Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 16
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 3A
04-06
Hospital Emergency Department
Provider Name: ________________________________
Provider-Based Physician
Provider Number: ______________________________
Allowable Availability Service Costs
Cost Reporting Year: Beginning __________________
Under Hourly Rate or Salary
Ending _____________ RCE Year ________________
Arrangements: Computation
Name of Physician: ___________________________
Specialty: ___________________________________
The Reasonable Cost of the Supervisory, Administrative and Availability Services Time is
Computed as Follows:
1. Determine the Applicable RCE Base:
Total Hours
(Supervisory, Administrative
and Availability Services)
X RCE (Use RCE from Table I) = RCE Base
Work Year Hours (2,080)
_____________________
X
$_____________________
=
$_________________
2,080
2. Determine the Limit on the Allowance for Membership in Professional Associations and
Continuing Education.
RCE Base
X 5%
= Limit
$____________ X .05
= $_________________
3. Provider Payments for Membership in Professional Associations and Continuing Medical
Education:
Membership in Professional Associations
$_________________
Continuing Medical Education
$_________________
Total
$_________________
4. Malpractice Insurance Expense
(Provider Services Portion)
$_________________
5. Adjusted RCE Base:
(Sum of #1 $________ + the lesser of #2 or #3 $________
+ #4 $________)
= $_________________
11-30
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