05-99 FORM CMS-2552-96 3690 (Cont.) REASONABLE COST DETERMINATION FOR THERAPY SERVICES PROVIDER NO.: PERIOD: "WORKSHEET A-8-4," "FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998" FROM __________ PARTS I & II __________ TO ___________ Check applicable box: [ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology PART I - GENERAL INFORMATION 1 Total number of weeks worked (excluding aides) (see instructions) 1 2 Line 1 multiplied by 15 hours per week 2 3 Number of unduplicated days in which supervisor or therapist was on provider site (see instructions) 3 4 Number of unduplicated days in which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (see instructions) 4 5 Number of unduplicated offsite visits - supervisors or therapists (see instructions) X 5 6 Number of unduplicated offsite visits - therapy assistants (include only visits made by therapy assistant and on which X 6 supervisor and/or therapist was not present during the visit(s)) (see instructions) 7 Standard travel expense rate 7 8 Optional travel expense rate per mile 8 Supervisors Therapists Assistants Aides Trainees 1 2 3 4 5 9 Total hours worked X X X X X 9 10 AHSEA (see instructions) X X X X X 10 11 " Standard travel allowance (columns 1 and 2, one-half of column 2," 11 " line 10; column 3, one-half of column 3, line 10)" 12 Number of travel hours (see instructions) X X X 12 13 Number of miles driven (see instructions) X X X 13 PART II - SALARY EQUIVALENCY COMPUTATION 14 " Supervisors (column 1, line 9 times column 1, line 10)" X 14 15 " Therapists (column 2, line 9 times column 2, line 10)" X 15 16 " Assistants (column 3, line 9 times column 3, line10)" X 16 17 Subtotal allowance amount (sum of lines 14 and 15 for respiratory therapy or lines 14-16 for all others) X 17 18 " Aides (column 4, line 9 times column 4, line 10)" X 18 19 " Trainees (column 5, line 9 times column 9, line 10)" X 19 20 Total allowance amount (sum of lines 17-19 for respiratory therapy or lines 17 and 18 for all others) X 20 " If the sum of columns 1 and 2 for respiratory therapy or columns 1-3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2, " make no entries on lines 21 and 22 and enter on line 23 the amount from line 20. Otherwise complete lines 21-23. 21 " Weighted average rate excluding aides and trainees (line 17 divided by sum of columns 1 and 2, line 9 for respiratory therapy or columns 1 thru 3, line 9 for all others)" X 21 22 Weighted allowance excluding aides and trainees (line 2 times line 21) X 22 23 Total salary equivalency (see instructions) X 23 "FORM CMS-2552-96 (5/1999) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3616.8-3616.10)" Rev. 5 36-523.1 12-99 FORM CMS-2552-96 3690 (Cont.) REASONABLE COST DETERMINATION FOR THERAPY SERVICES PROVIDER NO.: PERIOD: "WORKSHEET A-8-4," "FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998" FROM _________ PARTS III & IV _____________ TO ___________ Check applicable box: [ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE Standard Travel Allowance 24 " Therapists (line 3 times column 2, line 11)" 24 25 " Assistants (line 4 times column 3, line 11)" 25 26 Subtotal (line 24 for respiratory therapy or sum of lines 24 and 25 for all others) 26 27 Standard travel expense (line 7 times line 3 for reslpiratory therapy or sum of lines 3 and 4 for all others) 27 28 Total standard travel allowance and standard travel expense at the provider site (sum of lines 26 and 27) X 28 Optional Travel Allowance and Optional Travel Expense 29 " Therapists (column 2, line 10 times the sum of columns 1 and 2, line 12 )" 29 30 " Assistants (column 3, line 10 times column 3, line 12)" 30 31 Subtotal (line 29 for respiratory therapy or sum of lines 29 and 30 for all others) 31 32 " Optional travel expense (line 8 times columns 1 and 2, line 13 for respiratory therapy or sum of columns 1-3, line 13 for all others)" 32 33 Standard travel allowance and standard travel expense (line 28) 33 34 Optional travel allowance and standard travel expense (sum of lines 27 and 31) 34 35 Optional travel allowance and optional travel expense (sum of lines 31 and 32) 35 PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE Standard Travel Expense 36 " Therapists (line 5 times column 2, line 11)" 36 37 " Assistants (line 6 times column 3, line 11)" 37 38 Subtotal (sum of lines 36 and 37) 38 39 Standard travel expense (line 7 times the sum of lines 5 and 6) 39 Optional Travel Allowance and Optional Travel Expense 40 " Therapists (sum of columns 1 and 2, line 12 .01 times column 2, line 10)" 40 41 " Assistants (column 3, line 12.01 times column 3, line 10)" 41 42 Subtotal (sum of lines 40 and 41) 42 43 " Optional travel expense (line 8 times the sum of columns 1-3, line 13.01)" 43 Total Travel Allowance and Travel Expense - Offsite Services; Complete one of the following " three lines 44, 45, or 46, as appropriate." 44 Standard travel allowance and standard travel expense (sum of lines 38 and 39 - see instructions) 44 45 Optional travel allowance and standard travel expense (sum of lines 39 and 42 - see instructions) 45 46 Optional travel allowance and optional travel expense (sum of lines 42 and 43 - see instructions) 46 "FORM CMS-2552-96 (12/1999) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3616.8, 3616.11-3616.12)" Rev. 6 36-523.2 12-99 FORM CMS-2552-96 3690 (Cont.) REASONABLE COST DETERMINATION FOR THERAPY SERVICES PROVIDER NO.: PERIOD: "WORKSHEET A-8-4," "FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998" FROM _________ PARTS V-VII ____________ TO ___________ Check applicable box: [ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology PART V - OVERTIME COMPUTATION Therapists Assistants Aides Trainees Total 1 2 3 4 5 47 " Overtime hours worked during reporting period (if column 5, " 47 " line 47, is zero or equal to or greater than 2,080, do not complete " X X X X X lines 48-55 and enter zero in each column of line 56) 48 Overtime rate (see instructions) X X X X 48 49 Total overtime (including base and overtime allowance) (multiply 49 line 47 times line 48) CALCULATION OF LIMIT 50 Percentage of overtime hours by category (divide the hours in each 50 " column on line 47 by the total overtime worked - column 4, line 47)" 51 Allocation of provider's standard workyear for one full-time 51 employee times the percentages on line 50) (see instructions) DETERMINATION OF OVERTIME ALLOWANCE 52 Adjusted hourly salary equivalency amount (see instructions) 52 53 Overtime cost limitation (line 51 times line 52) 53 54 Maximum overtime cost (enter the lessor of line 49 or line 53) 54 55 Portion of overtime already included in hourly computation at the AHSEA (multiply 55 line 47 times line 52) 56 Overtime allowance (line 54 minus line 55 - if negative enter zero) ( Enter in column 5 the X X X X X 56 " sum of columns 1, 3, and 4 for respiratory therapy and columns 1 through 3 for all others.)" PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT 57 Salary equivalency amount (from line 23) 57 58 " Travel allowance and expense - provider site (from lines 33, 34, or 35))" 58 59 " Travel allowance and expense - Offsite services (from lines 44, 45, or 46)" X 59 60 " Overtime allowance (from column 5, line 56)" 60 61 Equipment cost (see instructions) X 61 62 Supplies (see instructions) X 62 63 Total allowance (sum of lines 57-62) X 63 64 Total cost of outside supplier services (from your records) X 64 65 " Excess over limitation (line 64 minus line 63 - if negative, enter zero)" X 65 PART VII - ALLOCATION OF THERAPY EXCESS COST OVER LIMITATION FOR NONSHARED THERAPY DEPARTMENT SERVICES 66 Cost of outside supplier services - (see instructions) (from your records) X 66 67 Total cost (sum of line 66 and subscripts) (this line must agree with line 64) X 67 68 Ratio of cost of outside supplier services to total cost (line 66 and subscripts divided by line 67) 68 69 " Excess of cost over limitation (see instructions) (transfer to Wkst. A-8, lines as indicated in instructions)" 69 70 Total excess of cost over limitation (sum of line 69 and subscripts of line 69) (this line must agree with line 65) X 70 "FORM CMS-2552-96 (5/1999) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3616.8 and 3616.13-3616.15)" Rev. 6 36-523.3