02-06 CMS FORM-2552-96 3690 (Cont.) CALCULATION OF REIMBURSEMENT PROVIDER NO.: PERIOD: "WORKSHEET E," SETTLEMENT ________________ FROM ____________ PART A COMPONENT NO.: TO _______________ ________________ Check [ ] Hospital Applicable Box [ ] Subprovider PART A - INPATIENT HOSPITAL SERVICES UNDER PPS DRG Amount 1 Other Than Outlier Payments occurring prior to October 1 X 1 1.01 Other than Outlier Payments occurring on or after October 1 and before January 1. X 1.01 1.02 Other than Outlier Payments occurring on or after January 1 X 1.02 Managed Care Patients 1.03 Payments prior to March 1st or October 1st. X 1.03 1.04 Payments on or after October 1 and prior to January 1. X 1.04 1.05 Payments on or after January 1st but before April 1st/October 1st. X 1.05 1.06 Additional amount received or to be received (see instructions) X 1.06 1.07 "Payments for discharges on or after April 1, 2001 through September 30, 2001." X 1.07 1.08 "Simulated payments from the PS&R on or after April 1, 2001 through September 30, 2001." X 1.08 2 "Outlier payments for discharges occurring prior to October 1, 1997 (see instructions)" X 2 2.01 "Outlier payments for discharges occurring on or after October 1, 1997 (see instructions)" X 2.01 3 Bed days available divided by number of days in the cost reporting period (see instructions) X 3 Indirect Medical Education Adjustment 3.01 " Number of Interns & Residents from Worksheet S-3, Part I" X 3.01 3.02 Indirect medical education percentage (see instructions) X 3.02 3.03 " Indirect medical education adjustment (sum of lines 1, 1.01, 1.02, and 2 times line 3.02)" X 3.03 3.04 FTE count for allopathic and osteopathic programs for the most recent cost reporting period ending on or 3.04 before 12/31/1996.(see instructions) X 3.05 FTE count for allopathic and osteopathic programs which meet the criteria for an add-on to the cap for new programs in 3.05 accordance with section 1886(d)(5)(B)(viii) 3.06 Adjusted FTE count for allopathic and osteopathic programs for affiliated programs in accordance with X 3.06 section 1886(d)(5)(B)(viii) 3.07 Sum of lines 3.04 through 3.06 (see instructions). X 3.07 3.08 FTE count for allopathic and osteopathic programs in the current year from your records X 3.08 3.09 " For cost reporting periods beginning before October 1, enter the percentage of discharges occurring prior to October 1." X 3.09 3.10 " For cost reporting periods beginning before October 1, enter the percentage of discharges occurring on or after October 1." X 3.10 3.11 FTE count for the period identified in line 3.09 X 3.11 3.12 FTE count for the period identified in line 3.10 X 3.12 3.13 FTE count for residents in dental and podiatric programs. X 3.13 3.14 Current year allowable FTE (see instructions) X 3.14 3.15 " Total allowable FTE count for the prior year, if none but prior year teaching was in effect enter 1 here……….." _________ X 3.15 3.16 " Total allowable FTE count for the penultimate year if that year ended on or after September 30, 1997, otherwise enter zero." 3.16 If there was no FTE count in this period but prior year teaching was in effect enter 1 here………………………………. _________ X 3.17 Sum of lines 3.14 through 3.16 divided by the number of those lines in excess of zero (see instructions). X 3.17 3.18 Current year resident to bed ratio (line 3.17 divided by line 3). X 3.18 3.19 Prior year resident to bed ratio (see instructions) X 3.19 3.20 " For cost reporting periods beginning on or after October 1, 1997, enter the lesser of lines 3.18 or 3.19. (see instructions)" X 3.20 3.21 IME payments for discharges occurring prior to October 1 (see instructions) X 3.21 3.22 IME payments for discharges occurring on or after October 1 but before January 1 (see instructions) X 3.22 3.23 IME payments for discharges occurring on or after January 1 (see instructions) X 3.23 3.24 Sum of lines 3.21 through 3.23 (see instructions). X 3.24 Disproportionate Share Adjustment 4 Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions) X 4 4.01 " Percentage of Medicaid patient days to total days reported on Worksheet S-3, Part I" X 4.01 4.02 Sum of lines 4 and 4.01 X 4.02 4.03 Allowable disproportionate share percentage (see instructions) X 4.03 4.04 Disproportionate share adjustment (see instructions) X 4.04 "FORM CMS-2552-96 (2/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3630.1)" Rev. 15 36-587 3690 (Cont.) CMS FORM-2552-96 02-06 CALCULATION OF REIMBURSEMENT PROVIDER NO.: PERIOD: "WORKSHEET E," SETTLEMENT ________________ FROM ____________ PART A (Cont.) COMPONENT NO.: TO _______________ ________________ Check [ ] Hospital Applicable Box [ ] Subprovider PART A - INPATIENT HOSPITAL SERVICES UNDER PPS Additional payment for high percentage of ESRD beneficiary discharges 5 "Total Medicare discharges on Worksheet S-3, Part I excluding discharges for DRGs 302, 316, and 317." X 5 5.01 " Total ESRD Medicare discharges excluding DRGs 302, 316, and 317" X 5.01 5.02 " Divide line 5.01 by line 5 (if less than 10%, you do not qualify for adjustment)" X 5.02 5.03 " Total Medicare ESRD inpatient days excluding DRGs 302, 316, and 317" X 5.03 5.04 Ratio of average length of stay to one week (line 5.03 divided by line 5.01 divided by 7) X 5.04 5.05 Average weekly cost for dialysis treatments (see instructions) X 5.05 5.06 Total additional payment (line 5.04 times line 5.05 times line 5.01) X 5.06 6 Subtotal (see instructions) X 6 7 "Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only.(see instructions)" X 7 7.01 "Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only.See instructions FY beg. 10/1/00)" X 7.01 8 Total payment for inpatient operating costs SCH and MDH only (see instructions) X 8 9 "Payment for inpatient program capital (from Worksheet L, Parts I, II, or III, as applicable)" X 9 10 "Exception payment for inpatient program capital (Worksheet L, Part IV, see instructions)" X 10 11 "Direct graduate medical education payment (from Worksheet E-3, Part IV, see instructions)." X 11 11.01 Nursing and Allied Health Managed Care payment X 11.01 11.02 Special add-on payments for new technologies X 11.02 12 Net organ acquisition cost X 12 13 Cost of teaching physicians X 13 14 Routine service other pass through costs X 14 15 Ancillary service other pass through costs X 15 16 Total (sum of amounts on lines 8 through 15) X 16 17 Primary payer payments X 17 18 Total amount payable for program beneficiaries (line 16 minus line 17) X 18 19 Deductibles billed to program beneficiaries X 19 20 Coinsurance billed to program beneficiaries X 20 21 Reimbursable bad debts (see instructions) X 21 21.01 Adjusted reimbursable bad debts (see instructions) X 21.01 21.02 Reimbursable bad debts for dual eligible beneficiaries (see instructions) X 21.02 22 Subtotal (line 18 plus line 21.01 minus lines 19 and 20) X 22 23 Recovery of excess depreciation resulting from provider termination or a decrease in program utilization X 23 24 Other adjustments (see instructions) (specify) X 24 25 Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets X 25 26 Amount due provider (line 22 plus or minus lines 24 and 25 minus line 23) X 26 27 Sequestration adjustment (see instructions) X 27 28 Interim payments X 28 28.01 Tentative settlement (for fiscal intermediary use only) X 28.01 29 "Balance due provider (Program) (line 26 minus the sum of lines 27, 28, and 28.01)" X 29 30 "Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2" X 30 TO BE COMPLETED BY INTERMEDIARY 50 "Original outlier amount from Worksheet E, Part A line 2.01" X 50 51 Outlier reconciliation amount (see instructions) X 51 52 The rate used to calculate the Time Value of Money X 52 53 Time Value of Money (see instructions) X 53 FORM CMS-2552-96 (2/2006) (INSTRUCTIONS FOR THIS WORKSHEET IS PUBLISHED IS PUBLISHED IN CMS PUB. 15-II SECTION 3630.1) 36-587.1 Rev. 15