Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 22
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251102.3 (Cont.)
EXHIBIT 4A (Cont.)
04-06
Provider Name __________________________________Provider Number ___________________________
Name of Physician _________________________________________________________________________
12. Adjusted RCE Base:
(Sum of #8 ______________ + the Lesser of #9 or #10 ______________ + #11 ______________)
= $_______________
13. Actual Minimum Guarantee Amount
$_______________
14. Reasonable Minimum Guarantee Amount
(Lesser of #12 or #13)
$_______________
15. Total Charges:
Billed Inpatient Charges
$______________
Billed Outpatient Charges
$______________
Imputed Inpatient Charges
$______________
Imputed Outpatient Charges
$______________
Imputed Employee Charges
$______________
Total
$_______________
16. Reasonable Unmet Guarantee Amount
$_______________
(#14 Less #15)
17. Summary of Allowable Provider Costs:
Supervisory and Administrative Services (#7)
$_______________
Reasonable Unmet Guarantee Amount (#16)
$_______________
Total
$_______________
11-36
Rev. 6
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