Worksheet A-8
- Return to Cost Report Summary
- Form A800
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3519, REV 4
HERITAGE HEALTHCARE AT SUNRISE LLC
MOULTRIE, GA 31768
MOULTRIE, GA 31768
Medicare Provider Number: 115668
Cost report status: Settled Without Audit
[Record Code 1055103 - 2010]
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| ADJUSTMENTS TO EXPENSES | Provider CCN: 115668 | PERIOD: FROM 07/01/2012 TO 06/30/2013 |
WORKSHEET A-8 | |||
| Description (1) | Basis for Adjustment (2) | Amount | Expense Classification on Wkst. A to/from which the amount is to be adjusted |
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| Cost Center | Line No. | |||||
| 0 | 1 | 2 | 3 | 4 | ||
| 1 | Investment income on restricted funds (Chapter 2) | 1 | ||||
| 2 | Trade, quantity and time discounts on purchases (Chapter 8) | 2 | ||||
| 3 | Refunds and rebates of expenses Chapter 8) | 3 | ||||
| 4 | Rental of provider space by suppliers Chapter 8) | 4 | ||||
| 5 | Telephone services (pay stations excluded) (Chapter 21) | 5 | ||||
| 6 | Television and radio service (Chapter 21) | 6 | ||||
| 7 | Parking lot (Chapter 21) | 7 | ||||
| 8 | Remuneration applicable to provider-based physician adjustment | Worksheet A-8-2 | 8 | |||
| 9 | Home office costs (Chapter 21) | 9 | ||||
| 10 | Sale of scrap, waste, etc. (Chapter 23) | 10 | ||||
| 11 | Nonallowable costs related to certain Capital expenditures (Chapter 24) | 11 | ||||
| 12 | Adjustment resulting from transactions with related organizations (Chapter 10) | Worksheet A-8-1 | ### | 12 | ||
| 13 | Laundry and Linen service | 13 | ||||
| 14 | Revenue - Employee meals | ### | ### | ### | ### | 14 |
| 15 | Cost of meals - Guests | 15 | ||||
| 16 | Sale of medical supplies to other than patients | 16 | ||||
| 17 | Sale of drugs to other than patients | 17 | ||||
| 18 | Sale of medical records and abstracts | 18 | ||||
| 19 | Vending machines | ### | ### | ### | ### | 19 |
| 20 | Income from imposition of interest, finance or penalty charges (Chapter 21) | 20 | ||||
| 21 | Interest expense on Medicare overpayments and borrowings to repay Medicare overpayments | 21 | ||||
| 22 | Utilization review--physicians' compensation (Chapter 21) | Utilization Review- SNF | 82 | 22 | ||
| 23 | Depreciation--buildings and fixtures | Capital Related Cost- Building | 1 | 23 | ||
| 24 | Depreciation--movable equipment | Capital Related Cost-Movable | 2 | 24 | ||
| 25 | Other Adjustment specify - WORKERS COMP-ADMIN | ### | ### | ### | ### | 25 |
| 26.00 | WORKERS COMP-MAINTENANCE | ### | ### | ### | ### | 26.00 |
| 27.00 | WORKERS COMP-LAUNDRY | ### | ### | ### | ### | 27.00 |
| 28.00 | WORKERS COMP-HOUSEKEEPING | ### | ### | ### | ### | 28.00 |
| 29.00 | WORKERS COMP-DIETARY | ### | ### | ### | ### | 29.00 |
| 30.00 | WORKERS COMP-NURSING ADMIN | ### | ### | ### | ### | 30.00 |
| 31.00 | WORKERS COMP-MEDICAL RECORDS | ### | ### | ### | ### | 31.00 |
| 32.00 | WORKERS COMP-SOCIAL SERVICES | ### | ### | ### | ### | 32.00 |
| 33.00 | WORKERS COMP-ACTIVITIES | ### | ### | ### | ### | 33.00 |
| 34.00 | WORKERS COMP-NURSING | ### | ### | ### | ### | 34.00 |
| 38.00 | ALLOC HEALTH INSURANCE-ADMIN | ### | ### | ### | ### | 38.00 |
| 40.00 | ALLOC HEALTH INSURANCE-LAUNDRY | ### | ### | ### | ### | 40.00 |
| 42.00 | ALLOC HEALTH INSURANCE-DIETARY | ### | ### | ### | ### | 42.00 |
| 43.00 | ALLOC HEALTH INSURANCE-NRSG ADMIN | ### | ### | ### | ### | 43.00 |
| 45.00 | ALLOC HEALTH INSURANCE-SOCIAL | ### | ### | ### | ### | 45.00 |
| 46.00 | ALLOC HEALTH INSURANCE-ACTIVITIES | ### | ### | ### | ### | 46.00 |
| 47.00 | ALLOC HEALTH INSURANCE-NURSING | ### | ### | ### | ### | 47.00 |
| 48.00 | POLICY HOLDER DISTRIBUTION-W/C | ### | ### | ### | ### | 48.00 |
| 49.00 | POLICY HOLDER DISTRIBUTION-W/C | ### | ### | ### | ### | 49.00 |
| 50.00 | POLICY HOLDER DISTRIBUTION-W/C | ### | ### | ### | ### | 50.00 |
| 51.00 | POLICY HOLDER DISTRIBUTION-W/C | ### | ### | ### | ### | 51.00 |
| 52.00 | POLICY HOLDER DISTRIBUTINO-W/C | ### | ### | ### | ### | 52.00 |
| 53.00 | POLICY HOLDER DISTRIBUTION-W/C | ### | ### | ### | ### | 53.00 |
| 54.00 | POLICY HOLDER DISTRIBUTION-W/C | ### | ### | ### | ### | 54.00 |
| 55.00 | POLICY HOLDER DISTRIBUTION-W/C | ### | ### | ### | ### | 55.00 |
| 56.00 | POLICY HOLDER DISTRIBUTION-W/C | ### | ### | ### | ### | 56.00 |
| 57.00 | POLICY HOLDER DISTRIBUTION-W/C | ### | ### | ### | ### | 57.00 |
| 59.00 | ADJ DEPRECIATION-UM/UNICHOICE | ### | ### | ### | ### | 59.00 |
| 61.00 | DISALLOW RELATED PARTY INTEREST | ### | ### | ### | ### | 61.00 |
| 63.00 | MISCELLANEOUS INCOME OFFSET | ### | ### | ### | ### | 63.00 |
| 68.00 | REMOVE ADMIN ADVERTISING | ### | ### | ### | ### | 68.00 |
| 70.00 | REMOVE ADMIN U/A DUES | ### | ### | ### | ### | 70.00 |
| 71.00 | REMOVE CONTRIBUTIONS | ### | ### | ### | ### | 71.00 |
| 72.00 | REMOVE POLITICAL CONTRIBUTIONS | ### | ### | ### | ### | 72.00 |
| 74.00 | REMOVE NONALLOWABLE EXPENSE | ### | ### | ### | ### | 74.00 |
| 83.00 | REMOVE PHYSICIANS SERVICES | ### | ### | ### | ### | 83.00 |
| 85.00 | REMOVE 10% UNIHEALTH ALLOCATION | ### | ### | ### | ### | 85.00 |
| 92.00 | PROPERTY INSURANCE-RELATED PARTY | ### | ### | ### | ### | 92.00 |
| 93.00 | PROPERTY TAX-RELATED PARTY | ### | ### | ### | ### | 93.00 |
| 94.00 | POLICY HOLDER ACCRUED NOT PAID | ### | ### | ### | ### | 94.00 |
| 95.00 | POLICY HOLDER ACCRUED 2012 PAID 2013 | ### | ### | ### | ### | 95.00 |
| 100 | TOTAL (sum of lines 1 through 99) (transfer to Wkst. A, col. 6, line 100) |
### | 100 | |||
(1) Description - all chapter references in this column pertain to CMS Pub. 15-1 (2) Basis for adjustment (see instructions) |
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A. Costs - if cost, including applicable overhead, can be determined B. Amount Received - if cost cannot be determined |
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| FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4116) | ||||||
| 41-320 | Rev. 1 | |||||