05-04		       FORM CMS-2552-96				           3690 (Cont.)		
CALCULATION OF HHA REIMBURSEMENT			PROVIDER NO.:	 PERIOD:	"WORKSHEET H-7,"			
SETTLEMENT			______________	 FROM___________	Parts I & II			
			HHA NO.:	 TO______________				
			______________					
Check Applicable Box		 [ ] Title V	[  ]  Title XVIII	[  ]  Title XIX				
PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES								
				Part B				
				Not Subject to	Subject to			
				Deductibles	Deductibles			
			Part A	& Coinsurance	& Coinsurance			
	        Description		1	2	3			
	Reasonable Cost of Part A & Part B Services							
1 	Reasonable cost of services (see instructions)		X	X	X	1 		
2 	Total charges 		X	X	X	2 		
	Customary Charges							
3 	Amount actually collected from patients liable for payment		X	X	X	3 		
	for services on a charge basis (from your records)							
4 	Amount that would have been realized from patients liable					4 		
	for payment for services on a charge basis had such		X	X	X			
	payment been made in accordance with 42 CFR 413.13(b)							
5 	Ratio of line 3 to line 4 (not to exceed 1.000000)		X	X	X	5 		
6 	Total customary charges (see instructions)		X	X	X	6 		
7 	Excess of total customary charges over total reasonable		X	X	X	7 		
	cost (complete only if line 6 exceeds line 1)							
8 	Excess of reasonable cost over customary charges 		X	X	X	8 		
	(complete only if line 1 exceeds line 6)							
9 	Primary payer amounts		X	X	X	9 		
PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT								
				Part A Services	Part B Services			
	        Description			1	2			
10 	Total reasonable cost (see instructions)			X	X	10 		
10.01 	Total PPS Reimbursement - Full Episodes without Outliers			X	X	10.01 		
10.02 	Total PPS Reimbursement - Full Episodes with Outliers			X	X	10.02 		
10.03 	Total PPS Reimbursement - LUPA Episodes			X	X	10.03 		
10.04 	Total PPS Reimbursement - PEP Episodes			X	X	10.04 		
10.05 	Total PPS Reimbursement - SCIC within a PEP Episodes			X	X	10.05 		
10.06 	Total PPS Reimbursement - SCIC Episodes			X	X	10.06 		
10.07 	Total PPS Outlier Reimbursement - Full Episodes with Outliers			X	X	10.07 		
10.08 	Total PPS Outlier Reimbursement - PEP Episodes			X	X	10.08 		
10.09 	Total PPS Outlier Reimbursement - SCIC within a PEP Episodes			X	X	10.09 		
 10.10 	Total PPS Outlier Reimbursement - SCIC Episodes			X	X	 10.10 		
 10.11 	Total Other Payments			X	X	 10.11 		
 10.12 	DME Payments			X	X	 10.12 		
 10.13 	Oxygen Payments			X	X	 10.13 		
 10.14 	Prosthetic and Orthotic Payments			X	X	 10.14 		
11 	Part B deductibles billed to Medicare patients (exclude coinsurance)				X	11 		
12 	Subtotal (sum of lines 10 thru 10.14 minus line 11)			X	X	12 		
13 	Excess reasonable cost (from line 8)			X	X	13 		
14 	Subtotal (line 12 minus line 13)			X	X	14 		
15 	Coinsurance billed to program patients (from your records)				X	15 		
16 	Net cost (line 14 minus line 15)			X	X	16 		
17 	Reimbursable bad debts (from your records)			X	X	17 		
17.01 	Reimbursable bad debts for dual eligible beneficiaries (see instructions)			X	X	17.01 		
18 	Total costs - current cost reporting period (line 16 plus line 17)			X	X	18 		
19 	Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets			X	X	19 		
20 	Recovery of excess depreciation resulting from agencies' termination or			X	X	20 		
	decrease in program utilization							
21 	Other adjustments (see instructions) (specify)			X	X	21 		
22 	Subtotal (line 18 plus/minus lines 19 and 21 minus line 20)			X	X	22 		
23 	Sequestration adjustment (see instructions)			X	X	23 		
24 	Subtotal (line 22 minus line 23)			X	X	24 		
25 	Interim payments (see instructions)			X	X	25 		
25.01 	Tentative settlement (for fiscal intermediary use only)			X	X	25.01 		
26 	Balance due provider/program (line 24 minus lines 25 and 25.01)			X	X	26 		
27 	Protested amounts (nonallowable cost report items) in accordance with CMS			X	X	27 		
	"Pub. 15-II, section 115.2"							
"FORM CMS-2552-96 (5/2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3648.2)"								
Rev. 12						             36-618.1