Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 21
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2504-06
EXHIBIT 4A (Cont.)
1102.3 (Cont.)
Provider Name __________________________________Provider Number ___________________________
Name of Physician _________________________________________________________________________
Computation of Reasonable Allowable Cost for an Unmet Guarantee Amount
8.
Determine the Applicable RCE Base:
Total Hours (Professional
and Availability Services)
X RCE (Use RCE from Table I)
= RCE Base
Work Year Hours (2,080)
_____________________
X $ _________________________
= $________________
2,080
9.
Determine the Limit on the Allowance for Membership in Professional Associations
and Continuing Medical Education:
RCE Base
X 5%
=
Limit
$____________
X .05
= $________________
10. Determine Actual Provider Payment for Membership in Professional Associations and
Continuing Medical Education Applicable to Professional and Availability Services:
Total Hours (Professional and
Total Payments for Membership
Availability Services)
X
in Professional Associations and
Total Hours Worked
Continuing Medical Education
=
Actual Provider Payment
________________________ X $______________________________
= $________________
11. Determine the Allowance for Malpractice Insurance:
(Professional and Availability Services)
Total Hours (Professional and
Availability Services)
X Total Payments for
Total Hours Worked
Malpractice Insurance
=
Actual Provider Payment
________________________ X $______________________________
= $________________
Rev. 6
11-35
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