Arizona Rural Health Clinic Designation Manual - Arizona Center for ...

F. RHC Cost Report (con’t)
Fringe Benefi ts and Employer related payroll taxes of each employee.
6) Total number of vaccines given for the following vaccinations for all insurances totaled together:
A. Pneumovax
B. Infl uenza
Total number of above vaccines given - broken down by the following:
I. Medicare vaccines given for Pneumo and Infl uenza listed separately.
II. Medicaid vaccines given for Pneumo and Infl uenza listed separately.
III. Vaccine logs for Medicare Pneumovax and Infl uenza vaccines to include Patients name, HIC
Number, and Date of Injection to support the above Medicare vaccinations.
IV. Cost per dose of each vaccine.
7) Payments Received for the following:
A. Medicare Payments
B. Medicaid Straight or Regular FFS Payments
C. Medicaid HMO Payments per each HMO
D. Medicare Crossover Payments made by Medicare
E. Medicaid Crossover Payments made by Medicare
F. Medicaid Other Third Party Payments (i.e. primary insurance’s, besides Medicare, that have
paid when Medicaid is the secondary insurance)
G. Medicare Benefi ciary Deductible Received (Payments made by the Medicare Patient)
8) Any new assets purchased If so, submit the following:
A. Date Asset Purchased
B. Description of Asset
C. Cost of Asset
D. Depreciation Schedule to match depreciated expenses in Financial Statement
9) Listing of Medicare Bad Debts with Medicare Patients, to include the following information:
A. Beneficiary Name
B. Beneficiary HIC Number
C. Date(s) of Service
D. Date of First Bill
E. Medicare Paid Date
F. Date of Write-Off
G. Amount of Debt
H. Medicare Deductible and Coinsurance amount
I. Medicaid Payment Amount
In order to be considered “allowable bad debt”, debt must be written off during cost reporting period.
NOTE: Reasonable collection efforts may be waived for Medicare indigent patients. A Medicare benefi ciary
who also qualifi es for Medicaid may be considered indigent automatically. For other Medicare benefi ciaries,
the provider should apply its customary practices for determining indigency. Please refer to PRM Section
312 for the factors, which should be incorporated into the provider’s indigency guidelines. The bad debt for
an indigent patient may be written off and claimed upon discharge or upon the determination of indigency,
whichever is later. If indigency is determined, please indicate Medicaid number of recipient, if applicable,
to claim as bad debt to Medicare.
10) Copy of PSR from Medicare Fiscal Intermediary to compare clinic visit and payment information for the
cost reporting period.
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