3690 (Cont.) Cms Form-2552-96

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3690 (Cont.)
CMS FORM-2552-96
05-99
CALCULATION OF REIMBURSEMENT
PROVIDER NO.:
PERIOD:
WORKSHEET E,
SETTLEMENT
_______________
FROM _____________ PART D
COMPONENT NO.:
TO ________________
________________
Check
[ ] Title V
[ ] Hospital
Applicable
[ ] Title XVIII
[ ] Subprovider
Box
[ ] Title XIX
PART D - OUTPATIENT RADIOLOGY SERVICES
1 Prevailing charges (from PS&R or your records)
1
2 62 percent of line 1
2
3 Deductibles
3
4 Applicable of coinsurance (80% of the sum of line 2 minus line 3)
4
5 Blended charge proportion (for column 1, 58% of line 4, and column 1.01, 58% of line 2)
5
6 Cost of outpatient radiology (from Worksheet D, Part V (see instructions))
6
COMPUTATION OF LESSER OF REASONABLE COST OR CHARGES
7 Total charges
7
CUSTOMARY CHARGES
8 Aggregate amount actually collected from patients liable for payment for services on a charge basis
8
9 Amounts that would have been realized from patients liable for payment for services on a charge
9
basis had such payment been made in accordance with 42 CFR 413.13 (e)
10 Ratio of line 8 to line 9 (not to exceed 1.000000)
10
11 Total customary charges (see instructions)
11
12 Excess of customary charges over reasonable cost (complete only if line 11 exceeds line 6) (see instru.)
12
13 Excess of reasonable cost over customary charges (complete only if line 6 exceeds line 11) (see instru.)
13
14 Lesser of cost or charges (see instructions)
14
COMPUTATION OF REIMBURSEMENT SETTLEMENT
15 Deductibles and coinsurance (exclude professional component) (see instructions)
15
16 Total (see instructions)
16
17 Cost proportion (column 1 enter 42% of line 16 and column 1.01 enter 42% of line 14)
17
18 Outpatient radiology blended amount (sum of line 5 plus line 17)
18
19 Lesser of lines 16 or 18
19
20 Part B deductibles and coinsurance
20
21 Radiology payment amount (column 1 amount from line 19, column 1.01, line 19 minus line 20)
21
FORM CMS-2552-96 (5/1999) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3630.4)
36-590
Rev. 5

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