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State of Utah
Disproportionate Share Hospital (DSH) Audit Survey
For Federal Fiscal Year ending 2005, 2006 & 2007
DSH Survey Checklist (Need one survey and supporting information per year)
     Federal Fiscal Year Ending 9/30/2005          Federal Fiscal Year Ending 9/30/2006                                        Federal Fiscal Year Ending 9/30/2007
         DSH Audit Survey                                                 DSH Audit Survey                                   DSH Audit Survey
         (Section 1-7, including 6.1, 6.2 & 6.3)                          (Section 1-7, including 6.1, 6.2 & 6.3)            (Section 1-7, including 6.1, 6.2 & 6.3)
         State MMIS data of In-State Uncompensated                        State MMIS data of In-State Uncompensated          State MMIS data of In-State Uncompensated
         Medicaid Charges/Days & Pymts                                    Medicaid Charges/Days & Pymts                      Medicaid Charges/Days & Pymts
         (Section 6.1-A)                                                  (Section 6.1-A)                                    (Section 6.1-A)
         Supporting Documentation for In-State                            Supporting Documentation for In-State              Supporting Documentation for In-State
         Uncompensated Medicaid Charges/Days & Pymts                      Uncompensated Medicaid Charges/Days & Pymts        Uncompensated Medicaid Charges/Days & Pymts
         (Section 6.1-B)                                                  (Section 6.1-B)                                    (Section 6.1-B)
         Reconciliation to State MMIS data                                Reconciliation to State MMIS data                  Reconciliation to State MMIS data
         (Section 6.1-C)                                                  (Section 6.1-C)                                    (Section 6.1-C)
         Direct Graduate Medical Education Allocation                     Computation of Direct Graduate Medical Education   Computation of Direct Graduate Medical Education
         (Section 6.1-D)                                                  (Section 6.1-D)                                    (Section 6.1-D)


         Organ Acquisition Cost per Organ                                 Organ Acquisition Cost per Organ                   Organ Acquisition Cost per Organ
         (Section 6.1-E)                                                  (Section 6.1-E)                                    (Section 6.1-E)


         Supporting Documentation for Out-of-State                        Supporting Documentation for Out-of-State          Supporting Documentation for Out-of-State
         Uncompensated Medicaid Charges/Days & Pymts                      Uncompensated Medicaid Charges/Days & Pymts        Uncompensated Medicaid Charges/Days & Pymts
         (Section 6.2-A)                                                  (Section 6.2-A)                                    (Section 6.2-A)

         Supporting Documentation for Uninsured                           Supporting Documentation for Uninsured             Supporting Documentation for Uninsured
         Uncompensated Care Charges/Days & Pymts                          Uncompensated Care Charges/Days & Pymts            Uncompensated Care Charges/Days & Pymts
         (Section 6.3-A)                                                  (Section 6.3-A)                                    (Section 6.3-A)

         Utah DSH Payments                                                Utah DSH Payments                                  Utah DSH Payments
         (Section 6.4)                                                    (Section 6.4)                                      (Section 6.4)
         Copy of the Medicare 2552-96 Hospital Cost                       Copy of the Medicare 2552-96 Hospital Cost         Copy of the Medicare 2552-96 Hospital Cost
         Report(s) needed to cover the complete DSH Year                  Report(s) needed to cover the complete DSH Year    Report(s) needed to cover the complete DSH Year
         under audit.                                                     under audit.                                       under audit.

         Relevant financial statement(s) and queries                      Relevant financial statement(s) and queries        Relevant financial statement(s) and queries
         generated by the hospital's accounting system                    generated by the hospital's accounting system      generated by the hospital's accounting system
         needed to support information provided in DSH                    needed to support information provided in DSH      needed to support information provided in DSH
         survey                                                           survey                                             survey

         Revenue code cross-walk used to allocate cost to                 Revenue code cross-walk used to allocate cost to   Revenue code cross-walk used to allocate cost to
         the appropriate cost centers                                     the appropriate cost centers                       the appropriate cost centers

         A detailed working trial balance used to prepare                 A detailed working trial balance used to prepare   A detailed working trial balance used to prepare
         each cost report                                                 each cost report                                   each cost report


Please return to:
James Phelps
Reimbursement Unit
Utah Medicaid and Health Financing
288 North 1460 West
P. O. Box 143102
Salt Lake City, Utah 84114-3102
Email: jsphelps@utah.gov
Phone: (801) 538-9184

A desk review will be performed on the information provided in the DSH Audit Survey and Carver, Florek & James will be conducting on-site visits to verify
information provided. The completed electronic survey with all the electronic [1] and hardcopy supporting documentation must be emailed to James Phelps at
jsphelps@utah.gov by March 1, 2010. A signed and dated hard copy of the survey and all supporting documentation must also be mailed to James Phelps using a
traceable U.S. mail carrier authorized to transfer protected health information (PHI).

Audit verification conducted by:
Carver Florek & James, LLC
Attention: Heidi Herrick
2246 N. University Park Blvd.
Layton, Utah 84041
hherrick@chfcpas.com
(801) 926-1177


For Questions or additional information regarding the DSH Audits, please contact Brent Florek at (801) 926-1177 or brent@chfcpas.com.

Notes:
[1]
      Preferred format of all electronic copies is Excel (xls), Comma Separated Values (CSV), or Access (mdb).



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                                                                                                                                                          Acronyms



Acronyms and Abbreviations
A&G           Administrative and General
AHSEA         Adjusted Hourly Salary Equivalency Amount
ARRA          American Recovery and Reinvestment Act of 2009
ASC           Ambulatory Surgical Center
BBA           Balanced Budget Act
BBRA          Balanced Budget Reform Act
BIPA          Benefits Improvement and Protection Act
CAH           Critical Access Hospitals (10/97)
CAPD          Continuous Ambulatory Peritoneal Dialysis
CAP-REL       Capital-Related
CBSA          Core Based Statistical Areas
CCN           CMS Certification Number (formerly known as a provider number)
CCPD          Continuous Cycling Peritoneal Dialysis
CCU           Coronary Care Unit
CDU           Chemical Dependence Unit
CFR           Code of Federal Regulations
CMHC          Community Mental Health Center
CMS           Center for Medicare and Medicaid Services
COL           Column
CORF          Comprehensive Outpatient Rehabilitation Facility
CRNA          Certified Registered Nurse Anesthetist
CTC           Certified Transplant Center
DRA           Deficit Reduction Act of 2005
DRG           Diagnostic Related Group
DSH           Disproportionate Share Hospital
EACH          Essential Access Community Hospital
ESRD          End Stage Renal Disease
FFS           Fee-For-Service
FQHC          Federally Qualified Health Center
FR            Federal Register
FTE           Full Time Equivalent
GME           Graduate Medical Education
HHA           Home Health Agency
HMO           Health Maintenance Organization
HSR           Hospital Specific Rate
I & Rs        Interns and Residents
I/P           Inpatient
ICF           Intermediate Care Facility
ICF/MR        Intermediate Care Facility for the Mentally Retarded (9/96)
ICU           Intensive Care Unit
IME           Indirect Medical Education
INPT          Inpatient
IPF           Inpatient Psychiatric Facility
IRF           Inpatient Rehabilitation Facility
LCC           Lesser of Reasonable Cost or Customary Charges
LIP           Low Income Patient
LOS           Length of Stay
LTC           Long Term Care
LTCH          Long Term Care Hospital
M+C           Medicare + Choice (also known as Medicare Part C)
MA            Medicare Advantage (previously known as M+C)
MCO           Managed Care Organization
MCP           Monthly Capitation Payment
MCR           Medicare Cost Report
MDH           Medicare Dependent Hospital (10/97)
MED-ED        Medical Education
MIPPA         Medicare Improvements for Patients and Providers Act of 2008
MMA           Medicare Prescription Drug Improvement and Modernization Act of 2003
MMIS          Medical Management Information Systems
MSA           Metropolitan Statistical Area (10/97)
MS-DRG        Medicare Severity Diagnosis-Related Group
MSP           Medicare Secondary Payer
NF            Nursing Facility
NHCMQ         Nursing Home Case Mix and Quality Demonstration
NPI           National Provider Identifier
O/P           Outpatient
OBRA          Omnibus Budget Reconciliation Act
OLTC          Other Long Term Care
OOT           Outpatient Occupational Therapy
OPD           Outpatient Department
OPO           Organ Procurement Organization
OPPS          Outpatient Prospective Payment System
OPT           Outpatient Physical Therapy
ORF           Outpatient Rehabilitation Facility
OSP           Outpatient Speech Pathology
PBP           Provider-Based Physician
PCN           Primary Care Network
PHI           Protected Health Information
PPS           Prospective Payment System
PRM           Provider Reimbursement Manual
PRO           Professional Review Organization
PRTF          Psychiatric Residential Treatment Facility
PS&R          Provider Statistical and Reimbursement System aka Remittance Advice Summary or Paid Claims Summary
PT            Physical Therapy
RCE           Reasonable Compensation Equivalent
RHC           Rural Health Clinic
RPCH          Rural Primary Care Hospitals
RT            Respiratory Therapy
RUG           Resource Utilization Group
SCH           Sole Community Hospitals
SCHIP         State Children Health Insurance Program
SNF           Skilled Nursing Facility
SSI           Supplemental Security Income
UMAP          Utah Medical Assistance Program
UPL           Upper Payment Limit
WKST          Worksheet
Source: Medicare Cost Report




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                                                                                                                                                                                                                Section 1-7



                                                                        State of Utah
                                                                 DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                       Federal Fiscal Year Ended 9/30/ 2005
 GENERAL INSTRUCTIONS: URBAN HOSPITALS COMPLETE ALL SECTIONS AS OUTLINED. RURAL HOSPITAL COMPLETE ONLY SECTIONS: 1, 3, 5, 6 & 7.
Rural Hospitals-All rural hospitals qualify automatically for DSH
Urban Hospitals- Must have met 1. and 2. (below) and at least one of the criteria shown in 3.
1. Having a Medicaid Utilization Rate of at least 1%.
2. Have at least 2 obstetricians who have staff privileges & agree to provide these services to individuals entitled to "medical assistance".
3. Have a Medicaid utilization rate of at least 14% or a "low income" utilization rate of at least 25%.
   That is, if a facility has the required OB staff and have either a 14% Medicaid Inpatient Utilization Rate (MIUR) or over 25% Low Income Utilization Rate (LIUR), then they qualify.


DSH Survey for Federal Fiscal Year ended 9/30/                                               2005

SECTION 1: HOSPITAL INFORMATION
Complete the following in-state hospital information in the space provided.
Hospital Name (select your facility from the drop down menu provided):    ALLEN MEMORIAL
                                                                          HOSPITAL
Contact Person:
E-mail Address of Contact Person:
Address:




Utah Medicaid Provider #:
Utah Medicaid Subprovider #:
Utah Medicare Provider #:
Fiscal Year End: (Should coincide with the 2005 Medicare Cost Report)                        12/31


Out-of-State Hospital Information
Per federal regulation, the DSH audit must examine both in-state and out-of-state Medicaid services. Provide all out-of-state name(s) and provider number(s) in the space
provided.

Out-of-State Name
Out-of-State Medicaid Provider #:
Out-of-State Medicare Provider #:

<<Please provide additional Out-of-State provider's name here if needed>>
<<Please provide additional Out-of-State Medicaid Provider # here if needed>>
<<Please provide additional Out-of-State Medicare Provider # here if needed>>

Identify the Medicare Cost Report(s) related to the audited DSH Year:
In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost
reporting period does not correspond with the federal fiscal year under audit. Please identify the cost report(s) needed to cover the complete DSH year under audit below, note if
the cost report is finalized and audited or as filed, etc. and provide a full copy of the filed report(s) to the State/auditors.


                                                                                Begin Date                End Date                    Type: Unaudited, Audited,   Copy Provided to
DSH Year                                                                        10/1/2004                 9/30/2005                   Final, As Filed, etc.?      State/Auditors?
Medicare Cost Report                                                                                                                                                     Yes           No
<<Please provide additional Medicare Cost Report items here if needed>>                                                                                                  Yes           No

<<Please provide additional Medicare Cost Report items here if needed>>                                                                                                  Yes           No




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                                                                                                                                                                                                          Section 1-7



                                                                             State of Utah
                                                                      DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                            Federal Fiscal Year Ended 9/30/ 2005

SECTION 2: VOLUMES AND REVENUES
Medicaid Patient & Inpatient Days & Other Information (Traditional, HMO, PCN, UMAP, etc.): Includes days that are determined to be medically necessary but for which payment is
denied by Medicaid because the provider did not bill timely, days that are beyond the number of days for which a State will pay, days that are utilized by a member prior to an
admission approval, but for which a valid enrollment is determined within the prescribed period, and days for which payment is NOT made by a third party. Includes rehabilitation,
nursery, on-site PRTF, and exempt unit days; however, the following should NOT be included: NF, SNF, LTC, CDU, ICF, HHA, observation bed days, swing bed days, or off-site
PRTF.

Inpatient Days for Dual Eligibles includes Medicaid inpatient days attributed to dual eligible patients (Medicaid and any other third party coverage including Medicare) is
appropriate to the extent they qualify as Medicaid days. Examples include when a dually eligible patient exhausts their Medicare days (Part A) or are only eligible for Part B
Medicare.

Provide the following information for the 12 months ending:                            9/30/2005

                 MEDICAID UTILIZATION INFORMATION
                  (Traditional, HMO, PCN, UMAP Etc.)                                               Days
Utah Medicaid - FFS (Regular Medicaid)
Utah Medicaid - Managed Care or HMO Claims
Utah Medicaid - FFS Crossover
Utah Medicaid - Managed Care Crossover
Out-of-State Medicaid - FFS (Regular Medicaid)
Out-of-State Medicaid - Managed Care or HMO Claims
Out-of-State Medicaid - FFS Crossover
Out-of-State Medicaid - Managed Care Crossover
                                                                       Total Days                              0

Inpatient Days (Inpatient hospital days only)
Inpatient Days for Dual Eligibles (dual eligible days that qualify as Medicaid days)
                                                                Total Inpatient Days                           0

                                    Medicaid Inpatient Utilization Rate (MIUR)                            #DIV/0! #DIV/0!




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                                                                                                                                                                                                         Section 1-7



                                                                           State of Utah
                                                                    DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                          Federal Fiscal Year Ended 9/30/ 2005
SECTION 3: OBSTETRICIAN QUALIFYING INFORMATION
Qualifying Information: Obstetrical Care.
SSA§1923(d), [42 U.S.C. §1396r-4(d)] Requires "…at least 2 obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to individuals
who are entitled to medical assistance for such services .." Note: Hospitals located in rural settings may utilize other qualified physicians for obstetric services in lieu of
obstetricians.

Provide the following information for the 12 months ending:                       9/30/2005

                                                                                    Names of Qualifying OB
                                                                                         Physicians
                                                                  Physician #1:
                                                                  Physician #2:

                                                                                   Names of Qualifying Other-
                                                                                   Non Obstetrical Physicians
                                                                                  Who supply obstetric services
                                                                                      (Rural Areas Only)

                                                                  Physician #1:
                                                                  Physician #2:

                                                                                   Exempt Under this Exception
                                                                                  (Initial of Authorized Person &
                                                                                                Date)
A hospital is exempt from this requirement if that hospital did not offer non-
emergency obstetric services to the general public when federal Medicaid DSH       Exempt
regulations were enacted on December 22, 1987.
                                                                                   _______________________
                                                                                     (Initial & Date Above)
A hospital is exempt from this requirement if the patients served are
predominantly under 18 years of age.                                                Exempt

                                                                                   _______________________
                                                                                     (Initial & Date Above)

SECTION 4: LOW INCOME UTILIZATION RATE (LIUR)
Cash Subsidies and Charity Care Charges are used to calculate Medicaid DSH eligibility under the federal low income utilization rate (LIUR).
Per §413 of the Utah State Medicaid Plan a provider may qualify if its low income utilization rate (LIUR) exceeds 25%. Therefore this factor must be calculated below in order to
qualify under this criteria. Note: The provider may choose to not qualify under this criteria.

In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost
reporting period does not correspond with the federal fiscal year under audit. Please identify the information requested below for all cost report(s) needed to cover the complete
DSH Year under audit.




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                                                                                                                                                                                                                                                                      Section 1-7



                                                                                         State of Utah
                                                                                  DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                        Federal Fiscal Year Ended 9/30/ 2005
Amount from Medicare Cost Report ended                                                                            12/31/2004

Medicare Cost Report Information                                                                                    Inpatient                            Outpatient                             Total
Line 1: Allowable patient total Medicaid payments[1]                                                                                                                               $                             -
Line 2: Cash subsidies[2] for patient services received from state & local                                                                                                         $                             -
governments low income payments for patient care (Line 1 plus Line 2)
Line 3: Total                                                                                          $                                   -   $                               -   $                             -
Line 4: Total patient net revenues & cash subsides for patient services (gross                                                                                                     $                             -
revenues less contractuals)
Line 5: Low income revenue percentage (Line 3 divided by Line 4)                                                                   #DIV/0!                              #DIV/0!                          #DIV/0!
Line 6: Amount of patient hospital charges attributable to charity care [3] (not                                                                                                   $                             -
including contractual allowances and discounts)
Line 7: Total amount of patient hospital charges[4] (gross revenue per                                                                                                             $                             -
Worksheet G-2 of the Medicare cost report less SNF - or financial statements)
Line 8: Charity care charge percentage (Line 6 divided by Line 7)                                                                  #DIV/0!                              #DIV/0!                          #DIV/0!
Line 9: LIUR[5] (Line 5 plus Line 8)                                                                                               #DIV/0!                              #DIV/0!                          #DIV/0!                #DIV/0!

<<Please provide additional cost report information here if needed>>
Amount from Medicare Cost Report ended                                                                            12/31/2005

                                                                                                                    Inpatient                            Outpatient                             Total
Line 1: Allowable patient total Medicaid payments[1]                                                                                                                               $                             -
                             [2]                                                                                                                                                   $                             -
Line 2: Cash subsidies for patient services received from state & local
governments low income payments for patient care (Line 1 plus Line 2)
Line 3: Total                                                                                          $                                   -   $                               -   $                             -
Line 4: Total patient net revenues & cash subsides for patient services (gross                                                                                                     $                             -
revenues less contractuals)
Line 5: Low income revenue percentage (Line 3 divided by Line 4)                                                                   #DIV/0!                              #DIV/0!                          #DIV/0!
Line 6: Amount of patient hospital charges attributable to charity care [3] (not                                                                                                   $                             -
including contractual allowances and discounts)
Line 7: Total amount of patient hospital charges[4] (gross revenue per                                                                                                             $                             -
Worksheet G-2 of the Medicare cost report less SNF - or financial statements)
Line 8: Charity care charge percentage (Line 6 divided by Line 7)                                                                  #DIV/0!                              #DIV/0!                          #DIV/0!
Line 9: LIUR[5] (Line 5 plus Line 8)                                                                                               #DIV/0!                              #DIV/0!                          #DIV/0!                #DIV/0!

[1]: Medicaid Payment - All Medicaid payments received for IP/OP hospital services, do not include non-hospital services i.e., physician, ambulance, lab, etc. Also include any supplemental Medicaid program payments made to your facility
outside the rate structure such as GME and UPL programs, excluding DSH.

[2]: State and Local Subsidies - Subsidies are funds the hospital received from state or local government sources to assist hospitals to provide care to uninsured and underinsured patients, includes local taxes collected to be used for
patient care. Do not include regular Medicaid payments, supplemental (UPL) Medicaid payments, or Medicaid/Medicare DSH payments. If the subsidies cannot be specified as inpatient or outpatient, record the subsidies in the total
column.
[3]: Charity Care Charges - Health care services that were never expected to result in cash inflows. Charity care results from a provider's policy to provide health care services free-of-charge to individuals who meet certain financial criteria.
Charity care does not include contractual allowances, discounts, partial payments, patients that have a third party with any responsibility for their care, care paid for in full or part by local governments, etc. Bad debts are not considered
charity care for DSH qualification purposes.

[4]: Total Charges - All hospital billed charges for all types of services rendered. Do not include billed charges for SNF, NF, HHA or off-site PRTF units.

[5]: LIUR - The percentage derived by dividing total Medicaid revenues (including Medicaid managed care revenues) plus UMAP revenues by total revenues and adding the percentage to the percentage derived from dividing total charges
for charity care by total charges.




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                                                                                                                                                                                                                                                                Section 1-7



                                                                                        State of Utah
                                                                                 DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                       Federal Fiscal Year Ended 9/30/ 2005

SECTION 5: MEDICAID RETURNS
Section 455.304 of the final rule requires the independent auditor to verify that each hospital retain their DSH payments.

Did you retain 100% of the DSH payments for the DSH year under audit?                                   Yes               No

Amount of Medicaid DSH Payments Returned to State
Reason For Returned DSH Payments:

Section 6: Total Uncompensated Care
This section is designed to report the "uncompensated care" that you as a provider have rendered.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires states to ensure that only uncompensated care costs of providing inpatient hospital
and outpatient hospital services to Medicaid eligible individuals and uninsured individuals are to be included in the calculation of total uncompensated care which represents
hospital-specific DSH limits. Section 1923(g)(1) of the Act requires the calculation of hospital-specific DSH limits to be determined under Medicare cost principles. Furthermore,
in calculating the hospital specific DSH limits, services that are not defined under the State Medicaid Plan as allowable inpatient or outpatient services, should not be included. 42
CFR Parts 447 and 455 clarify that bad debt arising from non-payment on behalf of individuals who have third party coverage is not part of services to Medicaid and other
uninsured patients and is not to be included in the determination of hospital-specific DSH limits.


                                                                                   Exempt from reporting uncompensated care costs for the uninsured (Section 6.3):
Hospitals may be exempt from reporting DSH Audit requirements related to the
uninsured if the hospital meets all 3 of the criteria outlined below:           I have reviewed the applicable accounting books and records and certify that the hospital incurred additional
1) Only received DSH Add-on payments                                           uncompensated care costs serving the uninsured for the DSH year under audit.
2) Medicaid uncompensated care costs exceeded DSH payments for the year
3) The provider certifies that they incurred additional uncompensated care
costs serving the uninsured.
(Additional Information on the DSH Reporting and Audit Requirements, page 7-8)    _______________________
                                                                                     (Initial & Date Above)

Net Uncompensated Care Costs (See Section 6.1-6.3)
This section summarizes the information provided in Sections 6.1-6.3, and is designed to report net Uncompensated Care for both Routine and Ancillary Inpatient and Outpatient
Services for In-State, Out-of-State, and the Uninsured.


                                                                                                     Net Uncompensated Costs               Ref:
                                                                       Medicaid In-State            $                        -             6.1
                                                                    Medicaid Out-of-State           $                        -             6.2
                                                                              Uninsured             $                        -             6.3
                                                            Total Uncompensated Costs               $                        -

[1]: Uncompensated Care - The amount of non-reimbursed costs written off as non recoverable for services rendered to the uninsured, i.e., indigent, and includes the difference between cost of providing services to those eligible for
medical assistance under the State plan and the payment for those services by the State by Medicaid or any other payer methodology (as revised in 2004 by the National Institutional Reimbursement Team NIRT).



DSH Payments (See Section 6.2 & 6.4)
This section summarizes the DSH payment information provided in Sections 6.2 and 6.4.

                                                                                                              DSH Payments               Ref:
                                                                                   Add-On           $                                  - 6.4
                                                                              Supplemental          $                                  - 6.4
                                                                               Out-of-State         $                                  - 6.2
                                                                       Total DSH Payments           $                                  -




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                                                                                                                                                                                                       Section 1-7



                                                                      State of Utah
                                                               DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                     Federal Fiscal Year Ended 9/30/ 2005
SECTION 7: CERTIFICATION
I declare that I have examined this worksheet, and to the best of my knowledge and belief, it is true, correct, complete, and in agreement with the books and records maintained by
the facility.




Signature of Officer / Administrator                                      Printed Name                                                                     Date

Chief Financial Officer
Title




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                                                                                                                                                                                                                                                                                                Section 6.1




                                                                                             State of Utah
                                                                   DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                       Federal Fiscal Year Ended 9/30/ 2005
SECTION 6.1: IN-STATE UNCOMPENSATED MEDICAID SERVICES
Section 6.1 is used to report the uncompensated care cost of services less related payments provided to Utah Medicaid patients using Medicare cost allocation methodologies.

Provide the following information for the 12 months ending:            9/30/2005
                                                                                         92                      273
                                                                     (Worksheet D-1, II)        (Worksheet D-1, II)
                                                                   Per Diem Costs for         Per Diem Costs for
ROUTINE COSTS (ROOM & BOARD):                                         MCR ended                  MCR ended                                      FFS                      MCO                FFS Crossover            MCO Crossover                Uninsured
                                                                                                                                         Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient                                         Total
                                                                                                                       Composite Per     Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid Medicaid                              Inpatient   Outpatient Medicaid Utah Medicaid
State   Cost Report Line        Cost Center Description                12/31/2004                12/31/2005             Diem Costs         Days     Charges     Days     Charges     Days     Charges     Days     Charges                      Days       Charges    Days    Routine Costs
Utah    25                      Adults & Peds                                                                                    -                                                                                                                                           0          -
Utah    26                      Intensive Care                                                                                   -                                                                                                                                           0          -
Utah    26.01                   Intermediate Care Unit                                                                           -                                                                                                                                           0          -
Utah    27                      Coronary Care                                                                                    -                                                                                                                                           0          -
Utah    28                      Burn Intensive Care                                                                              -                                                                                                                                           0          -
Utah    29                      Surgical Intensive Care                                                                          -                                                                                                                                           0          -
Utah    30                      Bone Marrow Intensive Care                                                                       -                                                                                                                                           0          -
Utah    30                      Thoracic Intensive Care                                                                          -                                                                                                                                           0          -
Utah    30.01                   Newborn ICU                                                                                      -                                                                                                                                           0          -
Utah    30.02                   Respiratory Intensive Care                                                                       -                                                                                                                                           0          -
Utah    31                      Subprovider Rehab                                                                                -                                                                                                                                           0          -
Utah    31                      Subprovider Psych                                                                                -                                                                                                                                           0          -
Utah    31.01                   Subprovider Psych                                                                                -                                                                                                                                           0          -
Utah    31.01                   Subprovider Rehab                                                                                -                                                                                                                                           0          -
Utah    33                      Nursery                                                                                          -                                                                                                                                           0          -
Utah    <<Please provide additional Cost Center items here if needed>>                                                           -                                                                                                                                           0          -
Utah    <<Please provide additional Cost Center items here if needed>>                                                           -                                                                                                                                           0          -
Utah    <<Please provide additional Cost Center items here if needed>>                                                           -                                                                                                                                           0          -
                                                                                                                                Total            0                        0                        0                      0                                                  0          -
                                                                                                                                                                                                                    Total per State of Utah Section 6.1-A                    0
                                                                                                                                                                                                       Unreconciled Difference (Explain in Section 6.1-C)                    0
                                                                                         92                      273
                                                                      (Worksheet C, I)           (Worksheet C, I)
                                                                   Cost to Charge Ratio       Cost to Charge Ratio
ANCILLARY COSTS:                                                     for MCR ended              for MCR ended                                   FFS                      MCO                FFS Crossover            MCO Crossover                Uninsured
                                                                                                                                         Inpatient   Outpatient   Inpatient   Outpatient   Inpatient    Outpatient   Inpatient   Outpatient                          Total
                                                                                                                       Composite Cost    Ancillary    Ancillary   Ancillary    Ancillary   Ancillary     Ancillary   Ancillary    Ancillary   Inpatient   Outpatient Ancillary Utah Medicaid
State   Cost Report Line       Cost Center Description                12/31/2004                 12/31/2005            to Charge Ratio   Charges      Charges     Charges      Charges     Charges       Charges     Charges      Charges     Charges      Charges Charges Ancillary Costs
Utah    37                     Operating Room                                                                               -                                                                                                                                           -               -
Utah    38                     Recovery Room                                                                                -                                                                                                                                           -               -
Utah    39                     Labor & Delivery Room                                                                        -                                                                                                                                           -               -
Utah    40                     Anesthesiology                                                                               -                                                                                                                                           -               -
Utah    41                     Radiology-Diagnostic                                                                         -                                                                                                                                           -               -
Utah    41.01                  Radiology-Diagnostic CT                                                                      -                                                                                                                                           -               -
Utah    41.02                  Radiology-Diagnostic MRI                                                                     -                                                                                                                                           -               -
Utah    41.03                  Radiology-Diagnostic Ultrasound                                                              -                                                                                                                                           -               -
Utah    42                     Radiology-Therapeutic                                                                        -                                                                                                                                           -               -
Utah    43                     Radioisotope                                                                                 -                                                                                                                                           -               -
Utah    44                     Laboratory                                                                                   -                                                                                                                                           -               -
Utah    47                     Blood Storing, Processing & Trans                                                            -                                                                                                                                           -               -
Utah    48                     Intravenous Therapy                                                                          -                                                                                                                                           -               -
Utah    48.01                  Home IV Therapy                                                                              -                                                                                                                                           -               -
Utah    49                     Respiratory Therapy                                                                          -                                                                                                                                           -               -
Utah    50                     Physical Therapy                                                                             -                                                                                                                                           -               -
Utah    51                     Occupational Therapy                                                                         -                                                                                                                                           -               -
Utah    51.01                  Rehab Ancillary                                                                              -                                                                                                                                           -               -
Utah    52                     Speech Pathology                                                                             -                                                                                                                                           -               -
Utah    53                     Electrocardiology                                                                            -                                                                                                                                           -               -
Utah    54                     Electroencephalography                                                                       -                                                                                                                                           -               -
Utah    54.01                  Meg Lab                                                                                      -                                                                                                                                           -               -




                                                                                                                                                                                                                                                                 75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.1
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                                                                                                                                                                                                                                              Section 6.1




                                                                                            State of Utah
                                                                  DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                      Federal Fiscal Year Ended 9/30/ 2005
Utah   55                      Medical Supplies                                          -                                                                                                                          -                  -
Utah   56                      Drugs Charged to Patients                                 -                                                                                                                          -                  -
Utah   57                      Renal Dialysis                                            -                                                                                                                          -                  -
Utah   58                      ASC (Non-Distinct Part)                                   -                                                                                                                          -                  -
Utah   58.01                   CV Monitoring                                             -                                                                                                                          -                  -
Utah   59                      Acute Adult Dialysis                                      -                                                                                                                          -                  -
Utah   59                      Psychotherapy                                             -                                                                                                                          -                  -
Utah   59.01                   Acute Pediatric Dialysis                                  -                                                                                                                          -                  -
Utah   59.01                   Fitness Institute                                         -                                                                                                                          -                  -
Utah   59.02                   Gastrointestinal Lab                                      -                                                                                                                          -                  -
Utah   59.03                   Pulmonary Lab                                             -                                                                                                                          -                  -
Utah   60                      Clinic                                                    -                                                                                                                          -                  -
Utah   60.01                   Clinics Hospital Internal Medicine                        -                                                                                                                          -                  -
Utah   60.01                   St Joseph's Partial Hospital                              -                                                                                                                          -                  -
Utah   60.02                   Clinics Hospital Other                                    -                                                                                                                          -                  -
Utah   60.02                   Clinical Dietetics                                        -                                                                                                                          -                  -
Utah   60.03                   Clinic OB Diagnostic Center                               -                                                                                                                          -                  -
Utah   60.04                   Clinics Wasatch                                           -                                                                                                                          -                  -
Utah   60.05                   Clinics Community                                         -                                                                                                                          -                  -
Utah   60.07                   Community Clinics                                         -                                                                                                                          -                  -
Utah   60.08                   Clinics HCH & UOC                                         -                                                                                                                          -                  -
Utah   61                      Emergency                                                 -                                                                                                                          -                  -
Utah   62                      Observation                                               -                                                                                                                          -                  -
Utah   64                      Home Program Dialysis                                     -                                                                                                                          -                  -
Utah   65                      Ambulance                                                 -                                                                                                                          -                  -
Utah   71                      Home Health Agency                                        -                                                                                                                          -                  -
Utah   82                      Lung Acquisition                                          -                                                                                                                          -                  -
Utah   83                      Kidney Acquisition                                        -                                                                                                                          -                  -
Utah   84                      Liver Acquisition                                         -                                                                                                                          -                  -
Utah   85                      Heart Acquisition                                         -                                                                                                                          -                  -
Utah   85.01                   Pancreas Acquisition                                      -                                                                                                                          -                  -
Utah   85.02                   Intestine Acquisition                                     -                                                                                                                          -                  -
Utah   86                      Other Organ Acquisition                                   -                                                                                                                          -                  -
Utah   86.01                   Bone Marrow Acquisition                                   -                                                                                                                          -                  -
Utah   90                      Other Capital Related Costs                               -                                                                                                                          -                  -
Utah   94                      Resource Nursing                                          -                                                                                                                          -                  -
Utah   94.01                   Messenger Services                                        -                                                                                                                          -                  -
Utah   94.02                   Bone Marrow Acquisition                                   -                                                                                                                          -                  -
Utah   100                     Non Reimbursable                                          -                                                                                                                          -                  -
Utah   <<Please provide additional Cost Center items here if needed>>                    -                                                                                                                          -                  -
Utah   <<Please provide additional Cost Center items here if needed>>                    -                                                                                                                          -                  -
Utah   <<Please provide additional Cost Center items here if needed>>                    -                                                                                                                          -                  -
                                                                                               Total       -            -         -         -        -           -         -         -                              -                  -
                                                                                                                                                                        Total per State of Utah Section 6.1-A       -
                                                                                                                                                           Unreconciled Difference (Explain in Section 6.1-C)       -



ORGAN ACQUISITION COSTS:                                                             (Section 6.1-E)           FFS                    MCO        FFS Crossover         MCO Crossover          Uninsured
                                                                                    Composite Cost                   Usable             Usable               Usable              Usable              Usable       Total     Utah Organ
State Cost Report Line       Cost Center Description                                  per Organ        Charges       Organs   Charges   Organs   Charges     Organs    Charges   Organs    Charges   Organs      Organs   Acquisition Costs
Utah                         Lung Acquisition                                            -                                       1.00                                                                                -                 -
Utah                         Kidney Acquisition                                          -                                                                                                                           -                 -
Utah                         Liver Acquisition                                           -                                                                                                                           -                 -
Utah                         Heart Acquisition                                           -                                                                                                                           -                 -
Utah                         Pancreas Acquisition                                        -                                                                                                                           -                 -
Utah                         Intestinal Acquisition                                      -                                                                                                                           -                 -
Utah <<Please provide additional Cost Center items here if needed>>                      -                                                                                                                           -                 -
                                                                                               Total       -            -        1.00       -        -           -         -         -                               -                 -

GRADUATE MEDICAL EDUCATION COSTS (Section 6.1-D):                                                                                                                                                                                      -

                                                                                                                                                                                 Total In-State Medicaid Service Costs                0.00




                                                                                                                                                                                                              75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.1
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                                                                                                                                                                                                                                                                            Section 6.1




                                                                                                           State of Utah
                                                                                 DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                                     Federal Fiscal Year Ended 9/30/ 2005
CLAIMS AND OTHER PAYMENTS APPLICABLE TO IN-STATE MEDICAID:
Medicaid Payments (excludes TPL)
Medicaid Managed Care Org. Payments/Revenues
Medicaid Supplemental/Enhanced Payments (UPL, IME, GME, non-claim specific)
Third Party Liability Payments (excludes Medicare)
Medicare Payments (excludes coinsurance/deductibles)
Medicare Cross-Over (includes coinsurance deductible paid by Medicaid)
Medicare Supplemental/Enhanced Payments (DSH, IME, GME)
Coinsurance, Deductible & Other Payment (patient's responsibility)
less: DSH Add-on if included in Medicaid Payment(s) above
                                                                         Total         -                                                                                                                                              Total Payments                    -

                                                                                                                                                                                                  In-State Net Uncompensated Medicaid Services                          -

Routine Costs: Input all Utah IP/OP routine days and charges by cost center. Using your Medicare cost report input the appropriate rates for the respective cost center. Routine room and board costs are determined by applying per diem costs for the
applicable hospital routine cost center to the number of hospital days billed for Utah Medicaid eligible patients. Information in this section should be reconciled to State of Utah information provided in Section 6.1-A. This reconciliation is to be performed in
Section 6.1-C. In the event that hospital records are insufficient, default to information provided by the State of Utah.

Per Diem Costs: In the Medicare 2552-96 cost report, a per diem is computed for each routine cost center. Record the routine per diem cost per day for each hospital routine cost center present on your Medicare cost report. These amounts are
calculated on Worksheet D-1, Part II of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period does not
correspond with the federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH year under audit. The composite per diem is determined by applying the weighted average
applicable rate over the federal fiscal year.

Cost to Charge Ratio: In the Medicare 2552-96 cost report, a cost-to-charge ratio is computed for each ancillary cost center. Record the ancillary cost-to-charge ratio for each hospital cost center present on your Medicare cost report. These amounts are
calculated on Worksheet C, Part I of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period does not
correspond with the federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH Year under audit. The composite cost to charge ratio is determined by applying the weighted
average applicable rate over the federal fiscal year.

Ancillary Costs: Input all Utah IP/OP ancillary charges by cost center. Using your Medicare cost report fill in the appropriate ratio for the applicable cost center. Ancillary costs are determined by applying per cost to charge costs for the applicable hospital
ancillary cost center to the charges billed for Utah Medicaid eligible patients.

Medicaid Payments: Input all Medicaid payments from the State of Utah, excluding all DSH payments. Payments must include all amounts collected on behalf of Medicaid patients including Medicaid payments, third party payments and patient co-pays (if
any). All Medicaid payments received from non-State sources not already accounted for, including payments from or on behalf of patients for Medicaid services.

Medicare Payments: Input all Medicare payments attributable to dual eligible patients. Medicare payments should include a) Medicare regular rate payments, including any patient co-pays, coinsurance and deductibles, b) Medicare allowable bad debt
payments and c) supplemental and enhanced Medicare payments attributable to dual eligible patients, including Medicare DSH (adjustment), Medicare IME and GME payments. Report payments using the accrual method of accounting.

Dual Eligibles: The total amount of IP/OP charges and related payments attributed to dual eligible patients (Medicaid and any other third party coverage including Medicare) is appropriate to the extent that the IP/OP payments qualify as Medicaid
payments. Examples include when a dually eligible patient exhausts their Medicare days (Part A) or are only eligible for Part B Medicare. Only include outpatient hospital payments that are under the hospital benefit; do not include payments for services
paid under some other benefit i,e, physician, lab, drugs, etc. Do not include payments for NF, SNF, HHA, or off-site PRTF. State MMIS data includes this data.




                                                                                                                                                                                                                                           75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.1
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                                                                                                                                                                                                      Section 6.1-A


Section 6.1-A         State MMIS Data

Hospital billings for Routine Room & Board to the state (per MMIS):

 Revenue
  Code      Revenue Code Description                                      Utah Medicaid Inpatient Days


            Filled in with data sent with letter requesting survey.

            If you need copy of your hospital's data, contact:

            James Phelps
            Reimbursement Unit
            Utah Medicaid and Health financing
            288 North 1460 West
            P. O. Box 143102
            Salt Lake City, Utah 84114-3102
            Email: jsphelps@utah.gov
            Phone: (801-538-9184




Total days per State of Utah                                                                                    0



Hospital billings for Ancillary Services to the state (per MMIS):

 Revenue                                                                                                            Ancillary Charges for Outpatient
  Code      Revenue Code Description                                  Ancillary Charges for Inpatient Clients                    Clients               Total Charges
                                                                                                                                                                       -
                                                                                                                                                                       -
            Filled in with data sent with letter requesting survey.                                                                                                    -
                                                                                                                                                                       -
            If you need copy of your hospital's data, contact:                                                                                                         -
                                                                                                                                                                       -
            James Phelps                                                                                                                                               -
            Reimbursement Unit                                                                                                                                         -
            Utah Medicaid and Health financing                                                                                                                         -
            288 North 1460 West                                                                                                                                        -
            P. O. Box 143102                                                                                                                                           -
            Salt Lake City, Utah 84114-3102                                                                                                                            -
            Email: jsphelps@utah.gov                                                                                                                                   -
            Phone: (801-538-9184                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -


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                                                                                            Section 6.1-A


                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -
                                                             -

Total ancillary charges per State of Utah                    -

Total Payments by State of Utah (excluding DSH) (per MMIS)



                                                             75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.1-A
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                                                                                                                                                                 Section 6.1-B


Section 6.1-B      Supporting Documentation for In-State Uncompensated Medicaid Charges/Days & Payments
Instructions: If your facility is not relying upon the days and charges provided by the State (MMIS) to determine uncompensated costs, you must provide an electronic copy of
the information relied upon to complete Section 6.1. The information should include: patient ID, claim type (crossover, Medicaid, MCO), claim status (denied claim, paid claim),
service date, type of service, revenue/cost center codes, and units. Detailed supporting documentation is required to substantiate the amounts claimed in 6.1.




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                                                                                                                                                                                          Section 6.1-C




Section 6.1-C          Reconciliations
Instructions: In the event that Hospital records do not agree with the State of Utah records, provide a description of the applicable reconciling items.

Total days reconciliation table
            Inpatient days entered from (6.1), per provider (In-State)
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
            Inpatient days entered above, per provider (In-State) + Reconciliation Items
            Inpatient days, per State of Utah's records

Total ancillary charges reconciliation table
             Ancillary charges entered from (6.1), per provider (In-State)
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
             Ancillary charges entered per provider (In-State) + Reconciliation Items
             Ancillary charges, per State MMIS

Payment Reconciliation Table
            Medicaid payments entered from (6.1), per provider (In-State)
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
<<Please provide a description of reconciling items here>>
            Medicaid payments entered per provider (In-State) + Reconciliation Items
            Medicaid payments, per State of Utah's records




                                                                                                                                                           75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.1-C
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                                                                                                                                           Section 6.1-D

Section 6.1-D    Allocation of Direct Graduate Medical Education
Instructions: Use this section to calculate the direct graduate medical education (GME) costs.
                                                                                                    92                   273

                                                                                    GME for MCR ended    GME for MCR ended
GRADUATE MEDICAL EDUCATION (GME):                                                      12/31/2004           12/31/2005         Composite
A) Number of FTE Residents (Worksheet E-3 Part IV Line 3.15)                                                                           -
B) Updated Per Resident Amount (Worksheet E-3 Part IV Line 3.17)                                                                       -
C) Number of FTE Residents (Worksheet E-3 Part IV Line 3.21)                                                                           -
D) Updated Per Resident Amount (Worksheet E-3 Part IV Line 3.23)                                                                       -
E) Aggregate Approved Amount (Line A x Line B) + (Line C x Line D)                                  0                      0           -
F) Total Inpatient Days (Worksheet E-3 Part IV Line 5)                                                                                     -

IN-STATE ALLOCATION OF GME:
G) In-State Medicaid Inpatient Days (Section 6.1, Line 34)                                                                               -
H) Ratio of Medicaid In-State Days to Total Inpatient Days ( Line G ÷ Line F)                                                        0.00%
I) In-State GME Allocation (Line E x Line H)                                                                                           -

OUT-OF-STATE ALLOCATION OF GME:
J) Out-of-State Medicaid Inpatient Days (Section 6.2, Line 34)                                                                           -
K) Ratio of Medicaid Out-of-State Days to Total Inpatient Days ( Line J ÷ Line F)                                                    0.00%
L) Out-of-State GME Allocation (Line E x Line K)                                                                                       -

UNINSURED ALLOCATION OF GME:
M) Uninsured Medicaid Inpatient Days (Section 6.3, Line 34)                                                                              -
N) Ratio of Medicaid Uninsured Days to Total Inpatient Days ( Line M ÷ Line F)                                                       0.00%
O) Uninsured GME Allocation (Line E x Line N)                                                                                          -




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                                                                                                                                                Section 6.1-E

Section 6.1-E     Organ Acquisition Cost per Organ
Instructions: This section is only to be completed by hospitals that have incurred Medicaid or
uninsured organ acquisition costs.

                  92                                   273                   92               273
                                                              Organ Acquisition  Organ Acquisition
                                                             Cost for MCR ended Cost for MCR ended

                                                                12/31/2004         12/31/2005        Composite
Lung Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61)                                                        -
Medicare Usable Organs (Wksht D-6, III, Line 55)                                                            -
Medicare Organ Acquisition Cost per Organ                             -                  -                  -

Kidney Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61)                                                        -
Medicare Usable Organs (Wksht D-6, III, Line 55)                                                            -
Medicare Organ Acquisition Cost per Organ                             -                  -                  -

Liver Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61)                                                        -
Medicare Usable Organs (Wksht D-6, III, Line 55)                                                            -
Medicare Organ Acquisition Cost per Organ                             -                  -                  -

Heart Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61)                                                        -
Medicare Usable Organs (Wksht D-6, III, Line 55)                                                            -
Medicare Organ Acquisition Cost per Organ                             -                  -                  -

Pancreas Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61)                                                        -
Medicare Usable Organs (Wksht D-6, III, Line 55)                                                            -
Medicare Organ Acquisition Cost per Organ                             -                  -                  -

Intestinal Acquisition
Net Organ Acquisition Cost (Wksht D-6, III, Line 61)                                                        -
Medicare Usable Organs (Wksht D-6, III, Line 55)                                                            -
Medicare Organ Acquisition Cost per Organ                             -                  -                  -

Other
Net Organ Acquisition Cost (Wksht D-6, III, Line 61)                                                        -
Medicare Usable Organs (Wksht D-6, III, Line 55)                                                            -
Medicare Organ Acquisition Cost per Organ                             -                  -                  -
                                                                                                                 75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.1-E
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                                                                                                                                                                                                                                                                                                       Section 6.2




                                                                                         State of Utah
                                                              DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                  Federal Fiscal Year Ended 9/30/ 2005
SECTION 6.2: OUT-OF-STATE UNCOMPENSATED MEDICAID SERVICES
Section 6.2 is used to report the uncompensated care cost of services less related payments provided to Out-of-State Medicaid patients using Medicare cost allocation methodologies. Information provided in this section is subject to
confirmation from the respective State(s). Amounts reported on this schedule should reconcile to the out-of-state PS&R (or equivalent schedule) produced by the Medicaid program or managed care entity.


Provide the following information for the 12 months ending:         9/30/2005
                                                                                   92                  273
                                                                  (Worksheet D-1, II)   (Worksheet D-1, II)
                                                                  Per Diem Costs        Per Diem Costs
ROUTINE COSTS (ROOM & BOARD):                                     for MCR ended         for MCR ended                                  FFS                      MCO                FFS Crossover           MCO Crossover                Uninsured
                                                                                                                                Inpatient   Outpatient   Inpatient   Outpatient   Inpatient   Outpatient   Inpatient   Outpatient                           Total        Out-of-State
                                                                                                              Composite Per     Medicaid    Medicaid     Medicaid    Medicaid     Medicaid    Medicaid     Medicaid    Medicaid     Inpatient   Outpatient Medicaid       Medicaid
State Cost Report Line        Cost Center Description               12/31/2004           12/31/2005            Diem Costs         Days       Charges       Days       Charges       Days       Charges       Days       Charges       Days       Charges    Days        Routine Costs
      25                      Adults & Peds                                                                             -                                                                                                                                           0              -
      26                      Intensive Care                                                                            -                                                                                                                                           0              -
      26.01                   Intermediate Care Unit                                                                    -                                                                                                                                           0              -
      27                      Coronary Care                                                                             -                                                                                                                                           0              -
      28                      Burn Intensive Care                                                                       -                                                                                                                                           0              -
      29                      Surgical Intensive Care                                                                   -                                                                                                                                           0              -
      30                      Bone Marrow Intensive Care                                                                -                                                                                                                                           0              -
      30                      Thoracic Intensive Care                                                                   -                                                                                                                                           0              -
      30.01                   Newborn ICU                                                                               -                                                                                                                                           0              -
      30.02                   Respiratory Intensive Care                                                                -                                                                                                                                           0              -
      31                      Subprovider Rehab                                                                         -                                                                                                                                           0              -
      31                      Subprovider Psych                                                                         -                                                                                                                                           0              -
      31.01                   Subprovider Psych                                                                         -                                                                                                                                           0              -
      31.01                   Subprovider Rehab                                                                         -                                                                                                                                           0              -
      33                      Nursery                                                                                   -                                                                                                                                           0              -
      <<Please provide additional Cost Center items here if needed>>                                                    -                                                                                                                                           0              -
      <<Please provide additional Cost Center items here if needed>>                                                    -                                                                                                                                           0              -
      <<Please provide additional Cost Center items here if needed>>                                                    -                                                                                                                                           0              -
                                                                                                                       Total            0                        0                        0                        0                                                0              -


                                                                                   92                  273
                                                                   (Worksheet C, I)      (Worksheet C, I)
                                                                   Cost to Charge        Cost to Charge
                                                                   Ratio for MCR         Ratio for MCR
ANCILLARY COSTS:                                                       ended                 ended                                     FFS                      MCO                FFS Crossover           MCO Crossover                Uninsured
                                                                                                                                Inpatient   Outpatient   Inpatient   Outpatient   Inpatient   Outpatient   Inpatient   Outpatient                           Total       Out-of-State
                                                                                                              Composite Cost    Ancillary    Ancillary   Ancillary    Ancillary   Ancillary    Ancillary   Ancillary    Ancillary   Inpatient   Outpatient Ancillary Medicaid
State Cost Report Line       Cost Center Description               12/31/2004            12/31/2005           to Charge Ratio   Charges      Charges     Charges      Charges     Charges      Charges     Charges      Charges     Charges      Charges Charges Ancillary Costs
      37                     Operating Room                                                                        -                                                                                                                                           -                  -
      38                     Recovery Room                                                                         -                                                                                                                                           -                  -
      39                     Labor & Delivery Room                                                                 -                                                                                                                                           -                  -
      40                     Anesthesiology                                                                        -                                                                                                                                           -                  -
      41                     Radiology-Diagnostic                                                                  -                                                                                                                                           -                  -
      41.01                  Radiology-Diagnostic CT                                                               -                                                                                                                                           -                  -
      41.02                  Radiology-Diagnostic MRI                                                              -                                                                                                                                           -                  -
      41.03                  Radiology-Diagnostic Ultrasound                                                       -                                                                                                                                           -                  -
      42                     Radiology-Therapeutic                                                                 -                                                                                                                                           -                  -
      43                     Radioisotope                                                                          -                                                                                                                                           -                  -
      44                     Laboratory                                                                            -                                                                                                                                           -                  -
      47                     Blood Storing, Processing & Trans                                                     -                                                                                                                                           -                  -
      48                     Intravenous Therapy                                                                   -                                                                                                                                           -                  -
      48.01                  Home IV Therapy                                                                       -                                                                                                                                           -                  -
      49                     Respiratory Therapy                                                                   -                                                                                                                                           -                  -
      50                     Physical Therapy                                                                      -                                                                                                                                           -                  -
      51                     Occupational Therapy                                                                  -                                                                                                                                           -                  -
      51.01                  Rehab Ancillary                                                                       -                                                                                                                                           -                  -
      52                     Speech Pathology                                                                      -                                                                                                                                           -                  -
      53                     Electrocardiology                                                                     -                                                                                                                                           -                  -
      54                     Electroencephalography                                                                -                                                                                                                                           -                  -




                                                                                                                                                                                                                                                                        75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.2
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                                                                                                                                                                                                                                                        Section 6.2




                                                                                         State of Utah
                                                              DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                  Federal Fiscal Year Ended 9/30/ 2005
      54.01                   Meg Lab                                                 -                                                                                                                          -                   -
      55                      Medical Supplies                                        -                                                                                                                          -                   -
      56                      Drugs Charged to Patients                               -                                                                                                                          -                   -
      57                      Renal Dialysis                                          -                                                                                                                          -                   -
      58                      ASC (Non-Distinct Part)                                 -                                                                                                                          -                   -
      58.01                   CV Monitoring                                           -                                                                                                                          -                   -
      59                      Acute Adult Dialysis                                    -                                                                                                                          -                   -
      59                      Psychotherapy                                           -                                                                                                                          -                   -
      59.01                   Acute Pediatric Dialysis                                -                                                                                                                          -                   -
      59.01                   Fitness Institute                                       -                                                                                                                          -                   -
      59.02                   Gastrointestinal Lab                                    -                                                                                                                          -                   -
      59.03                   Pulmonary Lab                                           -                                                                                                                          -                   -
      60                      Clinic                                                  -                                                                                                                          -                   -
      60.01                   Clinics Hospital Internal Medicine                      -                                                                                                                          -                   -
      60.01                   St Joseph's Partial Hospital                            -                                                                                                                          -                   -
      60.02                   Clinics Hospital Other                                  -                                                                                                                          -                   -
      60.02                   Clinical Dietetics                                      -                                                                                                                          -                   -
      60.03                   Clinic OB Diagnostic Center                             -                                                                                                                          -                   -
      60.04                   Clinics Wasatch                                         -                                                                                                                          -                   -
      60.05                   Clinics Community                                       -                                                                                                                          -                   -
      60.07                   Community Clinics                                       -                                                                                                                          -                   -
      60.08                   Clinics HCH & UOC                                       -                                                                                                                          -                   -
      61                      Emergency                                               -                                                                                                                          -                   -
      62                      Observation                                             -                                                                                                                          -                   -
      64                      Home Program Dialysis                                   -                                                                                                                          -                   -
      65                      Ambulance                                               -                                                                                                                          -                   -
      71                      Home Health Agency                                      -                                                                                                                          -                   -
      82                      Lung Acquisition                                        -                                                                                                                          -                   -
      83                      Kidney Acquisition                                      -                                                                                                                          -                   -
      84                      Liver Acquisition                                       -                                                                                                                          -                   -
      85                      Heart Acquisition                                       -                                                                                                                          -                   -
      85.01                   Pancreas Acquisition                                    -                                                                                                                          -                   -
      85.02                   Intestine Acquisition                                   -                                                                                                                          -                   -
      86                      Other Organ Acquisition                                 -                                                                                                                          -                   -
      86.01                   Bone Marrow Acquisition                                 -                                                                                                                          -                   -
      90                      Other Capital Related Costs                             -                                                                                                                          -                   -
      94                      Resource Nursing                                        -                                                                                                                          -                   -
      94.01                   Messenger Services                                      -                                                                                                                          -                   -
      94.02                   Bone Marrow Acquisition                                 -                                                                                                                          -                   -
      100                     Non Reimbursable                                        -                                                                                                                          -                   -
      <<Please provide additional Cost Center items here if needed>>                  -                                                                                                                          -                   -
      <<Please provide additional Cost Center items here if needed>>                  -                                                                                                                          -                   -
      <<Please provide additional Cost Center items here if needed>>                  -                                                                                                                          -                   -
                                                                                           Total       -            -         -            -         -        -         -          -                             -                   -



ORGAN ACQUISITION COSTS:                                                         (Section 6.1-E)           FFS                    MCO            FFS Crossover      MCO Crossover            Uninsured


                                                                                Composite Cost                   Usable                 Usable             Usable               Usable             Usable     Total     Out-of-State Organ
State Cost Report Line        Cost Center Description                             per Organ        Charges       Organs   Charges       Organs   Charges   Organs   Charges     Organs   Charges   Organs    Organs      Acquisition Costs
                              Lung Acquisition                                        -                                                                                                                          -                   -
                              Kidney Acquisition                                      -                                                                                                                          -                   -
                              Liver Acquisition                                       -                                                                                                                          -                   -
                              Heart Acquisition                                       -                                                                                                                          -                   -
                              Pancreas Acquisition                                    -                                                                                                                          -                   -
                              Intestinal Acquisition                                  -                                                                                                                          -                   -
      <<Please provide additional Cost Center items here if needed>>                  -                                                                                                                          -                   -
                                                                                           Total       -            -         -            -         -        -         -          -                             -                   -

GRADUATE MEDICAL EDUCATION COSTS (Section 6.1-D):                                                                                                                                                                                    -

                                                                                                                                                                            Total Out-of-State Medicaid Service Costs                0.00




                                                                                                                                                                                                                         75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.2
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                                                                                                                                                                                                                                                                                   Section 6.2




                                                                                              State of Utah
                                                                   DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                       Federal Fiscal Year Ended 9/30/ 2005
CLAIMS AND OTHER PAYMENTS APPLICABLE TO OUT-OF-STATE MEDICAID:
State of _____ Payment Type/Description
State of _____ Payment Type/Description
State of _____ Payment Type/Description
                                             Total         -                                                                                                                                                                    Total Payments                    -

                                                                                                                                                                                         Out-of-State Net Uncompensated Medicaid Services                         -

OUT-OF-STATE DSH PAYMENTS:
State of _____ DSH Payment
State of _____ DSH Payment
State of _____ DSH Payment
                                                                Total              -

Routine Costs: Input all Out-of-State IP/OP routine days and charges by cost center, and identify the respective State. Using your Medicare cost report input the appropriate rates for the respective cost center. Routine room and board costs are
determined by applying per diem costs for the applicable hospital routine cost center to the number of hospital days billed for Out-of-State Medicaid eligible patients.
Per Diem Costs: In the Medicare 2552-96 cost report, a per diem is computed for each routine cost center. Record the routine per diem cost per day for each hospital routine cost center present on your Medicare cost report. These amounts are
calculated on Worksheet D-1, Part II of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period does
not correspond with the federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH year under audit. The composite per diem is determined by applying the weighted average
applicable rate over the federal fiscal year.

Cost to Charge Ratio: In the Medicare 2552-96 cost report, a cost-to-charge ratio is computed for each ancillary cost center. Record the ancillary cost-to-charge ratio for each hospital cost center present on your Medicare cost report. These amounts
are calculated on Worksheet C, Part I of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period
does not correspond with the federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH Year under audit. The composite cost to charge ratio is determined by applying the
weighted average applicable rate over the federal fiscal year.

Ancillary Costs: Input all Out-of-State IP/OP ancillary charges by cost center, and identify the respective State. Using your Medicare cost report fill in the appropriate ratio for the applicable cost center. Ancillary costs are determined by applying per
cost to charge costs for the applicable hospital ancillary cost center to the charges billed for Out-of-State Medicaid eligible patients.

Medicaid Payments: Input all Out-of-State Medicaid payments. Hospitals must separately identify a) Medicaid regular rate payments (including add-ons); b) supplemental and enhanced Medicaid payments, and; c) DSH payments. Payments must
include all amounts collected from the Medicare program, patient co-pays and deductible payments, and Medicaid payments, Managed care payments and other third party payments. All Medicaid payments received from non-State sources not already
accounted for, including payments from or on behalf of patients for Medicaid services. Report payments using the accrual method of accounting.

Dual Eligibles: The total amount of IP/OP charges and related payments attributed to dual eligible patients (Medicaid and any other third party coverage including Medicare) is appropriate to the extent that the IP/OP payments qualify as Medicaid
payments. Examples include when a dually eligible patient exhausts their Medicare days (Part A) or are only eligible for Part B Medicare. Only include outpatient hospital payments that are under the hospital benefit; do not include payments for
services paid under some other benefit i,e, physician, lab, drugs, etc. Do not include payments for NF, SNF, HHA, or off-site PRTF.




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                                                                                                                                                                Section 6.2-A


Section 6.2-A     Supporting Documentation for Out-of-State Uncompensated Medicaid Charges/Days & Payments
Instructions: Please provide an electronic copy of the information relied upon to complete Section 6.2. The information should include: patient ID, claim type (crossover,
Medicaid, MCO), claim status (denied claim, paid claim), service date, type of service, revenue/cost center codes, and units. Detailed supporting documentation is required to
substantiate the amounts claimed in 6.2.




                                                                                                                                75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.2-A
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                                                                                                                                                                                                                                                                                                                   Section 6.3




                                                                                                State of Utah
                                                                  DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                      Federal Fiscal Year Ended 9/30/ 2005
SECTION 6.3: UNINSURED UNCOMPENSATED MEDICAID SERVICES
Section 6.3 is used to report the uncompensated care cost of services less related payments provided to uninsured patients using Medicare cost allocation methodologies. Federal requirements mandate the uninsured services must be costed
using Medicare cost reporting methodologies. This section is used to report the costs of services provided to the uninsured. A detail listing by service date, patient name and type of service will be required to support information summarized in
this section.


Provide the following information for the 12 months ending:            9/30/2005
                                                                                     92                  273
                                                                    (Worksheet D-1, II)   (Worksheet D-1, II)
                                                                    Per Diem Costs        Per Diem Costs
ROUTINE COSTS (ROOM & BOARD):                                       for MCR ended         for MCR ended                                  FFS                      MCO                FFS Crossover           MCO Crossover                  Uninsured
                                                                                                                                  Inpatient Outpatient     Inpatient Outpatient     Inpatient Outpatient     Inpatient Outpatient                                    Total
                                                                                                                Composite Per     Medicaid Medicaid        Medicaid Medicaid        Medicaid Medicaid        Medicaid Medicaid        Inpatient       Outpatient   Uninsured        Uninsured Routine
State Cost Report Line        Cost Center Description                12/31/2004            12/31/2005            Diem Costs         Days     Charges         Days     Charges         Days     Charges         Days     Charges         Days           Charges       Days                 Costs
      25                      Adults & Peds                                                                               -                                                                                                                                                     0                -
      26                      Intensive Care                                                                              -                                                                                                                                                     0                -
      26.01                   Intermediate Care Unit                                                                      -                                                                                                                                                     0                -
      27                      Coronary Care                                                                               -                                                                                                                                                     0                -
      28                      Burn Intensive Care                                                                         -                                                                                                                                                     0                -
      29                      Surgical Intensive Care                                                                     -                                                                                                                                                     0                -
      30                      Bone Marrow Intensive Care                                                                  -                                                                                                                                                     0                -
      30                      Thoracic Intensive Care                                                                     -                                                                                                                                                     0                -
      30.01                   Newborn ICU                                                                                 -                                                                                                                                                     0                -
      30.02                   Respiratory Intensive Care                                                                  -                                                                                                                                                     0                -
      31                      Subprovider Rehab                                                                           -                                                                                                                                                     0                -
      31                      Subprovider Psych                                                                           -                                                                                                                                                     0                -
      31.01                   Subprovider Psych                                                                           -                                                                                                                                                     0                -
      31.01                   Subprovider Rehab                                                                           -                                                                                                                                                     0                -
      33                      Nursery                                                                                     -                                                                                                                                                     0                -
      <<Please provide additional Cost Center items here if needed>>                                                      -                                                                                                                                                     0                -
      <<Please provide additional Cost Center items here if needed>>                                                      -                                                                                                                                                     0                -
      <<Please provide additional Cost Center items here if needed>>                                                      -                                                                                                                                                     0                -
                                                                                                                         Total                                                                                                                    0   $     -                   0                -


                                                                                     92                  273
                                                                     (Worksheet C, I)      (Worksheet C, I)
                                                                   Cost to Charge Ratio Cost to Charge Ratio
ANCILLARY COSTS:                                                     for MCR ended        for MCR ended                                  FFS                      MCO                FFS Crossover           MCO Crossover                  Uninsured
                                                                                                                                  Inpatient   Outpatient   Inpatient   Outpatient   Inpatient   Outpatient   Inpatient   Outpatient                                Uninsured
                                                                                                                Composite Cost    Ancillary    Ancillary   Ancillary    Ancillary   Ancillary    Ancillary   Ancillary    Ancillary   Inpatient       Outpatient    Ancillary          Uninsured
State Cost Report Line        Cost Center Description                 12/31/2004           12/31/2005           to Charge Ratio   Charges      Charges     Charges      Charges     Charges      Charges     Charges      Charges     Charges          Charges      Charges          Ancillary Costs
      37                      Operating Room                                                                         -                                                                                                                                                     -                      -
      38                      Recovery Room                                                                          -                                                                                                                                                     -                      -
      39                      Labor & Delivery Room                                                                  -                                                                                                                                                     -                      -
      40                      Anesthesiology                                                                         -                                                                                                                                                     -                      -
      41                      Radiology-Diagnostic                                                                   -                                                                                                                                                     -                      -
      41.01                   Radiology-Diagnostic CT                                                                -                                                                                                                                                     -                      -
      41.02                   Radiology-Diagnostic MRI                                                               -                                                                                                                                                     -                      -
      41.03                   Radiology-Diagnostic Ultrasound                                                        -                                                                                                                                                     -                      -
      42                      Radiology-Therapeutic                                                                  -                                                                                                                                                     -                      -
      43                      Radioisotope                                                                           -                                                                                                                                                     -                      -
      44                      Laboratory                                                                             -                                                                                                                                                     -                      -
      47                      Blood Storing, Processing & Trans                                                      -                                                                                                                                                     -                      -
      48                      Intravenous Therapy                                                                    -                                                                                                                                                     -                      -
      48.01                   Home IV Therapy                                                                        -                                                                                                                                                     -                      -
      49                      Respiratory Therapy                                                                    -                                                                                                                                                     -                      -
      50                      Physical Therapy                                                                       -                                                                                                                                                     -                      -
      51                      Occupational Therapy                                                                   -                                                                                                                                                     -                      -
      51.01                   Rehab Ancillary                                                                        -                                                                                                                                                     -                      -
      52                      Speech Pathology                                                                       -                                                                                                                                                     -                      -




                                                                                                                                                                                                                                                                                    75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.3
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                                                                                                                                                                                                                                                                            Section 6.3




                                                                                             State of Utah
                                                               DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                   Federal Fiscal Year Ended 9/30/ 2005
      53                      Electrocardiology                                        -                                                                                                                                              -                  -
      54                      Electroencephalography                                   -                                                                                                                                              -                  -
      54.01                   Meg Lab                                                  -                                                                                                                                              -                  -
      55                      Medical Supplies                                         -                                                                                                                                              -                  -
      56                      Drugs Charged to Patients                                -                                                                                                                                              -                  -
      57                      Renal Dialysis                                           -                                                                                                                                              -                  -
      58                      ASC (Non-Distinct Part)                                  -                                                                                                                                              -                  -
      58.01                   CV Monitoring                                            -                                                                                                                                              -                  -
      59                      Acute Adult Dialysis                                     -                                                                                                                                              -                  -
      59                      Psychotherapy                                            -                                                                                                                                              -                  -
      59.01                   Acute Pediatric Dialysis                                 -                                                                                                                                              -                  -
      59.01                   Fitness Institute                                        -                                                                                                                                              -                  -
      59.02                   Gastrointestinal Lab                                     -                                                                                                                                              -                  -
      59.03                   Pulmonary Lab                                            -                                                                                                                                              -                  -
      60                      Clinic                                                   -                                                                                                                                              -                  -
      60.01                   Clinics Hospital Internal Medicine                       -                                                                                                                                              -                  -
      60.01                   St Joseph's Partial Hospital                             -                                                                                                                                              -                  -
      60.02                   Clinics Hospital Other                                   -                                                                                                                                              -                  -
      60.02                   Clinical Dietetics                                       -                                                                                                                                              -                  -
      60.03                   Clinic OB Diagnostic Center                              -                                                                                                                                              -                  -
      60.04                   Clinics Wasatch                                          -                                                                                                                                              -                  -
      60.05                   Clinics Community                                        -                                                                                                                                              -                  -
      60.07                   Community Clinics                                        -                                                                                                                                              -                  -
      60.08                   Clinics HCH & UOC                                        -                                                                                                                                              -                  -
      61                      Emergency                                                -                                                                                                                                              -                  -
      62                      Observation                                              -                                                                                                                                              -                  -
      64                      Home Program Dialysis                                    -                                                                                                                                              -                  -
      65                      Ambulance                                                -                                                                                                                                              -                  -
      71                      Home Health Agency                                       -                                                                                                                                              -                  -
      82                      Lung Acquisition                                         -                                                                                                                                              -                  -
      83                      Kidney Acquisition                                       -                                                                                                                                              -                  -
      84                      Liver Acquisition                                        -                                                                                                                                              -                  -
      85                      Heart Acquisition                                        -                                                                                                                                              -                  -
      85.01                   Pancreas Acquisition                                     -                                                                                                                                              -                  -
      85.02                   Intestine Acquisition                                    -                                                                                                                                              -                  -
      86                      Other Organ Acquisition                                  -                                                                                                                                              -                  -
      86.01                   Bone Marrow Acquisition                                  -                                                                                                                                              -                  -
      90                      Other Capital Related Costs                              -                                                                                                                                              -                  -
      94                      Resource Nursing                                         -                                                                                                                                              -                  -
      94.01                   Messenger Services                                       -                                                                                                                                              -                  -
      94.02                   Bone Marrow Acquisition                                  -                                                                                                                                              -                  -
      100                     Non Reimbursable                                         -                                                                                                                                              -                  -
      <<Please provide additional Cost Center items here if needed>>                   -                                                                                                                                              -                  -
      <<Please provide additional Cost Center items here if needed>>                   -                                                                                                                                              -                  -
      <<Please provide additional Cost Center items here if needed>>                   -                                                                                                                                              -                  -
                                                                                            Total           0              0           0            0           0            0           0            0        -          -           -                  -




ORGAN ACQUISITION COSTS:                                                          (Section 6.1-E)           FFS                        MCO               FFS Crossover           MCO Crossover                Uninsured

                                                                                 Composite Cost                   Usable                   Usable                   Usable                   Usable                  Usable                Uninsured Organ
State Cost Report Line        Cost Center Description                              per Organ        Charges       Organs       Charges     Organs       Charges     Organs       Charges     Organs       Charges    Organs   Total Organs Acquisition Costs
                              Lung Acquisition                                         -                                                                                                                                               -                 -
                              Kidney Acquisition                                       -                                                                                                                                               -                 -
                              Liver Acquisition                                        -                                                                                                                                               -                 -
                              Heart Acquisition                                        -                                                                                                                                               -                 -
                              Pancreas Acquisition                                     -                                                                                                                                               -                 -
                              Intestinal Acquisition                                   -                                                                                                                                               -                 -
      <<Please provide additional Cost Center items here if needed>>                   -                                                                                                                                               -                 -
                                                                                            Total       -            -             -          -             -          -             -          -              -          -            -                 -

GRADUATE MEDICAL EDUCATION COSTS (Section 6.1-D):                                                                                                                                                                                                        -

                                                                                                                                                                                                             Total Uninsured Service Costs               0.00




                                                                                                                                                                                                                                             75549a08-e42b-4442-a8b9-74645caaf10d.xls, 6.3
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                                                                                                                                                                                                                                                                                            Section 6.3




                                                                                                 State of Utah
                                                                   DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                       Federal Fiscal Year Ended 9/30/ 2005
CLAIMS AND OTHER PAYMENTS APPLICABLE TO THE UNINSURED:
 Payment from Uninsured/Self pay (cash basis)
 Section 1011 payments for hospital services
 Section 1011 payments for non-hospital services
<<Please provide additional payments here if needed>>
<<Please provide additional payments here if needed>>
<<Please provide additional payments here if needed>>
                                                                                    -                                                                                                                                                     Total Payments                   -

                                                                                                                                                                                                               Uninsured Net Uncompensated Services                        -




Routine Costs: Input all uninsured IP/OP routine days and charges by cost center. Using your Medicare cost report input the appropriate rates for the respective cost center. Routine room and board costs are determined by applying per diem costs for the
applicable hospital routine cost center to the number of hospital days billed for uninsured patients. Since the State’s MMIS system will not have information about payments generated from the uninsured, hospitals must use their financial statements and other
auditable hospital accounting records to substantiate claims.

Per Diem Costs: In the Medicare 2552-96 cost report, a per diem is computed for each routine cost center. Record the routine per diem cost per day for each hospital routine cost center present on your Medicare cost report. These amounts are calculated on
Worksheet D-1, Part II of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period does not correspond with the
federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH year under audit. The composite per diem is determined by applying the weighted average applicable rate over the federal fiscal
year.

Cost to Charge Ratio: In the Medicare 2552-96 cost report, a cost-to-charge ratio is computed for each ancillary cost center. Record the ancillary cost-to-charge ratio for each hospital cost center present on your Medicare cost report. These amounts are calculated
on Worksheet C, Part I of the cost report. In order to provide complete financial information for the federal fiscal year under audit, hospitals must use two or more Medicare 2552-96 Hospital Cost Report(s) if the cost reporting period does not correspond with the
federal fiscal year under audit. Please identify the information requested above for all cost report(s) needed to cover the complete DSH Year under audit. The composite cost to charge ratio is determined by applying the weighted average applicable rate over the
federal fiscal year.

Ancillary Costs: Input all uninsured IP/OP ancillary charges by cost center. Using your Medicare cost report fill in the appropriate ratio for the applicable cost center. Ancillary costs are determined by applying per cost to charge costs for the applicable hospital
ancillary cost center to the charges billed for uninsured patients. Since the State’s MMIS system will not have information about payments generated from the uninsured, hospitals must use their financial statements and other auditable hospital accounting records to
substantiate claims.

Uncompensated Services: For purposes of this section uncompensated services for the uninsured include cost incurred for IP/OP hospital services to individuals with no source of 3rd party coverage for the hospital services they receive, including all Section 1011
charges for undocumented aliens. The uninsured uncompensated amount cannot include amounts associated with unpaid co-pays or deductibles for individuals with 3rd party coverage or any other unreimbursed costs associated with inpatient or outpatient services
provided to individuals with 3rd party coverage but for which such 3rd party benefit package excludes such services. Nor does uncompensated care cost include bad debt or payor discounts related to services furnished to individuals who have any form of health
insurance coverage. The total uncompensated care cost for the uninsured includes the cost of furnishing inpatient and outpatient services less any direct or indirect payments from or on behalf of such uninsured individuals. Please note that prisoners and wards of
the state are not considered “uninsured” and should not be included in the calculation of uncompensated care.


Payments from the Uninsured: Input all payments received for and in behalf of patients with no source of third party coverage (uninsured), excluding DSH payments. Report all payments received for hospital patients that met the uninsured definition at the time of
the service. There will be no attempt to allocate payments received during the state plan rate year to services provided in prior periods. Since the goal of the audit is to determine uncompensated DSH costs for the DSH year under audit, all payments received in the
year will be counted as revenue to the hospital in that same year. It is understood that some costs incurred during the DSH year under audit may be associated with future revenue streams (legal decisions, payment plans, recoveries), but that the payments are not
counted as revenue until actually received. Report all payments on a cash basis (report in the year received, regardless of the year of service). Exclude state, county or other municipal subsidy payments made to hospitals for indigent care. Since the State’s MMIS
system will not have information about payments generated from the uninsured, hospitals must use their financial statements and other auditable hospital accounting records to substantiate claims. Note: IP/OP hospital payments received from state or local
government programs for individuals with no source of third party coverage for the hospital services they received should NOT be included as a revenue in this category.

Uninsured: Per federal guidelines uninsured patients are individuals with no credible source of third party healthcare coverage or other legally liable third party coverage (insurance) in effect at the time the services were rendered. If the patient had health insurance,
even if the third party insurer did not pay, those services are insured and cannot be reported as uninsured on the survey. 42 CFR 447.299 (14)

Section 1011 Payments: Section 1011 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 provides federal reimbursement for emergency health services furnished to undocumented aliens. If your hospital received these funds during
any cost report year covered by the survey, they must be reported here. If you can document that a portion of the payment received is related to non-hospital services (physician or ambulance services) report that amount in the Section 1011 non-hospital payments.
Include hospital charges for undocumented aliens with no source of third party coverage for hospital services.

Self Pay: Federal requirements mandate the hospital cost of providing services to the uninsured during the DSH year must be reduced by uninsured self-pay payments received during the DSH year. Section 6.3-A will assist hospitals in developing the data
necessary to support uninsured payments received during each cost reporting period. The data must be maintained in an auditable format and made available upon request.




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                                                                                                                                                               Section 6.3-A


Section 6.3-A      Supporting Documentation for Uninsured Uncompensated Care Charges/Days & Self-Pay Payments
Instructions: Please provide an electronic copy of the information relied upon to complete Section 6.3 (uninsured charges/days, self-pay payments, section 1011 payments).
The information should include: patient ID, claim type (crossover, Medicaid, MCO), claim status (denied claim, paid claim), TPL status (No TPL, TPL w/Reimb, TPL w/o Reimb),
service date, collection date, type of service, revenue/cost center codes, section 1011 payments, amount, payor source, and units. Detailed supporting documentation is
required to substantiate the amounts claimed in 6.3. Complete Section 6.3-A based on your individual State Medicaid hospital reimbursement methodology (discharge, admit,
or dates of service).




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                                                                                                                                                                                                                          Section 6.4



                                                                                              State of Utah
                                                                                DSH Audit Survey for ALLEN MEMORIAL HOSPITAL
                                                                                    Federal Fiscal Year Ended 9/30/ 2005
SECTION 6.4: DSH PAYMENTS
This section is used to report the DSH payments received by the hospital. If DSH payments cannot be broken out between Add-On and Supplemental input the information in the Total column. Supporting documentation should include:
DSH available (quarterly & cumulative), State Match Rate % applicable, DSH amount, match amount due from hospital, admin amount due from hospital, verification of payment.



Provide the following information for the 12 months ending:                       9/30/2005

DSH PAYMENTS:                                                                      #REF!               #REF!
Quarter                Date                                   Add-On            Supplemental            Total
Q1                                                                                                              -
Q2                                                                                                              -
Q3                                                                                                              -
Q4                                                                                                              -
<<Please provide additional items here if needed>>                                                              -
<<Please provide additional items here if needed>>                                                              -
                                                                       -                       -                -




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Description: Pro Med Hospital Discharge Form document sample