3290 (Cont.),,,,FORM CMS 1728-94 ,,,,05-00 ,,, CORF NO.:, FROM: _______________,,, WORKSHEET J-3, CALCULATION OF REIMBURSEMENT,,, ___________________, TO: _________________,,,, SETTLEMENT - CORF SERVICES,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, PART I-COMPUTATION OF CUSTOMARY CHARGES FOR CORF SERVICES,,,,,,,, ,,,,,,,, ,,,,,,,, 1,Total reasonable cost of CORF services (See instructions),,,,,,,1 1.1,Total reasonable cost of CORF services prior to 1/1/1998 (Reasonable cost basis) (See instructions),,,,,,,1.1 1.2,Total reasonable cost of CORF services on or after 1/1/1998 (Subject to LCC) (See instructions),,,,,,,1.2 2,Primary payment amounts (CORF services),,,,,,,2 3,Net cost (Line 1 minus line 2),,,,,,,3 4,Total CORF charges,,,,,,,4 ,Customary Charges,,,,,,, 5,Amounts actually collected from patients liable,,,,,,,5 ,for payments for CORF services on a charge basis (From,,,,,,, ,your records),,,,,,, 6,Amount that would have been realized from patients,,,,,,,6 ,liable for payment for CORF services on a charge basis ,,,,,,, ,had such payment been made in accordance with,,,,,,, ,42 CFR 413.13(b),,,,,,, 7,Ratio of line 5 to line 6 (Not to exceed 1.000000),,,,,,,7 8,Total customary charges - CORF services (Multiply line 7 x line 4),,,,,,,8 8.1,Total customary charges - CORF services prior to 1/1/1998 (Reasonable cost basis) (See instructions),,,,,,,8.1 8.2,Total customary charges - CORF services on or after 1/1/1998 (Subject to LCC) (See instructions),,,,,,,8.2 ,,,,,,,, ,COMPUTATION OF LESSER OF REASONABLE COSTS OR CUSTOMARY CHARGES FOR CORF,,,,,,, ,SERVICES FURNISHED IN CALENDAR YEAR 1998,,,,,,, 8.3,Excess of customary charges over reasonable costs (Complete only if line 8.2 exceeds line 1.2) (See instructions),,,,,,,8.3 8.4,Excess of reasonable costs over customary charges (Complete only if line 1.2 exceeds line 8.2) (See instructions),,,,,,,8.4 ,,,,,,,, ,,,,,,,, ,,,,,,,, PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT,,,,,,,, ,,,,,,,, 9,Cost of CORF services (From line 3 ),,,,,,,9 10,Part B deductible billed to Program patients (exclude coinsurance amounts),,,,,,,10 11,Net Cost (Line 9 minus line 10),,,,,,,11 11.1,Excess of reasonable costs over customary charges for services rendered on or after 1/1/1998 (from line 8.4),,,,,,,11.1 11.2,Subtotal (line11 minus line 11.1),,,,,,,11.2 12,80% of Part B cost (80% x line 11.2),,,,,,,12 13,Actual coinsurance billed to Program patients (From your records),,,,,,,13 14,Net cost less actual billed coinsurance (Line 11 minus line 13),,,,,,,14 15,Reimbursable bad debts (See instructions),,,,,,,15 16,Net reimbursable amount (Line 15 plus the lesser of line 12 or line 14),,,,,,,16 17,Amounts applicable to prior cost reporting periods resulting from disposition,,,,,,,17 ,of depreciable assets,,,,,,, 18,Recovery of excess depreciation resulting from facility's termination or a decrease in ,,,,,,,18 ,Program utilization,,,,,,, 19,Other adjustments (specify),,,,,,,19 20,Total Cost - reimbursable to provider (Line 16 minus lines 17 and 18 and plus or minus line 19),,,,,,,20 21,Sequestration Adjustment (See instructions),,,,,,,21 22,Amount due provider after sequestration adjustment (Amount on line 20 minus line 21),,,,,,,22 23,Interim payments,,,,,,,23 23.5,Tentative settlement (For intermediary use only),,,,,,,23.5 24,Balance due CORF/Program (Line 22 minus line 23) (Indicate overpayments in brackets),,,,,,,24 25,"Protested amounts (nonallowable cost report items) in accordance with PRM II, Sec. 115.2(B)",,,,,,,25 26,Balance due CORF/Program (Line 24 minus line 25) (Indicate overpayments in brackets),,,,,,,26 FORM CMS 1728-94-J-3 (5-2000) (INSTRUCTIONS PUBLISHED IN THIS WORKSHEET ARE PUBLISHED IN CMS,,,,,,,, "PUB. 15-II, SEC. 3223-3223.2",,,,,,,, ,,,,,,,, 32-330,,,,,,,,Rev. 9