Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 6
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251102.3 (Cont.)
EXHIBIT 1 (Cont.)
04-06
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
4. Provider has initiated an Intern-Resident program in the
current year or obtained a renewal of an existing program. If
"yes", submit certification/program approval.
5. Graduate Medical Education costs have been directly assigned
to cost centers other than the Intern-Resident Services in an
Approved Teaching Program, on Worksheet A, Form
CMS-2552.
If "yes", submit appropriate workpapers indicating to which
cost centers assigned and the amounts.
F.
Purchased Services
NOTE: Questions 1 and 2 to be completed only by hospitals
excluded from PPS (except Children’s) and PPS hospitals that
have a unit excluded from PPS. Question 3 to be completed only
by Inpatient PPS (IPPS) hospitals, hospitals with an IPPS
subprovider, hospitals that would be subject to IPPS if not
granted a waiver, and
SNFs.
1. Changes or new agreements have occurred in patient care
services furnished through contractual arrangements with
suppliers of services.
If "yes", submit copies of changes or contracts, or where
there are no written agreements, attach description.
NOTE: Hospitals are only required to submit such information
where the cost of the individual's services exceeds $25,000 per
year.
2.
The requirements of §2135.2 were applied pertaining to
competitive bidding.
If "no", attach explanation.
3.
Contract services are reported on Worksheet S-3, Part II,
line 9 (hospitals) or line 17 (SNFs).
If yes, submit a schedule showing the total direct patient care
related contract labor, hours and calculated rate for each
invoice paid during the year for the direct patient care related
contract labor reported on Worksheet S-3, Part II, line 9
(hospitals) or line 17
(SNFs).
Contracted labor will include
any wage related costs. The contracted amounts for the top
four management personnel (CEO, CFO, COO and Nursing
Administrator) are not required to be reported by individuals.
11-20
Rev. 6
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