3290 (Cont.),,FORM CMS 1728-94,,,,,05-07
CALCULATION OF REIMBURSEMENT SETTLEMENT - ,,, PROVIDER NO.:,, PERIOD:,,
PART A AND PART B SERVICES,,,,,From:  ___________,WORKSHEET D,
,,, ________________,,To: ___________,,
PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES,,,,,,,
,,,,PART B,,,
,,,,Not Subject,,Subject,
,,,,to Deductibles,,to Deductibles,
,,,PART A,& Coinsurance,,& Coinsurance,
,        Description,,1 ,2 ,,3,
Reasonable Cost of Title XVIII - Part A & Part B Services,,,,,,,
 1, Reasonable Cost of Services (See Instructions),,,,,, 1
 2,"Cost of Services, RHC & FQHC",,,,,, 2
 3,Sum of Lines 1 and 2,,,,,, 3
 4, Total charges for title XVIII - Part A and Part B Services - Pre 10/1/2000,,,,,, 4
 4.01, Total charges for title XVIII - Part A and Part B Services - Post 9/30/2000,,,,,, 4.01
,Customary Charges,,,,,,
 5,Amount actually collected from patients liable for payment for services on a,,,,,, 5
,charge basis (From your records),,,,,,
 6,Amount that would have been realized from patients liable for payment for services on,,,,,, 6
,a charge basis had such payment been made in accordance with 42 CFR 413.13(b),,,,,,
 7, Ratio of line 5 to 6 (Not to exceed 1.000000),,,,,, 7
 8,Total customary charges - title XVIII (Multiply line 7 by line 4 for column 1) (Multiply line 7,,,,,, 8
,"by the sum of lines 4 & 4.01 for columns 2 & 3, respectively)  (See Instructions)",,,,,,
 9,Excess of total customary charges over total reasonable cost (Complete only if,,,,,, 9
,line 8 exceeds line 3),,,,,,
 10,Excess of reasonable cost over customary charges (Complete only if line 3 exceeds line 8),,,,,, 10
 11,Primary Payer Amounts,,,,,, 11
,,,,,,,
PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT,,,,,,,
,,,,PART A,,PART B,
,,,,Services,,Services,
,        Description,,,1 ,,2,
12 , Total reasonable cost (See Instructions),,,,,,12 
12.01, Total PPS Payment - Full Episodes without Outliers,,,,,,12.01
12.02, Total PPS Payment - Full Episodes with Outliers,,,,,,12.02
12.03, Total PPS Payment - LUPA Episodes,,,,,,12.03
12.04, Total PPS Payment - PEP Only Episodes,,,,,,12.04
12.05, Total PPS Payment - SCIC within a PEP Episodes,,,,,,12.05
12.06, Total PPS Payment - SCIC Only Episodes,,,,,,12.06
12.07, Total PPS Outlier Payment - Full Episodes with Outliers,,,,,,12.07
12.08, Total PPS Outlier Payment - PEP Only Episodes ,,,,,,12.08
12.09, Total PPS Outlier Payment - SCIC within a PEP Episodes,,,,,,12.09
12.10, Total PPS Outlier Payment - SCIC Only Episodes,,,,,,12.10
12.11, Total Other Payments,,,,,,12.11
12.12, DME Payment,,,,,,12.12
12.13, Oxygen Payment,,,,,,12.13
12.14, Prosthetics and Orthotics Payment,,,,,,12.14
13 , Part B deductibles billed to Medicare patients (exclude coinsurance),,,,,,13 
14 , Subtotal (Sum of lines 12-12.14 minus line 13),,,,,,14 
15 , Excess reasonable cost (from line 10),,,,,,15 
16 , Subtotal (Line 14 minus line 15),,,,,,16 
17 , Coinsurance billed to Medicare patients (From your records),,,,,,17 
18 , Net cost (Line 16 minus line 17),,,,,,18 
19 , Reimbursable bad debts (From your records),,,,,,19 
20 , Pneumococcal Vaccine,,,,,,20 
21 , Total Costs - Current cost reporting period (See Instructions),,,,,,21 
22 ,Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets,,,,,,22 
23 ,Recovery of excess depreciation resulting from agencies' termination or decrease in Medicare utilization,,,,,,23 
24 ,Unrefunded charges to beneficiaries for excess costs erroneously collected based on correction of cost limit,,,,,,24 
25 ,Total cost before sequestration and other adjustments- (line 21,,,,,,25 
,plus/minus line 22 minus sum of lines 23 and 24),,,,,,
25.5,Other Adjustments (see instructions) (specify),,,,,,25.5
26 , Sequestration Adjustment (See Instructions),,,,,,26 
27 ,Amount reimbursable after sequestration and other adjustments (Line 25 plus line 25.5 minus line 26),,,,,,27 
28 ," Total interim payments (From Worksheet D-1, line 4)",,,,,,28 
28.5, Tentative settlement (For intermediary use only),,,,,,28.5
29 ,Balance due HHA/Medicare program (Line 27 minus line 28) (Indicate overpayments in brackets),,,,,,29 
30 ,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2",,,,,,30 
31 ,Balance due HHA/Medicare program (Line 29 minus line 30) (Indicate overpayments in brackets),,,,,,31 
"FORM CMS-1728-94-D  (3-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3216 - 3216.2)",,,,,,,
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32-322,,,,,,,Rev. 13