Worksheet S-7, Part IV
- Return to Cost Report Summary
- Form S704
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3514.4, REV 14
MCHS NORTH OLMSTED - #514
NORTH OLMSTED, OH 44070-
NORTH OLMSTED, OH 44070-
Medicare Provider Number: 365310
Cost report status: Settled Without Audit
[Record Code 139839 - 1996]
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| PROSPECTIVE PAYMENT FOR SNF STATISTICAL DATA | PROVIDER NO: 365310 |
PERIOD FROM 06/01/2000 TO 05/31/2001 |
WORKSHEET S-7, PART IV |
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| GROUP (1) | M3PI REV CODE | SERVICES PRIOR TO October 1 | SERVICES ON OR AFTER October 1 | AIDS Diagnosis 042 Prior to 10/01 | HIGH COST RUGs (2) | TOTAL (see instructions) | |||||
| RATE | DAYS | RATE | DAYS | RATE | DAYS | DAYS | |||||
| 1 | 2 | 3 | 3.01 | 4 | 4.01 | 4.02 | 4.03 | 4.05 | 5 | ||
| 1 | RUC | ### | ### | ### | 1 | ||||||
| 2 | RUB | ### | ### | ### | ### | ### | ### | ### | 2 | ||
| 3 | RUA | 3 | |||||||||
| 3.01 | RUX | 3.01 | |||||||||
| 3.02 | RUL | 3.02 | |||||||||
| 4 | RVC | ### | ### | ### | ### | ### | ### | ### | 4 | ||
| 5 | RVB | ### | ### | ### | ### | ### | ### | ### | 5 | ||
| 6 | RVA | ### | ### | ### | ### | ### | 6 | ||||
| 6.01 | RVX | 6.01 | |||||||||
| 6.02 | RVL | 6.02 | |||||||||
| 7 | RHC | ### | ### | ### | ### | ### | ### | ### | ### | 7 | |
| 8 | RHB | ### | ### | ### | ### | ### | ### | ### | 8 | ||
| 9 | RHA | ### | ### | ### | ### | ### | 9 | ||||
| 9.01 | RHX | 9.01 | |||||||||
| 9.02 | RHL | 9.02 | |||||||||
| 10 | RMC | ### | ### | ### | ### | ### | ### | ### | ### | 10 | |
| 11 | RMB | ### | ### | ### | ### | ### | ### | ### | ### | 11 | |
| 12 | RMA | ### | ### | ### | ### | ### | 12 | ||||
| 12.01 | RMX | 12.01 | |||||||||
| 12.02 | RML | 12.02 | |||||||||
| 13 | RLB | 13 | |||||||||
| 14 | RLA | ### | ### | ### | ### | ### | 14 | ||||
| 14.01 | RLX | 14.01 | |||||||||
| 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 | ||||