61 Pa. Code § 521.6 — Reporting forms

Forms for determining reimbursable costs applicable to the Medical Assistance Program and the preparation of the report under either of the prescribed methods of apportionment are incorporated in the schedules and worksheets provided. All forms identified as Form AG12 ‘‘CD’’ shall be used by providers using either of the two prescribed methods of apportionment. Schedules B and B-1, identified as Form AG12 ‘‘C’’ Page 6 and Page 7, are required for use by Combination Method providers. Worksheets B and B-1, identified as Form AG12 ‘‘D’’ Page 6 and Page 7, are required for use by Departmental Method providers. These forms are detailed as follows: (1) Schedule A—Reclassification and Adjustment of Trial Balance of Expenses … AG12 CD PAGE 3 (2) Schedule A-1—Adjustments to Expenses … AG12 CD PAGE 4 (3) Schedule A-2—Administrative and General ExpensesAnalysis … AG12 CD PAGE 5 (4) Schedule B—Cost Allocation—General Service Costs.For use of providers using COMBINATION METHOD … AG 12 C PAGE 6 (5) Schedule B-1—Cost Allocation—Statistical BasisCOMBINATION METHOD (under 100 beds) … AG12 C PAGE 7 (6) Worksheet B—Cost Apportionment—General Services.For use of providers using DEPARTMENTAL METHOD … AG12 D PAGE 6 (7) Worksheet B-1—Cost Apportionment-StatisticalBasis DEPARTMENTAL METHOD (over 99 beds) … AG12 D PAGE 7 (8) Schedule C—Departmental Distribution of PatientCare Costs … AG12 CD PAGE 8 (9) Schedule C-1—Departmental Distribution of PatientCare Charges … AG12 CD PAGE 9 No part of the information on this site may be reproduced for profit or sold for profit. This material has been drawn directly from the official Pennsylvania Code full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.