08-99,,,,,,,,FORM CMS 1728-94,,,,,,,3290 (Cont.) ,,,,,,,, PROVIDER NO.:,,, PERIOD:,,,WORKSHEET J-1, ALLOCATION OF GENERAL SERVICE,,,,,,,, ___________________,,, FROM: _______________,,,PARTS I & II, COSTS TO CORF REIMBURSABLE COST CENTERS,,,,,,,, CORF NO.:,,, TO: _________________,,,, ,,,,,,,, ___________________,,,,,,, PART I - ALLOCATION OF GENERAL SERVICE COSTS TO CORF REIMBURSABLE COST CENTERS,,,,,,,,,,,,,,, ,,,,,NET,CAPITAL,,PLANT,,,,,ALLOCATED,, ,,,,,EXPENSES,RELATED COSTS,,OPERATION,,,A&G,,CORF,TOTAL, ,CORF COST CENTER,,,,FOR COST,BLDGS &,MOVABLE,& MAINTE-,TRANSPOR-,SUBTOTAL,SHARED,SUB-,A&G (SEE,(SUM OF, ,(OMIT CENTS),,,,ALLOCATION (1),FIXTURES,EQUIPMENT,NANCE,TATION,(cols. 0-4),COSTS,TOTAL,PART II),COLS 6 & 7), ,,,,,0,1,2,3,4,4A,5,6,7,8, 1, Administrative and General,,,,,,,,,,,,,, 1 2, Skilled Nursing Care,,,,,,,,,,,,,, 2 3, Physical Therapy,,,,,,,,,,,,,, 3 4, Occupational Therapy,,,,,,,,,,,,,, 4 5, Speech Pathology,,,,,,,,,,,,,, 5 6, Medical Social Services,,,,,,,,,,,,,, 6 7, Respiratory Therapy,,,,,,,,,,,,,, 7 8, Psychological Services,,,,,,,,,,,,,, 8 9, Prosthetic and Orthotic Devices,,,,,,,,,,,,,, 9 10, Drugs and Biologicals,,,,,,,,,,,,,,10 11, Medical Supplies,,,,,,,,,,,,,,11 12, Durable Medical Equipment-Rented,,,,,,,,,,,,,,12 13, Durable Medical Equipment-Sold,,,,,,,,,,,,,,13 14, Other Part B Services,,,,,,,,,,,,,,14 15, TOTALS (Sum of lines 1-14) (2),,,,,,,,,,,,,,15 ,"(1) Column 0, line 15 must agree with Wkst. A, column 10, line 24.",,,,,,,,,,,,,, ,"(2) Columns 0 through 5, line 15 must agree with the corresponding columns of Wkst. B, line 24",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,0 ,0 ,0 ,0 ,0 ,,,,, PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF CORF ADMINISTRATIVE AND GENERAL COSTS,,,,,,,,,,,,,,, 1," Amount from Part I, column 6, line 15",,,,,,,,,,,,,, 1 2," Amount from Part I, column 6, line 1",,,,,,,,,,,,,, 2 3, Line 1 minus line 2,,,,,,,,,,,,,, 3 4," Unit cost multiplier for CORF A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,",,,,,,,,,,,,,, 4 ," lines 2 through 14, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "FORM CMS 1728-94-J-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3221-3221.2)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, Rev. 7,,,,,,,,,,,,,,,32-327 05-00,,,,,,,,FORM CMS 1728-94,,,,,,,3290 (Cont.) ,,,,,,,, PROVIDER NO.:,,, PERIOD:,,, WORKSHEET J-2, COMPUTATION OF CORF COSTS,,,,,,,, ___________________,,, FROM: _______________,,,, ,,,,,,,, CORF NO.:,,, TO: __________________,,,, ,,,,,,,, ___________________,,,,,,, PART I - APPORTIONMENT OF CORF COST CENTERS NET OF THE APPLICABLE REASONABLE COST REDUCTION,,,,,,,,,,,,,,, ,,,,,,,,,,,TITLE XVIII,,,TITLE XVIII, ,,,,,,TOTAL COSTS,,RATIO OF,,TITLE XVIII,CORF,TITLE XVIII,REASONABLE,COST NET OF, ,,,,,,(FROM SUPP.,TOTAL,COSTS TO,TITLE XVIII,CORF COSTS,CHARGES ON,CORF,COST,REASONABLE, ,CORF COST CENTER,,,,,"WKST. J-1, PT.",CORF,CHARGES,CORF,(COL. 3 X,OR AFTER,COSTS ON OR,REDUCTION,COST, ,(OMIT CENTS),,,,,"I, COL. 8) (1)",CHARGES (2),(COL. 1 / COL. 2),CHARGES *,COL. 4),1/1/98 *,AFTER 1/1/98,AMOUNT ,REDUCTION, ,,,,,,1,2,3,4,5,6,7,8,9, 1, Administrative and General,,,,,,,,,,,,,, 1 2, Skilled Nursing Care,,,,,,,,,,,,,, 2 3, Physical Therapy,,,,,,,,,,,,,, 3 4, Occupational Therapy,,,,,,,,,,,,,, 4 5, Speech Pathology,,,,,,,,,,,,,, 5 6, Medical Social Services,,,,,,,,,,,,,, 6 7, Respiratory Therapy,,,,,,,,,,,,,, 7 8, Psychological Services,,,,,,,,,,,,,, 8 9, Prosthetic and Orthotic Devices,,,,,,,,,,,,,, 9 10, Drugs and Biologicals,,,,,,,,,,,,,,10 11, Medical Supplies,,,,,,,,,,,,,,11 12, Durable Medical Equipment-Rented,,,,,,,,,,,,,,12 13, Durable Medical Equipment-Sold,,,,,,,,,,,,,,13 14, Other Part B Services,,,,,,,,,,,,,,14 15, TOTALS (Sum of lines 2-14),,,,,,,,,,,,,,15 ,,,,,,,,,,,,,,, PART II - APPORTIONMENT OF COST OF CORF,,,,,,,,,,,,,,, SERVICES FURNISHED BY HHA DEPARTMENTS,,,,,"Fr. Wkst. B,",,,,,,,,,, ,,,,,"Col 6, Line:",,,,,,,,,, 16, Respiratory Therapy,,,,16,,,,,,,,,,16 17, Physical Therapy,,,,7,,,,,,,,,,17 18, Occupational Therapy,,,,8,,,,,,,,,,18 19, Speech Pathology,,,,9,,,,,,,,,,19 20, Supplies,,,,12,,,,,,,,,,20 21, Drugs Charged to Patients,,,,13,,,,,,,,,,21 ,,,,,,,,,,,,,,, 23, Total (Sum of lines 16 through 21),,,,,,,,,,,,,,23 ,"(1) Cost for Part II, lines 16-22 are obtained from Worksheet B, column 6, lines as appropriate",,,,,,,,,,,,,, ,"(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, PART III- TOTAL CORF COSTS,,,,,,,,,4,5,6,7,8,9, 24,"Total CORF costs - Add the amount from Part I, column 9, line 15 and the amount from Part II, column 9, line 23.",,,,,,,,,,,,,,24 ,"Add the amounts from Part I, line 15 and Part II, line 23 for columns 4 through 8, respectively.",,,,,,,,,,,,,, "Transfer the amount in Part III, column 9 to Worksheet J-3, line 1.",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "* See instructions for fee scheduled payment basis items for services rendered on or after January 1, 1999. ",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "FORM CMS 1728-94-J-A932 (8-1999) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3222-3222.3)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, Rev. 9,,,,,,,,,,,,,,,32-329