Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 13
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2504-06
EXHIBIT 1 (Cont.)
1102.3 (Cont.)
PR
OVIDER COST REPORT REIMBURSMENT QUE
STIONAIRE
YES
NO
N/A
1. Complete EXHIBIT 6, Part I (Per instructions). Part III must
be completed to reconcile any differences between any fringe
benefit cost reported on Worksheet A, Column 2, using
Medicare principles and the corresponding wage related costs
reported under GAAP for purposes of the wage index
computation.
2.
The individual wage related cost exceeds one percent of total
adjusted salaries after removing excluded salaries. (Salaries
reported on Worksheet S-3,
Part III, Column 3, line 3 (CMS-
2552-96), or Worksheet S-3, Part II, Column 3, Line 26
(CMS-
2540-96).)
3. Additional wage related costs were provided that meet ALL of
the following tests:
a.
The cost is not listed on Part I of EXHIBIT 6.
b.
If any
of the additional wage related cost applies to the
excluded areas of the hospital, the cost associated with
the excluded areas has been removed prior to making the
1 percent threshold test in question 2 above.
c.
The wage related cost has been reported to the IRS, as a
fringe benefit if so required by the IRS.
d.
The individual wage related cost is not included in
salaries reported on
Worksheet
S-3,
Part III, column 3,
line 3, (CMS-2552-96) or Worksheet S-3, Part II,
Column 3, Line 16 (CMS-2540-96).
e.
The wage related cost is not being furnished f
or the
convenience of the employer.
Rev. 6
11-27
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