Form DHCS3092 "Medi-Cal Supplemental Cost Report Schedules" - California

What Is Form DHCS3092?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2005;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHCS3092 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS3092 "Medi-Cal Supplemental Cost Report Schedules" - California

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State of California—Health and Human Services Agency
Department of Health Services
Audits and Investigations
MEDI-CAL SUPPLEMENTAL COST REPORT
SCHEDULES
Hospital Name
Fiscal Year End
Page 1 of 14
DHS 3092 (12/05)
State of California—Health and Human Services Agency
Department of Health Services
Audits and Investigations
MEDI-CAL SUPPLEMENTAL COST REPORT
SCHEDULES
Hospital Name
Fiscal Year End
Page 1 of 14
DHS 3092 (12/05)
A&I—MEDI-CAL SUPPLEMENTAL COST REPORT
INDEX OF SCHEDULES
Schedule 1
Medi-Cal Cost Report Acceptance
Schedule 2
Medi-Cal Required Worksheets and Schedules Check List
Schedule 3
Certification
Schedule 4
Provider Questionnaire
Schedule 5
Provider Based Physicians Questionnaire
Schedule 6
Summary of Medi-Cal Charges
Schedule 7
Summary of Medi-Cal Settlement
Schedule 8
Summary of Medi-Cal Psychiatric Inpatient Hospital Services
Schedule 9
Summary of Medi-Cal Charges and Ancillary Cost for Rural Health Clinic/Federally Qualified
Health Center
Schedule 10
Summary of Medi-Cal Rural Health Clinic/Federally Qualified Health Center Settlement
Schedule 11
Medi-Cal Credit Balance Report for Inpatients and Outpatients
Page 2 of 14
DHS 3092 (12/05)
A&I—MEDI-CAL SUPPLEMENTAL COST REPORT
Schedule 1
MEDI-CAL COST REPORT ACCEPTANCE
The following are the most common reasons for the Medi-Cal cost reports being returned to providers for insufficient or incorrect
information. Attention to these details will result in faster processing and acceptance of your report and avoidance of possible
withhold against payments:
1. Financial Statements not submitted
Worksheet G Series is not an acceptable substitute
for
financial statements.
2. Working trial balance not submitted
Submit a copy of the working trial balance
3. Medi-Cal supplemental schedules (DHS 3092) and
Complete and submit required Medi-Cal supplemental
RDB schedules (DHS 3094) incomplete
schedules (DHS 3092) and RDB schedules (DHS 3094).
4. Appeal items included in body of cost report
All appeal items must be removed from the body of the cost
report. The estimated Medi-Cal impact of appeal issues may
be added on Worksheet E-3, Part III, line 59, (CMS 2552-96).
5. Certification page of cost report not signed
Proper signature must be on Cost Report Certification,
Schedule 3, and on Worksheet S, Part I (CMS 2552-96).
6. Facility’s type of control not disclosed
Complete Worksheet S-2 in full (CMS 2552-96).
Page 3 of 14
DHS 3092 (12/05)
A&I—MEDI-CAL SUPPLEMENTAL COST REPORT
Schedule 2
MEDI-CAL REQUIRED WORKSHEETS AND SCHEDULES CHECK LIST
This Cost Report Worksheet and Schedules Check List is provided to identify each work sheet and schedule that must be
completed and included as part of the Medi-Cal cost report. If the same worksheet or schedule is needed more that once, please
use a separate blank form to report the data. Cost reports submitted without these worksheets and schedules will be returned as
incomplete. Other supplemental worksheets and schedules not listed may be submitted, depending upon the individual
circumstances of the hospital.
Worksheet/Schedule
Part
Completed
N/A
Core Worksheets—(CMS 2552–96)
S
I and II
S–1
I
S–2
S–3
A
A–6
A–8
B
I
B–1
II
C
D–1
I–III
D–4
G to G–3
Medicare Worksheets (CMS 2552–96)
A–8–1
E–3
A–8–2
III
Financial statements
Working trial balance
Medi-Cal Supplemental Cost Report Schedules (DHS 3092)
Schedule 1
Medi-Cal (M/C) Cost Report Acceptance
Schedule 2
Medi-Cal Required Worksheets and Schedules Check List
Schedule 3
Certification
Schedule 4
Provider Questionnaire
Schedule 5
Provider Based Physicians Questionnaire
Schedule 6
Summary of Medi-Cal Charges
Schedule 7
Summary of Medi-Cal Settlement
Schedule 8
Summary of Medi-Cal Psychiatric Inpatient Hospital Services
Summary of Medi-Cal Charges and Ancillary Costs for Rural Health
Schedule 9
Clinic/Federally Qualified Health Center
Summary of Medi-Cal Rural Health Clinic/Federally Qualified Health
Schedule 10
Center Settlement
Schedule 11
Medi-Cal Credit Balance Report
Page 4 of 14
DHS 3092 (12/05)
A&I—MEDI-CAL SUPPLEMENTAL COST REPORT
Schedule 3
CERTIFICATION
In accordance with Section 14107.4 of the Welfare and Institutions Code of Regulations:
(a) Any person who, with the intent to defraud, certifies as true and correct any cost report submitted by a hospital to a state
agency for reimbursement pursuant to Section 14170, knowingly fails to disclose in writing on the cost report any significant
beneficial interest, as defined in subdivision (d), which the owners of the provider, or members of the provider governing
board, or employees of the provider, or independent contractor of the provider, have in the contractors or vendors to the
providers, is guilty of a public offense.
(b) Any person who, with the intent to defraud, knowingly causes any material false information to be included in any cost report
submitted by a hospital to a state agency for reimbursement pursuant to Section 14170 shall be guilty of an offense punishable
by imprisonment in the state prison, or by a fine not exceeding five thousand dollars ($5,000), or by both.
(c) The provider’s chief executive officer shall certify that any cost report submitted by a hospital to a state agency for
reimbursement pursuant to Section 14170 shall be true and correct. In the case of a hospital that is operated as a unit of a
coordinated group on health facilities and under common management, either the hospital’s chief executive officer or
administrator, or the chief financial officer of the operating region of which the hospital is a part, shall certify to the accuracy
of the report.
(d) As used in this section, “significant beneficial interest” means any financial interest that is equal to or greater than
25
thousand dollars ($25,000) of ownership interest or 5 percent of the ownership or any other contractual or compensatory
arrangement with vendors or contractors or immediate family members of vendors or contractors. “Immediate family” means
spouse, son, daughter, father, mother, father-in-law, mother-in-law, daughter-in-law, or son-in-law. Interest held by these
persons specified in subdivision (a) and members of these persons’ immediate family shall be combined and included as a
single interest.
(e) Any person who violates the provisions of subdivision (a) shall be subject to imprisonment in the county jail for a period not
to exceed one year or in state prison, or by a fine not to exceed five thousand dollars ($5,000), or both.
(f) Effective with cost report periods ending on or after June 30, 1982, the Department has implemented the provisions of Section
14171.5 of the Welfare and Institutions Code. Pursuant to this section, hospitals that include costs within their Medi-Cal cost
reports previously determined by departmental audit to be nonreimbursable, will be subject to a penalty assessment of interest
on the improperly claimed amount, and recovery of the cost of state audit. The penalty will be ten percent of the improperly
claimed amount, except when it is established that the hospital fraudulently claimed and received payments, in which case
the penalty will be 25 percent. Interest will be assessed at the rate specified in subdivision (e), Section 14171, Welfare and
Institutions Code.
Hospitals that wish to preserve appeal rights or to challenge the Department’s positions regarding appeal issues may claim
such costs provided they are identified and presented separately in the cost report. This has been interpreted to mean that
the approximate settlement effect of each disputed issue must be calculated on a separate work sheet. Only the total
settlement effect of all issues is to be carried forward to cost report Worksheet E-3, Part III, and entered on line 59.
(g) Be advised that continued submission of claims or cost reports for items or services which were not provided as claimed or
were not reimbursable under the Medi-Cal program, or were claimed in violation of an agreement with the State, may subject
you (your organization) to civil money penalty assessment in accordance with Welfare and Institutions Code, Section
14123.2.
I hereby certify that the attached cost report for the fiscal period
, was prepared in accordance
with the above Welfare and Institutions Code references and, to the best of my knowledge, is a true, correct, and complete
statement prepared from the books and records of
,
in accordance with the applicable instructions.
Signature
Title
Date
Page 5 of 14
DHS 3092 (12/05)