04-05 FORM CMS-2552-96 3690 (Cont.) CALCULATION OF PROVIDER NO.: PERIOD: "WORKSHEET E," REIMBURSEMENT SETTLEMENT ___________________ FROM ________ PART B COMPONENT NO.: TO __________ ___________________ Check applicable box [ ] Hospital [ ] Subprovider [ ] SNF PART B - MEDICAL AND OTHER HEALTH SERVICES 1 Medical and other services (see instructions) X 1 1.01 "Medical and other services rendered on or after April 1, 2001 (see instructions)." X 1.01 1.02 PPS payments received including outliers. X 1.02 1.03 Enter the hospital specific payment to cost ratio.(see instructions) X 1.03 1.04 Line 1.01 times line 1.03. X 1.04 1.05 Line 1.02 divided by line 1.04. X 1.05 1.06 Transitional corridor payment (see instructions) X 1.06 1.07 "Enter the amount from Worksheet D, Part IV, (sum of columns 9, 9.01 and 9.02) line 101." X 1.07 2 Interns and residents X 2 3 Organ acquisitions X 3 4 Cost of teaching physicians X 4 5 Total cost (see instructions) X 5 COMPUTATION OF LESSER OF COST OR CHARGES Reasonable charges 6 Ancillary service charges X 6 7 Interns and residents service charges X 7 8 "Organ acquisition charges (from Worksheet D-6, Part III, line 61, col. 4)" X 8 9 Charges of professional services of teaching physicians X 9 10 Total reasonable charges (sum of lines 6 through 9) X 10 Customary charges 11 Aggregate amount actually collected from patients liable for payment for services on a charge basis X 11 12 Amounts that would have been realized from patients liable for payment for services on a charge 12 basis had such payment been made in accordance with 42 CFR 413.13(e) X 13 Ratio of line 11 to line 12 (not to exceed 1.000000) X 13 14 Total customary charges (see instructions) X 14 15 Excess of customary charges over reasonable cost (complete only if line 14 exceeds line 5) (see instructions) X 15 16 Excess of reasonable cost over customary charges (complete only if line 5 exceeds line 14) (see instructions) X 16 17 Lesser of cost or charges (line 5 or line 14) (for CAH see instructions) X 17 17.01 "Total prospective payment (sum of lines 1.02, 1.06, and 1.07)" X 17.01 COMPUTATION OF REIMBURSEMENT SETTLEMENT 18 Deductibles and coinsurance (see instructions) X 18 18.01 Deductibles and Coinsurance relating to amount on line 17.01 (see instructions) X 18.01 19 Subtotal (lines 17 and 17.01 minus lines 18 and 18.01) (see instructions) X 19 20 "Sum of amounts from Worksheet E, Parts C, D, and E (see instructions)" X 20 21 "Direct graduate medical education payments (from Worksheet E-3, Part IV)" X 21 22 "ESRD direct medical education costs (from Worksheet E-3, Part IV)" X 22 23 Subtotal (sum of lines 19 through 22) X 23 24 Primary payer payments X 24 25 Subtotal (line 23 minus line 24) X 25 Reimbursable bad debts (exclude bad debts for professional services) 26 "Composite rate ESRD (from Worksheet I-5, line 9)" X 26 27 Bad debts (see instructions) X 27 27.01 Adjusted reimbursable bad debts (see instructions) X 27.01 27.02 Reimbursable bad debts for dual eligible beneficiaries (see instructions) X 27.02 28 "Subtotal (sum of lines 25, 26, and 27 or 27.01) (line 27.01 hospital and subprovider only)" X 28 29 Recovery of excess depreciation resulting from provider termination or a decrease in program utilization X 29 30 Other adjustments (specify) (see instructions) X 30 31 Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets X 31 32 Subtotal (line 28 plus or minus lines 30 and 31 minus line 29) X 32 33 Sequestration adjustment (see instructions) X 33 34 Interim payments X 34 34.01 Tentative settlement (for fiscal intermediary use only) X 34.01 35 "Balance due provider/program (line 32 minus the sum of lines 33, 34, and 34.01) " X 35 36 "Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2" X 36 "FORM CMS-2552-96 (4/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3630.2)" Rev. 14 36-587.2