Checklist
State of Utah
Disproportionate Share Hospital (DSH) Audit Survey
For Federal Fiscal Year ending 2005, 2006 & 2007
DSH Survey Checklist (Need one survey and supporting information per year)
Federal Fiscal Year Ending 9/30/2005 Federal Fiscal Year Ending 9/30/2006 Federal Fiscal Year Ending 9/30/2007
DSH Audit Survey DSH Audit Survey DSH Audit Survey
(Section 1-7, including 6.1, 6.2 & 6.3) (Section 1-7, including 6.1, 6.2 & 6.3) (Section 1-7, including 6.1, 6.2 & 6.3)
State MMIS data of In-State Uncompensated State MMIS data of In-State Uncompensated State MMIS data of In-State Uncompensated
Medicaid Charges/Days & Pymts Medicaid Charges/Days & Pymts Medicaid Charges/Days & Pymts
(Section 6.1-A) (Section 6.1-A) (Section 6.1-A)
Supporting Documentation for In-State Supporting Documentation for In-State Supporting Documentation for In-State
Uncompensated Medicaid Charges/Days & Pymts Uncompensated Medicaid Charges/Days & Pymts Uncompensated Medicaid Charges/Days & Pymts
(Section 6.1-B) (Section 6.1-B) (Section 6.1-B)
Reconciliation to State MMIS data Reconciliation to State MMIS data Reconciliation to State MMIS data
(Section 6.1-C) (Section 6.1-C) (Section 6.1-C)
Direct Graduate Medical Education Allocation Computation of Direct Graduate Medical Education Computation of Direct Graduate Medical Education
(Section 6.1-D) (Section 6.1-D) (Section 6.1-D)
Organ Acquisition Cost per Organ Organ Acquisition Cost per Organ Organ Acquisition Cost per Organ
(Section 6.1-E) (Section 6.1-E) (Section 6.1-E)
Supporting Documentation for Out-of-State Supporting Documentation for Out-of-State Supporting Documentation for Out-of-State
Uncompensated Medicaid Charges/Days & Pymts Uncompensated Medicaid Charges/Days & Pymts Uncompensated Medicaid Charges/Days & Pymts
(Section 6.2-A) (Section 6.2-A) (Section 6.2-A)
Supporting Documentation for Uninsured Supporting Documentation for Uninsured Supporting Documentation for Uninsured
Uncompensated Care Charges/Days & Pymts Uncompensated Care Charges/Days & Pymts Uncompensated Care Charges/Days & Pymts
(Section 6.3-A) (Section 6.3-A) (Section 6.3-A)
Utah DSH Payments Utah DSH Payments Utah DSH Payments
(Section 6.4) (Section 6.4) (Section 6.4)
Copy of the Medicare 2552-96 Hospital Cost Copy of the Medicare 2552-96 Hospital Cost Copy of the Medicare 2552-96 Hospital Cost
Report(s) needed to cover the complete DSH Year Report(s) needed to cover the complete DSH Year Report(s) needed to cover the complete DSH Year
under audit. under audit. under audit.
Relevant financial statement(s) and queries Relevant financial statement(s) and queries Relevant financial statement(s) and queries
generated by the hospital's accounting system generated by the hospital's accounting system generated by the hospital's accounting system
needed to support information provided in DSH needed to support information provided in DSH needed to support information provided in DSH
survey survey survey
Revenue code cross-walk used to allocate cost to Revenue code cross-walk used to allocate cost to Revenue code cross-walk used to allocate cost to
the appropriate cost centers the appropriate cost centers the appropriate cost centers
A detailed working trial balance used to prepare A detailed working trial balance used to prepare A detailed working trial balance used to prepare
each cost report each cost report each cost report
Please return to:
James Phelps
Reimbursement Unit
Utah Medicaid and Health Financing
288 North 1460 West
P. O. Box 143102
Salt Lake City, Utah 84114-3102
Email: jsphelps@utah.gov
Phone: (801) 538-9184
A desk review will be performed on the information provided in the DSH Audit Survey and Carver, Florek & James will be conducting on-site visits to verify
information provided. The completed electronic survey with all the electronic [1] and hardcopy supporting documentation must be emailed to James Phelps at
jsphelps@utah.gov by March 1, 2010. A signed and dated hard copy of the survey and all supporting documentation must also be mailed to James Phelps using a
traceable U.S. mail carrier authorized to transfer protected health information (PHI).
Audit verification conducted by:
Carver Florek & James, LLC
Attention: Heidi Herrick
2246 N. University Park Blvd.
Layton, Utah 84041
hherrick@chfcpas.com
(801) 926-1177
For Questions or additional information regarding the DSH Audits, please contact Brent Florek at (801) 926-1177 or brent@chfcpas.com.
Notes:
[1]
Preferred format of all electronic copies is Excel (xls), Comma Separated Values (CSV), or Access (mdb).
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Acronyms
Acronyms and Abbreviations
A&G Administrative and General
AHSEA Adjusted Hourly Salary Equivalency Amount
ARRA American Recovery and Reinvestment Act of 2009
ASC Ambulatory Surgical Center
BBA Balanced Budget Act
BBRA Balanced Budget Reform Act
BIPA Benefits Improvement and Protection Act
CAH Critical Access Hospitals (10/97)
CAPD Continuous Ambulatory Peritoneal Dialysis
CAP-REL Capital-Related
CBSA Core Based Statistical Areas
CCN CMS Certification Number (formerly known as a provider number)
CCPD Continuous Cycling Peritoneal Dialysis
CCU Coronary Care Unit
CDU Chemical Dependence Unit
CFR Code of Federal Regulations
CMHC Community Mental Health Center
CMS Center for Medicare and Medicaid Services
COL Column
CORF Comprehensive Outpatient Rehabilitation Facility
CRNA Certified Registered Nurse Anesthetist
CTC Certified Transplant Center
DRA Deficit Reduction Act of 2005
DRG Diagnostic Related Group
DSH Disproportionate Share Hospital
EACH Essential Access Community Hospital
ESRD End Stage Renal Disease
FFS Fee-For-Service
FQHC Federally Qualified Health Center
FR Federal Register
FTE Full Time Equivalent
GME Graduate Medical Education
HHA Home Health Agency
HMO Health Maintenance Organization
HSR Hospital Specific Rate
I & Rs Interns and Residents
I/P Inpatient
ICF Intermediate Care Facility
ICF/MR Intermediate Care Facility for the Mentally Retarded (9/96)
ICU Intensive Care Unit
IME Indirect Medical Education
INPT Inpatient
IPF Inpatient Psychiatric Facility
IRF Inpatient Rehabilitation Facility
LCC Lesser of Reasonable Cost or Customary Charges
LIP Low Income Patient
LOS Length of Stay
LTC Long Term Care
LTCH Long Term Care Hospital
M+C Medicare + Choice (also known as Medicare Part C)
MA Medicare Advantage (previously known as M+C)
MCO Managed Care Organization
MCP Monthly Capitation Payment
MCR Medicare Cost Report
MDH Medicare Dependent Hospital (10/97)
MED-ED Medical Education
MIPPA Medicare Improvements for Patients and Providers Act of 2008
MMA Medicare Prescription Drug Improvement and Modernization Act of 2003
MMIS Medical Management Information Systems
MSA Metropolitan Statistical Area (10/97)
MS-DRG Medicare Severity Diagnosis-Related Group
MSP Medicare Secondary Payer
NF Nursing Facility
NHCMQ Nursing Home Case Mix and Quality Demonstration
NPI National Provider Identifier
O/P Outpatient
OBRA Omnibus Budget Reconciliation Act
OLTC Other Long Term Care
OOT Outpatient Occupational Therapy
OPD Outpatient Department
OPO Organ Procurement Organization
OPPS Outpatient Prospective Payment System
OPT Outpatient Physical Therapy
ORF Outpatient Rehabilitation Facility
OSP Outpatient Speech Pathology
PBP Provider-Based Physician
PCN Primary Care Network
PHI Protected Health Information
PPS Prospective Payment System
PRM Provider Reimbursement Manual
PRO Professional Review Organization
PRTF Psychiatric Residential Treatment Facility
PS&R Provider Statistical and Reimbursement System aka Remittance Advice Summary or Paid Claims Summary
PT Physical Therapy
RCE Reasonable Compensation Equivalent
RHC Rural Health Clinic
RPCH Rural Primary Care Hospitals
RT Respiratory Therapy
RUG Resource Utilization Group
SCH Sole Community Hospitals
SCHIP State Children Health Insurance Program
SNF Skilled Nursing Facility
SSI Supplemental Security Income
UMAP Utah Medical Assistance Program
UPL Upper Payment Limit
WKST Worksheet
Source: Medicare Cost Report
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Section 1-7
Leave Cells Blank
Provider Completes Blue Cells
Yellow Cells Calculated CALCULATED
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
GENERAL INSTRUCTIONS: URBAN HOSPITALS COMPLETE ALL SECTIONS AS OUTLINED. RURAL HOSPITAL COMPLETE ONLY SECTIONS: 1, 3, 5, 6 & 7.
Rural Hospitals-All rural hospitals qualify automatically for DSH
Urban Hospitals- Must have met 1. and 2. (below) and at least one of the criteria shown in 3.
1. Having a Medicaid Utilization Rate of at least 1%.
2. Have at least 2 obstetricians who have staff privileges & agree to provide these services to individuals entitled to "medical assistance".
3. Have a Medicaid utilization rate of at least 14% or a "low income" utilization rate of at least 25%.
That is, if a facility has the required OB staff and have either a 14% Medicaid Inpatient Utilization Rate (MIUR) or over 25% Low Income Utilization Rate (LIUR), then they qualify.
DSH Survey for Federal Fiscal Year ended 9/30/ 2005
SECTION 1: HOSPITAL INFORMATION
Complete the following in-state hospital information in the space provided.
Hospital Name (select your facility from the drop down menu provided): ALLEN MEMORIAL
HOSPITAL
Contact Person:
E-mail Address of Contact Person:
Address:
Utah Medicaid Provider #:
Utah Medicaid Subprovider #:
Utah Medicare Provider #:
Fiscal Year End: (Should coincide with the 2005 Medicare Cost Report) 12/31
Out-of-State Hospital Information
Per federal regulation, the DSH audit must examine both in-state and out-of-state Medicaid services. Provide all out-of-state name(s) and provider number(s) in the space
provided.
Out-of-State Name
Out-of-State Medicaid Provider #:
Out-of-State Medicare Provider #:
>
>
>
Identify the Medicare Cost Report(s) related to the audited DSH Year:
In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost
reporting period does not correspond with the federal fiscal year under audit. Please identify the cost report(s) needed to cover the complete DSH year under audit below, note if
the cost report is finalized and audited or as filed, etc. and provide a full copy of the filed report(s) to the State/auditors.
Begin Date End Date Type: Unaudited, Audited, Copy Provided to
DSH Year 10/1/2004 9/30/2005 Final, As Filed, etc.? State/Auditors?
Medicare Cost Report Yes No
> Yes No
> Yes No
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Section 1-7
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
SECTION 2: VOLUMES AND REVENUES
Medicaid Patient & Inpatient Days & Other Information (Traditional, HMO, PCN, UMAP, etc.): Includes days that are determined to be medically necessary but for which payment is
denied by Medicaid because the provider did not bill timely, days that are beyond the number of days for which a State will pay, days that are utilized by a member prior to an
admission approval, but for which a valid enrollment is determined within the prescribed period, and days for which payment is NOT made by a third party. Includes rehabilitation,
nursery, on-site PRTF, and exempt unit days; however, the following should NOT be included: NF, SNF, LTC, CDU, ICF, HHA, observation bed days, swing bed days, or off-site
PRTF.
Inpatient Days for Dual Eligibles includes Medicaid inpatient days attributed to dual eligible patients (Medicaid and any other third party coverage including Medicare) is
appropriate to the extent they qualify as Medicaid days. Examples include when a dually eligible patient exhausts their Medicare days (Part A) or are only eligible for Part B
Medicare.
Provide the following information for the 12 months ending: 9/30/2005
MEDICAID UTILIZATION INFORMATION
(Traditional, HMO, PCN, UMAP Etc.) Days
Utah Medicaid - FFS (Regular Medicaid)
Utah Medicaid - Managed Care or HMO Claims
Utah Medicaid - FFS Crossover
Utah Medicaid - Managed Care Crossover
Out-of-State Medicaid - FFS (Regular Medicaid)
Out-of-State Medicaid - Managed Care or HMO Claims
Out-of-State Medicaid - FFS Crossover
Out-of-State Medicaid - Managed Care Crossover
Total Days 0
Inpatient Days (Inpatient hospital days only)
Inpatient Days for Dual Eligibles (dual eligible days that qualify as Medicaid days)
Total Inpatient Days 0
Medicaid Inpatient Utilization Rate (MIUR) #DIV/0! #DIV/0!
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Section 1-7
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
SECTION 3: OBSTETRICIAN QUALIFYING INFORMATION
Qualifying Information: Obstetrical Care.
SSA§1923(d), [42 U.S.C. §1396r-4(d)] Requires "…at least 2 obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to individuals
who are entitled to medical assistance for such services .." Note: Hospitals located in rural settings may utilize other qualified physicians for obstetric services in lieu of
obstetricians.
Provide the following information for the 12 months ending: 9/30/2005
Names of Qualifying OB
Physicians
Physician #1:
Physician #2:
Names of Qualifying Other-
Non Obstetrical Physicians
Who supply obstetric services
(Rural Areas Only)
Physician #1:
Physician #2:
Exempt Under this Exception
(Initial of Authorized Person &
Date)
A hospital is exempt from this requirement if that hospital did not offer non-
emergency obstetric services to the general public when federal Medicaid DSH Exempt
regulations were enacted on December 22, 1987.
_______________________
(Initial & Date Above)
A hospital is exempt from this requirement if the patients served are
predominantly under 18 years of age. Exempt
_______________________
(Initial & Date Above)
SECTION 4: LOW INCOME UTILIZATION RATE (LIUR)
Cash Subsidies and Charity Care Charges are used to calculate Medicaid DSH eligibility under the federal low income utilization rate (LIUR).
Per §413 of the Utah State Medicaid Plan a provider may qualify if its low income utilization rate (LIUR) exceeds 25%. Therefore this factor must be calculated below in order to
qualify under this criteria. Note: The provider may choose to not qualify under this criteria.
In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost
reporting period does not correspond with the federal fiscal year under audit. Please identify the information requested below for all cost report(s) needed to cover the complete
DSH Year under audit.
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Section 1-7
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
Amount from Medicare Cost Report ended 12/31/2004
Medicare Cost Report Information Inpatient Outpatient Total
Line 1: Allowable patient total Medicaid payments[1] $ -
Line 2: Cash subsidies[2] for patient services received from state & local $ -
governments low income payments for patient care (Line 1 plus Line 2)
Line 3: Total $ - $ - $ -
Line 4: Total patient net revenues & cash subsides for patient services (gross $ -
revenues less contractuals)
Line 5: Low income revenue percentage (Line 3 divided by Line 4) #DIV/0! #DIV/0! #DIV/0!
Line 6: Amount of patient hospital charges attributable to charity care [3] (not $ -
including contractual allowances and discounts)
Line 7: Total amount of patient hospital charges[4] (gross revenue per $ -
Worksheet G-2 of the Medicare cost report less SNF - or financial statements)
Line 8: Charity care charge percentage (Line 6 divided by Line 7) #DIV/0! #DIV/0! #DIV/0!
Line 9: LIUR[5] (Line 5 plus Line 8) #DIV/0! #DIV/0! #DIV/0! #DIV/0!
>
Amount from Medicare Cost Report ended 12/31/2005
Inpatient Outpatient Total
Line 1: Allowable patient total Medicaid payments[1] $ -
[2] $ -
Line 2: Cash subsidies for patient services received from state & local
governments low income payments for patient care (Line 1 plus Line 2)
Line 3: Total $ - $ - $ -
Line 4: Total patient net revenues & cash subsides for patient services (gross $ -
revenues less contractuals)
Line 5: Low income revenue percentage (Line 3 divided by Line 4) #DIV/0! #DIV/0! #DIV/0!
Line 6: Amount of patient hospital charges attributable to charity care [3] (not $ -
including contractual allowances and discounts)
Line 7: Total amount of patient hospital charges[4] (gross revenue per $ -
Worksheet G-2 of the Medicare cost report less SNF - or financial statements)
Line 8: Charity care charge percentage (Line 6 divided by Line 7) #DIV/0! #DIV/0! #DIV/0!
Line 9: LIUR[5] (Line 5 plus Line 8) #DIV/0! #DIV/0! #DIV/0! #DIV/0!
[1]: Medicaid Payment - All Medicaid payments received for IP/OP hospital services, do not include non-hospital services i.e., physician, ambulance, lab, etc. Also include any supplemental Medicaid program payments made to your facility
outside the rate structure such as GME and UPL programs, excluding DSH.
[2]: State and Local Subsidies - Subsidies are funds the hospital received from state or local government sources to assist hospitals to provide care to uninsured and underinsured patients, includes local taxes collected to be used for
patient care. Do not include regular Medicaid payments, supplemental (UPL) Medicaid payments, or Medicaid/Medicare DSH payments. If the subsidies cannot be specified as inpatient or outpatient, record the subsidies in the total
column.
[3]: Charity Care Charges - Health care services that were never expected to result in cash inflows. Charity care results from a provider's policy to provide health care services free-of-charge to individuals who meet certain financial criteria.
Charity care does not include contractual allowances, discounts, partial payments, patients that have a third party with any responsibility for their care, care paid for in full or part by local governments, etc. Bad debts are not considered
charity care for DSH qualification purposes.
[4]: Total Charges - All hospital billed charges for all types of services rendered. Do not include billed charges for SNF, NF, HHA or off-site PRTF units.
[5]: LIUR - The percentage derived by dividing total Medicaid revenues (including Medicaid managed care revenues) plus UMAP revenues by total revenues and adding the percentage to the percentage derived from dividing total charges
for charity care by total charges.
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Section 1-7
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
SECTION 5: MEDICAID RETURNS
Section 455.304 of the final rule requires the independent auditor to verify that each hospital retain their DSH payments.
Did you retain 100% of the DSH payments for the DSH year under audit? Yes No
Amount of Medicaid DSH Payments Returned to State
Reason For Returned DSH Payments:
Section 6: Total Uncompensated Care
This section is designed to report the "uncompensated care" that you as a provider have rendered.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires states to ensure that only uncompensated care costs of providing inpatient hospital
and outpatient hospital services to Medicaid eligible individuals and uninsured individuals are to be included in the calculation of total uncompensated care which represents
hospital-specific DSH limits. Section 1923(g)(1) of the Act requires the calculation of hospital-specific DSH limits to be determined under Medicare cost principles. Furthermore,
in calculating the hospital specific DSH limits, services that are not defined under the State Medicaid Plan as allowable inpatient or outpatient services, should not be included. 42
CFR Parts 447 and 455 clarify that bad debt arising from non-payment on behalf of individuals who have third party coverage is not part of services to Medicaid and other
uninsured patients and is not to be included in the determination of hospital-specific DSH limits.
Exempt from reporting uncompensated care costs for the uninsured (Section 6.3):
Hospitals may be exempt from reporting DSH Audit requirements related to the
uninsured if the hospital meets all 3 of the criteria outlined below: I have reviewed the applicable accounting books and records and certify that the hospital incurred additional
1) Only received DSH Add-on payments uncompensated care costs serving the uninsured for the DSH year under audit.
2) Medicaid uncompensated care costs exceeded DSH payments for the year
3) The provider certifies that they incurred additional uncompensated care
costs serving the uninsured.
(Additional Information on the DSH Reporting and Audit Requirements, page 7-8) _______________________
(Initial & Date Above)
Net Uncompensated Care Costs (See Section 6.1-6.3)
This section summarizes the information provided in Sections 6.1-6.3, and is designed to report net Uncompensated Care for both Routine and Ancillary Inpatient and Outpatient
Services for In-State, Out-of-State, and the Uninsured.
Net Uncompensated Costs Ref:
Medicaid In-State $ - 6.1
Medicaid Out-of-State $ - 6.2
Uninsured $ - 6.3
Total Uncompensated Costs $ -
[1]: Uncompensated Care - The amount of non-reimbursed costs written off as non recoverable for services rendered to the uninsured, i.e., indigent, and includes the difference between cost of providing services to those eligible for
medical assistance under the State plan and the payment for those services by the State by Medicaid or any other payer methodology (as revised in 2004 by the National Institutional Reimbursement Team NIRT).
DSH Payments (See Section 6.2 & 6.4)
This section summarizes the DSH payment information provided in Sections 6.2 and 6.4.
DSH Payments Ref:
Add-On $ - 6.4
Supplemental $ - 6.4
Out-of-State $ - 6.2
Total DSH Payments $ -
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Section 1-7
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
SECTION 7: CERTIFICATION
I declare that I have examined this worksheet, and to the best of my knowledge and belief, it is true, correct, complete, and in agreement with the books and records maintained by
the facility.
Signature of Officer / Administrator Printed Name Date
Chief Financial Officer
Title
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Section 6.1
Leave Cells Blank
Provider Completes Blue Cells
Yellow Cells Calculated CALCULATED 12/31/2004 12 2004
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
SECTION 6.1: IN-STATE UNCOMPENSATED MEDICAID SERVICES
Section 6.1 is used to report the uncompensated care cost of services less related payments provided to Utah Medicaid patients using Medicare cost allocation methodologies.
Provide the following information for the 12 months ending: 9/30/2005
92 273
(Worksheet D-1, II) (Worksheet D-1, II)
Per Diem Costs for Per Diem Costs for
ROUTINE COSTS (ROOM & BOARD): MCR ended MCR ended FFS MCO FFS Crossover MCO Crossover Uninsured
Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Total
Composite Per Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Inpatient Outpatient Medicaid Utah Medicaid
State Cost Report Line Cost Center Description 12/31/2004 12/31/2005 Diem Costs Days Charges Days Charges Days Charges Days Charges Days Charges Days Routine Costs
Utah 25 Adults & Peds - 0 -
Utah 26 Intensive Care - 0 -
Utah 26.01 Intermediate Care Unit - 0 -
Utah 27 Coronary Care - 0 -
Utah 28 Burn Intensive Care - 0 -
Utah 29 Surgical Intensive Care - 0 -
Utah 30 Bone Marrow Intensive Care - 0 -
Utah 30 Thoracic Intensive Care - 0 -
Utah 30.01 Newborn ICU - 0 -
Utah 30.02 Respiratory Intensive Care - 0 -
Utah 31 Subprovider Rehab - 0 -
Utah 31 Subprovider Psych - 0 -
Utah 31.01 Subprovider Psych - 0 -
Utah 31.01 Subprovider Rehab - 0 -
Utah 33 Nursery - 0 -
Utah > - 0 -
Utah > - 0 -
Utah > - 0 -
Total 0 0 0 0 0 -
Total per State of Utah Section 6.1-A 0
Unreconciled Difference (Explain in Section 6.1-C) 0
92 273
(Worksheet C, I) (Worksheet C, I)
Cost to Charge Ratio Cost to Charge Ratio
ANCILLARY COSTS: for MCR ended for MCR ended FFS MCO FFS Crossover MCO Crossover Uninsured
Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Total
Composite Cost Ancillary Ancillary Ancillary Ancillary Ancillary Ancillary Ancillary Ancillary Inpatient Outpatient Ancillary Utah Medicaid
State Cost Report Line Cost Center Description 12/31/2004 12/31/2005 to Charge Ratio Charges Charges Charges Charges Charges Charges Charges Charges Charges Charges Charges Ancillary Costs
Utah 37 Operating Room - - -
Utah 38 Recovery Room - - -
Utah 39 Labor & Delivery Room - - -
Utah 40 Anesthesiology - - -
Utah 41 Radiology-Diagnostic - - -
Utah 41.01 Radiology-Diagnostic CT - - -
Utah 41.02 Radiology-Diagnostic MRI - - -
Utah 41.03 Radiology-Diagnostic Ultrasound - - -
Utah 42 Radiology-Therapeutic - - -
Utah 43 Radioisotope - - -
Utah 44 Laboratory - - -
Utah 47 Blood Storing, Processing & Trans - - -
Utah 48 Intravenous Therapy - - -
Utah 48.01 Home IV Therapy - - -
Utah 49 Respiratory Therapy - - -
Utah 50 Physical Therapy - - -
Utah 51 Occupational Therapy - - -
Utah 51.01 Rehab Ancillary - - -
Utah 52 Speech Pathology - - -
Utah 53 Electrocardiology - - -
Utah 54 Electroencephalography - - -
Utah 54.01 Meg Lab - - -
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Section 6.1
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
Utah 55 Medical Supplies - - -
Utah 56 Drugs Charged to Patients - - -
Utah 57 Renal Dialysis - - -
Utah 58 ASC (Non-Distinct Part) - - -
Utah 58.01 CV Monitoring - - -
Utah 59 Acute Adult Dialysis - - -
Utah 59 Psychotherapy - - -
Utah 59.01 Acute Pediatric Dialysis - - -
Utah 59.01 Fitness Institute - - -
Utah 59.02 Gastrointestinal Lab - - -
Utah 59.03 Pulmonary Lab - - -
Utah 60 Clinic - - -
Utah 60.01 Clinics Hospital Internal Medicine - - -
Utah 60.01 St Joseph's Partial Hospital - - -
Utah 60.02 Clinics Hospital Other - - -
Utah 60.02 Clinical Dietetics - - -
Utah 60.03 Clinic OB Diagnostic Center - - -
Utah 60.04 Clinics Wasatch - - -
Utah 60.05 Clinics Community - - -
Utah 60.07 Community Clinics - - -
Utah 60.08 Clinics HCH & UOC - - -
Utah 61 Emergency - - -
Utah 62 Observation - - -
Utah 64 Home Program Dialysis - - -
Utah 65 Ambulance - - -
Utah 71 Home Health Agency - - -
Utah 82 Lung Acquisition - - -
Utah 83 Kidney Acquisition - - -
Utah 84 Liver Acquisition - - -
Utah 85 Heart Acquisition - - -
Utah 85.01 Pancreas Acquisition - - -
Utah 85.02 Intestine Acquisition - - -
Utah 86 Other Organ Acquisition - - -
Utah 86.01 Bone Marrow Acquisition - - -
Utah 90 Other Capital Related Costs - - -
Utah 94 Resource Nursing - - -
Utah 94.01 Messenger Services - - -
Utah 94.02 Bone Marrow Acquisition - - -
Utah 100 Non Reimbursable - - -
Utah > - - -
Utah > - - -
Utah > - - -
Total - - - - - - - - - -
Total per State of Utah Section 6.1-A -
Unreconciled Difference (Explain in Section 6.1-C) -
ORGAN ACQUISITION COSTS: (Section 6.1-E) FFS MCO FFS Crossover MCO Crossover Uninsured
Composite Cost Usable Usable Usable Usable Usable Total Utah Organ
State Cost Report Line Cost Center Description per Organ Charges Organs Charges Organs Charges Organs Charges Organs Charges Organs Organs Acquisition Costs
Utah Lung Acquisition - 1.00 - -
Utah Kidney Acquisition - - -
Utah Liver Acquisition - - -
Utah Heart Acquisition - - -
Utah Pancreas Acquisition - - -
Utah Intestinal Acquisition - - -
Utah > - - -
Total - - 1.00 - - - - - - -
GRADUATE MEDICAL EDUCATION COSTS (Section 6.1-D): -
Total In-State Medicaid Service Costs 0.00
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Section 6.1
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
CLAIMS AND OTHER PAYMENTS APPLICABLE TO IN-STATE MEDICAID:
Medicaid Payments (excludes TPL)
Medicaid Managed Care Org. Payments/Revenues
Medicaid Supplemental/Enhanced Payments (UPL, IME, GME, non-claim specific)
Third Party Liability Payments (excludes Medicare)
Medicare Payments (excludes coinsurance/deductibles)
Medicare Cross-Over (includes coinsurance deductible paid by Medicaid)
Medicare Supplemental/Enhanced Payments (DSH, IME, GME)
Coinsurance, Deductible & Other Payment (patient's responsibility)
less: DSH Add-on if included in Medicaid Payment(s) above
Total - Total Payments -
In-State Net Uncompensated Medicaid Services -
Routine Costs: Input all Utah IP/OP routine days and charges by cost center. Using your Medicare cost report input the appropriate rates for the respective cost center. Routine room and board costs are determined by applying per diem costs for the
applicable hospital routine cost center to the number of hospital days billed for Utah Medicaid eligible patients. Information in this section should be reconciled to State of Utah information provided in Section 6.1-A. This reconciliation is to be performed in
Section 6.1-C. In the event that hospital records are insufficient, default to information provided by the State of Utah.
Per Diem Costs: In the Medicare 2552-96 cost report, a per diem is computed for each routine cost center. Record the routine per diem cost per day for each hospital routine cost center present on your Medicare cost report. These amounts are
calculated on Worksheet D-1, Part II of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period does not
correspond with the federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH year under audit. The composite per diem is determined by applying the weighted average
applicable rate over the federal fiscal year.
Cost to Charge Ratio: In the Medicare 2552-96 cost report, a cost-to-charge ratio is computed for each ancillary cost center. Record the ancillary cost-to-charge ratio for each hospital cost center present on your Medicare cost report. These amounts are
calculated on Worksheet C, Part I of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period does not
correspond with the federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH Year under audit. The composite cost to charge ratio is determined by applying the weighted
average applicable rate over the federal fiscal year.
Ancillary Costs: Input all Utah IP/OP ancillary charges by cost center. Using your Medicare cost report fill in the appropriate ratio for the applicable cost center. Ancillary costs are determined by applying per cost to charge costs for the applicable hospital
ancillary cost center to the charges billed for Utah Medicaid eligible patients.
Medicaid Payments: Input all Medicaid payments from the State of Utah, excluding all DSH payments. Payments must include all amounts collected on behalf of Medicaid patients including Medicaid payments, third party payments and patient co-pays (if
any). All Medicaid payments received from non-State sources not already accounted for, including payments from or on behalf of patients for Medicaid services.
Medicare Payments: Input all Medicare payments attributable to dual eligible patients. Medicare payments should include a) Medicare regular rate payments, including any patient co-pays, coinsurance and deductibles, b) Medicare allowable bad debt
payments and c) supplemental and enhanced Medicare payments attributable to dual eligible patients, including Medicare DSH (adjustment), Medicare IME and GME payments. Report payments using the accrual method of accounting.
Dual Eligibles: The total amount of IP/OP charges and related payments attributed to dual eligible patients (Medicaid and any other third party coverage including Medicare) is appropriate to the extent that the IP/OP payments qualify as Medicaid
payments. Examples include when a dually eligible patient exhausts their Medicare days (Part A) or are only eligible for Part B Medicare. Only include outpatient hospital payments that are under the hospital benefit; do not include payments for services
paid under some other benefit i,e, physician, lab, drugs, etc. Do not include payments for NF, SNF, HHA, or off-site PRTF. State MMIS data includes this data.
Organ Acquisition Costs: This section is to be completed by hospitals that have incurred In-State Medicaid organ acquisition costs. The total Medicaid organ acquisition cost is calculated based on the ratio of Medicaid usable organs to total organs.
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Section 6.1
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Section 6.1
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Section 6.1
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Section 6.1-A
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Section 6.1-A State MMIS Data
Hospital billings for Routine Room & Board to the state (per MMIS):
Revenue
Code Revenue Code Description Utah Medicaid Inpatient Days
Filled in with data sent with letter requesting survey.
If you need copy of your hospital's data, contact:
James Phelps
Reimbursement Unit
Utah Medicaid and Health financing
288 North 1460 West
P. O. Box 143102
Salt Lake City, Utah 84114-3102
Email: jsphelps@utah.gov
Phone: (801-538-9184
Total days per State of Utah 0
Hospital billings for Ancillary Services to the state (per MMIS):
Revenue Ancillary Charges for Outpatient
Code Revenue Code Description Ancillary Charges for Inpatient Clients Clients Total Charges
-
-
Filled in with data sent with letter requesting survey. -
-
If you need copy of your hospital's data, contact: -
-
James Phelps -
Reimbursement Unit -
Utah Medicaid and Health financing -
288 North 1460 West -
P. O. Box 143102 -
Salt Lake City, Utah 84114-3102 -
Email: jsphelps@utah.gov -
Phone: (801-538-9184 -
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
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Section 6.1-A
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Total ancillary charges per State of Utah -
Total Payments by State of Utah (excluding DSH) (per MMIS)
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Section 6.1-B
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Section 6.1-B Supporting Documentation for In-State Uncompensated Medicaid Charges/Days & Payments
Instructions: If your facility is not relying upon the days and charges provided by the State (MMIS) to determine uncompensated costs, you must provide an electronic copy of
the information relied upon to complete Section 6.1. The information should include: patient ID, claim type (crossover, Medicaid, MCO), claim status (denied claim, paid claim),
service date, type of service, revenue/cost center codes, and units. Detailed supporting documentation is required to substantiate the amounts claimed in 6.1.
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Section 6.1-C
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Section 6.1-C Reconciliations
Instructions: In the event that Hospital records do not agree with the State of Utah records, provide a description of the applicable reconciling items.
Total days reconciliation table
Inpatient days entered from (6.1), per provider (In-State)
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
Inpatient days entered above, per provider (In-State) + Reconciliation Items
Inpatient days, per State of Utah's records
Total ancillary charges reconciliation table
Ancillary charges entered from (6.1), per provider (In-State)
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
Ancillary charges entered per provider (In-State) + Reconciliation Items
Ancillary charges, per State MMIS
Payment Reconciliation Table
Medicaid payments entered from (6.1), per provider (In-State)
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
Medicaid payments entered per provider (In-State) + Reconciliation Items
Medicaid payments, per State of Utah's records
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Section 6.1-D
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Section 6.1-D Allocation of Direct Graduate Medical Education
Instructions: Use this section to calculate the direct graduate medical education (GME) costs.
92 273
GME for MCR ended GME for MCR ended
GRADUATE MEDICAL EDUCATION (GME): 12/31/2004 12/31/2005 Composite
A) Number of FTE Residents (Worksheet E-3 Part IV Line 3.15) -
B) Updated Per Resident Amount (Worksheet E-3 Part IV Line 3.17) -
C) Number of FTE Residents (Worksheet E-3 Part IV Line 3.21) -
D) Updated Per Resident Amount (Worksheet E-3 Part IV Line 3.23) -
E) Aggregate Approved Amount (Line A x Line B) + (Line C x Line D) 0 0 -
F) Total Inpatient Days (Worksheet E-3 Part IV Line 5) -
IN-STATE ALLOCATION OF GME:
G) In-State Medicaid Inpatient Days (Section 6.1, Line 34) -
H) Ratio of Medicaid In-State Days to Total Inpatient Days ( Line G ÷ Line F) 0.00%
I) In-State GME Allocation (Line E x Line H) -
OUT-OF-STATE ALLOCATION OF GME:
J) Out-of-State Medicaid Inpatient Days (Section 6.2, Line 34) -
K) Ratio of Medicaid Out-of-State Days to Total Inpatient Days ( Line J ÷ Line F) 0.00%
L) Out-of-State GME Allocation (Line E x Line K) -
UNINSURED ALLOCATION OF GME:
M) Uninsured Medicaid Inpatient Days (Section 6.3, Line 34) -
N) Ratio of Medicaid Uninsured Days to Total Inpatient Days ( Line M ÷ Line F) 0.00%
O) Uninsured GME Allocation (Line E x Line N) -
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Section 6.1-E
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Section 6.1-E Organ Acquisition Cost per Organ
Instructions: This section is only to be completed by hospitals that have incurred Medicaid or
uninsured organ acquisition costs.
92 273 92 273
Organ Acquisition Organ Acquisition
Cost for MCR ended Cost for MCR ended
12/31/2004 12/31/2005 Composite
Lung Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61) -
Medicare Usable Organs (Wksht D-6, III, Line 55) -
Medicare Organ Acquisition Cost per Organ - - -
Kidney Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61) -
Medicare Usable Organs (Wksht D-6, III, Line 55) -
Medicare Organ Acquisition Cost per Organ - - -
Liver Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61) -
Medicare Usable Organs (Wksht D-6, III, Line 55) -
Medicare Organ Acquisition Cost per Organ - - -
Heart Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61) -
Medicare Usable Organs (Wksht D-6, III, Line 55) -
Medicare Organ Acquisition Cost per Organ - - -
Pancreas Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61) -
Medicare Usable Organs (Wksht D-6, III, Line 55) -
Medicare Organ Acquisition Cost per Organ - - -
Intestinal Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61) -
Medicare Usable Organs (Wksht D-6, III, Line 55) -
Medicare Organ Acquisition Cost per Organ - - -
Other
Net Organ Acquisition Cost (Wksht D-6, III, Line 61) -
Medicare Usable Organs (Wksht D-6, III, Line 55) -
Medicare Organ Acquisition Cost per Organ - - -
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Section 6.2
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State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
SECTION 6.2: OUT-OF-STATE UNCOMPENSATED MEDICAID SERVICES
Section 6.2 is used to report the uncompensated care cost of services less related payments provided to Out-of-State Medicaid patients using Medicare cost allocation methodologies. Information provided in this section is subject to
confirmation from the respective State(s). Amounts reported on this schedule should reconcile to the out-of-state PS&R (or equivalent schedule) produced by the Medicaid program or managed care entity.
Provide the following information for the 12 months ending: 9/30/2005
92 273
(Worksheet D-1, II) (Worksheet D-1, II)
Per Diem Costs Per Diem Costs
ROUTINE COSTS (ROOM & BOARD): for MCR ended for MCR ended FFS MCO FFS Crossover MCO Crossover Uninsured
Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Total Out-of-State
Composite Per Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Inpatient Outpatient Medicaid Medicaid
State Cost Report Line Cost Center Description 12/31/2004 12/31/2005 Diem Costs Days Charges Days Charges Days Charges Days Charges Days Charges Days Routine Costs
25 Adults & Peds - 0 -
26 Intensive Care - 0 -
26.01 Intermediate Care Unit - 0 -
27 Coronary Care - 0 -
28 Burn Intensive Care - 0 -
29 Surgical Intensive Care - 0 -
30 Bone Marrow Intensive Care - 0 -
30 Thoracic Intensive Care - 0 -
30.01 Newborn ICU - 0 -
30.02 Respiratory Intensive Care - 0 -
31 Subprovider Rehab - 0 -
31 Subprovider Psych - 0 -
31.01 Subprovider Psych - 0 -
31.01 Subprovider Rehab - 0 -
33 Nursery - 0 -
> - 0 -
> - 0 -
> - 0 -
Total 0 0 0 0 0 -
92 273
(Worksheet C, I) (Worksheet C, I)
Cost to Charge Cost to Charge
Ratio for MCR Ratio for MCR
ANCILLARY COSTS: ended ended FFS MCO FFS Crossover MCO Crossover Uninsured
Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Total Out-of-State
Composite Cost Ancillary Ancillary Ancillary Ancillary Ancillary Ancillary Ancillary Ancillary Inpatient Outpatient Ancillary Medicaid
State Cost Report Line Cost Center Description 12/31/2004 12/31/2005 to Charge Ratio Charges Charges Charges Charges Charges Charges Charges Charges Charges Charges Charges Ancillary Costs
37 Operating Room - - -
38 Recovery Room - - -
39 Labor & Delivery Room - - -
40 Anesthesiology - - -
41 Radiology-Diagnostic - - -
41.01 Radiology-Diagnostic CT - - -
41.02 Radiology-Diagnostic MRI - - -
41.03 Radiology-Diagnostic Ultrasound - - -
42 Radiology-Therapeutic - - -
43 Radioisotope - - -
44 Laboratory - - -
47 Blood Storing, Processing & Trans - - -
48 Intravenous Therapy - - -
48.01 Home IV Therapy - - -
49 Respiratory Therapy - - -
50 Physical Therapy - - -
51 Occupational Therapy - - -
51.01 Rehab Ancillary - - -
52 Speech Pathology - - -
53 Electrocardiology - - -
54 Electroencephalography - - -
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Section 6.2
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
54.01 Meg Lab - - -
55 Medical Supplies - - -
56 Drugs Charged to Patients - - -
57 Renal Dialysis - - -
58 ASC (Non-Distinct Part) - - -
58.01 CV Monitoring - - -
59 Acute Adult Dialysis - - -
59 Psychotherapy - - -
59.01 Acute Pediatric Dialysis - - -
59.01 Fitness Institute - - -
59.02 Gastrointestinal Lab - - -
59.03 Pulmonary Lab - - -
60 Clinic - - -
60.01 Clinics Hospital Internal Medicine - - -
60.01 St Joseph's Partial Hospital - - -
60.02 Clinics Hospital Other - - -
60.02 Clinical Dietetics - - -
60.03 Clinic OB Diagnostic Center - - -
60.04 Clinics Wasatch - - -
60.05 Clinics Community - - -
60.07 Community Clinics - - -
60.08 Clinics HCH & UOC - - -
61 Emergency - - -
62 Observation - - -
64 Home Program Dialysis - - -
65 Ambulance - - -
71 Home Health Agency - - -
82 Lung Acquisition - - -
83 Kidney Acquisition - - -
84 Liver Acquisition - - -
85 Heart Acquisition - - -
85.01 Pancreas Acquisition - - -
85.02 Intestine Acquisition - - -
86 Other Organ Acquisition - - -
86.01 Bone Marrow Acquisition - - -
90 Other Capital Related Costs - - -
94 Resource Nursing - - -
94.01 Messenger Services - - -
94.02 Bone Marrow Acquisition - - -
100 Non Reimbursable - - -
> - - -
> - - -
> - - -
Total - - - - - - - - - -
ORGAN ACQUISITION COSTS: (Section 6.1-E) FFS MCO FFS Crossover MCO Crossover Uninsured
Composite Cost Usable Usable Usable Usable Usable Total Out-of-State Organ
State Cost Report Line Cost Center Description per Organ Charges Organs Charges Organs Charges Organs Charges Organs Charges Organs Organs Acquisition Costs
Lung Acquisition - - -
Kidney Acquisition - - -
Liver Acquisition - - -
Heart Acquisition - - -
Pancreas Acquisition - - -
Intestinal Acquisition - - -
> - - -
Total - - - - - - - - - -
GRADUATE MEDICAL EDUCATION COSTS (Section 6.1-D): -
Total Out-of-State Medicaid Service Costs 0.00
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Section 6.2
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
CLAIMS AND OTHER PAYMENTS APPLICABLE TO OUT-OF-STATE MEDICAID:
State of _____ Payment Type/Description
State of _____ Payment Type/Description
State of _____ Payment Type/Description
Total - Total Payments -
Out-of-State Net Uncompensated Medicaid Services -
OUT-OF-STATE DSH PAYMENTS:
State of _____ DSH Payment
State of _____ DSH Payment
State of _____ DSH Payment
Total -
Routine Costs: Input all Out-of-State IP/OP routine days and charges by cost center, and identify the respective State. Using your Medicare cost report input the appropriate rates for the respective cost center. Routine room and board costs are
determined by applying per diem costs for the applicable hospital routine cost center to the number of hospital days billed for Out-of-State Medicaid eligible patients.
Per Diem Costs: In the Medicare 2552-96 cost report, a per diem is computed for each routine cost center. Record the routine per diem cost per day for each hospital routine cost center present on your Medicare cost report. These amounts are
calculated on Worksheet D-1, Part II of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period does
not correspond with the federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH year under audit. The composite per diem is determined by applying the weighted average
applicable rate over the federal fiscal year.
Cost to Charge Ratio: In the Medicare 2552-96 cost report, a cost-to-charge ratio is computed for each ancillary cost center. Record the ancillary cost-to-charge ratio for each hospital cost center present on your Medicare cost report. These amounts
are calculated on Worksheet C, Part I of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period
does not correspond with the federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH Year under audit. The composite cost to charge ratio is determined by applying the
weighted average applicable rate over the federal fiscal year.
Ancillary Costs: Input all Out-of-State IP/OP ancillary charges by cost center, and identify the respective State. Using your Medicare cost report fill in the appropriate ratio for the applicable cost center. Ancillary costs are determined by applying per
cost to charge costs for the applicable hospital ancillary cost center to the charges billed for Out-of-State Medicaid eligible patients.
Medicaid Payments: Input all Out-of-State Medicaid payments. Hospitals must separately identify a) Medicaid regular rate payments (including add-ons); b) supplemental and enhanced Medicaid payments, and; c) DSH payments. Payments must
include all amounts collected from the Medicare program, patient co-pays and deductible payments, and Medicaid payments, Managed care payments and other third party payments. All Medicaid payments received from non-State sources not already
accounted for, including payments from or on behalf of patients for Medicaid services. Report payments using the accrual method of accounting.
Dual Eligibles: The total amount of IP/OP charges and related payments attributed to dual eligible patients (Medicaid and any other third party coverage including Medicare) is appropriate to the extent that the IP/OP payments qualify as Medicaid
payments. Examples include when a dually eligible patient exhausts their Medicare days (Part A) or are only eligible for Part B Medicare. Only include outpatient hospital payments that are under the hospital benefit; do not include payments for
services paid under some other benefit i,e, physician, lab, drugs, etc. Do not include payments for NF, SNF, HHA, or off-site PRTF.
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Section 6.2
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Section 6.2-A
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Section 6.2-A Supporting Documentation for Out-of-State Uncompensated Medicaid Charges/Days & Payments
Instructions: Please provide an electronic copy of the information relied upon to complete Section 6.2. The information should include: patient ID, claim type (crossover,
Medicaid, MCO), claim status (denied claim, paid claim), service date, type of service, revenue/cost center codes, and units. Detailed supporting documentation is required to
substantiate the amounts claimed in 6.2.
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Section 6.3
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Yellow Cells Calculated CALCULATED 12/31/2004 12 2004
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
SECTION 6.3: UNINSURED UNCOMPENSATED MEDICAID SERVICES
Section 6.3 is used to report the uncompensated care cost of services less related payments provided to uninsured patients using Medicare cost allocation methodologies. Federal requirements mandate the uninsured services must be costed
using Medicare cost reporting methodologies. This section is used to report the costs of services provided to the uninsured. A detail listing by service date, patient name and type of service will be required to support information summarized in
this section.
Provide the following information for the 12 months ending: 9/30/2005
92 273
(Worksheet D-1, II) (Worksheet D-1, II)
Per Diem Costs Per Diem Costs
ROUTINE COSTS (ROOM & BOARD): for MCR ended for MCR ended FFS MCO FFS Crossover MCO Crossover Uninsured
Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Total
Composite Per Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Inpatient Outpatient Uninsured Uninsured Routine
State Cost Report Line Cost Center Description 12/31/2004 12/31/2005 Diem Costs Days Charges Days Charges Days Charges Days Charges Days Charges Days Costs
25 Adults & Peds - 0 -
26 Intensive Care - 0 -
26.01 Intermediate Care Unit - 0 -
27 Coronary Care - 0 -
28 Burn Intensive Care - 0 -
29 Surgical Intensive Care - 0 -
30 Bone Marrow Intensive Care - 0 -
30 Thoracic Intensive Care - 0 -
30.01 Newborn ICU - 0 -
30.02 Respiratory Intensive Care - 0 -
31 Subprovider Rehab - 0 -
31 Subprovider Psych - 0 -
31.01 Subprovider Psych - 0 -
31.01 Subprovider Rehab - 0 -
33 Nursery - 0 -
> - 0 -
> - 0 -
> - 0 -
Total 0 $ - 0 -
92 273
(Worksheet C, I) (Worksheet C, I)
Cost to Charge Ratio Cost to Charge Ratio
ANCILLARY COSTS: for MCR ended for MCR ended FFS MCO FFS Crossover MCO Crossover Uninsured
Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Uninsured
Composite Cost Ancillary Ancillary Ancillary Ancillary Ancillary Ancillary Ancillary Ancillary Inpatient Outpatient Ancillary Uninsured
State Cost Report Line Cost Center Description 12/31/2004 12/31/2005 to Charge Ratio Charges Charges Charges Charges Charges Charges Charges Charges Charges Charges Charges Ancillary Costs
37 Operating Room - - -
38 Recovery Room - - -
39 Labor & Delivery Room - - -
40 Anesthesiology - - -
41 Radiology-Diagnostic - - -
41.01 Radiology-Diagnostic CT - - -
41.02 Radiology-Diagnostic MRI - - -
41.03 Radiology-Diagnostic Ultrasound - - -
42 Radiology-Therapeutic - - -
43 Radioisotope - - -
44 Laboratory - - -
47 Blood Storing, Processing & Trans - - -
48 Intravenous Therapy - - -
48.01 Home IV Therapy - - -
49 Respiratory Therapy - - -
50 Physical Therapy - - -
51 Occupational Therapy - - -
51.01 Rehab Ancillary - - -
52 Speech Pathology - - -
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Section 6.3
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
53 Electrocardiology - - -
54 Electroencephalography - - -
54.01 Meg Lab - - -
55 Medical Supplies - - -
56 Drugs Charged to Patients - - -
57 Renal Dialysis - - -
58 ASC (Non-Distinct Part) - - -
58.01 CV Monitoring - - -
59 Acute Adult Dialysis - - -
59 Psychotherapy - - -
59.01 Acute Pediatric Dialysis - - -
59.01 Fitness Institute - - -
59.02 Gastrointestinal Lab - - -
59.03 Pulmonary Lab - - -
60 Clinic - - -
60.01 Clinics Hospital Internal Medicine - - -
60.01 St Joseph's Partial Hospital - - -
60.02 Clinics Hospital Other - - -
60.02 Clinical Dietetics - - -
60.03 Clinic OB Diagnostic Center - - -
60.04 Clinics Wasatch - - -
60.05 Clinics Community - - -
60.07 Community Clinics - - -
60.08 Clinics HCH & UOC - - -
61 Emergency - - -
62 Observation - - -
64 Home Program Dialysis - - -
65 Ambulance - - -
71 Home Health Agency - - -
82 Lung Acquisition - - -
83 Kidney Acquisition - - -
84 Liver Acquisition - - -
85 Heart Acquisition - - -
85.01 Pancreas Acquisition - - -
85.02 Intestine Acquisition - - -
86 Other Organ Acquisition - - -
86.01 Bone Marrow Acquisition - - -
90 Other Capital Related Costs - - -
94 Resource Nursing - - -
94.01 Messenger Services - - -
94.02 Bone Marrow Acquisition - - -
100 Non Reimbursable - - -
> - - -
> - - -
> - - -
Total 0 0 0 0 0 0 0 0 - - - -
ORGAN ACQUISITION COSTS: (Section 6.1-E) FFS MCO FFS Crossover MCO Crossover Uninsured
Composite Cost Usable Usable Usable Usable Usable Uninsured Organ
State Cost Report Line Cost Center Description per Organ Charges Organs Charges Organs Charges Organs Charges Organs Charges Organs Total Organs Acquisition Costs
Lung Acquisition - - -
Kidney Acquisition - - -
Liver Acquisition - - -
Heart Acquisition - - -
Pancreas Acquisition - - -
Intestinal Acquisition - - -
> - - -
Total - - - - - - - - - - - -
GRADUATE MEDICAL EDUCATION COSTS (Section 6.1-D): -
Total Uninsured Service Costs 0.00
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Section 6.3
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
CLAIMS AND OTHER PAYMENTS APPLICABLE TO THE UNINSURED:
Payment from Uninsured/Self pay (cash basis)
Section 1011 payments for hospital services
Section 1011 payments for non-hospital services
>
>
>
- Total Payments -
Uninsured Net Uncompensated Services -
Routine Costs: Input all uninsured IP/OP routine days and charges by cost center. Using your Medicare cost report input the appropriate rates for the respective cost center. Routine room and board costs are determined by applying per diem costs for the
applicable hospital routine cost center to the number of hospital days billed for uninsured patients. Since the State’s MMIS system will not have information about payments generated from the uninsured, hospitals must use their financial statements and other
auditable hospital accounting records to substantiate claims.
Per Diem Costs: In the Medicare 2552-96 cost report, a per diem is computed for each routine cost center. Record the routine per diem cost per day for each hospital routine cost center present on your Medicare cost report. These amounts are calculated on
Worksheet D-1, Part II of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period does not correspond with the
federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH year under audit. The composite per diem is determined by applying the weighted average applicable rate over the federal fiscal
year.
Cost to Charge Ratio: In the Medicare 2552-96 cost report, a cost-to-charge ratio is computed for each ancillary cost center. Record the ancillary cost-to-charge ratio for each hospital cost center present on your Medicare cost report. These amounts are calculated
on Worksheet C, Part I of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period does not correspond with the
federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH Year under audit. The composite cost to charge ratio is determined by applying the weighted average applicable rate over the
federal fiscal year.
Ancillary Costs: Input all uninsured IP/OP ancillary charges by cost center. Using your Medicare cost report fill in the appropriate ratio for the applicable cost center. Ancillary costs are determined by applying per cost to charge costs for the applicable hospital
ancillary cost center to the charges billed for uninsured patients. Since the State’s MMIS system will not have information about payments generated from the uninsured, hospitals must use their financial statements and other auditable hospital accounting records to
substantiate claims.
Uncompensated Services: For purposes of this section uncompensated services for the uninsured include cost incurred for IP/OP hospital services to individuals with no source of 3rd party coverage for the hospital services they receive, including all Section 1011
charges for undocumented aliens. The uninsured uncompensated amount cannot include amounts associated with unpaid co-pays or deductibles for individuals with 3rd party coverage or any other unreimbursed costs associated with inpatient or outpatient services
provided to individuals with 3rd party coverage but for which such 3rd party benefit package excludes such services. Nor does uncompensated care cost include bad debt or payor discounts related to services furnished to individuals who have any form of health
insurance coverage. The total uncompensated care cost for the uninsured includes the cost of furnishing inpatient and outpatient services less any direct or indirect payments from or on behalf of such uninsured individuals. Please note that prisoners and wards of
the state are not considered “uninsured” and should not be included in the calculation of uncompensated care.
Payments from the Uninsured: Input all payments received for and in behalf of patients with no source of third party coverage (uninsured), excluding DSH payments. Report all payments received for hospital patients that met the uninsured definition at the time of
the service. There will be no attempt to allocate payments received during the state plan rate year to services provided in prior periods. Since the goal of the audit is to determine uncompensated DSH costs for the DSH year under audit, all payments received in the
year will be counted as revenue to the hospital in that same year. It is understood that some costs incurred during the DSH year under audit may be associated with future revenue streams (legal decisions, payment plans, recoveries), but that the payments are not
counted as revenue until actually received. Report all payments on a cash basis (report in the year received, regardless of the year of service). Exclude state, county or other municipal subsidy payments made to hospitals for indigent care. Since the State’s MMIS
system will not have information about payments generated from the uninsured, hospitals must use their financial statements and other auditable hospital accounting records to substantiate claims. Note: IP/OP hospital payments received from state or local
government programs for individuals with no source of third party coverage for the hospital services they received should NOT be included as a revenue in this category.
Uninsured: Per federal guidelines uninsured patients are individuals with no credible source of third party healthcare coverage or other legally liable third party coverage (insurance) in effect at the time the services were rendered. If the patient had health insurance,
even if the third party insurer did not pay, those services are insured and cannot be reported as uninsured on the survey. 42 CFR 447.299 (14)
Section 1011 Payments: Section 1011 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 provides federal reimbursement for emergency health services furnished to undocumented aliens. If your hospital received these funds during
any cost report year covered by the survey, they must be reported here. If you can document that a portion of the payment received is related to non-hospital services (physician or ambulance services) report that amount in the Section 1011 non-hospital payments.
Include hospital charges for undocumented aliens with no source of third party coverage for hospital services.
Self Pay: Federal requirements mandate the hospital cost of providing services to the uninsured during the DSH year must be reduced by uninsured self-pay payments received during the DSH year. Section 6.3-A will assist hospitals in developing the data
necessary to support uninsured payments received during each cost reporting period. The data must be maintained in an auditable format and made available upon request.
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Section 6.3
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
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Section 6.3
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Section 6.3
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Section 6.3
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Section 6.3
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Section 6.3-A
Leave Cells Blank
Provider Completes Blue Cells
Yellow Cells Calculated CALCULATED
Section 6.3-A Supporting Documentation for Uninsured Uncompensated Care Charges/Days & Self-Pay Payments
Instructions: Please provide an electronic copy of the information relied upon to complete Section 6.3 (uninsured charges/days, self-pay payments, section 1011 payments). The
information should include: patient ID, claim type (crossover, Medicaid, MCO), claim status (denied claim, paid claim), TPL status (No TPL, TPL w/Reimb, TPL w/o Reimb),
service date, collection date, type of service, revenue/cost center codes, section 1011 payments, amount, payor source, and units. Detailed supporting documentation is required
to substantiate the amounts claimed in 6.3. Complete Section 6.3-A based on your individual State Medicaid hospital reimbursement methodology (discharge, admit, or dates of
service).
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Section 6.4
Leave Cells Blank
Provider Completes Blue Cells
Yellow Cells Calculated CALCULATED 12/31/2004 12 2004
State of Utah
DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
Federal Fiscal Year Ended 9/30/ 2005
SECTION 6.4: DSH PAYMENTS
This section is used to report the DSH payments received by the hospital. If DSH payments cannot be broken out between Add-On and Supplemental input the information in the Total column. Supporting documentation should include:
DSH available (quarterly & cumulative), State Match Rate % applicable, DSH amount, match amount due from hospital, admin amount due from hospital, verification of payment.
Provide the following information for the 12 months ending: 9/30/2005
DSH PAYMENTS: #REF! #REF!
Quarter Date Add-On Supplemental Total
Q1 -
Q2 -
Q3 -
Q4 -
> -
> -
- - -
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