Form Cms-216-94 - Organ Procurement Organization-Histo-Compatibility Lab Statement Of Reimbursable Costs Page 14
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1806-02
Form CMS-216-94
3390 (Cont.)
CALCULATION OF REIMBURSEMENT
MEDICARE
REPORTING PERIOD
WORKSHEET D
SETTLEMENT
NUMBER
FROM_____________
TO________________
1
2
Kidney Acquisition
Tissue Typing Lab
1
Medicare Reimbursable Cost-Kidney Acquisition-
1
Worksheet-C,Column 1,line 5
Tissue Typing-Laboratory W/S-C, Column 2, Line 5
2
Total Revenue Received for Lab Services Furnished to
2
Foreign Countries, Military and DVA Hospitals
3
Total Cost Reimbursable to OPO/LAB (Line 1-Line 2)
3
4
Total Payments Received and Receivable from OPOs
4
and Transplant Hospitals for Kidneys Furnished or
Laboratory Services Provided for Kidney Transplantation
(From Your Records)
5
Subtotal (Line 3-Line 4)
5
6
Sequestration Adjustment (See Instructions)
6
7
Interim Payments
7
8
Net Balance Due OPO/LAB (Medicare Program)
8
(Line 5 - (Line 6 + Line 7)
Form CMS-216-94 (3/95) (INSTRUCTION FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, Section 3313)
Rev. 3
33-315
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