Form Preview Example

05-13					FORM CMS-1728-94						3290 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result
in all interim payments made since the beginning of the cost reporting period being deemed										FORM APPROVED
as overpayments (42 USC 1395g).										OMB NO. 0938-0022
HOME HEALTH AGENCY COST REPORT						PROVIDER CCN:			PERIOD:
CERTIFICATION AND SETTLEMENT SUMMARY									From: ___________		WORKSHEET S
						_______________			To: ___________
	Intermediary Use Only:
[ ]	Audited	Date Received			____________		[	]	Initial		[ ] Re-opened
[ ]	Desk Reviewed	Contractor No.			____________		[	]	Final
PART I - CERTIFICATION

Check		[	]	Electronically filed cost report					Date: ___________
applicable box		[	]	Manually submitted cost report					Time: ___________

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY

BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT

UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED

OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE

ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.

CERTIFICATION BY OFFICER OR DIRECTOR OF THE AGENCY

IHEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually submitted Home Health Agency Cost Report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________________________(Provider name(s) and number(s)) for the cost report beginning _____________________and ending __________________________, and that to the best of my knowledge

and belief, this report and statement are true, correct, complete and prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that the services identified in this cost report were provided in compliance with such laws and regulations.

(Signed) __________________________________________

Officer or Director

__________________________________________

Title

__________________________________________

Date

PART II - SETTLEMENT SUMMARY

			TITLE XVIII
		PART A		PART B
		1		2
1	HOME HEALTH AGENCY				1
2	HOME HEALTH-BASED CORF				2
3	HOME HEALTH-BASED CMHC				3
3.5	HOME HEALTH-BASED RHC/FQHC				3.5
	(specify)
4	TOTAL				4

"According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0022. The time required to complete this information collection is estimated to average 226 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850."

FORM CMS-1728-94-(5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECS. 3203-3203.2)

Rev. 16

32-303

3290 (Cont.)		FORM CMS-1728-94								05-13
HOME HEALTH AGENCY COMPLEX			PROVIDER CCN:		PERIOD:
IDENTIFICATION DATA					From: ___________		WORKSHEET S-2
			________________		To: ___________
Home Health Agency Complex Address:
1	Street:			P.O. Box:							1
1.01	City:	State:		Zip Code:							1.01
Home Health Agency Component Identification
	Contractor No.
	Component	Component Name			Provider No.			Date Certified
	0	1			2			3
2	Home Health Agency										2
3	HHA-based CORF										3
3.50	HHA-based Hospice										3.50
4	HHA-based CMHC										4
5	HHA- based RHC										5
6	HHA-based FQHC										6

7	Cost Reporting Period (mm/dd/yyyy)		From: ______________				To: ______________				7

8	Type of control (see instructions)										8

9	If this a low or no Medicare utilization cost report, enter "L" for Low or "N" for No Medicare Utilization.										9
Depreciation: Enter the amount of depreciation reported in this HHA for the methods indicated.
10	Straight Line										10
11	Declining Balance										11
12	Sum of the Years' Digits										12
13	Sum of lines 10, 11 and 12										13

14	Were there any disposals of capital assets during this cost reporting period?										14
15	Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period?										15
16	Was accelerated depreciation claimed on assets acquired on or after August l, l970 (See PRM 15-1,										16
	Chapter l)?
17	If depreciation is funded, enter the balance at end of period.										17
18	Did the provider cease to participate in the Medicare program at the end of										18
	the period to which this cost report applies (See PRM 15-1, Chapter 1)?
19	Was there substantial decrease in health insurance proportion of allowable										19
	costs from prior cost reporting periods (See PRM 15-1, Chapter 1)?
20	Does the provider qualify as a small HHA (defined in 42 CFR 413.24(d))?										20
21	Does the HHA qualify as a nominal charge provider (defined in 42 CFR 409.3)?										21
22	Does the HHA contract with outside suppliers for physical therapy services?										22
22.01	Does the HHA contract with outside suppliers for occupational therapy services?										22.01
22.02	Does the HHA contract with outside suppliers for speech therapy services?										22.02
If this facility contains a non-public provider that qualifies for an exemption from the application of the
lower of costs or charges, enter "Y" for each component and type of service that qualifies for the exemption.
						Part A			Part B
							1		2
23	HHA										23
24	CORF										24
25	CMHC										25
26	If the HHA componentized (or fragmented) its administrative and general service										26
	costs, indicate whether option one or option two is being utilized. (See Section 3214)
	(Enter "1" for option one and "2" for option two)

27	List amounts of malpractice premiums and paid losses:										27
27.01	Premiums										27.01
27.02	Paid Losses										27.02
27.03	Self Insurance										27.03
28	Are malpractice premiums and/or paid losses reported in other than the Administrative and General										28
	cost center? If yes, submit a supporting schedule listing cost centers and amounts contained therein.
29	If you are part of a chain organization, enter "Y" for yes and enter the name and address of the home										29
FORM	office, otherwise, enter "N" for no.
29.01	Home Office Name:	Home Office No. :			Contractor No. :						29.01
29.02	Street:	P.O. Box:		Contractor Name:							29.02
29.03	City:	State:		Zip Code:							29.03

FORM CMS 1728-94-S-2 (05-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3204)

32-304

Rev. 16

05-07

FORM CM S-1728-94

3290 (Cont.)

HOME HEALTH AGENCY STATISTICAL DATA

PROVIDER NO.:

______________

PERIOD:

From: ___________

To: ___________

WORKSHEET S-3 PARTS I - III

PART I - STATISTICAL DATA				COUNTY		Cook

		Title XVIII			Other		Total
	DESCRIPTION	Visits	Patients	Visits		Patients	Visits	Patients
		1	2	3		4	5	6
1	Skilled Nursing								1
2	Physical Therapy								2
3	Occupational Therapy								3
4	Speech Pathology								4
5	Medical Social Service								5
6	Home Health Aide								6
7	All Other Services								7
8	Total Visits								8
9	Home Health Aide Hours								9
10	Unduplicated Census Count -								10
	Full Cost Reporting Period
10.01	Unduplicated Census Count -								10.01
	Pre 10/1/2000
10.02	Unduplicated Census Count -								10.02
	Post 9/30/2000
PART II - EMPLOYMENT DATA
(FULL TIME EQUIVALENT)
	Number of hours in
	your normal work week __________					Staff	Contract	Total
						1	2	3
11	Administrator and Assistant Administrator(s)								11
12	Director and Assistant Director(s)								12
13	Other Administrative Personnel								13
14	Direct Nursing Service								14
15	Nursing Supervisor								15
16	Physical Therapy Service								16
17	Physical Therapy Supervisor								17
18	Occupational Therapy Service								18
19	Occupational Therapy Supervisor								19
20	Speech Pathology Service								20
21	Speech Pathology Supervisor								21
22	Medical Social Service								22
23	Medical Social Supervisor								23
24	Home Health Aide								24
25	Home Health Aide Supervisor								25
26									26
27									27
PART III - METROPOLITAN STATISTICAL AREA (MSA) AND CORE BASED STATISTICAL AREA (CBSA) CODES
							1	1.01
	Enter the total number of MSAs in column 1 and/or CBSAs in column 2 where Medicare
28	covered services were provided during the cost reporting period.								28
	List all MSA and CBSA codes in which Medicare covered home health services were						MSA Codes	CBSA Codes
29	provided during the cost reporting period (line 29 contains the first code):								29
									29.01
									29.02
									29.03
									29.04
									29.05
									29.06
									29.07
									29.08
									29.09

FORM CMS-1728-94 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3205)

Rev. 13

32-305

3290 (Cont.)

FORM CM S-1728-94

05-07

HOME HEALTH AGENCY STATISTICAL DATA

PROVIDER NO.:

______________

PERIOD:

From: ______________

To: ______________

WORKSHEET S-3 PART IV

PART IV - PPS ACTIVITY DATA - Applicable for Services Rendered on or After October 1, 2000						Cook

		Full Episodes	Full Episodes	LUPA Episodes	PEP Only	SCIC within a	SCIC Only	Totals
	DESCRIPTION	without Outliers	with Outliers		Episodes	PEP	Episodes
		1	2	3	4	5	6	7
30	Skilled Nursing Visits								30
31	Skilled Nursing Visit Charges								31
32	Physical Therapy Visits								32
33	Physical Therapy Visit Charges								33
34	Occupational Therapy Visits								34
35	Occupational Therapy Visit Charges								35
36	Speech Pathology Visits								36
37	Speech Pathology Visit Charges								37
38	Medical Social Service Visits								38
39	Medical Social Service Visit Charges								39
40	Home Health Aide Visits								40
41	Home Health Aide Visit Charges								41
42	Total Visits (Sum of lines 30,32,34,36,38,40)								42
43	Other Charges								43
44	Total Charges (Sum of lines 31,33,35,37,39,41,43)								44
45	Total Number of Episodes								45
46	Total Number of Outlier Episodes								46
47	Total Non-Routine Medical Supply Charges								47

FORM CMS-1728-94 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3205)

32-305.1

Rev. 13

05-13			FORM CM S-1728-94				3290 (Cont.)
HHA-BASED RURAL HEALTH CLINIC/				PROVIDER CCN:	PERIOD:		WORKSHEET S-4
FEDERALLY QUALIFIED HEALTH CENTER				_____________	FROM: __________
PROVIDER STATISTICAL DATA				COMPONENT CCN:	TO: ___________
				_____________
Check		[ ] RHC
Applicable Box		[ ] FQHC
Clinic Address and Identification:
1	Street:							1
1.01	City:			State:	Zip Code:	County:		1.01
2	Designation (for FQHCs only) - Enter "R" for rural or "U" for urban							2

Source of Federal Funds:						Grant Award	Date
						1	2
3	Community Health Center (Section 330(d), PHS Act)							3
4	Migrant Health Center (Section 329(d), PHS Act)							4
5	Health Services for the Homeless (Section 340(d), PHS Act)							5
6	Appalachian Regional Commission							6
7	Look-Alikes							7
8	Other (specify)							8

Physician Information:		Physician	Billing
		Name	Number
9	Physician(s) furnishing services at the clinic or under agreement (see instructions)

												Physician		Hours of
												Name		Supervision
10	Supervisory physician(s) and hours of supervision during period (see instructions)															10

11	Does the facility operate as other than an RHC or FQHC? If yes, indicate number of other operations in column 2 and															11
	list the other type(s) of operation(s) and hours on subscripts of line 12.
	Enter the clinic hours on line 12 and list the other type(s) of operation(s) and hours on subscripts of line 12. (1)
		Sunday		Monday		Tuesday		Wednesday		Thursday		Friday		Saturday
		from	to	from	to	from	to	from	to	from	to	from	to	from	to
	0	1	2	3	4	5	6	7	8	9	10	11	12	13	14
12	Clinic															12
12.01	Specify:															12.01
12.02	Specify:															12.02
12.03	Specify:															12.03

(1) List hours of operation based on a 24 hour clock. For example, 8:30am is 0830, 5:30pm is 1730 and 12 midnight is 2400.

13	Has the facility been approved for an exception to the productivity standard?					13
14	Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)? If yes, enter in column 2 the					14
	number of providers included in this report. List all provider names and numbers below.
15	Provider name: ______________________________	Provider number: _______________				15
15.01	Provider name: ______________________________	Provider number: _______________				15.01
15.02	Provider name: ______________________________	Provider number: _______________				15.02
15.03	Provider name: ______________________________	Provider number: _______________				15.03
16	Are you claiming allowable GME costs as a result of "substantial payment" for interns		Y/N	XVIII	TOTAL	16
	and residents? If yes, enter the number of Medicare visits in column 2 and total visits in column 3		1	2	3
	performed by interns and residents and complete Worksheet RF-1, lines 20 and 27 as applicable.

FORM CMS-1728-94-S4 (5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3233)

Rev. 16

32-305.2

3290 (CONT.)

FORM CMS-1728-94

05-13

HOSPICE IDENTIFICATION DATA

PROVIDER CCN:

_____________

HOSPICE CCN:

_____________

PERIOD:

FROM: _____________

TO: ________________

WORKSHEET S-5

PART I

			Title XVIII			Total
				Unduplicated		Unduplicated
				Skilled	Other	Days
			Unduplicated	Nursing	Unduplicated	(sum of
		Enrollment Days	Days	Facility Days	Days	cols. 1 & 3)
			1	2	3	4
1	Continuous Home Care						1
2	Routine Home Care						2
3	Inpatient Respite Care						3
4	General Inpatient Care						4
5	Total Hospice Days						5
PART I I
				Title XVIII
				Skilled		Total
				Nursing		(sum of
		Census Data	Title XVIII	Facility	Other	cols. 1 & 3)
			1	2	3	4
6	Number of Patients Receiving						6
	Hospice Care
7	Total Number of Unduplicated						7
	Continuous Care Hours
	Billable to Medicare

8	Average	Length of Stay (line 5 divided by line 6)					8
9	Unduplicated Census Count						9

NOTE: Parts I & II, column 1 also includes the days reported in column 2.

FORM CMS-1728-94-S-5 (5-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,

SECTIONS 3239 - 3239.2)

32-306

REV. 16

05-07			FORM CM S-1728-94							3290 (Cont.)
HHA-BASED CORF STATISTICAL DATA		PROVIDER NO.: _______________			PERIOD:				SUPPLEMENTAL
		CORF NO.: _______________			From: ___________				WORKSHEET S-6
					To: ___________
	CORF TREATMENTS				Title XVIII		Other		Total
				Treatments		Patients	Treatments	Patients	Treatments	Patients
				1		2	3	4	5	6
1	Skilled Nursing Care										1
2	Physical Therapy										2
3	Occupational Therapy										3
4	Speech Pathology										4
5	Medical Social Services										5
6	Respiratory Therapy										6
7	Psychological Services										7
8	All Other Service										8
9	Total Treatments (Sum of lines 1-8)										9
	CORF - NUMBER OF EMPLOYEES ( FULL TIME EQUIVALENT )
	Enter the number of hours
	in your normal workweek	__________			Staff		Contract		Total
				1			2		3
10	Administrators and Assistant Administrators										10
11	Directors and Assistant Directors										11
12	Other Administrative Personnel										12
13	Direct Nursing Service										13
14	Nursing Supervisor										14
15	Physical Therapy Service										15
16	Physical Therapy Supervisor										16
17	Occupational Therapy Service										17
18	Occupational Therapy Supervisor										18
19	Speech Pathology Service										19
20	Speech Pathology Supervisor										20
21	Medical Social Service										21
22	Medical Social Supervisor										22
23	Respiratory Therapy Service										23
24	Respiratory Therapy Supervisor										24
25	Psychological Service										25
26	Psychological Service Supervisor										26
27											27
28											28

FORM CMS 1728-94-S-6 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3220)

Rev. 13

32-307

3290 (Cont.)					FORM CMS-1728-94							05-07
								PROVIDER NO.:		PERIOD:
		RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES						_______________		From: ___________		WORKSHEET A
										To: ___________
						CONTRACTED				RECLASSI-		EXPENSES
				EMPLOYEE	TRANSPOR-	PURCHASED			RECLASSI-	FIED TRIAL		FOR COST
			SALARIES	BENEFITS	TATION (See	SERVICES	OTHER		FICATION	BALANCE	ADJUST-	ALLOCATION
			(Fr Wks A-1)	(Fr Wks A-2)	Instructions)	(Fr Wks A-3)	COSTS	TOTAL	(Fr Wks A-4)	(Cols 6 + 7)	MENTS	(Col 8 + 9)
			1	2	3	4	5	6	7	8	9	10
		GENERAL SERVICE COST CENTER
1	0100	Capital Related - Bldg. & Fix.											1
2	0200	Capital Related - Movable Equip											2
3	0300	Plant Operation & Maintenance											3
4	0400	Transportation (See Instructions)											4
5	0500	Administrative and General											5
		HHA REIMBURSABLE SERVICES
6	0600	Skilled Nursing Care											6
7	0700	Physical Therapy											7
8	0800	Occupational Therapy											8
9	0900	Speech Pathology											9
10	1000	Medical Social Services											10
11	1100	Home Health Aide											11
12	1200	Supplies (See Instructions)											12
13	1300	Drugs											13
13.20	1320	Cost of Administering Vaccines											13.20
14	1400	DME											14
		HHA NONREIMBURSABLE SERVICES
15	1500	Home Dialysis Aide Services											15
16	1600	Respiratory Therapy											16
17	1700	Private Duty Nursing											17
18	1800	Clinic											18
19	1900	Health Promotion Activities											19
20	2000	Day Care Program											20
21	2100	Home Delivered Meals Program											21
22	2200	Homemaker											22
23		Other											23
		SPECIAL PURPOSE COST CENTERS
24	2400	CORF											24
25	2500	Hospice											25
26	2600	CMHC											26
27	2700	RHC											27
28	2800	FQHC											28
29		Total											29

FORM CMS-1728-94 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3206)

32-308

Rev. 13

08-99					FORM CM S-1728-94						3290 (Cont.)
COMPENSATION ANALYSIS							PROVIDER NO.:		PERIOD:
SALARIES AND WAGES							_______________		From: ___________		WORKSHEET A-1
									To: ___________
		ADMINIS-								ALL	TOTAL
		TRATORS	DIRECTORS	CONSULTANTS		SUPERVISORS	NURSES	THERAPISTS	AIDES	OTHER	(1)
		1	2	3		4	5	6	7	8	9
	GENERAL SERVICE COST CENTER
1	Capital Related - Bldg. and Fixtures											1
2	Capital Related - Movable Equipment											2
3	Plant Operation & Maintenance											3
4	Transportation (See Instructions)											4
5	Administrative and General											5
	HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care											6
7	Physical Therapy											7
8	Occupational Therapy											8
9	Speech Pathology											9
10	Medical Social Services											10
11	Home Health Aide											11
12	Supplies											12
13	Drugs											13
14	DME											14
	HHA NONREIMBURSABLE SERVICES
15	Home Dialysis Aide Services											15
16	Respiratory Therapy											16
17	Private Duty Nursing											17
18	Clinic											18
19	Health Promotion Activities											19
20	Day Care Program											20
21	Home Delivered Meals Program											21
22	Homemaker Service											22
23	Other											23
	SPECIAL PURPOSE COST CENTERS
24	CORF											24
25	Hospice											25
26	CMHC											26
27	RHC											27
28	FQHC											28
29	Total											29

(1) Transfer the amounts in column 9 to Wkst. A, column 1

FORM CMS-1728-94-A-1 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3207)

Rev. 7

32-309

3290 (Cont.)				FORM CM S-1728-94						08-99
COMPENSATION ANALYSIS						PROVIDER NO.:		PERIOD:
EMPLOYEE BENEFITS (PAYROLL RELATED)						_______________		From: ___________		WORKSHEET A-2
								To: ___________
		ADMINIS-							ALL	TOTAL
		TRATORS	DIRECTORS	CONSULTANTS	SUPERVISORS	NURSES	THERAPISTS	AIDES	OTHER	(1)
		1	2	3	4	5	6	7	8	9
	GENERAL SERVICE COST CENTER
1	Capital Related - Bldg. and Fixtures										1
2	Capital Related - Movable Equipment										2
3	Plant Operation & Maintenance										3
4	Transportation (See Instructions)										4
5	Administrative and General										5
	HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care										6
7	Physical Therapy										7
8	Occupational Therapy										8
9	Speech Pathology										9
10	Medical Social Services										10
11	Home Health Aide										11
12	Supplies										12
13	Drugs										13
14	DME										14
	HHA NONREIMBURSABLE SRVS
15	Home Dialysis Aide Services										15
16	Respiratory Therapy										16
17	Private Duty Nursing										17
18	Clinic										18
19	Health Promotion Activities										19
20	Day Care Program										20
21	Home Delivered Meals Program										21
22	Homemaker Services										22
23	Other										23
	SPECIAL PURPOSE COST CENTERS
24	CORF										24
25	Hospice										25
26	CMHC										26
27	RHC										27
28	FQHC										28
29	Total										29

(1) Transfer the amounts in column 9 to Wkst. A, column 2

FORM CMS-1728-94-A-2 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 3208)

32-310

Rev. 7

Question	Answer
Form Name	Cms 1728 94 Form
Form Length	57 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	14 min 15 sec
Other names	cms 1728 94, cms 1564 cms r 297 printable form, 1728 form printable, dd form 1728 form

Cms 1728 94 Form – Fill Out and Use This PDF

Cms 1728 94 Form PDF Details

Form Preview Example

Cms 1728 94 Form isn’t the one you’re looking for?

Cms 1728 94 Form – Fill Out and Use This PDF

Cms 1728 94 Form PDF Details

Form Preview Example

Cms 1728 94 Form isn’t the one you’re looking for?

Related Documents