05-13,,Form CMS-222-92,,,,2990 ( Cont. ) DETERMINATION OF MEDICARE,,PROVIDER,PERIOD:,,WORKSHEET C, PAYMENT,,CCN:,FROM: ,,PART II, ,,,TO:,,, PART II - DETERMINATION OF TOTAL PAYMENT,,1 ,2 ,2.01 ,3 , 10 ,,Rate period 1,Rate Period 2,Rate Period 3,,10 ," Rate for Medicare Covered Visits (Part I, Line 9) ",,,,, 11 , Medicare Covered Visits Excluding Mental Health,,,,,11 , Services (From Intermediary Records),,,,, 12 , Medicare Cost Excluding Costs for Mental Health,,,,,12 , Services (Line 10 multiplied by Line 11),,,,, 13 , Medicare Covered Visits for Mental Health,,,,,13 , Services (From Intermediary Records),,,,, 14 , Medicare Covered Cost for Mental Health,,,,,14 , Services (Line 10 multiplied by Line 13),,,,, 15 , Limit Adjustment,,,,,15 , (Line 14 times the applicable percentage) (see instructions),,,,, 15.10,Graduate Medical Education Pass Through Cost,,,,,15.10 ,(see instructions),,,,, 16 , Total Medicare Cost,,,,,16 , (Line 12 plus line 15 plus line 15.10),,,,, 17 , Less: Beneficiary Deductible for RHC only (see instructions),,,,,17 , (From contractor records),,,,, 18 , Net Medicare Cost Excluding Pneumococcal ,,,,,18 , and Influenza Vaccine and Its (Their) Administration,,,,, , (see instructions),,,,, 18.01 , Total Medicare charges (see instructions)(from ,,,,,18.01 , contractor's records (PS&R Report) ),,,,, 18.02 , Total Medicare preventive charges (see instructions)(from,,,,,18.02 , provider's records),,,,, 18.03 , Total Medicare preventive costs ((line 18.02/line 18.01) ,,,,,18.03 , times line 16),,,,, 18.04 , Total Medicare non-preventive costs ((line 18 minus ,,,,,18.04 , line 18.03) times 80%),,,,, 18.05 , Net Medicare cost (see instructions),,,,,18.05 ,,,,,, 18.06 , Less: Beneficiary coinsurance for RHC/FQHC services ,,,,,18.06 , (see instructions) (from contractor records) ,,,,, 19 ," Reimbursable Cost of RHC/FQHC Services, Other Than Pneumococcal ",,,,,19 , and Influenza Vaccine (see instructions),,,,, 20 , Medicare Cost of Pneumococcal and Influenza Vaccine and,,,,,20 ," Its (Their) Administration (From Supp. Worksheet B-1, line 16)",,,,, ,,,,,, 20.50, Other adjustments (specify),,,,,20.50 21 , Total Reimbursable Medicare Cost (see instructions),,,,,21 ,,,,,, 22 , Less Payments to RHC/FQHC During Reporting Period,,,,,22 ,,,,,, 23 , Balance Due To/From The Medicare Program ,,,,,23 , Exclusive of Bad Debts (line 21 less line 22),,,,, 24 ," Total Reimbursable Bad Debts, Net of Bad Debt",,,,,24 , Recoveries (From Provider Records),,,,, 24.01, Total Gross Reimbursable Bad Debts for Dual Eligible Beneficiaries,,,,,24.01 , (From Provider Records),,,,, 24.02, Tentative settlement (for contractor use only),,,,,24.02 ,,,,,, 24.10, Adjusted reimbursable bad debts (see instructions),,,,,24.10 ,,,,,, 24.11, Sequestration adjustment (see instructions),,,,,24.11 ,,,,,, 25 , Total Amount Due To/From The Medicare Program (see instructions),,,,,25 ,,,,,, ,,,,,, ,,,,,, ,,,,,, ,,,,,, ,,,,,, "FORM CMS-222-92 (05-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,",,,,,, SECTIONS 2908 AND 2908.2),,,,,, ,,,,,, Rev. 11,,,,,,29-311 ,,,,,, ,,,,,, ,,,,,,