05-07,,,FORM CMS 1728-94,,,,,3290 (Cont.)
ANALYSIS OF PAYMENTS TO,,,  CORF NO.:,  FROM:  _______________,,,  WORKSHEET J-4,
PROVIDER-BASED CORF FOR,,,  ___________________,  TO:  _________________,,,,
SERVICES RENDERED TO PROGRAM,,,,,,,,
BENEFICIARIES,,,,,,,,
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,DESCRIPTION,,,,,PART B,,
,,,,,,1,2,
,,,,,,mm/dd/yyyy,Amount,
1,Total interim payments paid to CORF ,,,,,,,1
2,"Interim payments payable on individual bills either, submitted or to",,,,,,,2
,"be submitted to the intermediary, for services rendered in the",,,,,,,
,"cost reporting period.  If none, write ""NONE"" or enter a zero.",,,,,,,
3,List separately each retroactive lump sum ,,,,.01,,,3.01
,adjustment amount based on subsequent revision,,,Program ,.02,,,3.02
,of the interim rate for the cost reporting period.,,,to,.03,,,3.03
,Also show date of each payment.  If none write,,,Provider,.04,,,3.04
,"""NONE"" or enter a zero. (1)",,,,.05,,,3.05
,,,,,.50,,,3.50
,,,,Provider ,.51,,,3.51
,,,,to,.52,,,3.52
,,,,Program,.53,,,3.53
,,,,,.54,,,3.54
,"SUBTOTAL (Sum of lines 3.01-3.49, minus sum",,,,,,,
,of lines 3.50-3.98)                         ,,,,.99,,,3.99
4,"TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)",,,,,,,4
,"(Transfer to Supp. Wkst J-3, Part II, line 23)",,,,,,,
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,,TO BE COMPLETED BY INTERMEDIARY,,,,,,
,,,,,,,,
5,List separately each tentative settlement payment ,,,Program ,.01,,,5.01
,after desk review.  Also show date of each ,,,to,.02,,,5.02
,"payment.  If none, write ""NONE"" or enter     ",,,Provider,.03,,,5.03
,a zero. (1),,,Provider ,.50,,,5.50
,,,,to,.51,,,5.51
,,,,Program,.52,,,5.52
,"SUBTOTAL (Sum of lines 5.01-5.49, minus sum  ",,,,,,,
,of lines 5.50-5.98)      ,,,,.99,,,5.99
6,Determine net settlement amount (balance due) based,,,Program ,,,,
,on the cost report (SEE INSTRUCTIONS). (1),,,to,,,,
,,,,Provider,.01,,,6.01
,,,,Provider ,,,,
,,,,to,,,,
,,,,Program,.02,,,6.02
7,TOTAL MEDICARE PROGRAM LIABILITY (See Instructions),,,,,,,7
,,,,,,,,
 Name of Intermediary,,,,,    Intermediary Number,,,
,,,,,,,,
,,,,,,,,
 Signature of Authorized Person,,,,,"    Date:   (Month, Day, Year)",,,
,,,,,,,,
,,,,,,,,
" (1)  On lines 3, 5 and 6, where an amount is due ""Provider to Program,"" show the amount and date on which the provider",,,,,,,,
"      agrees to the amount of repayment, even though total repayment is not accomplished until a later date.",,,,,,,,
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"FORM CMS-1728-94-J-4  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,",,,,,,,,
SEC. 3224,,,,,,,,
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Rev. 13,,,,,,,,32-331