Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 9
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2504-06
EXHIBIT 1 (Cont.)
1102.3 (Cont.)
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
I.
Bad Debts
NOTE: Section I to be completed by all providers.
1. The provider seeks Medicare reimbursement for bad debts. If
"yes", complete Exhibit 5 or submit internal schedules
duplicating documentation required on Exhibit 5 to support
bad debts claimed. (see instructions)
2. The provider's bad debt collection policy changed during the
cost reporting period.
If "yes", submit copy.
3. The provider waives patient deductibles and/or copayments.
If yes, insure that they are not included on Exhibit 5.
J.
Bed Complement
NOTE: Section J to be completed by all providers.
The provider's total available beds have changed from prior cost
reporting period.
If "yes", provide an analysis of available beds and explain any
changes during the cost reporting period.
K.
PS&R Data
NOTE 1: Section K to be completed by all providers.
NOTE 2: Refer to the instructions regarding required
documentation and attachments.
1. The cost report was prepared using the PS&R only?
a)
Part A (including subproviders, SNF, etc.)?
b)
Part B (inpatient and outpatient).
Rev. 6
11-23
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