Worksheet S Parts I, II & III

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FORM CMS-2552-10
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 1

MEDICAL UNIVERSITY OF SOUTH CAROLINA - CHARLESTON, SC
Cost report status - As Submitted
[Record Code 741780 - 2010]
This is a prior filing for this period.

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HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT CERTIFICATION AND SETTLEMENT SUMMARY Provider CCN: 420004
PERIOD:
FROM 07/01/2021
TO 06/30/2022
WORKSHEET S
PARTS I, II & III
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).  
FORM APPROVED
OMB NO. 0938-0050
EXPIRES 03-31-2022
 
PART I - COST REPORT STATUS
Provider use only 1. [ ### ] Electronically prepared cost report   Date: Time:  
2. [ ] Manually prepared cost report    
3. [ ] If this is an amended report enter the number of times the provider resubmitted this cost report
4. [ ### ] Medicare Utilization. Enter "F" for full or "L" for low or "N" for no.
Contractor use only
5. [ ### ] Cost Report Status
(1) As Submitted
(2) Settled without audit
(3) Settled with audit
(4) Reopened
(5) Amended
 6. Date Received: ### 10. NPR Date:
7. Contractor No.: ### 11. Contractor's Vendor Code: ###
8. [ ### ] Initial Report for this Provider CCN 12. [ ] If line 5, column 1 is 4: Enter number of times reopened = 0-9.
9. [ ### ] Final Report for this Provider CCN  
 
PART II - CERTIFICATION BY A CHIEF FINANCIAL OFFICER OR ADMINISTRATOR OF PROVIDER(S)
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY CHIEF FINANCIAL OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Number(s)}for the cost reporting period beginning ______________ and ending ______________ and to the best of my knowledge and belief, this report and statement are true, correct, complete and prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that the services identified in this cost report were provided in compliance with such laws and regulations.
  SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR CHECKBOX ELECTRONIC SIGNATURE SETTLEMENT  
1 2  
1     I have read and agree with the above certification statement. I certify that I intend my electronic signature on this certification be the legally binding equivalent of my original signature. 1
2 Signatory Printed Name: ---Redacted by CMS ---     2
3 Signatory Title: ---Redacted by CMS ---     3
4 Signatory Date: ---Redacted by CMS ---     4
 
PART III - SETTLEMENT SUMMARY
  TITLE V TITLE XVIII HIT TITLE XIX  
PART A PART B
1 2 3 4 5
1 HOSPITAL ### ### ### 1
1.01 HOSPITAL-PARHM 1.01
2 SUBPROVIDER - IPF ### ###   2
3 SUBPROVIDER - IRF   3
4 SUBPROVIDER (OTHER)   4
5 SWING BED - SNF   5
5.01 SWING BED-PARHM (CAH ONLY)   5.01
6 SWING BED - NF       6
7 SNF   7
8 NF, ICF/IID       8
9 HOME HEALTH AGENCY   9
10 HOSPITAL-BASED - RHC     10
11 HOSPITAL-BASED -FQHC     11
12 OUTPATIENT REHABILITATION PROVIDER (Specify)     12
200 TOTAL ### ### ### 200
The above amounts represent "due to" or "due from" the applicable program for the element of the above complex indicated.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The number for this information collection is OMB 0938-0050 and the number for the Supplement to Form CMS 2552-10, Worksheet N95, is OMB 0938-1425. The time required to complete this information collection is estimated to be 675 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s), or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE.
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4003.1-4003.3)
07-23  Rev. 21