3690 (Cont.) FORM CMS-2552-96 02-06 PROSPECTIVE PAYMENT FOR SNF PROVIDER NO.: PERIOD: WORKSHEET S-7 STATISTICAL DATA FROM ____________ ________________ TO _______________ M3PI SERVICES PRIOR TO SERVICES ON OR AFTER Services through (1) High Cost (2) Swing Bed REVENUE October 1st October 1st 4/1/2001 - 9/30/2001 "April 1, 2000" SNF TOTAL GROUP CODE Rate Days Rate Days Rate Days Days Days (see instructions) 1 2 3 3.01 4 4.01 4.02 4.03 4.05 4.06 5 1 RUC X X X X X X X X 1 2 RUB X X X X X X X X 2 3 RUA X X X X X X X X 3 3.01 RUX X X X X X X X X 3.01 3.02 RUL X X X X X X X X 3.02 4 RVC X X X X X X X X 4 5 RVB X X X X X X X X 5 6 RVA X X X X X X X X 6 6.01 RVX X X X X X X X X 6.01 6.02 RVL X X X X X X X X 6.02 7 RHC X X X X X X X X X 7 8 RHB X X X X X X X X 8 9 RHA X X X X X X X X 9 9.01 RHX X X X X X X X X 9.01 9.02 RHL X X X X X X X X 9.02 10 RMC X X X X X X X X X 10 11 RMB X X X X X X X X X 11 12 RMA X X X X X X X X 12 12.01 RMX X X X X X X X X 12.01 12.02 RML X X X X X X X X 12.02 13 RLB X X X X X X X X 13 14 RLA X X X X X X X X 14 14.01 RLX X X X X X X X X 14.01 15 SE3 X X X X X X X X X 15 16 SE2 X X X X X X X X X 16 17 SE1 X X X X X X X X X 17 18 SSC X X X X X X X X X 18 19 SSB X X X X X X X X X 19 20 SSA X X X X X X X X X 20 21 CC2 X X X X X X X X X 21 22 CC1 X X X X X X X X X 22 23 CB2 X X X X X X X X X 23 24 CB1 X X X X X X X X X 24 25 CA2 X X X X X X X X X 25 26 CA1 X X X X X X X X X 26 27 IB2 X X X X X X X X 27 28 IB1 X X X X X X X X 28 29 IA2 X X X X X X X X 29 30 IA1 X X X X X X X X 30 31 BB2 X X X X X X X X 31 32 BB1 X X X X X X X X 32 33 BA2 X X X X X X X X 33 34 BA1 X X X X X X X X 34 35 PE2 X X X X X X X X 35 36 PE1 X X X X X X X X 36 37 PD2 X X X X X X X X 37 38 PD1 X X X X X X X X 38 39 PC2 X X X X X X X X 39 40 PC1 X X X X X X X X 40 41 PB2 X X X X X X X X 41 42 PB1 X X X X X X X X 42 43 PA2 X X X X X X X X 43 44 PA1 X X X X X X X X 44 45 Default rate X X X X X X X X 45 46 TOTAL X X X X X X X 46 (1) Enter in column 3.01 the days prior to October 1st and in column 4.01 the days on after October 1st. Enter in column 4.03 the days on 4/1/2001 " through 9/30/2001. The sum of the days in column 3.01, 4.01, and 4.03 must agree with the days reported on Wkst. S-3, Part I, column 4, line 15." " The sum of the days in column 4.06 must agree with the days reported on Wkst S-3, Part I column 4, line 3." (2) Enter in column 4.05 those days in either column 3.01 or 4.01 which cover the period of 4/1/2000 through 9/30/2000. These RUGs will be incremented by an additonal 20% payment. (3) Enter in column 4.06 the swing bed days for cost reporting periods beginning on or after 7/1/2002. "FORM CMS-2552-96 (2/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3609)" 36-510 Rev. 15