4290 (Cont.),,FORM CMS-265-11,,,,,,04-14 CALCULATION OF BAD DEBT REIMBURSEMENT,,, PROVIDER CCN:,, PERIOD:,," WORKSHEET E,", ,,,,, From: ,, PARTS I & II, ,,,,, To: ,,, ,,,,,,,, PART I - CALCULATION OF REIMBURSABLE BAD DEBTS TITLE XVIII - PART B,,,,,,,, 1 ," Total Expenses Related to Care of Medicare Beneficiaries (from Wkst. D, col. 5, line 11)",,,,,,,1 ,,,,,,,, ,,,,Column 1,,Column 2,, 2 ," Total payment due net of Part B deductibles (from Wkst. D, col. 7, line 11) (see instructions)",,,,,,,2 2.01 ," Total payment due net of Part B deductibles (from Wkst. D. col. 7.01, line 11) (see instr.)",,,,,,,2.01 2.02 ," Total payment due net of Part B deductibles (from Wkst. D. col. 7.02, line 11) (see instr.)",,,,,,,2.02 2.03 , Total payment due net of Part B deductibles (see instructions),,,,,,,2.03 3 , Outlier payments,,,,,,,3 4 ,,,,,,,,4 5 ," Program payments (80% of line 2.03, column 2)",,,,,,,5 6 , Amount of cost to be recovered from Medicare patients (line 1 minus line 5),,,,,,,6 7 , Deductibles and coinsurance billed to Medicare Part B patients (see instructions),,,,,,,7 7.01 , Deductibles and coinsurance billed to Medicare Part B patients (see instructions),,,,,,,7.01 7.02 , Deductibles and coinsurance billed to Medicare Part B patients (see instructions),,,,,,,7.02 7.03 , Total deductibles and coinsurance billed to Medicare Part B patients for comparison (see instructions),,,,,,,7.03 8 , Bad debts for deductibles and coinsurance net of bad debt recoveries for services rendered prior to 1/1/2011,,,,,,,8 9 , Transition period 1 (75-25%) bad debts for deductibles and coinsurance net of bad debt recoveries for,,,,,,,9 , services rendered on or after 1/1/2011 but before 1/1/2012,,,,,,, 10 , Transition period 2 (50-50%) bad debts for deductibles and coinsurance net of bad debt recoveries for,,,,,,,10 , services rendered on or after 1/1/2012 but before 1/1/2013,,,,,,, 11 , Transition period 3 (25-75%) bad debts for deductibles and coinsurance net of bad debt recoveries for,,,,,,,11 , services rendered on or after 1/1/2013 but before 1/1/2014,,,,,,, 12 , 100% PPS bad debts for deductibles and coinsurance net of bad debt recoveries for,,,,,,,12 , services rendered on or after 1/1/2014,,,,,,, 13 , Total bad debts (sum of line 8 through line 12),,,,,,,13 14 ," Net deductibles and coinsurance billed to Medicare Part B patients (line 7.03 minus line 13, col. 2)",,,,,,,14 15 ," Unrecovered from Medicare Part B patients (line 6 minus line 14) (If line 14 exceeds line 6, do not complete line 16)",,,,,,,15 16 , Reimbursable bad debts (see instructions),,,,,,,16 17 , Reimbursable bad debts for dual eligible beneficiaries (see instructions--informational only),,,,,,,17 18 , Tentative adjustment,,,,,,,18 19 , Sequestration adjustment amount,,,,,,,19 20 , Balance due provider/program (line 16 minus lines 18 and 19) (Indicate overpayment in parentheses) (see instructions),,,,,,,20 ,,,,,,,, ,,,,,,,, PART II - CALCULATION OF FACILITY SPECIFIC COMPOSITE COST PERCENTAGE,,,,,,,, 1 ," Total allowable expenses (from Wkst. C, col. 2, line 18)",,,,,1 ,, 2 ," Total composite costs (from Wkst. D, col. 2, line 11)",,,,,2 ,, 3 , Facility specific composite cost percentage (line 2 divided by line 1),,,,,3 ,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, "FORM CMS-265-11 (04/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4214)",,,,,,,, ,,,,,,,, 42-316,,,,,,,,Rev. 3