Worksheet A-8-2

Return to Profile
Filing History
FORM CMS-2552-10
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 1

ST MARYS HEALTH CARE SYSTEM INC - ATHENS, GA
Cost report status - As Submitted
[Record Code 708218 - 2010]
This is a prior filing for this period.

The data in this report have been replaced because you do not own it or are not logged in.

Add to Cart
PROVIDER-BASED PHYSICIANS ADJUSTMENTS Provider CCN: 110006
PERIOD:
FROM 07/01/2019
TO 06/30/2020
 WORKSHEET A-8-2
  Wkst. A Line # Cost Center/ Physician Identifier Total Remuneration Professional Component Provider Component RCE Amount Physician/ Provider Component Hours Unadjusted RCE Limit 5 Percent of Unadjusted RCE Limit  
1 2 3 4 5 6 7 8 9
1 ### ### ### ### 1
2 ### ### ### ### ### ### ### ### ### 2
3 ### ### ### ### 3
4 ### ### ### ### 4
5 ### ### ### ### ### 5
6 6
7 ### ### ### ### 7
8 ### ### ### ### ### ### ### ### ### 8
9 ### ### ### ### 9
10 ### ### ### ### 10
11 ### ### ### ### 11
12 ### ### ### ### ###
13 ### ### ### ### ### ### ### ### ###
200 TOTAL   ### ### ###   ### ### ### 200
                     
                     
  Wkst. A Line # Cost Center / Physician Identifier Cost of Memberships & Continuing Education Provider Component Share of col. 12 Physician Cost of Malpractice Insurance Provider Component Share of col. 14 Adjusted RCE Limit RCE Disallowance Adjustment  
  10 11 12 13 14 15 16 17 18  
1 ### ### ### 1
2 ### ### ### ### ### 2
3 ### ### ### 3
4 ### ### ### 4
5 ### ### ### 5
6 6
7 ### ### ### 7
8 ### ### ### ### ### 8
9 ### ### ### 9
10 ### ### ### 10
11 ### ### ### 11
12 ### ### ### ###
13 ### ### ### ### ### ###
200 TOTAL   ### ### ### 200
                     
FORM CMS-2552-9 (10/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4018)
10-12   Rev. 3