03-04,,,FORM CMS 1728-94,,,,,3290 (Cont.) ,,, PROVIDER NO.:, PERIOD:,,,WORKSHEET CM-3, CALCULATION OF REIMBURSEMENT,,, ___________________, FROM: _______________,,,, SETTLEMENT - CMHC SERVICES,,, CMHC NO.:, TO: _________________,,,, ,,,,,,,, ,,,,,,,, PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES,,,,,,,, ,,,,,,,, ,DESCRIPTION,,,,,1 ,1.01 , 1,Total reasonable cost (see instructions),,,,,,,1 1.01 ,CMHC PPS payments including outlier payments,,,,,,,1.01 1.02 ,1996 CMHC specific payment to cost ratio (obtain this ratio from your intermediary) ,,,,,,,1.02 1.03 ,"Line 1, column 1 times 1.02",,,,,,,1.03 1.04 ,Line 1.01 divided by line 1.03,,,,,,,1.04 1.05 ,CMHC transitional corridor payment (see instructions),,,,,,,1.05 2 ,Total charges for CMHC Services,,,,,,,2 ,,,,,,,, ,CUSTOMARY CHARGES,,,,,1 ,1.01 , 3 ,Amounts actually collected from patients liable,,,,,,,3 ,for payments for services on a charge basis (from,,,,,,, ,your records),,,,,,, 4 ,Amount that would have been realized from patients,,,,,,,4 ,liable for payment for services on a charge basis ,,,,,,, ,had such payment been made in accordance with,,,,,,, ,42 CFR 413.13(b),,,,,,, 5 ,Ratio of line 3 to line 4 (not to exceed 1.000000),,,,,,,5 6 ,Total Customary charges - title XVIII,,,,,,,6 ,(see instructions),,,,,,, 7 ,Excess of total customary charges over total,,,,,,,7 ,reasonable cost (complete only if line 6,,,,,,, ,exceeds line 1),,,,,,, 8 ,Excess of reasonable costs over customary charges,,,,,,,8 ,(complete only if line 1 exceeds line 6),,,,,,, 9 ,Primary payer amounts,,,,,,,9 ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT,,,,,,1 ,1.01 , 10 ,Cost of CMHC services (see instructions),,,,,,,10 11 ,Part B deductible billed to Program patients (exclude coinsurance amounts),,,,,,,11 12 ,Excess of reasonable costs (see instructions),,,,,,,12 13 ,Net cost (line10 minus lines 11 and 12),,,,,,,13 14 ,80% of Part B cost (80% x line 13) (see instructions),,,,,,,14 15 ,Actual coinsurance billed to Program patients (from your records),,,,,,,15 16 ,Net cost less actual billed coinsurance (Line 13 minus line 15),,,,,,,16 17 ,Reimbursable bad debts (see instructions),,,,,,,17 18 ,Net reimbursable amount (see instructions),,,,,,,18 19 ,Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets,,,,,,,19 20 ,Recovery of excess depreciation resulting from facility's termination or a decrease in Program utilization,,,,,,,20 21 ,Other adjustments (specify),,,,,,,21 22 ,"Total Cost (Sum of line 18, columns 1 and 2, minus lines 19 and 20, plus line 21)",,,,,,,22 23 ,Sequestration adjustment,,,,,,,23 24 ,Amount due provider (Line 22 minus line 23),,,,,,,24 25 ,Interim payments,,,,,,,25 25.5,Tentative settlement (for intermediary use only),,,,,,,25.5 26 ,Balance due CMHC/Program (Line 24 minus line 25) (Indicate overpayments in brackets),,,,,,,26 27 ,Protested amounts (see instructions),,,,,,,27 28 ,Balance due CMHC/Program (Line 26 minus line 27) (Indicate overpayments in brackets),,,,,,,28 ,,,,,,,, ,,,,,,,, ,,,,,,,, "FORM CMS 1728-94-CM-3 (3-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.",,,,,,,, 3227-3227.2),,,,,,,, ,,,,,,,, Rev. 12,,,,,,,,32-335