01-10,,FORM CMS 1728-94,,,,3290 (Cont.)
CALCULATION OF,,PROVIDER NO.:,PERIOD:,,WORKSHEET RF-3,
REIMBURSEMENT SETTLEMENT,,_______________,FROM: ___________,,,
FOR RHC/FQHC SERVICES,,COMPONENT NO.:,TO: ___________,,,
,,_______________,,,,
Check ,,  [  ]  RHC,,,,
Applicable Box:,,  [  ]  FQHC,,,,
DETERMINATION OF RATE FOR RHC/FQHC SERVICES,,,,,,
1 ,"Total Allowable Cost of RHC/FQHC Services (from Worksheet RF-2, line 20)",,,,,1 
2 ,"Cost of vaccines and their administration (from Worksheet RF-4, line 15)",,,,,2 
3 ,Total allowable cost excluding vaccine (line 1 minus line 2),,,,,3 
4 ,"Total FTEs and Visits (from Wkst. RF-2, col. 5, line 8)",,,,,4 
5 ,"Physicians visits under agreement (from Worksheet RF-2, column 5, line 9)",,,,,5 
6 ,Total adjusted visits (line 4 plus line 5),,,,,6 
7 ,Adjusted cost per visit (line 3 divided by line 6),,,,,7 
,,,,,,
,,,Calculation of Limit (1),,,
,,,Rate,Rate,Rate,
,,,Period 1,Period 2,Period 3,
,,,1 ,2 ,3 ,
8 ,Per visit payment limit (from your intermediary),,,,,8 
9 ,Rate for Medicare covered visits (lesser of line 7 or line 8) (See instructions),,,,,9 
,,,,,,
CALCULATION OF SETTLEMENT,,,,,,
10 ,Medicare covered visits excluding mental health services,,,,,10 
,(from intermediary records),,,,,
11 ,Medicare cost excluding costs for mental health services,,,,,11 
,(line 9 x line 10),,,,,
12 ,Medicare covered visits for mental health services,,,,,12 
,(from intermediary records),,,,,
13 ,Medicare covered cost for mental health services (line 9 x line 12),,,,,13 
14 ,Limit adjustment for mental health services ,,,,,14 
,(line 13 x the applicable percentage)  (see instructions),,,,,
,,,,,,
,,,,, 1 ,
15 ,Graduate Medical Education Pass Through Cost (see instructions),,,,,15 
15.5,Primary Payer Amounts,,,,,15.5
16 ,"Total Medicare cost (line 11, columns 1, 2 & 3 plus line 14, columns 1, 2, & 3 plus column",,,,,16 
," 1, line 15 minus \line 15.5)",,,,,
17 ,Less:  Beneficiary deductible (from intermediary records),,,,,17 
18 ,Net Medicare cost excluding vaccines (line 16 minus line 17),,,,,18 
19 ,"Reimbursable cost of RHC/FQHC services, excluding vaccine (80% of line 18)",,,,,19 
20 ,"Medicare cost of vaccines and their administration (from Worksheet. RF-4, line 16)",,,,,20 
21 ,Total reimbursable Medicare cost (line 19 plus line 20),,,,,21 
22 ,Reimbursable bad debts,,,,,22 
23 ,Other adjustments (specify),,,,,23 
24 ,"Net reimbursable amounts (sum of lines 21, 22 and 23)",,,,,24 
25 ,"Interim payments (From Worksheet RF-5, line 4)",,,,,25 
25.5,Tentative settlement (For intermediary use only),,,,,25.5
26 ,Balance due component/program (line 24 minus line 25),,,,,26 
27 ,Protested amounts (nonallowable cost report items) in accordance with CMS Pub.,,,,,27 
,"15-II, chapter I, section 115.2",,,,,
,,,,,,
"(1)  Enter chronologically in columns 1, 2, and 3, as applicable, the payment limit and corresponding data.",,,,,,
,,,,,,
FORM CMS-1728-94-RF-3  (1-2010)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.,,,,,,
"15-II, SECTIONS 3236 - 3236.1)",,,,,,
,,,,,,
Rev. 14,,,,,,32-345