Identification, Utilization, Statistical Data
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. S | Independent Renal Dialysis Facility Cost Report Certification | 4204 |
| Wkst. S, Parts I | General | 4204.1 |
| Wkst. S, Parts II | Certification by Officer or Administrator of Facility | 4204.2 |
| Wkst. S, Parts III | Certification by an Officer or Administrator of Facility | 4204.3 |
| Wkst. S-1 | Independent Renal Dialysis Facility Statistical Data | 4205 |
| Wkst. S-2 | Independent Renal Dialysis Facility Reimbursement Questionnaire | 4205.1 |
Reclassification And Adjustment Of Trial Balance Of Expenses
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. A | Reclassification and Adjustment of Trial Balance of Expenses | 4013 |
| Wkst. A | Reclassification and Adjustment of Trial Balance of Expenses | 4206 |
| Wkst. A-1 | Reclassifications | 4207 |
| Wkst. A-2 | Adjustments to Expenses | 4208 |
| Wkst. A-3 | Statement of Costs of Services From Related Organizations | 4209 |
| Wkst. A-4 | Statement of Compensation | 4210 |
Cost and Cost Allocation
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. B | Cost Allocation – General Service Costs | 4211 |
| Wkst. B-1 | Cost Allocation – Statistical Basis | 4211 |
Computation of Average Cost Per Treatment
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. C | Computation of the Average Cost Per Treatment for ESRD PPS Payment System | 4212 |
Calculation of Reimbursable Bad Debts (Title XVIII-Part B)
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. D | Computation of the Average Cost Per Treatment under Basic Composite Rate | 4213 |
Calculation of Reimbursement Settlement
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. E | Calculation of Bad Debt Reimbursement | 4214 |
| Wkst. E, Parts I | Calculation of Reimbursable Bad Debt Title XVIII | 4214.1 |
| Wkst. E, Parts II | Calculation of Facility Specific Composite Cost Percentage | 4214.2 |
| Wkst. E-1 | Analysis of Payments to Providers for Services Rendered | 4215 |
| Wkst. E-1, Parts I | Tentative Settlements (Contractor Use) | 4215.1 |
| Wkst. E-1, Parts II | Low Volume Payment | 4215.2 |
Financial Statements
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| Worksheet Section | Description | Reference |
|---|---|---|
| Wkst. F | Balance Sheet | 4216 |
| Wkst. F-1 | Statement of Revenues and Expenses | 4216 |