CAROLINA VILLAGE INC.
HENDERSONVILLE, NC  28792

Medicare Provider Number: 345123
Cost report status: Settled Without Audit
[Record Code 1078075 - 2010]

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CALCULATION OF REIMBURSEMENT SETTLEMENT TITLE FOR XVIII Provider CCN: 345123
PERIOD:
FROM 04/01/2013
TO 03/31/2014
WORKSHEET E PART I
PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT
1 Inpatient PPS amount (see instructions) ### 1
2 Nursing and Allied Health Education Activities (pass through payments) 2
3 Subtotal (sum of lines 1 and 2) ### 3
4 Primary payor amounts ### 4
5 Coinsurance ### 5
6 Allowable bad debts (from your records) 6
7 Allowable bad debts for dual eligible beneficiaries (see instructions) 7
8 Adjusted reimbursable bad debts (see instructions) 8
9 Recovery of bad debts - for statistical records only 9
10 Utilization review 10
11 Subtotal (see instructions) ### 11
12 Interim payments (see instructions) ### 12
13 Tentative adjustment 13
14 Other adjustment (see instructions) 14
14.50 Demonstration payment adjustment amount before sequestration 14.50
14.55 Demonstration payment adjustment amount after sequestration 14.55
14.75 Sequestration for non-claims based amounts (see instructions) 14.75
14.99 Sequestration amount (see instructions) ### 14.99
15 Balance due provider/program (line 11 minus line 12 and 13, plus or minus line 14) (Indicate overpayment in parentheses) (see instructions) 15
16 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 16
 
PART B - ANCILLARY SERVICE COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES - TITLE XVIII ONLY
17 Ancillary services Part B 17
18 Vaccine cost (from Wkst. D, Pt. II, line 3) ### 18
19 Total reasonable costs (sum of lines 17 and 18) ### 19
20 Medicare Part B ancillary charges (see instructions) ### 20
21 Cost of covered services (lesser of line 19 or line 20) ### 21
22 Primary payor amounts 22
23 Coinsurance and deductibles 23
24 Allowable bad debts (from your records) 24
24.01 Allowable bad debts for dual eligible beneficiaries (see instructions) 24.01
24.02 Reimbursable bad debts (see instructions) 24.02
25 Subtotal (sum of lines 21 and 24, minus lines 22 and 23) ### 25
26 Interim payments (see instructions) ### 26
27 Tentative adjustment 27
28 Other Adjustments (Specify _OTHER ADJUSTMENTS ROUNDING_) (see instructions) 28
28.50 Demonstration payment adjustment amounts before sequestration 28.50
28.55 Demonstration payment adjustment amounts after sequestration 28.55
28.99 Sequestration amount (see instructions) ### 28.99
29 Balance due provider/program (line 25 minus line 26, 27 and plus or minus line 28) (indicate overpayments in parentheses) (see instructions) ### 29
30 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 30
 
FORM CMS-2540-10 (06/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4130)
06-21       Rev. 10