Provider Number
Effective Date
PPS Waiver Indicator (Y=Not Under PPS;N=Under PPS)
Provider Type
Census Division
Federal PPS Blend Indicator
MSA - Actual Geographic Location
Fiscal Year End Date - MMDDYY
Case Mix Adjusted Cost Per Discharge/PPS Facility Specific Rate
Cost of Living Adjustment (COLA)
Intern/Resident to Bed Ratio
Special Provider Update Factor (Not Used as of 4/1/91)
Bed Size
Operating Disproportionate Share Adjustment (DSH) Percentage (Not Used as of 10/
Operating Cost to Charge Ratio
Case Mix Index
Report Date - MMDDYY
Intermediary Number
Fiscal Year Beginning Date - MMDDYY
Pass Through Amount for Capital
Pass Through Amount for Direct Medical Education
Pass Through Amount for Organ Acquisition
Pass Through Amount for Total Including Misc.
Supplemental Security Income (SSI) Ratio
Medicaid Ratio
Termination Date - MMDDYY
MSA - Wage Index Location
Change Code for Lugar Reclassification
MSA - Standardized Amount Location
Sole Community Hospital (SCH) Medical Dependent Hospital (MDH) Base Year
Capital PPS Code
Hospital Specfic Capital Rate
Old Capital Hold Harmless Rate
New Capital Hold Harmless Ratio
Capital Cost to Charge Ratio
New Hospital
Capital Indirect Medical Education Ratio
Capital Exception Payment Ratio
Fiscal Year (Based on Effective date)