des,,                  Form CMS-265-94,,,3490 (Cont.)
CALCULATION OF REIMBURSABLE,,FACILITY NO.,PERIOD:,,
BAD DEBTS  TITLE XVIII-PART B,,,FROM:______________                   ,WORKSHEET D,
,,                                                            ,TO:______________,,
,,,,,
1,Total Expenses Related to Care of Medicare Beneficiaries ,,,,1
,"(From Worksheet C, Column 5, line 11)",,,,
,,,,,
,,,,,
2,Total Payment Due (Net of Part B Deductibles),,,,2
,"(From Worksheet C, Column 7, line 11)",,,,
,,,,,
,,,,,
3,Program Payments(80% of Line 2),,,,3
,,,,,
,,,,,
4,Amount of Cost To Be Recovered From Medicare,,,,4
,Patients (Line 1 Minus Line 3),,,,
,,,,,
,,,           ,,
5,Deductibles and Coinsurance Billed to Medicare,,,,5
,(Part B) Patients,,,,
,,,,,
,,,,,
6,"Bad Debts for Deductibles and Coinsurance, Net",,,,6
,of Bad Debt Recoveries,,,,
,,,,,
,,,,,
7,Net Deductibles and Coinsurance Billed to,,,,7
,Medicare (Part B) Patients (Line 5 Minus Line 6),,,,
,,,,,
,,,,,
,,,,,
,Unrecovered From Medicare (Part B) Patients (Line 4,,,,
8,"Minus Line 7)( If Line 7 Exceeds Line 4, Do Not",,,,8
,Complete Line 9),,,,
,,,,,
,,,,,
9,Reimbursable Bad Debts(Lessor of Line 6 or Line 8),,,,9
,,,,,
,,,,,
9.01,Reimbursable bad debts for dual eligible beneficiaries (see,,,,9.01
,instructions),,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
,,,,,
"FORM CMS 265-94 (12-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,",,,,,
SECTION 3413),,,,,
,,,,,
Rev. 9,,,,,34-313