06-13,,,, FORM CMS-265-11,,,,,,4290 (Cont.) COST ALLOCATION - STATISTICAL BASIS,,,,, PROVIDER CCN:,, PERIOD:,, WORKSHEET B-1, ,,,,,,, From: ,,, ,,,,,,, To: ,,, ,,,CAP REL,STEP DOWN,MACH CAP,SALARIES,EH&W BENE,SUPPLIES,LABORATORY, ,,NET,OP & MAINT,OF COL. 2,REL OR RENT,FOR DIR,FOR DIR,,, ,,EXPENSES,& HOUSE,,& MAINT,PT CARE,PT CARE,,, ,,FOR,( SQUARE,( # TREAT,( % TIME ),( HRS OF,( GROSS,( CHARGES ),( CHARGES ), ,,COST ALLOC.,FEET ) (1),MENTS ) (3),(3),SERVICE ) (3),SALARIES ) (3),(3),(3), ,,1,2,3,4,5,6,7,8, 1 , COSTS TO BE ALLOCATED,,,,,,,,,1 2 , Drugs Included in Composite Rate ,,,,,,,,,2 3 , ESAs,,,,,,,,,3 4 , ESRD Related Other Drugs,,,,,,,,,4 5 ," Non-ESRD Related Drugs, Supplies & Lab",,,,,,,,,5 6 , Whole Blood and Packed Red Blood Cells,,,,,,,,,6 7 , Vaccines,,,,,,,,,7 ,REIMBURSABLE COST CENTERS,,,,,,,,, 8 , Maintenance-Hemodialysis,,,,,,,,,8 8.01 , Maintenance-Hemo Adult,,,,,,,,,8.01 8.02 , Maintenance-Hemo Pediatric,,,,,,,,,8.02 9 , Maintenance -IPD,,,,,,,,,9 9.01 , Maintenance-IPD Adult,,,,,,,,,9.01 9.02 , Maintenance-IPD Pediatric,,,,,,,,,9.02 10 , Training-Hemodialysis,,,,,,,,,10 10.01 , Training-Hemo Adult,,,,,,,,,10.01 10.02 , Training-Hemo Pediatric,,,,,,,,,10.02 11 , Training-IPD,,,,,,,,,11 11.01 , Training-IPD Adult,,,,,,,,,11.01 11.02 , Training-IPD Pediatric,,,,,,,,,11.02 12 , Training-CAPD,,,,,,,,,12 12.01 , Training-CAPD Adult,,,,,,,,,12.01 12.02 , Training-CAPD Pediatric,,,,,,,,,12.02 13 , Training-CCPD,,,,,,,,,13 13.01 , Training-CCPD Adult,,,,,,,,,13.01 13.02 , Training-CCPD Pediatric,,,,,,,,,13.02 14 , Home Program-Hemodialysis,,,,,,,,,14 14.01 , Home Program-Hemo Adult,,,,,,,,,14.01 14.02 , Home Program-Hemo Pediatric,,,,,,,,,14.02 15 , Home Program-IPD,,,,,,,,,15 15.01 , Home Program-IPD Adult,,,,,,,,,15.01 15.02 , Home Program-IPD Pediatric,,,,,,,,,15.02 16 , Home Program-CAPD,,,,,,,,,16 16.01 , Home Program-CAPD Adult,,,,,,,,,16.01 16.02 , Home Program-CAPD Pediatric,,,,,,,,,16.02 17 , Home Program-CCPD,,,,,,,,,17 17.01 , Home Program-CCPD Adult,,,,,,,,,17.01 17.02 , Home Program-CCPD Pediatric,,,,,,,,,17.02 18 , Subtotal (lines 2-16.02),,,,,,,,,18 ,NONREIMBURSABLE COST CENTERS,,,,,,,,, 19 , Physicians' Private Offices,,,,,,,,,19 20 , Method II Patients prior to 1/1/2011,,,,,,,,,20 21 , Other Nonreimbursable ,,,,,,,,,21 22 , Other Nonreimbursable ,,,,,,,,,22 23 , Total (see instructions) ,,,,,,,,,23 24 , Total Costs to be Allocated,,,,,,,,,24 25 , Unit Cost Multiplier (Line 24 div. by Line 23),,,,,,,,,25 "FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)",,,,,,,,,, Rev. 2,,,,,,,,,,42-313 4290 (Cont.),,,, FORM CMS-265-11,,,,,,06-13 COST ALLOCATION - STATISTICAL BASIS,,,,, PROVIDER CCN:,, PERIOD:,, WORKSHEET B-1, ,,,,,,, From: ,,, ,,,,,,, To: ,,, ,,,UNIT COST,DRUGS,DRUGS,,ESA'S,ESRD,TOTAL, ,,,MULTIPLIER,,INCLD IN,,,REL DRUGS,EXPENSES, ,,,,,COMP RATE,,,,ALL, ,,,,( CHARGES ),( CHARGES ),,( CHARGES ),( CHARGES ),PATIENT, ,,SUBTOTAL,COMPUTATION,(3),(3),SUBTOTAL,(3),(3),SERVICES, ,,8A,9,10,11,11A,12,13,13A, 1 , COSTS TO BE ALLOCATED,,,,,,,,,1 2 , Drugs Included in Composite Rate ,,,,,,,,,2 3 , ESAs,,,,,,,,,3 4 , ESRD Related Other Drugs,,,,,,,,,4 5 ," Non-ESRD Related Drugs, Supplies & Lab",,,,,,,,,5 6 , Whole Blood and Packed Red Blood Cells,,,,,,,,,6 7 , Vaccines,,,,,,,,,7 ,REIMBURSABLE COST CENTERS,,,,,,,,, 8 , Maintenance-Hemodialysis,,,,,,,,,8 8.01 , Maintenance-Hemo Adult,,,,,,,,,8.01 8.02 , Maintenance-Hemo Pediatric,,,,,,,,,8.02 9 , Maintenance -IPD,,,,,,,,,9 9.01 , Maintenance-IPD Adult,,,,,,,,,9.01 9.02 , Maintenance-IPD Pediatric,,,,,,,,,9.02 10 , Training-Hemodialysis,,,,,,,,,10 10.01 , Training-Hemo Adult,,,,,,,,,10.01 10.02 , Training-Hemo Pediatric,,,,,,,,,10.02 11 , Training-IPD,,,,,,,,,11 11.01 , Training-IPD Adult,,,,,,,,,11.01 11.02 , Training-IPD Pediatric,,,,,,,,,11.02 12 , Training-CAPD,,,,,,,,,12 12.01 , Training-CAPD Adult,,,,,,,,,12.01 12.02 , Training-CAPD Pediatric,,,,,,,,,12.02 13 , Training-CCPD,,,,,,,,,13 13.01 , Training-CCPD Adult,,,,,,,,,13.01 13.02 , Training-CCPD Pediatric,,,,,,,,,13.02 14 , Home Program-Hemodialysis,,,,,,,,,14 14.01 , Home Program-Hemo Adult,,,,,,,,,14.01 14.02 , Home Program-Hemo Pediatric,,,,,,,,,14.02 15 , Home Program-IPD,,,,,,,,,15 15.01 , Home Program-IPD Adult,,,,,,,,,15.01 15.02 , Home Program-IPD Pediatric,,,,,,,,,15.02 16 , Home Program-CAPD,,,,,,,,,16 16.01 , Home Program-CAPD Adult,,,,,,,,,16.01 16.02 , Home Program-CAPD Pediatric,,,,,,,,,16.02 17 , Home Program-CCPD,,,,,,,,,17 17.01 , Home Program-CCPD Adult,,,,,,,,,17.01 17.02 , Home Program-CCPD Pediatric,,,,,,,,,17.02 18 , Subtotal (lines 2-16.02),,,,,,,,,18 ,NONREIMBURSABLE COST CENTERS,,,,,,,,, 19 , Physicians' Private Offices,,,,,,,,,19 20 , Method II Patients prior to 1/1/2011,,,,,,,,,20 21 , Other Nonreimbursable ,,,,,,,,,21 22 , Other Nonreimbursable ,,,,,,,,,22 23 , Total (see instructions) ,,,,,,,,,23 24 , Total Costs to be Allocated,,,,,,,,,24 25 , Unit Cost Multiplier (Line 24 div. by Line 23),,,,,,,,,25 "FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)",,,,,,,,,, 42-313.1,,,,,,,,,,Rev. 2 04-14,,,, FORM CMS-265-11,,,,,,4290 (Cont.) ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,This page intentionally left blank.,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, "FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)",,,,,,,,,, ,,,,,,,,,, Rev. 3,,,,,,,,,,42-313.2