Provider Name

Provider Number

Cost Reporting Period:

INSTRUCTIONS

This Non-allowable Cost Report Review Checklist is designed to review the cost report for the inclusion of potentially non-allowable cost as define by the Medicare program (Chapter 21 of the Provider Reimbursement Manual (PRM)). This checklist should be completed prior to the submission of the cost report. Resource materials: 1) chart of accounts and definitions; 2) internal policies and procedures for cost report preparation; 3) Provider Reimbursement Manual; and 4) cost report workpapers.

PRM Reference[1]		YES	NO
2104.1	1. Are Ambulance Services provided by organization?	___	___
2104.2	2. Are private-duty nurses or other private-duty attendants utilized?	___	___
2104.3,B.1.	3. Does the provider have Luxury Accommodations as defined in 2104.3, B. of the PRM?	___	___
2104.3,B.2.	4. Are other luxury services available to patients, such as, food service, etc.?	___	___
2106	5. Is their a phone, television, and/or radio in the patient rooms?	___	___
2108	6. Do provider-based-physicians perform services for which they are compensated by or through the provider?	___	___
2108.8	7. Have there been any changes to the compensation arrangements for physicians that provide administrative, teaching, and/or direct medical care service?	___	___
2108.9	8. Are any provider-based-physician services combined billed (on Forms SSA-1453 or 1483 or on Form SSA-1554) by the organization?	____	____
2108.10	9. Do provider-based-physicians provide services to patients who are nonprovider patients?	____	____
2109.2,A.	10. Do Emergency Room Physicians receive compensation for availability of service?	___	___
2110 2110.1 2110.2 2110.3 2110.4	11. Does the provider have any of the following related to the billing of its services? · Cost for contract billing services · Income from interest, finance charges, or penalties on delinquent Accounts Receivable · Income from billing charges imposed on supplier of services furnished under arrangement · Physician billing cost	___ ___ ___ ___	___ ___ ___ ___
2112	12. Are nonphysician anesthetists’ services provided as hospital services?	___	___
2113	13. Does the provider have any cost associated with the coordination of Home Health services (intake coordination)?	___	___
2118	14. Are any provider services furnished under an arrangement with outside suppliers, including other providers?	___	___
2120	15. Are cost incurred for Interns or Residents?	___	___
2122	16. Has the provider paid any taxes?	___	___
2122.5, C.	17. Does the provider have any self-insurance programs?	___	___
2124	18. Has the cost of oxygen provide to patients been classified as a medical supply?	____	____
2125	19. Are Medicare patients afford the same opportunity as non-Medicare patients for reducing or eliminating blood fees?	____	____
2126	20. Has the provider incurred cost related to utilization review?	____	____
2130	21. Are cost incurred for life insurance where the provider is a direct or indirect beneficiary?	____	____
2132	22. Has there been any cost associated with organizational planning, start-up cost or other similar expenses related to patient care services?	____	____
2134	23. Have there been any organizational or other corporate cost incurred?	____	____
2135