SNF - PIP Quarterly Report Worksheet - Hospital Sub-Units

							                               Attachment 7 - SNF - PIP Quarterly Report Worksheet - HOSPITAL SUB-UNITS

Provider Name:                                                                             Prepared By:
Provider Number:                                                                           Phone Number:
For FYE:
Year-To-Date Through:
                                                                                             For Highmark Medicare Services Use
                                                     Submitted       Months                 Amounts used        Amounts to
                                                                 Actual Year Total Year       Previous           Be used
                                                     CR Data     To Date     Projection        Review          This Review
                SNF Providers
Patient Days:
 Title XVIII (w/s S-3 Part I, Col. 4, L 15)
        Please break out Medicare Days into
        the following categories:
           Paid Days
           Final Billed, But Not Paid*
           Days Not Yet Billed*
        Total Title XVIII Days

Primary Payor Payments (w/s E-3 Part I, L 5)
Deductibles (w/s E-3 Part I, L 7)
Coinsurance (w/s E-3 Part I, L 9

          Psych and Rehab Providers
Title XVIII Patient Days:
        Please break out Medicare Days
        into the following categories:
            Paid Days
            Final Billed, But Not Paid*
            Discharged, But Not Final Billed*
        Total Title XVIII Days

 Total Subprovider (w/s S-3 Part I, Col. 6, L 14)

Discharges:
 Title XVIII (w/s S-3 Part I, Col. 13, L 14)
       Please break out Medicare Discharges
       into the following categories:
           Paid Discharges
           Final Billed, But Not Paid*
           Discharged, But Not Final Billed*
       Total Title XVIII Discharges

 Total Subprovider (w/s S-3 Part I, Col. 15, L 14)

Primary Payor Payments (w/s E-3 Part I, L 5)
Deductibles (w/s E-3 Part I, L 7)
Coinsurance (w/s E-3 Part I, L 9

             IRF PPS Providers
From Remittance Advices
   Gross Reimbursement
   Net Reimbursement
Net Average Payment Per Discharge




                                                                                                    www.highmarkmedicareservices.com