Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 10
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
251102.3 (Cont.)
EXHIBIT 1 (Cont.)
04-06
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
If yes, attach a crosswalk between revenue codes and charges
found on the PS&R to the cost center groupings on the cost
report. This crosswalk will reflect a cost center to revenue
code match only.
2. The cost report was prepared using the PS&R for totals and
the provider records for allocation.
a)
Part A (including subproviders, SNF, etc).
b)
Part B (inpatient and outpatient).
If yes, include a detailed crosswalk between revenue codes,
departments and charges on the PS&R to the cost center
groupings on the cost report. This crosswalk must include
which revenue codes were allocated to each cost center.
Supporting workpapers must accompany this crosswalk to
provide sufficient documentation as to the accuracy of the
provider records.
If the PS&R is used for the allocation of ASC, Radiology,
Other Diagnostic, and All Other Part B, explain how the total
charges are detailed to the various PS&R Medicare outpatient
types. Include workpapers supporting the allocation of
charges into the various cost centers. If internal records are
used for either the type of service breakdown or the charge
allocation, the source of this information must be included in
the documentation.
3. Provider records only were used to complete the cost report?
a)
Part A (including subproviders, SNF, etc.).
b)
Part B (inpatient and outpatient).
If yes, attach detailed documentation of the system used to
support the data reported on the cost report. If the detail
documentation was previously supplied, submit only
necessary updated documentation.
11-24
Rev. 6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dhcs 3076 - Supplemental Cost Report Schedule B For Intermediate Care Facilityfor The Developmentallydisabled (habilitative Or Nursing) Adult Day Services And Related Transportation Cost
Legal
Related Categories
Parent category: Medical