Worksheet S-7, Part III
- Return to Cost Report Summary
- Form S703
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3514.3, REV 7
SUNCHASE NURSING CENTER
PINE BLUFF, AR
PINE BLUFF, AR
Medicare Provider Number: 045311
Cost report status: Settled Without Audit
[Record Code 2860 - 1996]
Print
Excel
PDF
You are not logged in or you have not purchased this report. This report has had its actual values replaced with dummy text ('###').
If you would like to become a subscriber, please look at our subscription details.
If you are already a subscriber, please login.
| PPS STATISTICAL DATA | PROVIDER NO: 045311 |
PERIOD: FROM 01/01/1999 TO 03/31/1999 |
WORKSHEET S-7 Part III |
||||||||
| TRANSITION PERIOD: [ ] YEAR # 1 [ ] YEAR # 2 [ ] YEAR # 3 [ ] YEAR # 4 - 100% Federal Case Mix Rate | |||||||||||
| HIPPS CODE GROUP | FACILITY SPECIFIC RATE | SERVICES PRIOR TO 10/01 | SERVICES AFTER 9/30 | SUBTOTAL |
YR 1: Col. 9 = Col. 7 X 25%
Col. 10 = Col. 8 X 75% |
||||||
FEDERAL CASE MIX RATE |
DAYS | FEDERAL CASE MIX RATE |
DAYS | FEDERAL CASE MIX (Col. 3 X 4, PLUS Col . 5 X 6) |
FACILITY SPECIFIC (Col. 4 + 6 X Col. 2) |
||||||
|
YR 2: Col. 9 = Col. 7 X 50%
Col. 10 = Col. 8 X 50% |
|||||||||||
|
YR 3: Col. 9 = Col. 7 X 75%
Col. 10 = Col. 8 X 25% |
|||||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | ||
| 1 | RUC | 1 | |||||||||
| 2 | RUB | ### | ### | ### | ### | ### | 2 | ||||
| 3 | RUA | 3 | |||||||||
| 4 | RVC | 4 | |||||||||
| 5 | RVB | ### | ### | ### | ### | ### | 5 | ||||
| 6 | RVA | ### | ### | ### | ### | ### | 6 | ||||
| 7 | RHC | ### | ### | ### | ### | ### | 7 | ||||
| 8 | RHB | 8 | |||||||||
| 9 | RHA | ### | ### | ### | ### | ### | 9 | ||||
| 10 | RMC | 10 | |||||||||
| 11 | RMB | 11 | |||||||||
| 12 | RMA | 12 | |||||||||
| 13 | RLB | 13 | |||||||||
| 14 | RLA | 14 | |||||||||
| 15 | SE3 | 15 | |||||||||
| 16 | SE2 | 16 | |||||||||
| 17 | SE1 | 17 | |||||||||
| 18 | SSC | ### | ### | ### | ### | ### | 18 | ||||
| 19 | SSB | 19 | |||||||||
| 20 | SSA | 20 | |||||||||
| 21 | CC2 | 21 | |||||||||
| 22 | CC1 | 22 | |||||||||
| 23 | CB2 | 23 | |||||||||
| 24 | CB1 | 24 | |||||||||
| 25 | CA2 | 25 | |||||||||
| 26 | CA1 | 26 | |||||||||
| 27 | IB2 | 27 | |||||||||
| 28 | IB1 | 28 | |||||||||
| 29 | IA2 | 29 | |||||||||
| 30 | IA1 | 30 | |||||||||
| 31 | BB2 | 31 | |||||||||
| 32 | BB1 | 32 | |||||||||
| 33 | BA2 | 33 | |||||||||
| 34 | BA1 | 34 | |||||||||
| 35 | PE2 | 35 | |||||||||
| 36 | PE1 | 36 | |||||||||
| 37 | PD2 | 37 | |||||||||
| 38 | PD1 | 38 | |||||||||
| 39 | PC2 | 39 | |||||||||
| 40 | PC1 | 40 | |||||||||
| 41 | PB2 | 41 | |||||||||
| 42 | PB1 | 42 | |||||||||
| 43 | PA2 | 43 | |||||||||
| 44 | PA1 | 44 | |||||||||
| 45 | Default Rate | 45 | |||||||||
| 46 | TOTAL | ### | ### | ### | 46 | ||||||