08-06		                          FORM CMS-2552-96				      3690 (Cont.)
CALCULATION OF REIMBURSEMENT 			PROVIDER NO.:	PERIOD:	WORKSHEET E-2 	
SETTLEMENt -  SWING BEDS			________________	FROM ________		
			COMPONENT NO.:	TO ___________		
			___________________			
Check		 [ ] Title V	 [ ] Swing Bed - SNF			
Applicable		 [ ] Title XVIII	 [ ] Swing Bed - NF			
Boxes		 [ ] Title XIX				
						
				PART A	PART B	
	COMPUTATION OF NET COST OF COVERED SERVICES			1	2	
1 	Inpatient routine services - swing bed-SNF (see instructions)			X	X	1 
2 	Inpatient routine services - swing bed-NF (see instructions)			X		2 
3 	"Ancillary services (from Wkst. D-4, column 3, line 101 for Part A, and sum of Wkst. D, Part V,"					3 
	"columns 9 and 11, line 104 and Wkst. D, Part VI, line 3 for Part B). For CAH (see instructions)"			X	X	
4 	Per diem cost for interns and residents not in approved teaching program (see instructions)			X	X	4 
5 	Program days			X	X	5 
6 	Interns and residents not in approved teaching program (see instructions)			X	X	6 
7 	Utilization review - physician compensation - SNF optional method only			X		7 
8 	Subtotal (sum of lines 1 through 3 plus lines 6 and 7)			X	X	8 
9 	Primary payer payments (see instructions)			X	X	9 
10 	Subtotal (line 8 minus line 9)			X	X	10 
11 	Deductibles billed to program patients (exclude amounts applicable to physician professional					11 
	services)			X	X	
12 	Subtotal (line 10 minus line 11)			X	X	12 
13 	Coinsurance billed to program patients (from provider records) (exclude coinsurance for					13 
	physician professional services)			X	X	
14 	80% of Part B costs (line 12 x 80%)				X	14 
15 	"Subtotal (enter the lesser of line 12 minus line 13, or line 14)"			X	X	15 
16 	Other adjustments (see instructions) (specify)			X	X	16 
17 	Reimbursable bad debts (see instructions)			X	X	17 
17.01 	Reimbursable bad debts for dual eligible beneficiaries (see instructions)			X	X	17.01 
18 	"Total (title XVIII, Part A - sum of lines 15 and 17, plus/minus line 16; Part B - sum of lines 15"					18 
	"and 17 plus/minus line 16) (titles V or XIX - sum of lines 15 and 17, plus/minus line 16)"			X	X	
19 	Sequestration adjustment (see instructions)			X	X	19 
20 	Interim payments 			X	X	20 
20.01 	Tentative settlement (for fiscal intermediary use only)			X	X	20.01 
21 	"Balance due provider/program (line 18 minus the sum of lines 19, 20,  and 20.01)"			X	X	21 
22 	"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II,"					22 
	section 115.2			X	X	
						
						
						
						
						
						
						
						
						
						
						
						
						
						
						
						
						
						
						
						
						
						
"FORM CMS-2552-96 (5/2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3632)"						
						
						
						
						
						
						
Rev. 16						               36-593