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									Supplemental Medicaid Schedules                                             Link: Schedule A
DSH and Enhanced Payment Data Submission
HFY: 2007

GENERAL INSTRUCTIONS

1.   If you have problems with these spreadsheets, please call Mary Sanford at (919) 855-4192.
2.   Do not alter the forms in any way. Current format is required for electronic data transfer.
3.   Complete the non-shaded areas only.
4.   Submit completed Schedules A and C to DMA by:                 August 22, 2008
     Schedule B is due with your Medicaid Cost Report
     for the same HFY.
5.   Email the completed electronic version of the schedules to Mary Sanford at:
                                Mary.Sanford@ncmail.net
6.   Send a signed and dated paper copy of all schedules A and C to the following:
                                                     Mary Sanford
                                                Finance Management-09
                                                2501 Mail Service Center
                                                Raleigh, NC 27699-2501

                                               Overnight to: Mary Sanford
                                                  DMA, Kirby Building
                                                  1985 Umstead Drive
                                                  Raleigh, NC 27603



7.   The payments that DMA makes based on supplemental Schedules A, B and C data are subject to audit.
     As such, hospitals must maintain all back-up documentation that supports the data they submit
     on Schedules A, B and C. Back-up to A and/or C is not maintained at DMA.

SCHEDULE A - INSTRUCTIONS
1.  Provider number should be the EDS Medicaid 7-character format, preferably numeric if possible. Do not
    use sub-provider numbers. Examples follow:
               Use General      3400001                            Do not use 3400001T
                or CAH          3401301                                    or 3400001S
2.   "Hospital Fiscal Year Ending" should designate the hospital fiscal year on which the data reported in
     Schedule A is based. For this submission (FFY2009) hospitals should enter their 2007 fiscal year end
     information.
3.   Provide phone, fax and email information for the individual to whom questions should be directed.


4.   Information reported should exclude data for services other than acute care, rehabilitation and psychiatric
     units; for example, SNF, NF, Home Health, Hospice, Renal Dialysis, free-standing Ambulatory Surgery
     Center, etc. should not be included.
5.   Hospitals must report Uncompensated Care Charges and Payments separately on Schedule A. It is not
     acceptable for a Hospital to report Net Uncompensated care Charges due to CMS requirements.


6.   Hospitals must report Inpatient and Outpatient Uncompensated Care information separately on Schedule
     A. It is not acceptable for a Hospital to combine these amounts due to CMS requirements.

.
7.   Use the "Comments" space to clarify data submitted or omitted as appropriate.



Schedule A Instructions                                                                                    3/2005
c6a17f60-417b-471f-90d7-69cc0aaf4a41.xls
    Cost Determination Protocol            SUPPLEMENTAL MEDICAID SCHEDULE - A                                                     Attachement A
    NC SPA 05-015
                                     Data for the Calculation of Uncompensated Care Costs
    Exhibit 1



PROVIDER NUMBER: (Medicaid 7 digit numeric)
PROVIDER NAME:
HOSPITAL FISCAL YEAR ENDING:
COMPLETED BY:
DATE:
PHONE:
FAX:
EMAIL:
INSTRUCTIONS:                                                       Complete data requested below using financial information from the hospital
                                                                    fiscal year indicated above.
CERTIFICATION:
                                                                                                   Link to Instructions: Instructions
I, [insert name of Chief Financial Officer or CEO]                certify the following:

'I have examined the accompanying electronically filed and manually submitted information and find that to the best of my knowledge and
belief, this information is true, correct and complete and prepared from the hospital's financial records for the fiscal year specified above. I also
certify that the numbers below are for Inpatient and Outpatient Hospital services only and do NOT include Professional services.



(Chief Financial Officer)

                                                                            Provider              Sub-Provider                    Subtotal
                                                                               A                       B                          C=A+B
Uninsured Gross Charges
DO NOT INCLUDE PROFESSIONAL CHARGES
1. Inpatient Uninsured Gross Charges                                                       -                         -                               -
2. Outpatient Uninsured Gross Charges                                                      -                         -                               -
3. Total Uninsured Gross Charges (Lines 1 + 2 or line 3)                                   -                         -                               -

Uninsured Payments
(Payments from All Sources Except Payments by State or Local
Government For Indigent Care)
4. Inpatient Uninsured Payments                                                            -                         -                               -
5. Outpatient Uninsured Payments                                                           -                         -                               -
6. Total Uninsured Payments (Lines 5 + 6 or line 7)                                        -                         -                               -


                                                                      Has facility's Public Hospital Status or Non-Public Hospital Status changed
                                                                                                  in the last fiscal year?


                                                                                                      Yes or No
Comments:




    c6a17f60-417b-471f-90d7-69cc0aaf4a41.xls                                                                                            11/10/2004
Supplemental Medicaid Schedules                                             Link: Schedule C
MRI Payment Data Submission
HFY: 2007

GENERAL INSTRUCTIONS

1.   If you have problems with these spreadsheets, please call Mary Sanford at (919) 855-4192.

2.   Do not alter the forms in any way. Current format is required for electronic data transfer.
3.   Complete the non-shaded areas only.
4.   Submit completed Schedules A and C to DMA by:               August 22, 2008
     Schedule B is due with your Medicaid Cost Report
     for the same HFY.
5.   Email the completed electronic version of the Schedules to Mary Sanford at:
                                 Mary.Sanford@ncmail.net
6.   Send a signed and dated paper copy of all schedules A and C to the following:
                                                     Mary Sanford
                                                Finance Management-09
                                                2501 Mail Service Center
                                                Raleigh, NC 27699-2501

                                               Overnight to: Mary Sanford
                                                  DMA, Kirby Building
                                                  1985 Umstead Drive
                                                  Raleigh, NC 27603


7.   The payments that DMA makes based on Schedules A, B and C data are subject to audit. As such,
     hospitals must maintain all back-up documentation that supports the data they submit on
     Schedules A, B and C. Back-up to A and/or C is not maintained at DMA.

SCHEDULE C - INSTRUCTIONS
1.   Provider number should be the EDS Medicaid 7-character format, preferably numeric if possible. Do not
     use sub-provider numbers. Examples follow:
                    General     3400001                              Do not use 3400001T
                    CAH         3401301                                      or 3400001S

2.   "Hospital Fiscal Year Ending" should designate the hospital fiscal year on which the data reported in
     Schedule C is based. For this submission (FFY 2009), Schedule C data must be based on hospital fiscal
     year 2007 financial data.

3.   Provide phone, fax and email data for the individual to whom questions should be directed.

4.   Space is provided to update your status as a Medicaid HMO or Piedmont Health Plan contractor. You
     should answer "yes" or "no" and provide requested and other details in the space provided below the
     question. Please elaborate as necessary.

5.   Use the "Comments" space to clarify data submitted or omitted as appropriate.




Schedule C Instructions
c6a17f60-417b-471f-90d7-69cc0aaf4a41.xls                                                               6/2004
                                   SUPPLEMENTAL MEDICAID SCHEDULE C
                       Data for the Calculation of North Carolina Medicaid HMO Deficits



PROVIDER NUMBER: (Medicaid 7 digit numeric)
PROVIDER NAME:
HOSPITAL FISCAL YEAR ENDING:
COMPLETED BY:
DATE:
PHONE:
FAX:
EMAIL:
INSTRUCTIONS:                                                  Print out and use instructions from Tab titled
                                                               "Schedule C Instructions".
                                                                                                               Schedule C
CERTIFICATION:                                                                                     Link:       Instructions

I,     [insert name of Chief Financial Officer or CEO]         certify the following:
I have examined the accompanying electronically filed and manually submitted information and find that to the best of my
knowledge and belief, this information is true, correct and complete and prepared from the hospital's books and records.



(Chief Financial Officer)



   North Carolina Piedmont Cardinal Health Plan Data*
  * Include data for Piedmont Cardinal Health Plan patients.
     North Carolina no longer has a Medicaid HMO               Inpatient Charges:                          $                      -
                                                               Inpatient Days:                                                    -
                                                               Inpatient Payments:                         $                      -
                                                               Outpatient Charges:                         $                      -
                                                               Outpatient Payments:                        $                      -


   Status Update: For your hospital's current fiscal year (2008), does your hospital contract
   with Piedmont Cardinal Health Plan?
                                                                                                                    (Yes or No)
   If you have claimed charges, etc. for any other HMO, please list them below with explanation:




   Other Comments:




    c6a17f60-417b-471f-90d7-69cc0aaf4a41.xls, Schedule C                                                            6/2004

								
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