NEW MILFORD NURSING HOME
NEW MILFORD, VT  06776

Medicare Provider Number: 075208
Cost report status: Settled Without Audit
[Record Code 210137 - 1996]

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CALCULATION OF REIMBURSEMENT SETTLEMENT
PROVIDER NO:
075208
PERIOD:
FROM 01/01/2001
TO 12/31/2001
WORKSHEET E Part III
PART III - SNF REIMBURSEMENT UNDER PPS
SNF - SNF Medicare - Title XVIII
PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES
1 Inpatient ancillary services - Part A - (See Instructions) 1
2 Interns & Residents and Medical Education cost for Title XVIII (See Instructions) 2
3 Total cost (Sum of lines 1 and 2) 3
4 Medicare inpatient ancillary charges (see instructions) 4
5 Intern and Resident Charges (From Provider Records) 5
6 Cost of covered services (lesser of line 3, or the sum of lines 4 and 5) 6
7 Inpatient PPS amount (see instructions) ### 7
8 Primary payor amounts 8
9 Coinsurance ### 9
10 Reimbursable bad debts (From your records) 10
10.01 Adjusted reimbursable bad debts for periods before 10/01/2005 (See instructions) 10.01
10.02 Reimbursable bad debts for dual eligible beneficiaries (See instructions) 10.02
10.03 Adjusted reimbursable bad debts for periods ending on & after 10/01/2005 (See instructions) 10.03
10.04 Recovery of reimbursable bad debts for dual eligible beneficiaries 10.04
11 Utilization review 11
12 Recovery of excess depreciation resulting from provider termination or a decrease in Program utilization. 12
13 Amounts applicable to prior cost reporting periods resulting from disposition 'in Program utilization. 13
14 Subtotal (See instructions) ### 14
15 Sequestration adjustment 15
16 Interim payments (See instructions) ### 16
16.01 Tentative adjustment (See instructions) 16.01
16.20 Other adjustments (See instructions) 16.20
17 Balance due provider/program (Line 14 minus the sum of lines 15 and 16) (Indicate overpayments in brackets) (See Instructions) 17
18 Protested amounts (Nonallowable cost report items in accordance with CMS Pub. 15-II, section 115.2) 18
PART B - ANCILLARY SERVICES COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES - TITLE XVIII ONLY
19 Ancillary services Part B 19
20 Vaccine cost (From Wkst D, Part II, line 3) ### 20
21 Intern and Resident Cost (From Worksheet D-2) 21
22 Total reasonable costs (Sum of lines 19 to 21) ### 22
23 Medicare Part B ancillary charges (See instructions) ### 23
24 Intern and Resident Charges (From Provider Records) 24
25 Cost of covered services (Lesser of line 22, or sum of lines 23 and 24) ### 25
26 Primary payor amounts 26
27 Coinsurance and deductibles 27
28 Reimbursable bad debts (From your records) 28
29 Recovery of unreimbursed cost under the lesser of reasonable cost or customary charges 29
30 80% of recovery of unreimbursed cost under the lesser of reasonable cost or customary charges (Line 29 times 0.80) 30
31 Recovery of excess depreciation resulting from provider termination or a decrease in Program utilization. 31
32 Other Adjustments (See instructions) Specify 32
33 Amounts applicable to prior cost reporting periods resulting from disposition of assets. (If minus, enter amount in brackets) 33
34 Subtotal (Sum of lines 25, 28, & 30, minus lines 26, 27, and 31, plus or minus line 32 and 33) ### 34
35 Sequestration adjustment 35
36 Interim payments (See instructions) ### 36
36.01 Tenative adjustment (See instructions) 36.01
36.20 OTHER adjustments (See instructions) 36.20
37 Balance due provider/program (Line 34 minus the sum of lines 35 and 36) (Indicate overpayments in brackets) (See Instructions) ### 37
38 Protested amounts (Nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2) 38