Worksheet S-7, Part III
- Return to Cost Report Summary
- Form S703
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3514.3, REV 7
IDAHO FALLS GOOD SAMARITAN CENTER
IDAHO FALLS, ID 83401-
IDAHO FALLS, ID 83401-
Medicare Provider Number: 135092
Cost report status: Settled Without Audit
[Record Code 519 - 1996]
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| PPS STATISTICAL DATA | PROVIDER NO: 135092 |
PERIOD: FROM 01/01/1999 TO 12/31/1999 |
WORKSHEET S-7 Part III |
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| 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% |
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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) |
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YR 2: Col. 9 = Col. 7 X 50%
Col. 10 = Col. 8 X 50% |
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YR 3: Col. 9 = Col. 7 X 75%
Col. 10 = Col. 8 X 25% |
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| 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 | |||||||