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					                 Provider Financial & Statistical Report
                                (PFSR)
                                         2009 Instructions
     1      Statutory Requirements
            All physician practices, clinics or clinic systems must complete the Provider Financial and Statistical Report (PFSR),
            under Minnesota Statutes, section 62J.301, subdivision 3, Minnesota Statutes, section 62J.41, and Minnesota Rules,
            chapter 4651. Report data only for the clinics or practices located in Minnesota.
            Minnesota Statutes, section 62J.301    Minnesota Statutes, section 62J.41   Minnesota Rules, chapter 4651

     2      Capital Expenditure Reporting
            Minnesota Statutes, section 62J.17 was modified during the 2007 legislative session to require the annual submission of
            major capital expenditure commitments. The law previously required this information to be submitted throughout the
            year, as the facilities made the spending commitments. Providers should now include this information with the
            submission of each PFSR report.
            Minnesota Statutes, section 62J.17
     3      Classification of Data
            Under Minnesota Statutes, section 62J.321, Subdivision 5, the information that is submitted in this report is classified as
            nonpublic and can only be made public in an aggregated form. The Capital Expenditure portion of the report is
            required under Minnesota Statutes, section 62J.17 and is considered public.
            Minnesota Statutes, section 62J.321    Minnesota Statutes, section 62J.17

     4      Form Information and Security
                 a       The Minnesota Department of Health (MDH) requires the use an electronic spreadsheet in completing this
                         formset. This formset is a multiple tabbed Microsoft Excel™ spreadsheet. Tabs can be found along the
                         bottom of the spreadsheet.
                 b       Please use your MDH assigned PFSR ID found in the address block of your notification letter.
                 c       Please report financial data in whole dollar amounts.
                 d       For security purposes, you are encouraged apply a password to the file before sending by email. To apply
                         the password to the file, go to Tools/Options/Security and type in the password. Use this password:
                         X2&Dvb@G
     5      Additional Formatting within the formset:
                 a       Error messages will show as RED text to the right of the potential error.
                 b       Tips throughout the report are highlighted in YELLOW.
                 c       Hyperlinks appear throughout the report for ease of navigation.
                 d       All items in the report are required unless otherwise noted.
                 e       Grey shaded cells will automatically calculate values.
     6      Submitting Reports
            Each physician practice, clinic, or clinic system must submit the following by April 1, 2010 :
                a      Completed 2009 Microsoft Excel™ formset by e-mail to:
                       health.drmreport@state.mn.us
                b      Signed Certification page (PDF attached to an e-mail or faxed to 651-201-5179)
                c      Additional information sufficient to allow MDH to complete a retrospective review of each major capital
                       spending commitment on the Capital Expend Project Specific tab of the formset
     7      Request for Extension
            If the reporting physician practice, clinic or clinic system is unable to submit the report by April 1, 2010 , the
            Commissioner may extend the period of time for submission. Any request for extension must be submitted in writing (e-
            mail is acceptable) by the due date and must include an explanation outlining why the extension is needed.


            Please send written requests (e-mail is acceptable) for an extension on or before April 1, 2010, to:
            health.drmreport@state.mn.us
     8      Questions
            If you have any questions about the PFSR contact Tom Major at 651-201-3574 or
            tom.major@state.mn.us


                                                                start of formset




Provider Financial and Statistical Report (PFSR)                   2009 Instructions                                       Division of Health Policy
health.drmreport@state.mn.us                                         page 1 of 37                                        Health Economics Program
           2009 Provider Financial and Statistical Report (PFSR)
        Complete this page, print it and have it signed. Indicate any changes or corrections to data shown.

Section 1: Clinic Identification and Certification                                                                        2009

                                             This is the unique ID assigned to your physician practice, clinic or clinic
                         PFSR ID             system for the PFSR data collection. Please click on the PFSR ID link for
                                             more information.
                                                                                   National Provider
                  Federal Tax ID                   #N/A                                                                  #N/A
                                                                                      Identifier (NPI)
               Practice, Clinic or
                                   #N/A
                   System Name

                         Address #N/A                                                      Reporting Time Period

                             City #N/A                                               Reporting 2009         Yes           No
                                                                                     Calendar Year
 Mailing                                                                                      Data?
                          County #N/A
 Address
                                                                                   2009 Fiscal Year
                            State #N/A                                                                             #N/A
                                                                                           End Date
                                                                                        # of Months in
                         Zip Code #N/A                                                                             #N/A
                                                                                        Reporting Year

               Provider Phone # #N/A                                                            Medicare Status

                  Provider Fax # #N/A                                                                       Yes           No
                                                                                      Participating
                                                                                 Medicare Provider?
              CEO/Admin Name #N/A                                                                           #N/A          #N/A

                CEO/Admin Title #N/A                                                     Accounting Method Type

               CEO/Admin email #N/A                                                                       Accrual         #N/A

                                                                                    Please VERIFY
                    CFO's Name #N/A                                                                         Cash          #N/A
                                                                                  Accounting Method
                                                                                                          Modified
        Provider website address #N/A                                                                                     #N/A
                                                                                                           Cash
             System Affiliation/
                                 #N/A                               #N/A
    Owned, Managed, or Leased

                                                                                 Type of Practice

                                    Please VERIFY
                                                            Primary Care           Specialty Care         Multi-specialty Care
                                    Type of Practice

                                                                 #N/A                    #N/A                      #N/A

                                                       Document any explanations in Section 10

This certification must be signed by an officer of the reporting clinic or clinic system such as the Administrator,
CEO, or CFO. The signed copy of this page must be either faxed or mailed, or emailed (pdf) to MDH.
Certification Statement: I hereby certify that I have examined the accompanying PFSR Report and, to the best of my
knowledge, the information contained in this report is accurate.

           Signature:

    Print/Type Name:                                                                              Date:

             Position:

Please Review. Clinic Site List, Percentage of MN Encounters, and the Physician List cannot be NULL. This error
may result in your report being rejected.




Provider Financial and Statistical Report (PFSR)                            2009                                                   Division of Health Policy
health.drmreport@state.mn.us                                             page 2 of 37                                            Health Economics Program
#N/A

Contact Information                                                             2009

Preparer
                Name of Person
                                  #N/A                             Title #N/A
             completing this form
              Organization Name #N/A

                        Address #N/A                              e-mail #N/A

                             City #N/A                         Phone # #N/A
                                                                 Phone
                          County #N/A                                   #N/A
                                                                    Ext
                           State #N/A                             Fax # #N/A

                        Zip Code #N/A

Courtesy Contact 1

         Courtesy Contact Name #N/A                                Title #N/A

              Organization Name #N/A

                        Address #N/A                              e-mail #N/A

                             City #N/A                         Phone # #N/A
                                                                 Phone
                          County #N/A                                   #N/A
                                                                    Ext
                           State #N/A                             Fax # #N/A

                        Zip Code #N/A

Courtesy Contact 2

         Courtesy Contact Name #N/A                                Title #N/A

              Organization Name #N/A

                        Address #N/A                              e-mail #N/A

                             City #N/A                         Phone # #N/A
                                                                 Phone
                          County #N/A                                   #N/A
                                                                    Ext
                           State #N/A                             Fax # #N/A

                        Zip Code #N/A

Capital Expenditure Contact (for sections 13, 14, 15)

     Capital Expenditure Contact #N/A                              Title #N/A

              Organization Name #N/A

                        Address #N/A                              e-mail #N/A

                             City #N/A                         Phone # #N/A
                                                                 Phone
                          County #N/A                                   #N/A
                                                                    Ext
                           State #N/A                             Fax # #N/A

                        Zip Code #N/A




Provider Financial and Statistical Report (PFSR)           2009                          Division of Health Policy
health.drmreport@state.mn.us                            page 3 of 37                   Health Economics Program
#N/A

Section 2: Employee Classification of FTEs                                 2009

Full-time equivalent employee (FTE) means an employee or any combination of
employees that are paid by the facility for 2,080 hours of employment per year.

                                                                                    Required Item. Enter
   1300    MD and DO (definition)
                                                                                    employed MDs or DOs on the
                                                                                    Physician tab.
   1301    Chiropractor (definition)

   1302    Physician Assistants (definition)

           Adv. Practice Nurses (ANP, CNM, CRNA, etc.)
   1303
           (definition)

   1304    Registered Nurse (RN) (definition)

   1305    Other Patient Care Personnel (definition)

   1306    Provider Services Under Contract (definition)

   1307    Non-Patient Care Personnel (definition)

   1308    Total Clinic FTEs                                                    0.00 Required item.




Section 3: Patient Encounters                                              2009
An encounter is a contact between a patient and a health care provider during
which a service is rendered.

   1309    Minnesota Resident Encounters (definition)

   1310    Non-Minnesota Resident Encounters (definition)

   1311    Total Number of Patient Encounters                                     0 Required item.




Provider Financial and Statistical Report (PFSR)                      2009                                         Division of Health Policy
health.drmreport@state.mn.us                                       page 4 of 37                                  Health Economics Program
#N/A

Section 4: Patient Revenue                                                   2009

   1312    HMO Revenue (definition)                              $                  -

   1313          HMO Private Revenue

   1314          HMO Medicare Revenue

                HMO MN Public Prog.
   1315         Rev. (MA, GAMC,
                MNCare)
           Commercial Insurers, Blue Cross Blue Shield Revenue
   1316
           (definition)
           Workers' Compensation and Auto Insurance Revenue
   1317
           (definition)

   1318    Medicare (Non-HMO) Revenue (definition)

           MA, GAMC, MinnesotaCare (Non-HMO) Revenue
   1319
           (definition)

   1320    Other Public Payers Revenue (definition)

   1321    Direct Patient Payments Revenue (definition)

   1322    Contracted Patient Revenue (definition)

   1323    Total Patient Revenue                                 $                  -   Required item.




Section 5: Non-Patient Revenue                                               2009
Non-patient revenue does not include revenue from interest payments other than
patient account interest, revenue from investments, sale of capital equipment, or
real estate.
           Private Donations, Grants, and Subsidies Revenue
   1324
           (definition)
           Public Donations, Grants, and Subsidies Revenue
   1325
           (definition)

   1326    Research and Education Revenue (definition)                                  This includes MERC revenues.

   1327    Other Revenue (definition)

   1328    Total Non-Patient Revenue                             $                  -   Required item.




Section 6: Total Revenue                                                     2009

   1329    Total Revenue (Patient and Non-Patient Revenue)       $                  -




Provider Financial and Statistical Report (PFSR)                        2009                                             Division of Health Policy
health.drmreport@state.mn.us                                         page 5 of 37                                      Health Economics Program
#N/A

Section 7: Capitated Payments                                                   2009

   1330    Capitated Payment Revenue (definition)                                          Required item.



Section 8: Charity Care, Bad Debt, and Contractual
                                                                                2009
Adjustments

   1331    Charity Care and Bad Debt* (definition)

           Discounts, Contractual Adjustments, Disallowed
   1332
           Charges* (definition)
           Total Charity Care, Bad Debt, and Contractual            $                  -
   1333
           Adjustments*



Section 9: Clinic Costs                                                         2009

   1334    Patient Care Personnel Costs (definition)                                       Required item.

   1335    Other Patient Care Costs* (definition)

   1336    Malpractice Costs (definition)                                                  Required item.

           Patient Registration, Scheduling, and Admissions
   1337
           Costs* (definition)

   1338    Billing and Collection Costs* (definition)

   1339    Financial Accounting and Reporting Costs* (definition)                          * Items are not required if Total
                                                                                           Patient and Non-Patient
           Quality Assurance and Utilization Review Costs*                                 revenue is less than one million
   1340                                                                                    dollars.
           (definition)

   1341    Promotion and Marketing Costs* (definition)

   1342    Other Costs* (definition)

   1510    Education Costs (definition)                                                    Required item.

   1511    Research Costs (definition)                                                     Required item.

   1343    MinnesotaCare Tax (definition)                                                  Required item.

   1344    Total Clinic Costs                                       $                  -   Required item.




Provider Financial and Statistical Report (PFSR)                           2009                                                  Division of Health Policy
health.drmreport@state.mn.us                                            page 6 of 37                                           Health Economics Program
#N/A

Section 10: Information Regarding Reporting                                  2009


Use the space below for elaborations or explanations for any of the information
supplied on this form, or to document any changes in methods used from prior
years' data. You can use the hyperlinks to return to specific sections in the form.


  Section Number                                   Explanation



Section 1




Section 2




Section 3




Section 4




Section 5




Section 6




Section 7




Section 8




Section 9



Section 12:
Business Change




Provider Financial and Statistical Report (PFSR)                       2009             Division of Health Policy
health.drmreport@state.mn.us                                        page 7 of 37      Health Economics Program
#N/A

Section 11: Time Spent on Report                                                 2009

           Estimate the time (in hours) spent to compile
   1345                                                                                   Please report in hours
           information and complete this PFSR report.



Section 12: Business Change                                                      2009

Since January 1, 2007, did the organization make a significant business change that
would affect data collected on this report? For instance, has it merged with another
organization, acquired or been acquired by another organization, or opened or closed
office sites? Please put an "X" in the appropriate boxes, and explain any yes responses
in Section 10 above.


                                                                      Yes        No       Please explain any Yes
           Were any Clinics Merged, Closed, Acquired, or                                  responses in Section 10
   1346
           Opened?


   1347    Other Significant Business Change?




Provider Financial and Statistical Report (PFSR)                          2009                                        Division of Health Policy
health.drmreport@state.mn.us                                           page 8 of 37                                 Health Economics Program
#N/A

Separate attachments for EACH project over 1 million need to be submitted along with this formset. Reporting this
information is required by Minnesota Statutes, section 62J.17, subdivision 2 and 144.698, subdivision 1.

Section 13: Capital Expenditure Commitment Summary                                                         FY 2009

                                                                                                        Yes         No
           Did your Facility have any Major Capital Expenditure Commitments in FY 2008 that were
   7594
           over $1 million dollars each?


   7595    Total number of Capital Expenditure projects over $1 million dollars each

   7596    Total Major Capital Expenditure Commitments (for projects listed in code 7595 above)




Provider Financial and Statistical Report (PFSR)                           2009                                            Division of Health Policy
health.drmreport@state.mn.us                                            page 9 of 37                                     Health Economics Program
   #N/A
For all projects that are over 1 million, report the detail in this section. Note that the parts of any project can be reported in more than one category, but should not be
double counted. Reporting this information is required by Minnesota Statutes, section 62J.17, subdivision 2 and 144.698, subdivision 1.

Section 14: Capital Expenditure Commitment Detail                                                                                                               FY 2009

                                                                                                                         Other Capital                       Total Capital
                                               Medical Equipment                  Building and Space
                                                                                                                         Expenditures                        Expenditures

Patient Care Services                 7597         $                 -   7620        $                  -   7643        $                  -    7666        $                  -

            Cardiac Care              7598                               7621                               7644                                7667        $                  -

            Chemical
                                      7599                               7622                               7645                                7668        $                  -
            Dependency
            Emergency / Urgent
                                      7600                               7623                               7646                                7669        $                  -
            Care

            Mental Health             7602                               7625                               7648                                7671        $                  -

            Neurology                 7603                               7626                               7649                                7672        $                  -

            Obstetrics                7604                               7627                               7650                                7673        $                  -

            Orthopedics               7605                               7628                               7651                                7674        $                  -

            Radiation Therapy         7606                               7629                               7652                                7675        $                  -

            Rehabilitation            7607                               7630                               7653                                7676        $                  -

            Surgery                   7608                               7631                               7654                                7677        $                  -

            Other Patient Care
                                      7609                               7632                               7655                                7678        $                  -
            Services

            Diagnostic Imaging
            (includes new and
                                      7610         $                 -   7633        $                  -   7656        $                  -    7679        $                  -
            replacement
            equipment)

                         MRI          7611                               7634                               7657                                7680        $                  -

                         CT           7612                               7635                               7658                                7681        $                  -

                         PET          7613                               7636                               7659                                7682        $                  -

                         Other
                                      7614                               7637                               7660                                7683        $                  -
                         Imaging

General Infrastructure                7615         $                 -   7638        $                  -   7661        $                  -    7684        $                  -

            Building,
            Renovation, Non-          7616                               7639                               7662                                7685        $                  -
            Patient
            Computer,
            Laboratory, Phone,        7617                               7640                               7663                                7686        $                  -
            or Monitoring
            Electronic Medical
                                      7618                               7641                               7664                                7687        $                  -
            Records

Total Major Capital
Expenditure Commitment                7619         $                 -   7642        $                  -   7665        $                  -    7688        $                  -
Expense




                                                           Capital Expenditure Project Specific Tab
                                                          Please supply information on each project




Provider Financial and Statistical Report (PFSR)                                    2009                                                               Division of Health Policy
health.drmreport@state.mn.us                                                     page 10 of 37                                                      Health Economics Program
  #N/A
                                                                             Projects Reported    0     Total value of Projects Reported                    $0
Section 15: Capital Expenditure Detail by Project                 Next Section          Retrospective Review Reporting Exceptions          2009 Report Year

This information is required by Minnesota Statutes, section 62J.17, subdivision 5a in order for the Minnesota Department of Health (MDH) to complete a
retrospective review for each project totaling over $1 million. If you have questions about completing this information, please contact Tom Major at MDH
at 651-201-3574 or at tom.major@state.mn.us.

Project 1

#N/A

Project Location Name

Address

City



Date of Spending                                   Please specify actual commitment date (e.g.
Commitment:                                        3/1/2009)
Total Cost of Project:

Distance (miles) to the location of the
nearest equivalent service or technology



Title and General Description of Project




Please describe the purpose of the project. Provide sufficient detail including the reason for the project, the project scope, the types of patient care
addressed in the project, types of equipment purchased and whether it is replacement equipment, whether expenditures increase service capacity or
replace capacity, and other information necessary for complete review of the project.




Provider Financial and Statistical Report (PFSR)                                2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                                 page 11 of 37                                                  Health Economics Program
  #N/A                                                                                                                                       Project 1

Please describe in detail the expected impact of the project on clinical effectiveness or the quality of care received by the patients that the provider
serves.




Please list providers (name and town/city) of equivalent services or technology currently available within a service area of 10 miles.




Please state and describe the pursuit of or existence of any lawful collaborative arrangements, the names of the parties and a description of their
involvement.




Provider Financial and Statistical Report (PFSR)                              2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                               page 12 of 37                                                  Health Economics Program
  #N/A                                                                                                                                     Project 2

Project 2                                                                                                                         2009 Report Year

#N/A

Project Location Name

Address

City



Date of Spending                                   Please specify actual commitment date (e.g.
Commitment:                                        3/1/2009)
Total Cost of Project:

Distance (miles) to the location of the
nearest equivalent service or technology



Title and General Description of Project




Please describe the purpose of the project. Provide sufficient detail including the reason for the project, the project scope, the types of patient care
addressed in the project, types of equipment purchased and whether it is replacement equipment, whether expenditures increase service capacity or
replace capacity, and other information necessary for complete review of the project.




Provider Financial and Statistical Report (PFSR)                                2009                                                       Division of Health Policy
health.drmreport@state.mn.us                                                 page 13 of 37                                              Health Economics Program
  #N/A                                                                                                                                       Project 2

Please describe in detail the expected impact of the project on clinical effectiveness or the quality of care received by the patients that the provider
serves.




Please list providers (name and town/city) of equivalent services or technology currently available within a service area of 10 miles.




Please state and describe the pursuit of or existence of any lawful collaborative arrangements, the names of the parties and a description of their
involvement.




Provider Financial and Statistical Report (PFSR)                              2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                               page 14 of 37                                                  Health Economics Program
  #N/A                                                                                                                                     Project 3

Project 3                                                                                                                         2009 Report Year

#N/A

Project Location Name

Address

City



Date of Spending                                   Please specify actual commitment date (e.g.
Commitment:                                        3/1/2009)
Total Cost of Project:

Distance (miles) to the location of the
nearest equivalent service or technology



Title and General Description of Project




Please describe the purpose of the project. Provide sufficient detail including the reason for the project, the project scope, the types of patient care
addressed in the project, types of equipment purchased and whether it is replacement equipment, whether expenditures increase service capacity or
replace capacity, and other information necessary for complete review of the project.




Provider Financial and Statistical Report (PFSR)                                2009                                                       Division of Health Policy
health.drmreport@state.mn.us                                                 page 15 of 37                                              Health Economics Program
  #N/A                                                                                                                                       Project 3

Please describe in detail the expected impact of the project on clinical effectiveness or the quality of care received by the patients that the provider
serves.




Please list providers (name and town/city) of equivalent services or technology currently available within a service area of 10 miles.




Please state and describe the pursuit of or existence of any lawful collaborative arrangements, the names of the parties and a description of their
involvement.




Provider Financial and Statistical Report (PFSR)                              2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                               page 16 of 37                                                  Health Economics Program
  #N/A                                                                                                                                     Project 4

Project 4                                                                                                                         2009 Report Year

#N/A

Project Location Name

Address

City



Date of Spending                                   Please specify actual commitment date (e.g.
Commitment:                                        3/1/2009)
Total Cost of Project:

Distance (miles) to the location of the
nearest equivalent service or technology



Title and General Description of Project




Please describe the purpose of the project. Provide sufficient detail including the reason for the project, the project scope, the types of patient care
addressed in the project, types of equipment purchased and whether it is replacement equipment, whether expenditures increase service capacity or
replace capacity, and other information necessary for complete review of the project.




Provider Financial and Statistical Report (PFSR)                                2009                                                       Division of Health Policy
health.drmreport@state.mn.us                                                 page 17 of 37                                              Health Economics Program
  #N/A                                                                                                                                       Project 4

Please describe in detail the expected impact of the project on clinical effectiveness or the quality of care received by the patients that the provider
serves.




Please list providers (name and town/city) of equivalent services or technology currently available within a service area of 10 miles.




Please state and describe the pursuit of or existence of any lawful collaborative arrangements, the names of the parties and a description of their
involvement.




Provider Financial and Statistical Report (PFSR)                              2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                               page 18 of 37                                                  Health Economics Program
  #N/A                                                                                                                                     Project 5

Project 5                                                                                                                         2009 Report Year

#N/A

Project Location Name

Address

City



Date of Spending                                   Please specify actual commitment date (e.g.
Commitment:                                        3/1/2009)

Total Cost of Project:

Distance (miles) to the location of the
nearest equivalent service or technology



Title and General Description of Project




Please describe the purpose of the project. Provide sufficient detail including the reason for the project, the project scope, the types of patient care
addressed in the project, types of equipment purchased and whether it is replacement equipment, whether expenditures increase service capacity or
replace capacity, and other information necessary for complete review of the project.




Provider Financial and Statistical Report (PFSR)                                2009                                                       Division of Health Policy
health.drmreport@state.mn.us                                                 page 19 of 37                                              Health Economics Program
  #N/A                                                                                                                                       Project 5

Please describe in detail the expected impact of the project on clinical effectiveness or the quality of care received by the patients that the provider
serves.




Please list providers (name and town/city) of equivalent services or technology currently available within a service area of 10 miles.




Please state and describe the pursuit of or existence of any lawful collaborative arrangements, the names of the parties and a description of their
involvement.




Provider Financial and Statistical Report (PFSR)                              2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                               page 20 of 37                                                  Health Economics Program
  #N/A                                                                                                                                     Project 6

Project 6                                                                                                                         2009 Report Year

#N/A

Project Location Name

Address

City



Date of Spending                                   Please specify actual commitment date (e.g.
Commitment:                                        3/1/2009)

Total Cost of Project:

Distance (miles) to the location of the
nearest equivalent service or technology



Title and General Description of Project




Please describe the purpose of the project. Provide sufficient detail including the reason for the project, the project scope, the types of patient care
addressed in the project, types of equipment purchased and whether it is replacement equipment, whether expenditures increase service capacity or
replace capacity, and other information necessary for complete review of the project.




Provider Financial and Statistical Report (PFSR)                                2009                                                       Division of Health Policy
health.drmreport@state.mn.us                                                 page 21 of 37                                              Health Economics Program
  #N/A                                                                                                                                       Project 6

Please describe in detail the expected impact of the project on clinical effectiveness or the quality of care received by the patients that the provider
serves.




Please list providers (name and town/city) of equivalent services or technology currently available within a service area of 10 miles.




Please state and describe the pursuit of or existence of any lawful collaborative arrangements, the names of the parties and a description of their
involvement.




Provider Financial and Statistical Report (PFSR)                              2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                               page 22 of 37                                                  Health Economics Program
  #N/A                                                                                                                                     Project 7

Project 7                                                                                                                         2009 Report Year

#N/A

Project Location Name

Address

City



Date of Spending                                   Please specify actual commitment date (e.g.
Commitment:                                        3/1/2009)

Total Cost of Project:

Distance (miles) to the location of the
nearest equivalent service or technology



Title and General Description of Project




Please describe the purpose of the project. Provide sufficient detail including the reason for the project, the project scope, the types of patient care
addressed in the project, types of equipment purchased and whether it is replacement equipment, whether expenditures increase service capacity or
replace capacity, and other information necessary for complete review of the project.




Provider Financial and Statistical Report (PFSR)                                2009                                                       Division of Health Policy
health.drmreport@state.mn.us                                                 page 23 of 37                                              Health Economics Program
  #N/A                                                                                                                                       Project 7

Please describe in detail the expected impact of the project on clinical effectiveness or the quality of care received by the patients that the provider
serves.




Please list providers (name and town/city) of equivalent services or technology currently available within a service area of 10 miles.




Please state and describe the pursuit of or existence of any lawful collaborative arrangements, the names of the parties and a description of their
involvement.




Provider Financial and Statistical Report (PFSR)                              2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                               page 24 of 37                                                  Health Economics Program
  #N/A                                                                                                                                     Project 8

Project 8                                                                                                                         2009 Report Year

#N/A

Project Location Name

Address

City



Date of Spending                                   Please specify actual commitment date (e.g.
Commitment:                                        3/1/2009)

Total Cost of Project:

Distance (miles) to the location of the
nearest equivalent service or technology



Title and General Description of Project




Please describe the purpose of the project. Provide sufficient detail including the reason for the project, the project scope, the types of patient care
addressed in the project, types of equipment purchased and whether it is replacement equipment, whether expenditures increase service capacity or
replace capacity, and other information necessary for complete review of the project.




Provider Financial and Statistical Report (PFSR)                                2009                                                       Division of Health Policy
health.drmreport@state.mn.us                                                 page 25 of 37                                              Health Economics Program
  #N/A                                                                                                                                       Project 8

Please describe in detail the expected impact of the project on clinical effectiveness or the quality of care received by the patients that the provider
serves.




Please list providers (name and town/city) of equivalent services or technology currently available within a service area of 10 miles.




Please state and describe the pursuit of or existence of any lawful collaborative arrangements, the names of the parties and a description of their
involvement.




Provider Financial and Statistical Report (PFSR)                              2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                               page 26 of 37                                                  Health Economics Program
  #N/A                                                                                                                                     Project 9

Project 9                                                                                                                         2009 Report Year

#N/A

Project Location Name

Address

City



Date of Spending                                   Please specify actual commitment date (e.g.
Commitment:                                        3/1/2009)

Total Cost of Project:

Distance (miles) to the location of the
nearest equivalent service or technology



Title and General Description of Project




Please describe the purpose of the project. Provide sufficient detail including the reason for the project, the project scope, the types of patient care
addressed in the project, types of equipment purchased and whether it is replacement equipment, whether expenditures increase service capacity or
replace capacity, and other information necessary for complete review of the project.




Provider Financial and Statistical Report (PFSR)                                2009                                                       Division of Health Policy
health.drmreport@state.mn.us                                                 page 27 of 37                                              Health Economics Program
  #N/A                                                                                                                                       Project 9

Please describe in detail the expected impact of the project on clinical effectiveness or the quality of care received by the patients that the provider
serves.




Please list providers (name and town/city) of equivalent services or technology currently available within a service area of 10 miles.




Please state and describe the pursuit of or existence of any lawful collaborative arrangements, the names of the parties and a description of their
involvement.




Provider Financial and Statistical Report (PFSR)                              2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                               page 28 of 37                                                  Health Economics Program
  #N/A                                                                                                                                     Project 10

Project 10                                                                                                                        2009 Report Year

#N/A

Project Location Name

Address

City



Date of Spending                                   Please specify actual commitment date (e.g.
Commitment:                                        3/1/2009)

Total Cost of Project:

Distance (miles) to the location of the
nearest equivalent service or technology



Title and General Description of Project




Please describe the purpose of the project. Provide sufficient detail including the reason for the project, the project scope, the types of patient care
addressed in the project, types of equipment purchased and whether it is replacement equipment, whether expenditures increase service capacity or
replace capacity, and other information necessary for complete review of the project.




Provider Financial and Statistical Report (PFSR)                                2009                                                       Division of Health Policy
health.drmreport@state.mn.us                                                 page 29 of 37                                              Health Economics Program
  #N/A                                                                                                                                       Project 10

Please describe in detail the expected impact of the project on clinical effectiveness or the quality of care received by the patients that the provider
serves.




Please list providers (name and town/city) of equivalent services or technology currently available within a service area of 10 miles.




Please state and describe the pursuit of or existence of any lawful collaborative arrangements, the names of the parties and a description of their
involvement.




Provider Financial and Statistical Report (PFSR)                              2009                                                           Division of Health Policy
health.drmreport@state.mn.us                                               page 30 of 37                                                  Health Economics Program
#N/A
Section 16: Clinic Site List                                                          link to Section 17 (Physician List)

Provide clinic or practice site location information. For services provided at non-system or practice locations, use "hospital outreach" or "clinic outreach" as the Clinic Site. For locations outside of
Minnesota, use "out of state" as the Clinic Site. Complete all columns for each location. Encounters should total 100.00 percent. TAB to insert more rows as necessary.

                                              Indicate Practice Type
                                                                                                                                          Error! Total Encounters must equal 100 Percent           % of Total
                                                (P, S. or M - one only)
                                                                                                                                                                                                   Encounters
                                              P=Primary, S=Specialty,                                                                                                                              (Required)
Clinic Site                                                                 Street Address                  Suite number           City                County             State    Zip
                                                 M=Multi-specialty




Provider Financial and Statistical Report (PFSR)                                                      2009                                                                                 Division of Health Policy
health.drmreport@state.mn.us                                                                      page 31 of 37                                                                          Health Economics Program
Section 17: Physician List                           Return to Start of Formset for review                         2009
Use this form to list all physicians (MD and DO) working in the system/practice. Complete all columns as shown
in the header for each physician and include only Minnesota physicians. TAB to enter more rows as
necessary. If Physicians are contracted, enter "Contracted Physicians Only" in the First Name column.
                                                                          Licensure
                                                                                              License
        First Name              MI                 Last Name                Degree                                 NPI
                                                                                             Identifier #
                                                                          (MD or DO)




Provider Financial and Statistical Report (PFSR)            2009                                         Division of Health Policy
health.drmreport@state.mn.us                            page 32 of 37                                  Health Economics Program
                                            Definitions for completing the 2009 PFSR:

Code      Label                                     Definition
1300      Medical Doctors and Osteopaths            The number of FTEs for licensed medical doctors (MD) and osteopaths (DO).

1301      Chiropractors                             The number of FTEs for licensed chiropractors (DC).
1302      Physician Assistants                      The number of FTEs for employees who are licensed as physician assistants (PAC).
1303      Advanced Practice Nurses                  The number of FTEs for employees who are licensed and certified as nurse practitioners,
                                                    nurse midwives, certified registered nurse anesthetists, and other types of advanced
                                                    practice nurses.
1304      Registered Nurse (RN)                     The number of FTEs for employees who are licensed as registered nurses (RN). Do not
                                                    include the advanced practice nurses already listed.
1305      Other Patient Care Personnel              The number of FTEs for all employees whose primary job responsibilities are patient care,
                                                    but who are not listed in the above categories.
1306      Provider Services Under Contract          The number of FTEs for providers with whom your organization contracts to provide health
                                                    care services to your patients, and for whose services you bill. Do not include consulting or
                                                    “outreach program” physicians for whom you do not bill. (They should report only on the
                                                    form of the clinic which bills for them).
1307      Non-patient care personnel                The number of FTEs for all personnel who do not provide patient care at your organization.
                                                    Examples of individuals to be listed here would be receptionists, clinic administrators,
                                                    business office personnel, accountants, secretaries, transcriptionists and medical records
                                                    personnel, computer staff, maintenance personnel, or cafeteria personnel. PLEASE NOTE:
                                                    You may have personnel who perform patient care as part of their job functions, but who
                                                    also have non-patient care functions. For these personnel please divide their time in simple
                                                    fractions to the appropriate categories. See following example: The clinic has an employee
                                                    who spends about half of his time as a patient care aide and about half as a receptionist.
                                                    Therefore, this time is allocated half (.5) in each of the two spaces for “Other patient care
                                                    personnel” and “Non-patient care personnel”.
1309      Encounter: Minnesota Resident             A contact between a patient, who is a Minnesota resident, and a health care provider during
                                                    which a service is rendered. An encounter also means an instance of the professional
                                                    component of laboratory and radiology services. Patients may have more than one
                                                    encounter per day. An encounter does not include failed appointments, telephone contacts,
                                                    or the technical component of radiology or laboratory services.
1310      Encounter: non-Minnesota Resident         A contact between a patient, who is a non-Minnesota resident, and a health care provider
                                                    during which a service is rendered. An encounter also means an instance of the
                                                    professional component of laboratory and radiology services. Patients may have more than
                                                    one encounter per day. An encounter does not include failed appointments, telephone
                                                    contacts, or the technical component of radiology or laboratory services.
1312      HMO Revenue:                              Includes net revenues or receipts from HMOs. This category does not include patient
                                                    copayments, deductibles, and amounts paid by patients for which they are reimbursed.
                                                    Include all patient payments in line 7.
                         HMO Private                Revenue from patients with private coverage through an HMO, for example Blue Plus.
                                                    Revenue from patients covered by Medicare whose coverage is administered by an HMO.
                         HMO Medicare

                       HMO Medical Assistance,      Revenue from patients covered by MA, GAMC, or MNCare whose coverage is administered
                       General Assistance Medical   by an HMO.
                       Care, MinnesotaCare (MA,
                       GAMC, MNCare)
1316      Commercial Insurers, Blue Cross Blue      Includes net revenues or receipts from private health insurance provided by commercial
          Shield, and PPOs                          insurers, preferred provider organizations or non-profit health carriers such as BCBSM’s
                                                    commercial insurance. This category does not include BCBSM’s HMO products. This
                                                    category does not include worker’s compensation payments or automobile personal injury
                                                    protection payments. This category does not include patient copayments, deductibles, and
                                                    amounts paid by patients for which they are reimbursed. Include all patient payments in line
                                                    1321.
1317      Workers’ compensation or automobile       This category includes workers’ compensation payments or automobile personal injury
          personal injury insurance                 protection payments. This category does not include patient copayments, deductibles, and
                                                    amounts paid by patients for which they are reimbursed. Include all patient payments in line
                                                    1321.
1318      Medicare                                  Includes revenues or receipts received directly from Medicare as either a participating or
                                                    non-participating provider. This category does not include patient copayments, deductibles,
                                                    and amounts paid by patients for which they are reimbursed. Include all patient payments in
                                                    line 1321. This category does not include HMO Medicare payments.
1319      Medical Assistance, General               Includes net revenues or receipts collected directly from Medical Assistance (MA), General
          Assistance Medical Care, and              Assistance Medical Care (GAMC), and MinnesotaCare. This category does not include
          MinnesotaCare                             patient copayments, deductibles or spenddowns. Include all patient payments in line 1321.
                                                    This category does not include HMO MA, GAMC, and MinnesotaCare revenues.




Provider Financial and Statistical Report (PFSR)                            2009 Definitions                                                          Division of Health Policy
health.drmreport@state.mn.us                                                 page 33 of 37                                                          Health Economics Program
                                            Definitions for completing the 2009 PFSR:

Code      Label                                     Definition
1320      Other Public Payers                       Includes net revenues or receipts for providing health care under programs like CHAMPUS,
                                                    Head Start, Indian Health Service (IHS), VocRehab, VA, SSA, court ordered exams, and
                                                    other public health programs. This category does not include patient copayments,
                                                    deductibles, or spenddowns. Include all patient payments in line 1321.
1321      Direct Patient Payments                   Includes all revenues or receipts from patients for deductibles, co-payments, out-of-pocket
                                                    payments, and services or products not covered by insurance. Some persons prefer to file
                                                    their insurance themselves and be reimbursed by their insurance company; these self-filed
                                                    payments should be included in this line.

1322      Contracted Patient Revenues Which         Includes all revenues or receipts which are for providing patient services, but for which you
          Cannot Be Allocated to Above              do not know the revenue source. For example, this would include contracts with institutions
          Categories                                or employers that include providing patient services. Example: a clinic has a contract with a
                                                    school district for providing psychological services, and is paid by the school district on an
                                                    annual contract. This payment goes in line 1322. This category does not include
                                                    Independent Medical Examinations (IMEs) or professional services sold to another provider
                                                    or clinic (“purchased services”). These are listed in line 1335.

1324      Private Donations, Grants, & Subsidies Includes revenues or receipts from any private individual, group, foundation, or corporate
                                                 donor with or without specific purpose that are not connected with payment for patient care
                                                 and not for the purpose of research or education.
1325      Public Donations, Grants, & Subsidies     Includes all revenues or receipts from any public group, foundation, or government entity
                                                    with or without specific purpose which are not in connection with payment for patient care
                                                    and not for the purpose of research or education.
1326      Research & Education Revenue              Includes all revenues or receipts received, for activities that are part of a formal program of
                                                    medical or scientific research, approved by the governing body of the health care provider.
                                                    This would include both clinical research as well as basic science research, and may or may
                                                    not involve patients. This category also includes all revenues or receipts received or earned
                                                    by the clinic or health care provider to provide training or education to students, health care
                                                    professionals, or members of the community. This includes MERC revenues.
1327      Other Revenue                             Includes all revenue or receipts from selling purchased services, independent medical
                                                    examinations, interest charged on patient accounts, medical directorships or testimony or
                                                    expert witness fees that were paid to the clinic (not the individual provider), copying medical
                                                    records, parking fees, cafeteria, vending commissions, and other revenues or receipts,
                                                    which are not patient care revenues and which were not captured in the above categories.

1330      Capitated Payments                        Please list the part of your revenues or receipts which are received on a contractual per-
                                                    member per-month capitated basis, where the amount the provider is reimbursed is not
                                                    directly related to the amount or coding of services provided. This only includes contracts
                                                    for which the provider is paid per-member per-month. Do not include “withholding” contracts
                                                    or other types of shared risk contracts.

1331      Charity Care & Bad Debt                   Charity care includes total amount charged, but written off, for care provided to patients who
                                                    do not have the ability to pay for the care received because of limited income or unusual
                                                    circumstances. Charity care does not include professional courtesy discounts, employee
                                                    discounts, Medical Assistance fee schedule write-offs or other contractual write-offs. Bad
                                                    debt means the actual amounts of charges that were not collected from patients who were
                                                    considered as patients with the ability to pay, when a collection attempt has been made.


1332      Discounts, Contractual Adjustments        This is optional for all clinics. Total amount of dollars billed but not received due to
          and Disallowed Charges                    discounts, contractual adjustments or disallowed amounts. Each contract paid under a fee
                                                    schedule (including Medical Assistance, Medicare, commercial insurance payments
                                                    including some BCBSM payments, PPOs, some HMO payments, workers’ compensation
                                                    payments, and payments which are limited by usual and customary fees) may contribute a
                                                    write-off amount to this category. This category also includes professional courtesy
                                                    discounts and employee discounts.

1334      Patient Care Personnel Costs              Includes all compensation costs for personnel involved in providing health care services
                                                    directly to patients, including the costs of patient care personnel who own the reporting clinic
                                                    or group, who are employees, or who are independent contractors.
1335      Other Patient Care Costs                  Includes ALL costs of providing care to patients, other than the personnel costs included in
                                                    line 1334. These costs include expenses for professional services purchased from other
                                                    providers (such as radiology services purchased from a radiology clinic); drugs and
                                                    medications, transportation of health care staff, laboratory, radiology, physical therapy or
                                                    optical supplies; costs for medical equipment (movable or non-movable) including
                                                    depreciation on owned equipment or rental fees on leased equipment, medical equipment
                                                    maintenance, information and communication systems that directly support health care
                                                    professionals (such as laboratory information systems and paging systems), medical waste
                                                    disposal, uniforms, linen service, allocated occupancy costs (such as rent, depreciation, and
                                                    utilities), and costs for space used for direct patient care services e.g. exam rooms, nurses
                                                    stations, laboratories.




Provider Financial and Statistical Report (PFSR)                             2009 Definitions                                                        Division of Health Policy
health.drmreport@state.mn.us                                                  page 34 of 37                                                        Health Economics Program
                                            Definitions for completing the 2009 PFSR:

Code      Label                                     Definition
1336      Malpractice Costs                         Includes all costs related to malpractice or professional liability if separate from the hospital.
                                                    These costs include premiums paid for malpractice and professional liability insurance,
                                                    malpractice claim reserves, actual claims paid, premiums for tail insurance coverage, and
                                                    attorney fees to defend claims.

1337      Patient Registration, Scheduling, &       Includes all costs related to the processing of information necessary to provide care to
          Admissions Costs                          patients within your organization other than the direct, "hands on" patient care costs
                                                    included in lines 1334 and 1335 above. These costs would include scheduling patient visits
                                                    and patient services within and outside the provider's clinic, registering patients, maintaining
                                                    medical records for patient visits, admissions, pre-certification, or other related functions.
                                                    Patient registration, scheduling, and admissions costs also include the costs of
                                                    receptionists, appointment schedulers, medical transcriptionists, pre-admission review
                                                    personnel, including the costs of the personnel performing or supervising these functions
                                                    (such as salary and benefits) as well as the costs of occupancy (such as rent, depreciation
                                                    and utilities), costs for space used for these functions, and any other related expenses such
                                                    as supplies and equipment.
1338      Billing and Collection Costs              Includes all costs incurred as a result of, or while performing or supervising the various
                                                    functions involved in, the process of billing and collecting for patient care services provided
                                                    by your organization. These costs include all expenses involved with the preparation of
                                                    patient billings, submission of insurance claims (including Medicare, Medicaid or any other
                                                    government program), receipt of cash, posting of payment and collection of past due
                                                    accounts. Billing and collections costs also include all expenses of the personnel performing
                                                    these functions (including salary and benefits) as well as costs of occupancy (rent,
                                                    depreciation, utilities) for space used for these functions. This category also includes costs
                                                    such as billing and collection systems (whether manual or computerized), electronic claims
                                                    processing systems, payments to collection agencies, billing and collection forms and
                                                    supplies; postage; payments to outside billing service bureaus or any other costs related to
                                                    the billing and collection function.
1339      Financial, Accounting, & Reporting        Includes all costs incurred in the accumulation of financial accounting information as well as
          Costs                                     the preparation and filing of financial, statistical or utilization reports required by
                                                    management (internal and external), federal, state, county or local governmental agencies or
                                                    other non-governmental entities. Financial, accounting, and reporting costs include general
                                                    accounting, financial reporting, budgeting, cost accounting, payroll, accounts payable,
                                                    inventory accounting, fixed assets accounting or tax and government reporting. This
                                                    category also includes the costs of the personnel performing or supervising these functions
                                                    (such as salary and benefits) as well as the costs of occupancy (such as rent, depreciation,
                                                    and utilities), costs for space used for these functions, and any other related expenses such
                                                    as supplies and equipment.




Provider Financial and Statistical Report (PFSR)                              2009 Definitions                                                             Division of Health Policy
health.drmreport@state.mn.us                                                   page 35 of 37                                                             Health Economics Program
                                            Definitions for completing the 2009 PFSR:

Code      Label                                     Definition
1340      Quality Assurance and Utilization         Includes all costs of programs or activities specifically established for the purpose of
          Review Costs                              monitoring and measuring the use of health care resources and the quality of care provided
                                                    to patients. These costs include expenses for utilization review, quality assurance, quality
                                                    improvement, or peer review. Utilization review and quality assurance costs include the
                                                    costs of individuals, departments or units who dedicate their time or a portion of their time to
                                                    perform these functions. It is not necessary to separately report these types of activities if
                                                    they are carried on as a normal part of providing patient care. This category includes the
                                                    costs of personnel (individuals, departments or units) performing or supervising these
                                                    functions (such as salary and benefits) as well as the costs of occupancy (such as rent,
                                                    depreciation and utilities), costs for space used for these functions, and any other related
                                                    expenses such as supplies and equipment. This category does not include personnel costs
                                                    associated with requesting preauthorization from payers, which should be included in line
                                                    1334.
1341      Promotion and Marketing Costs             Includes all costs related to marketing activities such as advertising, printing, marketing
                                                    personnel or representative wages and fringe benefits, commissions, broker fees, travel,
                                                    occupancy, and other expenses allocated to the marketing activity. Promotion and
                                                    marketing costs include the cost of the yellow pages listings, advertising agency fees,
                                                    advertising materials, and external marketing representatives. This category does not
                                                    include the costs associated with health promotion, wellness education, and patient
                                                    education programs.


1342      Other Costs                               Includes all other costs or expenses not included in, or allocated to, the other categories
                                                    listed. Include personnel costs that cannot be attributed and allocated into above
                                                    categories, such as general administration or human resources personnel. This category no
                                                    longer includes research and education costs.


1510      Education Costs                           Includes costs for health promotion, wellness, and disease-specific patient information, and
                                                    for providing educational programs or materials intended for patients or the public. It
                                                    includes costs for planned programs of study approved by the health care provider which
                                                    result in the conferring of a degree or specialty designation (these activities must be
                                                    licensed if required by state law or, if licensing is not required, then the program must be
                                                    approved by the recognized national professional organization for that particular activity). It
                                                    includes all costs incurred for continuing education programs, staff development seminars,
                                                    and other training programs for health care professional staff and any other clinic personnel.
                                                    It includes costs of personnel, occupancy (rent, depreciation, and utilities), space, training
                                                    materials, supplies, equipment, registration fees, travel expenses, lodging, and course
                                                    materials.

1511      Research Costs                            Includes the direct and general program costs for activities which are part of a formal
                                                    program of medical or scientific research approved by the governing body of the health care
                                                    provider. It includes clinical, general health services, outcomes, and basic science research,
                                                    and may or may not involve patients. Research costs includes the cost of the personnel
                                                    performing or supervising these functions, including salary and benefits; costs of occupancy
                                                    expenses, including rent, depreciation, and utilities; costs for space used for these functions;
                                                    and any other costs related to this function such as supplies and equipment.


1343      MinnesotaCare Tax                         Includes the amount of the MinnesotaCare Provider tax for the reporting period.
NPI       National Provider Identifier (NPI)        Enter this number if the clinic system/physician practice has an assigned National Provider
                                                    Identifier (NPI) from the Centers for Medicare & Medicaid Services (CMS). See
                                                    http://www.cms.hhs.gov/NationalProvIdentStand/ for more information.
Primary   Primary Care                              All physicians have primary care specialties (Family Practice, General Practice, Internal
Care                                                Medicine, Pediatrics, Geriatrics, Obstetrics/Gynecology); most patients self-refer, most
                                                    illnesses and injuries are evaluated but may be referred for treatment.
Specialty Specialty Care                            All phycians in organization are specialists (e.g. surgeons, radiologists, oncologists); most or
Care                                                many patients have been referred; specific illnesses or injuries, body systems, or
                                                    populations treated (e.g. orthopedics, endocrinology, occupational medicine).
Multi-    Multi-specialty Care                      The clinic group contains both primary care and specialty care physicians; patients may be
Specialty                                           referred within the group.
Care
PFSR ID   PFSR_ID                                   This is a Minnesota Department of Health assigned ID number which is used to identify
                                                    each specific physician practice, clinic or clinic system.
                                                    The PFSR_ID is in the address block of your notification letter. If you need assistance with
                                                    the PFSR_ID please contact Tom Major at tom.major@state.mn.us or at 651-201-3574.




Provider Financial and Statistical Report (PFSR)                             2009 Definitions                                                        Division of Health Policy
health.drmreport@state.mn.us                                                  page 36 of 37                                                        Health Economics Program
                                             Definitions for completing the 2009 PFSR:

Code       Label                                     Definition
           Capital Expenditure                       An expenditure which, under generally accepted accounting principles, is not properly
                                                     chargeable as an expense of operation and maintenance.
7594       Major Capital Expenditure                 “Major spending commitment” means an expenditure in excess of $1,000,000 for:
           Commitments
                                                        (1) acquisition of a unit of medical equipment;
                                                        (2) a capital expenditure for a single project for the purposes of providing health care
                                                     services, other than for the
back to    Date of Spending Commitment               The date the project was authorized by an Executive or Board of Directors
formset
           Health Care Service                       (1) a service or item that would be covered by the medical assistance program under
                                                     Minnesota Statutes Chapter 256B if provided in accordance with medial assistance
                                                     requirements to an eligible medical assistance recipient; and

                                                     (2) a service or item that
                                                     Minnesota Statutes Chapter 256B.0625
           Medical Equipment                         Fixed and movable equipment that is used by a provider in the provision of a health care
                                                     service.
           New Specialized Service                   A specialized health care procedure or treatment regimen offered by a provider that was not
                                                     previously offered by the provider.
           Specialty Care                            Includes but is not limited to cardiac, neurology, orthopedic, obstetrics, mental health,
                                                     chemical dependency, and emergency services.
Project    Exceptions                                Capital Expenditure Retrospective Review reporting requirement in do not apply to the
Specific                                             following capital activities:
tab
                                                        (1) commitment made by a research and teaching institution for purposes of conducting
                                                     medical education, medical research supported or sponsored by a medical school, or by a
                                                     federal or foundation grant or clinical trials;

                                                        (2) a major spending commitment for building maintenance including heating, water,
                                                     electricity, and other maintenance-related expenditures; and

                                                         (3) a major spending commitment for activities, not directly related to the delivery of
                                                     patient care services, including food service, laundry, housekeeping, and other service-
                                                     related activities.

                                                        (4) mergers, acquisitions, and other changes in ownership or control that, in the judgment
                                                     of the commissioner, do not involve a substantial expansion of service capacity or a
                                                     substantial change in the nature of health care services provided.




 Provider Financial and Statistical Report (PFSR)                             2009 Definitions                                                       Division of Health Policy
 health.drmreport@state.mn.us                                                  page 37 of 37                                                       Health Economics Program

				
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