCE,,,,,,,,,,
37," Adjusted hourly salary equivalency amount (AHSEA) (From Part I, cols 2-4, line 8)",,,,,,,,,,37
38, Overtime cost limitation (Line 36 times line 37),,,,,,,,,,38
39, Maximum overtime cost (Enter the lesser of line 34 or line 38),,,,,,,,,,39
40, Portion of overtime already included in hourly computation at the AHSEA (Multiply line 32 times line 37),,,,,,,,,,40
41," Overtime allowance (Line 39 minus line 40 - if negative enter zero) (Col 4, sum of cols 1-3)",,,,,,,,,,41
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,PART V - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT,,,,,,,,,,
42," Salary equivalency amount (from Part II, line 20)",,,,,,,,,,42
43," Travel allowance and expense - HHA services (from Part III, lines 29, 30 or 31)",,,,,,,,,,43
44," Overtime allowance (from Part IV, col. 4, line 41)",,,,,,,,,,44
45, Equipment cost (See Instructions),,,,,,,,,,45
46, Supplies (See Instructions),,,,,,,,,,46
47, Total allowance (Sum of lines 42-46),,,,,,,,,,47
48, Total cost of outside supplier services (from provider records),,,,,,,,,,48
49," Excess over limitation (line 48 minus line 47 - transfer amount to A-5, line 10, 10.1, or 10.2 as applicable - if negative, enter zero -- See Instructions)",,,,,,,,,,49
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"FORM CMS-1728-94-A-8-3  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECS 3219.4 AND 3219.5) ",,,,,,,,,,,
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Rev. 13,,,,,,,,,,,32-317