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End User Manual V4.0 - MA

1. jbewedatonesemseforpenod S 7587 3 Sa 6 expenseforperiod JI column B gt 0 must not be blank fnot blank must be wholemumber 750 751 F May be blank If not blank must be whole number ee Was Depreciation expense for period Line 11 must line 5 and 6 10 Line 11 must be lt column B Line 11 must SchC34D d iati 753 759 ag eost Mistbe wholemumber Blankor 760 SchG Saaryceost SchC29A must line 20 If SchAaprovedas lt gt 2 lines 1 7 must line 20 76 3dG Frat operating co Sci 2 Jct ve costs E must 78 dG A Jet operating cost fess administrative costs Line 21 Tess line 22 must line 23 Oo o 78 Sei Tit on adminisraive cons Line 237 88 rounded 1o 0 places mis Tne A UUE 765 SchG 25 Excess administrative costs If line 21 less line 24 lt 0 then must be 0 else must line 21 less line 24 SchE19A must line 25 766 72 SdG 12 p Fringebosis Mesbewholemmmbrblnkor m so 29 B Pimsebenfts SchC29B must line 20 IF SchAaprovedas lt 2 lines 1 7 must line 20 74 9 sdG i49 C Musbewhoemumbrblnkor O
2. Mesbewholemumbrblnkor 3 28 Other expenses Lines 21 27 mus line 28 2 C jOerewemes 282 3 C Other expenses Limes2o 28ami29mut lime30 353 39 se 3138 C Other expenses Mast be whole number blank or 0 x 39 C Other expenses EEE E 3 U l l t C 3 49 C jOhrewenes Dms30 39mwtzlmedo 35 31 She T D Towexems 5 OdwmA BrCmuiccdumD se o j D Tealexpnss Column A B C must column D Lines 19 must Tine 20 33 319 Sac 2 27 D Toa expenses E m 28 D Colum A B C must column D Lines 21 27 must line 28 mi sac 2 J D 30 D Teulexpmses O Column A B C must column D Lines 20 28 and 29 must Tine 30 323 330 338 D mulewpmes CoumCms coumb 77 x se 3 D Column C must column D Lines 31 38 must Tine 39 339 Sh 4 j D Toa expenses B C column Line 30 39 maste Tine 40 353 35 T E Adjustments Meshewholemumbrbnkor 32 9 E Adw
3. of seno Must be lt 1500 u Pung 4 Alba Changes intetal beds dusrg penod be S00 asd SID 3 15 6 Altos beds be gt 300 sad lt b fhunimg Facdiy E Altes Charges in tatal beds duirg period Must bo gt 500 and lt SD v l actty 7 Adde Charges ir talal dusrg panad be gt 500 asd lt 6 Paice Facey z Mie p Mte ens 7 141 SSS gt Figure 4 1 MA 11 Spreadsheet Template The following table describes the columns that make up the template COLUMN NAME DESCRIPTION DATA V4 0 Enter data that you wish to transmit into this column SEQ The sequence number that is assigned to each field on the sequentially numbered cost report schedules in Appendix D of this manual SCH LINE COLUMN The schedule line and column location of the field on the cost report schedule DESCRIPTION The full name of the field on the cost report schedule VALIDATION The computer validation that is used to determine if the value submitted for a field is valid These are taken from the MA 11 Standard File Validations MAX LENGTH The maximum number of characters that will be stored by the MA 11 Cost Report Submission System when the cost report standard file is transmitted Although an unlimited number of characters may be entered into the template field only the number of characters specified will be saved The remaining
4. 79 sso o C Other expenses Seh 29C must line 20 Ir SchAapprovedas 72 lines 1 19 must line 20 94 89 SdG 17 D Pmexems CwmA BrCmuszcohmnD i 301 87 S D Tcaexene OoumnCmuizcoumnD J MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 35 Cost or other basis Line I 4 must line 5 e eee STANDARD FILE VALIDATION 1 YES 0 NO VALIDATION si3 29 D pulexess CwumA B CadSchCHDmust coumnD Sh 5 j oio ESehHSA O mustnot be Blank SSCS sis ShH Position SeHilA 0mutnobebak 56 839 13 j A jBWavceowkes whole number Blank or C Sh 6 SS lary coffees Lines 1 Sand Se CTA must linc 6 899 836 7 A Salary costifees Metbewholemmberblnkor S S 7 A 7 11 must ine 12 I ine 12 not Blank must be lt SchCIC Sh A jBHevceowfes E C L5 B Fiebeehts MesBewholemmberblnkor0 4 6 Fimsbendis 1 5 and SchCIB must linc 6 85 89 C A not blank musmobeblank O
5. NETSCAPE COMMUNICATOR OPTIONAL SETUP ettet APPENDIX B DOWNLOADS 64 DOWNLOADING COST REPORT UPDATE FILES ssttt 64 APPENDIX C ACCEPTED MA 11 COST REPORT DATA 67 INDIVIDUAL COST REPORT FILES MULTIPLE COST REPORT FILES tate tete estuate pt a eis adhe APPENDIX D NUMBERED COST REPORT FORM 71 MA 11 COST REPORT SUBMISSION SYSTEM Contents ii Revised 08 26 2005 SECTION 1 INTRODUCTION Glossary Terms Used In This Section Certification Report Cost Report Standard File Department Department of Public Welfare Download Excel Spreadsheet Template MA MA 11 Cost Report Submission System Netscape Navigator NF Sequence Number Standard File Validations Validation Web Site Definitions for these terms are found in Section 9 ABOUT THIS MANUAL This manual provides information and instructions pertaining to the MA 11 Cost Report Submission System for the electronic filing of cost reports by nursing facilities NFs This system enables you to connect electronically to the submission web site transmit cost report standard files and receive feedback via the system The manual is intended for use as a reference and learning tool for the MA 11 Cost Report Submission System HOW THIS MANUAL IS ORGANIZED This user s manual is organized into nine sections and four appendices MA 11 COST REPORT SUBMISSION SYSTEM Section 1 Introduction provides general information about this man
6. Welcome to the Cost Report Update Page This page is provided to assist you in keeping the MA 11 Automation System up to dite The links below contain informasen and dowsboadable files MA 11 Cost Report Submission System End User Mammal v3 0 Excel Spreadsheet Template 3 6 Questions amd Answers for MA 11 3 0 Crosswalk v3 0 MA 11 Accepted Data Suggested Sch C Line 32 Supporting Documentation Format deeribadhwq fro uba Ig kwa wan com D rere Figure B 1 Cost Report Update Page There are six options available on this page Other downloadable items may be available in the future MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX B DOWNLOADS 64 Revised 08 26 2005 MA 11 Cost Report Submission System End User Manual includes instructions for electronically submitting the cost report standard file MA 11 acceptability validations and completing the spreadsheet template method of creating a cost report standard file This document is saved in a pdf format and must be viewed and printed using Adobe Acrobat Reader Excel Spreadsheet Template includes a standard spreadsheet template that may be opened in Lotus or Excel This template is only used by those facilities choosing to submit using the spreadsheet standard file method rather than the text standard file method or facilities whose MA 11 program does not include the creation of the cost report standard file Instructions for entering data into the t
7. Residential Allocation amp Other Basis Fringe Allowable Nursing Residential Nursing Benefits Expenses Expenses Adjustments Costs Facility amp Other Facility G H om COST CENTERS RESIDENT CARE COSTS z El 366 367 428 429 430 431 432 433 434 191 1253 1333 254 334 255 335 256 336 195 257 337 196 258 338 197 259 339 198 260 340 199 261 341 10 1200 262 342 201 263 343 Physical Occupational amp Speech Therapy 234 305 345 266 2 17 Total Resident Care Costs 241 Il OTHER RESIDENT RELATED COSTS Dietary and Food Laundry and Linens Housekeeping Plant Operation amp Maintenance 188 189 t Related Costs 398 399 458 459 485 486 487 488 489 Direct 92481 Direct 8845 Resid amp ittd Jays Direct Galary Direct Galang Resid ntDay 491 492 369 370 371 401 402 403 461 462 463 w BEEBEEE N o gt ax un e N S ess ole oo e D 493 Actual Bi win N gt D h de gt AIR AG A N WIL y gt gt S 8 S ee D 5 e 2 N a 495 gt ge 5 o pm gt gt He 4 aja aN y VLL I He Q N 22 zal lt 27 E hs
8. 12 Have all personal expenses been excluded from the cost report Examples direct or indirect payment for administrator s or owners employe s living quarters or expenses personal portion of company car trips conventions meals and lodging phone entertainment etc If NO please provide specific details including amounts Schedule and line on which this is recorded If YES attach a separate schedule identifying to whom amount and interest during report 13 Were there any loans notes or advances to officers employes members of the Board of Directors or owners due to the facility during the report period period Were there any loans notes or advances from officers employes members of the Board of 14 Directors or owners due from the facility during the report period If YES identify on the schedule submitted under Schedule Part item 4 ora M8 Is the facility a Continuing Care Retirement Community CCRC 17 Is it the formal or informal policy of the facility to require and admission fee on or before the date of admission Is your facility owned managed contracted or affiliated with a single entity that manages or controls two or more nursing facilities located in one or more states Identity Entity 927 15 Has an adjustment been made for those types of expenses that were disallowed in prior audits re otherwise nonallowable If YES attach a listing of the components of the entire
9. 5 23 K Allocation basis If column F 0 and column I or column J is not 1 0000 must not be blank 534 535 24 25 K basis Must be either SQ FT or ACTUAL Al A AL ALA 536 537 2627 K Allocation basis If column F 0 and column I or column J is not 1 0000 must not be blank 538 29 Allocation basis Must be TOTAL NO COST 539 540 3132 K Allocation basis Must be either SQ FT or ACTUAL 5413542 JReveme cost center column A or column B not blank or O must not be blank ost center column A or column B not blank or must not be blank Sen 30 Frere eosteenter rcotemn A or column B not blank or 0 must not be Blank 549 560 SchD 1 12 General ledger Must be whole number blank or 0 Seb 18 A era ledge Lines T 12 must linc 13 562 573 14 25 jj General ledger Must be whole number blank or 0 sb 2 A enera Teer Lines li 25 must line 26 gt Ae eg Lines 13 26 must ln 27 Must not bc Blank or 576 518 28 30 A General ledger Must be whole number blank or 0 359 sh ovni ledge Lines 28 30 must line 31 580 Sh 32 General ledger Line 27 less line 31 must line 32 Must not be blank or 0 Geeniledger Linc 33 must SchC40D L5 Generi Tedger Line 32 less line 33 must T
10. EN EN N pu N 2 276 6 4 4 4 40 4 AR 49 0 4 S 09 4 1 Q 5 Q N 2 gt gt Un il 4 rw RE E TTE E kE T T T E E ES N D LT elc o p fo po 1 x 6 L EL 64 um Nursing Facility Assessmen Depreciation nterest on Capital Indebtedness Rent of Facility Amortization Capital Costs otal Capital Costs 409 3 Cees 12221 p 13321 L nes 3 r3 Major Movable Property A 08 09 4 8 Q 4 S Q 2222929213 APPENDIX D NUMBERED COST REPORT FORMS e 75 Schedule D REVENUES AND ADJUSTMENTS TO REVENUES REVENUE GENERAL ADJUSTMENTS SCHEDULE C LEDGER TO SCHEDULE C LINE NUMBER REVENUES A B C 1 RESIDENT CARE Nursing Care Practitioners Pharmacy Prescription Drugs Over the Counter Drugs Medical Supplies Laboratory and X rays Physical Occupational amp Speech Therap Oxygen ER 14 LU 5 25 T A D 2 Kal ce ID Sv 4 or a e Exceptional DME Grant Payments Attach Schedule O qO Oo to oo po oo DO gt to po e 0 0 gt OO C ro Subtotal Resident Care Il OTHER INCOME Guest and Employe Meals Discounts Vending Machines Television Telephone Unrestricted Interest Investment Income
11. 99991111 Current Facility Name MYERS AND STAUFFER LC Cost Report Period 01 01 1999 12 31 1999 Validations Version 1 00 Assigned Audit Number 99991111 00 1999 Assigned File Name M 99991111 02022001104207 Submission ID 5361 Production Test Status Production Report Date Time 02 02 2001 10 43 16 Submission Date Time 02 02 2001 10 42 07 Status Submission Received Invalid Sequence Field SchCERT1C Description Facility Name Invalid Data MY NURSING HOME Error 639 The Provider must match the one on the Password and Connectivity document Sequence Field Description 11 costs for nonresident meals removed Invalid Data Error s 122 Valid answer 0 1 or Figure 5 10 Final Validation Report The actual time it takes to generate the Final Validation Report may depend on system activity therefore it is not necessary for you to remain on line to wait for this report You may terminate the communication connection following the instructions presented earlier in this manual If the cost report standard file was rejected this will be clearly indicated in the detail section You will need to make corrections to the cost report standard file save the corrected file and resubmit it Examples of rejection criteria include corrupted file structure invalid facility identification or incorrect cost report begin and end periods In these cases no data will be extracted Your Final Validation Report will in
12. SO Sh 6 j C Howmpid _ Lmsi 5mus fine 6 Mi amp s SdH 7 C A not blank mustmobebank 6 Sh gt C Hms7 limwt lml2 _ 7 Sh C Hompid Dws iZmwzlne 3 135 D 3 6 j D Lines T Smust Tine 54 58 73 D Howwokd Must be to column 9 i D Howwokd dEDms7 Iimwtzlmiz SO Sh D Hms6riZmwizlneis Revised 08 26 2005 6 Sh 6 72 2 873 3 874 I 1 2 Ze 2 1 xj Sh ja 2 2a 2e Number of FTEs or equivalents at year end May be blank If not blank must be whole number Number of FTEs or equivalents at year end Lines 1 5 must line 6 Number of FTEs or equivalents at year end Lines 6 12 must line 13 Valid answers 0 1 or Interest investment income offset If Line 1 NO Number of FTEs or equivalents at year end May be blank If not blank must be whole number Number of FTEs or equivalents at year end Lines 7 11 must line 12 TLimel NO IfSchli
13. 1273 1277 SchL End of prior period May be blank If not blank must be whole number If SchLcompleted 0 po s 1278 uyU Endofprior period Lines 5 must line 6 If SchLcompleted 0 must be blank 1279 1282 SchL End of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 123 Sh End of prior period Lines 7 10 must line 11 If SchLcompleted 0 must be blank 8 of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1285 Endofprior period Line 11 less line 12 must line 13 If SchLcompleted 0 must be blank 1286 1287 SchL of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 128 Sh l of prior period Line 6 13 14 15 must line 16 If SchLcompleted 0 must be blank us sr 1292 2n 84 of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1203 Sh End of prior period Lines 17 20 must line 21 If SchLcompleted 0 must be blank 1296 7 04 of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1297 B J Endofprior period Lines 21 24 must line 25 If SchLcompleted 0 must be blank 1298 1303 SchL 2631 End of prior per
14. 43 4 3132 T Nursing facility allocation percent L0000 less column J If not blank or O must be rounded to 4 decimas rounded to 4 decimals Must be blank or 0 if Column H blank or zero 493 494 SchC 10 11 pum cue e EM If Column H not blank or zero must be Column H divided by Column F rounded to 4 decimals Must be blank or 0 if Column H blank or zero 495 501 SchC 13 19 J Residential and other allocation percent If Column H not blank or zero must be Column H divided by Column F 502 508 SchC 21 27 J Residential and other allocation percent If Column H not blank or zero must be Column H divided by Column F SchC 29 Lu a eu c If Column H not blank or zero must be Column H divided by Column F rounded to 4 decimals Must be blank or 0 if Column H blank or zero 510 511 SchC 31 32 J Residential and other allocation percent If Column H not blank or zero must be Column H divided by Column F S P S si rounded to 4 decimals Must be blank or 0 if Column H blank or zero eoe SC jJ ir Oj se 8 K Al ALA ws si T 320 536 5 K Alleation basis Must not be blank Alloation basis Must be either SQ FT ACTUAL T 1 Tx Allocation basis Must not be blank 529 530 18 19 K Allocation basis f column F gt 0 and column I or column J is not 1 0000 must not be blank 531 532 2122 K Allocation basis Must not be blank
15. A Start Copying Files window will appear showing the settings you have chosen Select the Install button A setup window will appear showing the progress of the installation Then it will flash the Netscape Communicator folder on the screen and go directly to the setup window showing the progress of the ShivaRemote setup These may take several minutes depending on the size of your PC and the speed of your CD ROM drive When this is complete a message box will appear asking if you want to set up the modem s now Select the Yes button A question box will appear asking Do you want to set up the modem s now Select Yes The modem setup window will appear There is a check box next to an option that states Don t detect my modem let me specify it If you leave that check box blank the system can look for your modem and specify it for you Select the Next button The next modem setup window will display the name of the modem detected The name will be as uniquely identified as possible If more than one name is provided select the name which most accurately identifies your modem If necessary you may select the Change button and choose from the list provided to more accurately identify your modem Select the Next button The final window for modem setup will appear You may select the Back button to go back and change any previous settings Select the Finish button if you are satisfied with the settings you selected A message box
16. To submit your cost report standard file point and click on Submit MA 11 Cost Report Data on the MA 11 Cost Report Main Menu The MA 11 File Submission window includes instructions and information about submitting cost report standard files and a data entry field for the name of the cost report standard file Figure 5 6 on page 16 MA 11 File Submission Netscape 11 Cost Report File Submission Select the COST REPORT file to submit by pressing the Browse button and choosing a file from your computer to send Once you have selected a file press the Send button to upload the file Some initial validation checks will be performed on the COST REPORT file and an Initial Validation Report will be displayed The full validation process may take some time so it is suggested that you log off system and check back for your full Validation Report later To get your validation report select Receive Validation Reports from the 11 Cost Report Submissions main menu Name ofthe Cost Report Retum to MA 11 Cost Report Submissions main menu Figure 5 6 MA 11 File Submission Window MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 16 Be sure and save your file prior to selecting it for submission Revised 08 26 2005 You have two options for entering a cost report standard file name If you know the cost report standard file name you may point a
17. 0 must not be blank If nor blank must be whole number sh 2t j J roameas T WValidanswers0 1orNA Personal laundry expense removed Valid answers 0 1 or NA If SchI3 1 or NA must be blank or 0 If SchI3 0 must be gt 0 If not Fi 7 885 Schl 3a If Line 3 NO blank must be whole number Capital assets greater than 500 expensed Valid answers 0 1 or NA Administrative expenses in other cost centers Valid answers 0 1 or NA ao 888 SchI og bL Facility maintains residential and other areas not reported on Valid answer 0 or 1 If SchI6identify not blank must be 1 cost report 59 Sh 6 ldenityresidenialandoheraras T muxmotbebunk 9 Sh 7 j square footage of facihiy 3 Sh 8 S Nowlowslcotcmes E 39 Sh 8 dmy denifynomalowablecostcemers fSehlS imuxnotbeba O C 393 Sh Sa j ______ Square footage of nonallowable costcenters ISeh I mustnotbe blank 894 Schl Indirect costs for nonallowable cost centers eliminated on Valid answers 0 1 or NA Schedule E 395 3 Sdi Wah Administrator salary Mexbewhoemumberbunkor 903 910 Sci i i 5 Admiismauorfingebenc Must be whole number blankor0 oO o 91 918 Sci I C Admimsrat
18. Bookmark Browser Cost Report Standard File Department Dialer Download Internet Internet Explorer Internet Service Provider Intranet Login ID MA 11 Cost Report Submission System Modem Nursing Facility PC URL Web Site Definitions for these terms are found in Section 9 Internet Explorer can be used in place of Netscape when submitting cost report standard files However instructions for Internet Explorer are not provided with this manual Given the number of nursing facility users and potential variations of systems e g stand alone networked those with Internet connections those with Netscape those with Internet Explorer this version of the end user s manual will include only very basic instructions for setting up Netscape For further instructions please refer to the Installation and Setup Guide for Netscape We encourage you to work with your software vendors for Netscape Windows and the MA 11 software and any system or network administrators who support your facility to achieve the required configuration for the MA 11 Cost Report Submission System WINDOWS 3 X SET UP INSTRUCTIONS FOR NETSCAPE Note These instructions should be used if you do not have Netscape already installed on your PC you do not have Internet access and you plan to use the Intranet dial up method to connect These instructions are based on having your modem physically installed 1 Logon to your PC and access Windows 2 Insert the C
19. NLD on C Y Miscellaneous If any line 20 25 greater than 500 provide separate detail with source amp amounts N gt D D N 4 Subtotal Other Income TOTAL GROSS REVENUES Add Lines 13 amp 26 Il DEDUCTIONS FROM REVENUES Uncollectible Accounts Contractual Adjustments N 2 N i o 4 4 4 4 4 E B p ooN fo N B i E 2 O ee 69 N NIN Sj qo oo Subtotal Deductions NET REVENUE Line 27 minus Line 31 LESS EXPENSES Sch C Line 40 Column D NET INCOME LOSS TOTAL SCHEDULE D ADJUSTMENTS TOTAL SCHEDULE E ADJUSTMENTS TOTAL ADJUSTMENTS oO Co lt gt Co o a Co fo APPENDIX D NUMBERED COST REPORT FORMS e 76 ADJUSTMENTS TO EXPENSES EXPENSE ADJUSTMENTS SCHEDULE C TO SCHEDULE C LINE NUMBER EXPENSES A B 1 NONALLOWABLE COSTS Direct Facility Payments Nonstandard or Nonuniform Fringe Benefits Employe and Guest Meals Taxes Free Care or Discounted Services Other Interest Personal TV B e gt IG 5 lc 5 Attach Schedule e 2 27 l EXPENSES NOT NECESSARY TO RESIDENT CARE Travel Entertainment Dues and Subscriptions Promotional Advertising Line 4 nel e fo n ll EXPENSE ADJUSTMENTS
20. Supporting Documents and Manual Review These validations are created by the Department in order to provide consistency completeness and greater accuracy in reporting validations must be passed prior to acceptance of the cost report Web Browser browser A software application used to locate and display web sites The two most popular browsers are Netscape Navigator and Microsoft Internet Explorer Web Page A World Wide Web document Web Site A site location on the World Wide Web Each web site contains a home page which is the first document users see when they enter the site The site might also contain additional documents and files Each site is owned and managed by an individual company or organization The MA 11 Cost Report Submission System web site was developed by Myers and Stauffer under contract with the Department World Wide Web A vast series of documents called web pages or web documents that are linked together over the Internet This means you can jump from one document to another simply by clicking on hot spots Not all Internet servers are part of the World Wide Web There are several applications called web browsers that make it easy to access the World Wide Web Two of the most popular being Netscape Navigator and Microsoft s Internet Explorer MA 11 COST REPORT SUBMISSION SYSTEM SECTION 9 GLOSSARY 53 Revised 08 26 2005 APPENDIX A NETSCAPE INSTALLATION Glossary Terms Used In This Section
21. e Appendix B Downloads contains instructions for downloading cost report update files Appendix C Accepted MA 11 Cost Report Data describes how to download cost report data that has been accepted by the Department for any provider Appendix D Numbered Cost Report Form contains a cost report that ties each data entry field to a sequence number in the cost report Standard File validations CONVENTIONS USED IN THIS MANUAL This manual uses the following conventions Bold Identifies words characters or commands that a user types in a window or key strokes Underlined Identifies the title of a link to another window Italics Identifies directory path file or field names or book titles Point Move the mouse until the tip of the mouse pointer rests on what you want to choose on the window such as in a field or on specified text Click Press and release the left mouse button without moving the mouse to select an item or execute a desired activity such as going to another window Double Click Click the left mouse button twice in rapid succession to select a file or execute an activity Right Click Click the right mouse button once and select the option referred to in this manual Icons Icons for specific software functions are used where applicable and available e g the Netscape Navigator icon MA 11 COST REPORT SUBMISSION SYSTEM SECTION 1 INTRODUCTION 2 Revised 08 26 2005 SECTIO
22. 0 mustbeblan 1209 1222 SchK 1 14 H ownership in nursing facility Valid answer blank or gt 0 lt 1 0000 If not blank or 0 must be rounded to 4 decimals If SchKcompleted 0 must be blank MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 37 C E F H I J A A C C 1 1 1 1 1 1 1 15 STANDARD FILE VALIDATION Revised 08 26 2005 1 YES 0 NO SEQUENCEF SCHEDULE LINE COLUMN FIELDNAME DESCRIPTION OF COST REPORTELEMENT VALIDATION D 1236 SchK 1 14 ownership in related business Valid answer blank or gt 0 lt 1 0000 If not blank or 0 must be rounded to 4 decimals If SchKcompleted 0 must be blank 1237 31 schLcompleted Is Schedule L completed Valid answer 0 or 1 1238 Sch 2 j identify Identify allowance for accounts and notes receivable May be blank If SchLcompleted 0 must be blank 1239 Identify inventories priced at If SchL3A not blank must not be blank If SchLcompleted 0 must be blank 1240 1244 SchL End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1245 Sh Endofcurent period Lines 1 5 must line 6 If SchLcompleted 0 must be blank 1246 End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1250 End of current period Lines 7 10 must line 11 If SchLcomplete
23. 11 or as soon as each is available Submit a copy of the combining detail trial balance and any other appropriate supporting documentation used to prepare the MA 11 This trial balance must show all general ledger account ending balances It must indicate the groupings of accounts to agree to the line item totals reported on Schedules C and D Submit a schedule of plant property and equipment additions for the report period This schedule should account for property plant and equipment reported on the Comparative Balance Sheet Schedule L and Depreciation Schedule F Include the following information for each asset acquired during the reporting period Item description Date acquired Cost or other depreciable basis Current annual depreciation Life and method of computing depreciation Provide a separate detailed schedule of deletions for the report period providing date of disposal and sales or disposal price Provide a separate detailed schedule to support major movable property reported on Schedule C Major movable property purchased item additions including acquisition date number of units property description unit acquisition cost and total acquisition cost Major movable property purchased item deletions including deletion date number of units property description original acquisition cost acquisition date AHA Life proceeds from sale or disposal remaining book value and total offset Major movable property rent
24. Cost Report Submission System web site is also accessible to the general public in order to download or view informational documents and accepted cost report data To access and use the area of the MA 11 Cost Report Submission System web site that is accessible to the general public a Login ID and a password is requested by the system if using the dial up connection method of access Follow the instructions beginning in Section 5 ESTABLISHING THE WEB SITE CONNECTION on page 11 to initially access the web site The Login ID for the dialer window is Guest leave the password field blank When accessing the system through the Internet you do not need a Login ID and password to access the public area of the MA 11 Cost Report Submission System COST REPORT STANDARD FILE If you are using the Excel spreadsheet template option see Appendix B for instructions on obtaining the spreadsheet template and Section 4 for data entry instructions The Department has specified a standard file format to be used when submitting cost report data to the MA 11 Cost Report Submission System Data submitted in any other format will be rejected by the system The cost report standard file format is best described as a column of data with each row or record containing the response to each question or data item on the MA 11 cost report schedules The facility may submit either of two types of cost report standard files a spreadsheet file or a text file For the spr
25. Definitions for these terms are found in Section 9 This appendix displays the sequence number for the cost report forms MA 11 The sequence number ties with the Standard File Validations in Section 6 and may also be used as a data entry tool when using the Excel spreadsheet template MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX D NUMBERED COST REPORT FORM e 71 FINANCIAL AND STATISTICAL REPORT FOR NURSING FACILITIES AND SERVICES o UNDER THE MEDICAL ASSISTANCE PROGRAM OF THE Certification Schedule DEPARTMENT OF PUBLIC WELFARE COMMONWEALTH OF PENNSYLVANIA TU gt A ZI COST REPORT AND FACILITY INFORMATION DESCRIPTION LOGIN D EEN ENHSESNNENESEE TEST T or F I2 a 2 FACILITY NAME MA NO REPORT BEGIN DATE REPORT END DATE PART Il PREPARER INFORMATION LINE QUESTION 2 Bi 2a COST REPORT PREPARED BY If Other than Facility 7 2b PREPARER S FIRM NAME If Applicable 8 2c FIRM TELEPHONE NUMBER 9 PART Ill CERTIFICATION STATEMENT Facility Officer or Administrator and Preparer if applicable must sign this statement on the Certification Report MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY FINE AND OR IMPRISONMENT UNDER STATE OR FEDERAL LAW CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER S I hereby certify that have read the above statement and that have examined the accompany
26. I want to set up communicator to access my account An Internet Service Provider window will appear Use the scroll bar on the right side of the list to scroll to the bottom Select None of the above Select the Next arrow at the bottom of the window An information window will appear telling you what you will need to know to fill in the options on the following window Select the Next arrow at the bottom of the window A window will appear asking for information about you Enter your first and last name Organization is optional Select the Next arrow at the bottom of the window A window will appear asking for the account access phone number Enter the phone number provided by the Department 717 541 5806 Select the Next arrow at the bottom of the window A window will appear asking for your account login and password This information has been provided to you by the Department Enter your login name and password You mustenter the password in both password locations Select the Next arrow at the bottom of the window A window will appear asking for your E mail login and password This is not needed for MA 11 Cost Report Submission System purposes Select the Next arrow at the bottom of the window A window will appear asking for your provider s mail and news servers This is not needed for MA 11 Cost Report Submission System purposes You may leave this information blank The information entered on the previous window w
27. Report Submission System 16 17 18 19 20 21 22 23 24 25 26 MA 11 COST REPORT SUBMISSION SYSTEM After logging back into your computer and accessing Windows select Start Programs Netscape Communicator Netscape Account Setup You may receive a window indicating Netscape can no longer be launched from a shortcut and asks if you want to use Netscape as your default browser You may select Yes or No The Netscape Account Setup window will appear Select the icon next to Start Account Setup It takes a few minutes for the entire window to be displayed A series of six information windows will appear in succession Select the single Next arrow at the bottom of each window after reading the information After the information windows an Account Setup window will be displayed Select the icon next to the option I already have an Internet account I want to set up communicator to access my account An Internet Service Provider window will appear Use the scroll bar on the right side of the list to scroll to the bottom Select None of the above Select the Next arrow at the bottom of the window An information window will appear telling you what you will need to know to fill in the options on the following window Select the Next arrow at the bottom of the window A window will appear asking for information about you Enter your first and last name Organization is optional Select the Next arrow
28. System This is a statewide sequential number tracking the number and order of cost report standard files that are submitted to the MA 11 Cost Report Submission System Batch Submission Type The type of cost report standard file Excel File Lotus File or submitted Text File Production Test Status Indication of whether the cost report Production or Test standard file was submitted as a test or if it is a production file in which the data is stored by the system Report Date Time The date and time the report was Date and Time to the generated by the MA 11 Cost Report nearest second Submission System Submission Date Time The date and time the cost report Date and Time to the standard file was uploaded to the nearest second MA 11 Cost Report Submission System by the facility Status Indication of whether the submitted Initial Submission cost report standard file was received Received successfully and if received Final Submissi inal Submission successfully if the cost report Received Invalid or standard file was invalid or valid Submission Received Valid Sequence The cost report sequence number of Numeric each error found in the cost report standard file These correlate with the numbered Cost Report beginning on page 71 The code for the field in error Form Location Code Invalid Data The actual data value submitted MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTAB
29. VALIDATION Revised 08 26 2005 1 YES 0 NO SEQUENCE SCHEDULE COLUMN FIELDNAME DESCRIPTION OF COST REPORT ELEMENT VALIDATION ia jom o Login ID as on the Password and Connectivity document CRT ie J Tes TorD 3 CE c powam Mst be name as listed on the Password and Connectivity document document Hr i ese Rept begin date Mt valid date lt CERTenddate 6 cr I eue Repotenddue valid date gt CERTbegdate and less than todays date 7 2a j msn __ Costreportpreparedby O O O O Maye 3 Hr 25 mms Preparer s irmname Maybebak s 9 CE X m Fmmteephonemumber May be blank I CERTfirmname not blank must be a I0 digi number 10 CERT 4a imemmame Name of Medicare intermediary May be blank If MAS8 2anot blank or 0 must not be blank 11 SchA approvedas Approved as Must be 1 4 If SchAapprovedas 2 must be Hospital based for case mix rates If SchAapprovedas 4 must be provider specialty type 31 12 SchA typeorg of organization Must be 1 6 If SchAapprovedas 4 must 6 If SchAapprovedas 1 2 or 3 must not 6 13 la Beds available at beginning of period Nursing Facility Must be 1500 Changes in total beds during period Nursing Facility Must be gt 5
30. a Medicare Home Office cost Required if SchI18 1 report this report and the intermediary audit report with adjustments must be submitted with the MA 11 at audit or when available 27 Sch line 15 Schedule ofrelated party profit s reported on any additional lines greater than 14 to support an entry of other than blank or zero on Schedule Required if SchK15C lt gt 0 or blank BUNC cd occ consed did 28 Sch line 16 Schedule of related party profit s to support an entry of other than blank on Schedule K line 16 Column C See Instructions for Schedule K for Required if SchK16C lt gt blank unos e nr TU 29 Financial Facility specific financial statements to support a response of to Schedule L Completed Schedule F line 11 column B less column C Required if Schedule L Completed Statements must equal net book value on the financial statements If the net book value does not agree an explanation of the discrepancy must be submitted with the financial statements 30 Sch L line 30 Schedule to support other R E account transactions on Schedule L line 30 Required if SchL30A 0 or blank and Schedule L Completed and SchAapprovedas lt gt 2 or 4 Sch line 6 Schedule of detailed list of assets purchased to support amount reported on Sch M line 6 Col B Required if SchM6B lt gt 0 or blank Sch M line 8 Schedule of specific details of loans receivable to
31. at the bottom of the window A window will appear asking for the account access phone number Enter the phone number provided by the Department 717 541 5806 APPENDIX A NETSCAPE INSTALLATION e 58 27 28 29 30 3 32 33 34 35 36 37 38 39 40 41 42 43 MA 11 COST REPORT SUBMISSION SYSTEM Revised 08 26 2005 Select the Next arrow at the bottom of the window A window will appear asking for your account login and password This information has been provided to you by the Department You must enter the password in both password locations Select the Next arrow at the bottom of the window A window will appear asking for your e mail login and password This is not needed for MA 11 Cost Report Submission System purposes Select the Next arrow at the bottom of the window A window will appear asking for your provider s mail and news servers This is not needed for MA 11 Cost Report Submission System purposes You may leave this information blank The information entered on the previous window will be displayed You may leave that information or delete it and leave those entries blank Select the Next arrow at the bottom of the window A window will appear asking for your provider s domain and DNS servers This is not needed for MA 11 Cost Report Submission System purposes You may leave this information blank Select the Next arrow at the bottom of the window A window will app
32. must first in place of Netscape as a ensure that a web browser has been correctly installed Installation instructions browser when submitting cost should have been provided by the respective vendors however some coordination report standard files with your system or network administrator may be required of the PC However instructions for equipment including the modem should be turned on before you access Netscape Internet Explorer are not There are two methods of establishing a connection with the MA 11 Cost Report provided with this manual Submission System an Internet connection or an Intranet dial up connection Internet Instructions If you are able to connect to the Internet you may connect to the system using the address http www pamall com Once you have connected to the system continue to follow the instructions under WEB SITE OPTIONS on page 13 You can configure Netscape so that you do not have to type in the address each time you wish to connect to the system by creating a bookmark Appendix A contains instructions on creating a Netscape bookmark If you do not have Internet access you must follow the instructions for the Intranet dial up connection below MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 11 Revised 08 26 2005 Intranet Dial up Instructions If you have an Internet service provider and have already completed Internet Instructions on pa
33. pmizu nas nias 1192 1220 1234 11221 11149 1193 1221 1235 mm EE 1151 k Co x a T lt pes E N Line 15 Total Column C Profits from any additional Schedule Leave blank if no additional lines greater than 14 are needed Line 16 Total Profit for Schedule in Column C Must agree with Schedule E Line 20 Column A APPENDIX D NUMBERED COST REPORT FORMS e 86 Schedule L Code YES as 1 NO as 0 SCHEDULE L COMPLETED 1 J 7 COMPARATIVE BALANCE SHEET LINE CURRENT PERIOD PRIOR PERIOD ii A B CURRENT ASSETS Accounts and notes receivable Less allowance 38 2 PROPERTY PLANT AND EQUIPMENT 1279 Total property plantand equipment Jan usa y y Less accumulated depreciation 2 psu mod _ Net Property Plant and Equipment daa 12522 rm1285 ooo OTHER ASSETS Other assets n dw mesa 27 tis 255 0288 CURRENT LIABILITIES 1289 O nass Deferredincome o eoo moo Y Total Current Liabilities ty L LONG TERM LIABILITIES 22 Notespayable Ci 262 295 Other id 10263 296 CAPITAL Owner s equity proprietary or p
34. report data submitted by the facility or their cost report preparer Internet Explorer can be used The MA 11 Cost Report Submission System may be accessed using one of two in place of Netscape as a methods For users that have access to the Internet the facility may transmit a cost browser when submitting cost report standard file using a web browser to access and to login to the Internet web report standard files site If a user does not have an Internet service provider the web site may be However instructions for accessed directly using a dial up connection and web browser Either method of Internet Explorer are not access to the MA 11 Cost Report Submission System is acceptable provided with this manual MA 11 COST REPORT SUBMISSION SYSTEM SECTION 3 OVERVIEW 4 Revised 08 26 2005 To submit a cost report standard file the user is issued a Login ID and password by the Department These Login IDs and passwords are facility specific and allow a provider to submit cost report standard files and access validation reports only for that facility They do not allow the facility to submit cost report standard files or access validation reports for any other facility For facilities using an accountant s or other third party services for the submission process the facility must provide their Login ID and password information to that party In addition to providing the ability to electronically submit the cost report standard file the MA 11
35. right corner of the window to try connecting later An icon is created in the Netscape Communicator folder with the login ID used You may double click that icon then select the Connect button whenever you want to connect to the MA 11 Cost Report Submission System Refer to Section 5 for information on submitting cost report standard files WINDOWS 95 SET UP INSTRUCTIONS FOR NETSCAPE Note These instructions should be used if you do not have Netscape already installed on your PC you do not have Internet access and you plan to use the Intranet dial up method to connect These instructions are based on having your modem physically installed and the modem driver installed l 2 3 MA 11 COST REPORT SUBMISSION SYSTEM Logon to your PC and access Windows Insert the CD for Netscape Communicator Internet Access Edition Within Windows select Start Run Enter D setup exe and select OK If D is not the correct letter identifying your CD ROM drive please substitute the correct letter When the Netscape Communicator opening window appears click on the icon next to the Netscape Communicator It is not necessary to install the bonus plug ins for MA 11 Cost Report Submission System purposes When the Netscape Communicator Internet Access Edition Setup window appears select the Next button After reviewing the software license agreement select Yes The Setup Type window will display the default setting for a TYPICAL setup and the
36. standard file Assistance in accessing saving or opening the files available using the Downloads and Accepted Cost Report links Every effort will be made to answer the caller s question promptly If the helpdesk representative is unable to answer the caller s question the helpdesk representative will take the caller s name and phone number and research the question The caller will be contacted when a response is determined PROBLEMS NOT SUPPORTED Some problem areas will not be supported by the Myers and Stauffer Helpdesk because they are the responsibility of other entities or are outside of the cost report standard file submission arena MA 11 COST REPORT SUBMISSION SYSTEM Questions regarding programs that have been developed internally by the provider or purchased for use to complete the MA 11 This includes running the program creating the cost report standard file transmitting the files and any errors within the program Technical support must be provided to the facility by the vendor Support for installation of hardware devices modems printer etc Support for Netscape or Internet Explorer other than what has been detailed in this manual Questions regarding interpretation of the MA 11 instructions or reporting requirements These questions should be directed to the Department at 717 787 1171 SECTION 8 HELPDESK 48 Revised 08 26 2005 SECTION 9 GLOSSARY COMMON TERMS AND ABBREVIATIONS This manual sectio
37. will appear asking if you want to view the readme txt You may select No to bypass this An information message box appears stating setup is complete Select the OK button A message box appears asking if you want to restart Windows You must restart Windows before you can use the Netscape Communicator The option Yes I want to restart my computer now is the default Select the OK button Note The Netscape installation has now been completed The remaining instructions will set up an account for Intranet dial up access to the MA 11 Cost Report Submission System 22 MA 11 COST REPORT SUBMISSION SYSTEM After logging back into your computer and accessing Windows double click on the Netscape Communicator program group APPENDIX A NETSCAPE INSTALLATION e 55 23 24 25 26 27 28 29 30 3 32 33 34 35 36 37 38 39 40 41 42 43 MA 11 COST REPORT SUBMISSION SYSTEM Revised 08 26 2005 Double click on the Netscape Communicator icon The Netscape Account Setup window will open Select the icon next to Start Account Setup It takes a few minutes for the entire window to be displayed A series of six information windows will appear in succession Select the Next arrow at the bottom of the window after reading the information After the information windows an Account Setup window will be displayed Select the icon next to the option I already have an Internet account
38. 00 and 500 15 5 ibb A Ts Changes in total beds during period Nursing Facility Must be 500 and 500 16 SA Ibe A JChangesintotal beds during period Nursing Facility Must be 500 and 500 17 Sha A JChangesin total beds during period Nursing Facility Must be gt 500 and 500 18 Sha J Beds available at end of period Nursing Facility Must SchA1aA SchAlbaA SchA1bbA SchATbcA SchA1bdA 11 Sh 2 A Beddaysavailble for period Nursing Facility Must be 10 of available bed calculation See example 20 5 3 J A Acta resident days for period Nursing Facility Must be lt SchA2A 854 4 OA Pests SA rounded decimals ex 5585 eere 22 Sh 5 gResidentdaysat9096 occupancy May be blank or whole number If not blank must SchA2A X 90 seh 5 foni MA resident days of care Must be lt SchA3A 24 SchA la Beds available at beginning of period Residential and Must be 1500 Other B Changes in total beds during period Residential amp Other Must be gt 500 and lt 500 26 5 B JChangesintotal beds during period Residential amp Other Must be gt 500 and lt 500 27 SchA ibe J B JjChansgesin total beds during period Residential amp Other Must be gt 500 and lt 500 28 SchA B JChangesi
39. 11 111 Another option for easier access to the MA 11 Cost Report Submission System is to use the Netscape function of establishing a bookmark A Netscape bookmark is a placeholder or tag that allows you as with a book to go directly to a specific page where you have been before l 2 3 Access Netscape Enter the correct URL in the Location or Go To field Move the cursor to the Bookmarks pull down menu Select Add a Bookmark If you have not previously added a bookmark this will be the first one on the list that will appear whenever you view the Bookmarks pull down menu Type a name for the bookmark Once you have established this bookmark you can select this item by choosing this name from the Bookmark menu NETSCAPE COMMUNICATOR OPTIONAL SETUP You may set Netscape Communicator to automatically display the Cost Report Welcome Page as the first screen to appear when you access Netscape and eliminate the need to enter the URL each time you access Netscape To do so l 2 3 4 Access Netscape Move the cursor to the Edit pull down menu and select Preferences Click on the Home Page radio button and enter the URL specified in Section 5 of this manual in the Location box This will be http 111 111 111 111 Click the OK button tosave changes Another option for easier access to the MA 11 Cost Report Submission System is to use the Netscape function of establishing a bookmark A Netscape bookmark is a placeh
40. 3 2001 99991111 02132001121619 init htm 02 13 2001 99991111 02132001092349 FINAL HTM 02 13 2001 M 99991111 02132001092349 init htm 02 13 2001 MA99991111 02132001091441 FINAL HTM 02 13 2001 MA99991111 02132001091441 init htm 02 13 2001 Figure 5 11 Validation Report Listing Window This window lists all reports beginning with the most recently generated report The reports are identified by the Assigned File Name followed by FINAL for Final Validation Reports init for Initial Feedback Reports and CERT for Certification Reports In order to access a report simply point and click on the underlined file name When you are done point and click on main menu at the bottom of the window to return to the MA 11 Cost Report Main Menu If you would like to save a report from this screen point and click your right mouse button on a specific underlined report title and then select Save Link As from the pop up menu If your computer or the computer designated for cost report submissions is connected to a printer you can select Print from the Netscape File menu to print a copy of the Final Validation Report You may also select Save As from the Netscape File menu and save the report to a floppy disk or your hard drive It is recommended that a copy of all Final Validation Reports be printed for reference in troubleshooting errors Interpreting Initial Feedback Report and Final Validation Report The Initial Fee
41. 7 Revised 08 26 2005 ET rtersesft Excel Al lw l amu ata ote lal xi TS te td Dee pet Pyre Dock Qe k o Convert Adon tiei E afi xi BLU EZuBex u0w A Al zs balan B C D B 2 ECHALNESCCLUME DEECCIDTION AUDATION LENCT SERTIa Loge IE Must be valid login D as Hstod on the Pasrwon ond p 2 Connectwty docurert 2 CERTIb Test T at FY be Toc T dentes teat date F desctes 3 ko daa J ran mme Mut be rome listed on the Pasrened and 4 Conmitiwty dat urrart 1 SERTId MAA nter Must bo tho prosdor eo 00104 en the sr Conewectrety b Report begn data be valid dais lt CERTen date CERT f n 5 Report and dat Must bo said gt CERTboodaM CERT TO 1 tran toetyy s dte Cast prepared by other ihon Nery Oe bark 70 8 tik 5 4 arm rome f appbrable May be blank 3 C 2 Fien number My De f nn name sot must ov 10 0 p d Nare cane inberrmecdi Nowy be blank Js fled care ratei sci blk ar n nist sot be Bhat n Aap dac g proved as Must be 1 4 Ht Sch amp pponedos 2 wast de Horpitakhwesd dor mie rte V ScbAacproved ae 2 4 must be prov dor 1 pe 35 12 Atypeorg Type of ongaelzaier Must be 1 6 V SchAappiovedes 4 must 6 13 Ech agprrvedas 12 013 must net Alat Bets a
42. 93 1053 1068 5 965 995 1055 1070 0 1011 1056 1071 1101 e 968 998 1073 1014 1059 1074 1104 0 970 1000 1060 1075 12 971 1001 1076 1106 13 973 1003 1018 1063 1078 Hm z o EN B mM m o o r9 _ lt lt B ES N Oo N N e E A U N Co N p eic A A o APPENDIX D NUMBERED COST REPORT FORMS e 85 FACILITY TRANSACTIONS WITH RELATED PARTIES Code YES as 1 NO as 0 SCHEDULE K COMPLETED 1 09 sii Owner s i Position EIN Ownershipl Ownership Schedule C Schedule C Service or or of Related in Nursing in Related LINE Line Amount Supply Name of Related Business SSN Business Facility Business No A B D H i ce E G me mm mm TRANSACTIONS WITH RELATED PARTIES ARE INCLUDED IN z o N X 55 E mm mur na mss fuze 1230 1132 1145 1189 1217 1231 1119 1133 1146 1190 1218 1232 1120 1147 1191 1219 12331
43. A1bcA or SchA1bcB not blank or 0 must be valid date gt SchA1bbD aR A A MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 31 STANDARD FILE VALIDATION Revised 08 26 2005 1 YES 0 NO VALIDATION SchA Date of Change for Total Beds during period If SchA1bdA or SchA1bdB not blank or 0 must be valid date gt SchA1bcD and lt CERTenddate pen 44 55 SchB 1 12 A Resident days of care month Must be month within CERTbegdate and CERTenddate All months within CERTbegdate and CERTenddate must be entered Must not be duplicate months Months must be coded in numeric format 56 67 1 2 B Resident days of care NF MA Must be blank if column A is blank SchB 13 Resident days of care NF MA Line 13 must lines 1 12 Column B C D E must SchA6A Column B C D E F G must SA3A 69 80 Sh 1 2 C Resident days of care NF Must be blank if column A is blank 81 SchB 13 C Resident days of care NF MA MCO Line 13 must lines 1 12 Column B C D must SchA6A Column B C D E F G must SchA3A 82 93 Sh 1 2 D Resident days of care NF MA LTCCAP Must be blank if column A is blank 94 SchB 13 Resident days of care NF MA LTCCAP Line 13 must lines 1 12 Column B C D E must SchA6A Column B C D E F G must SchA3A 95 106 S amp B 1 2 E JResdentdays of care NF MA Hospice Line 13 must lines 1 12 107 SchB 13 E Re
44. Commonwealth of Pennsylvania Department of Public Welfare Office of Medical Assistance Programs Bureau of Long Term Care Programs Division of Nursing Home Rates P O Box 2675 Harrisburg PA 17105 2675 OR The Certification Report and all supporting documents should be delivered to Commonwealth of Pennsylvania Department of Public Welfare Office of Medical Assistance Programs Bureau of Long Term Care Programs Division of Nursing Home Rates Bertolino Building 6 Floor 1401 North 7 Street Harrisburg PA 17102 Filing Deadlines The MA 11 Cost Report Submission System does not alter Chapter 1187 80 regulations concerning failure to file a cost report The following situations are defined to illustrate this 1 Ifa facility has submitted a valid cost report standard file to the MA 11 Cost Report Submission System and the Certification Report and all supporting documents have been received by the Department on or before the 120 day and deemed acceptable by the Department the cost report is timely filed and acceptable The receipt date recognized by the Department is the date the Certification Report and supporting documents are received at P O Box 2675 or are received and stamped in by the Division of Nursing Home Rates as of the close of business at 5 P M 2 Ifa facility has submitted a valid cost report standard file to the MA 11 Cost Report Submission System and the Certification Report and supporting documents have b
45. D for Netscape Communicator Internet Access Edition 3 Within Windows select File Run 4 Enter DAsetup exe and select OK If D is not the correct letter identifying your CD ROM drive please substitute the correct letter 5 When the Netscape Communicator opening window appears click on the icon next to the Netscape Communicator 6 When the Netscape Communicator Internet Access Edition Setup window appears select the Next button 7 After reviewing the software license agreement select Yes 8 TheSetup Type window will display the default setting for a TYPICAL setup and the default destination directory of C Netscape comm You may leave those default settings and select the MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX A NETSCAPE INSTALLATION e 54 10 11 12 13 14 15 16 17 18 19 20 21 Revised 08 26 2005 Next button It is not necessary to install the bonus plug ins for MA 11 Cost Report Submission System purposes If the C Netscape comm directory does not exist you will be prompted to see if you want it to be created Select the Yes button An information window is displayed regarding Video for Windows That is not required for MA 11 Cost Report Submission System purposes Select the OK button A window will display asking you to identify a name for the program group Netscape Communicator is the default name Select the Next button to accept the default name for the folder
46. F 0 must nor be Blank U G Sh 21 Ewews IfShE2IA nobank or 0 must not be Blank Sh 36 Fie xpenises HSchE2 Amobankor mutnobebnk 63 65 SmE 125 X Expense adjustments to Schedule Mast be whole mimber blankor0 o 69 Sh 27 A Expense adjustments to Schedule C Lines 26 must line 27 and must SchD35B 670 80 SdE 2 12 B SheddeClnemmbe lrcolummAmorblankor mustnotbe blank 8 603 se 14 26 SeheduleClinemmber IF column A notblank or 0 must not be blank 64 Sh 4 Propery plan amp equipmem IF column blank or 0 must not be blank 695 696 ser 9 10 desripion Prowery plam amp equipmem lcolummFmotblankor must not be blank 607 00 L4 A ___ Dateacquired B gt 0 mutmobeban 701 53 SchF 6 A B gt 0 mutmobeblan 704 705 Schk 3 0 A Dweweied Maybebak 706 79 Sc 14 p Cosoromerbas Mestbewholemumberblmkor ncs E s line 1 Re Cost or oer basis Liner and 6
47. ILITY PROCESS 22 Revised 08 26 2005 REPORT FIELD DESCRIPTION VALUES Error s Text information about the error s that were encountered for the corresponding field If the cost report standard file was rejected the report will clearly state FILE REJECTED and provide the reasons for the rejection The error messages that can appear in the detail section of the Final Validation Report are contained in Section 6 of this manual Any errors that appear on the validation reports must be corrected for the cost report standard file to be valid Certification Report If no errors are found in a submitted cost report standard file the Final Validation Report will state this finding and prompt the facility to print the Certification Report see Figure 5 12 on page 23 Z Netscape CERTIFICATION REPORT Page 1 of 5 Login ID MA99991111 Current Facility Name MYERS AND STAUFFER LC Cost Report Period 01 01 1999 12 31 1999 Validations Version 1 00 Assigned Audit Number 99991111 00 1999 Assigned File Name M 99991111 02092001102537 Submission ID 5408 Report Date Time 02 09 2001 10 27 15 Submission Date Time 02 09 2001 10 25 37 Status Submission Received Valid ADMINISTRATOR PREPARER SIGNATURE MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT M Y BE PUNISHABLE BY FINE AND OR IMPRISONMENT UNDER STATE OR FEDERAL LAW I hereby certify that I have read the above statement and that I have exam
48. If SchJcompleted 0 must be Blank UI 1 15 1 15 1 15 974 988 SchJ E Social security number If column A not blank must not be blank If SchJcompleted 0 must be blank Title function If column A not blank must not be blank If SchJcompleted 0 must be blank 989 1003 SchJ 1004 1018 SchJ Proprietorship partnership S corporation or C corporation If column A not blank must not be blank If not blank must be PR PA S or C If SchJcompleted 0 must be blank owned If column D PR must be 1 0000 If column A blank must be blank Must be gt 0 lt 1 0000 If not blank or 0 must be rounded to 4 decimals If SchJcompleted 0 must be blank profit and loss participation May be blank or gt 0 lt 1 0000 If not blank or 0 must be rounded to 4 decimals If SchJcompleted 0 must be blank ERI 049 1063 1064 1078 SchJ Number of nursing facility hours worked per week If column A not blank must lt 168 IfSchJcompleted 0 must be blank nursing facility time worked per week If column A not blank must be gt 0 1 0000 If not blank or 0 must be rounded to 4 decimals If SchJcompleted 0 must be blank Compensation included in allowable cost If column A not blank must be gt 0 If not blank must be whole number If SchJcompleted 0 must be blank Schedule C line number If column A not blank and column I not 0 must not be blank If SchJcompleted 0 must be b
49. L VALIDATION REPORT AND CERTIFICATION REPORT The validations are itemized in Section 6 of this manual Once the cost report standard file is received the MA 11 Cost Report Submission System will validate the file structure and data content These validations are based on the MA 11 Acceptability Validations The system generates two reports an Initial Feedback Report which indicates that the cost report standard file has been submitted and the Final Validation Report which provides a detailed account of any errors found during the validation of the submitted cost report standard file or provides information concerning the rejection of the cost report standard file After a cost report standard file has been successfully submitted and all data has passed the validations a Certification Report is generated reports are formatted as text files with column specifications so that they may be easily read printed or downloaded Initial Feedback Report The Initial Feedback Report should be received shortly after submitting the cost report standard file while you remain on line Figure 5 9 on page 18 Ihttp 111 111 111 111 cgi upload exe Retum to MA 11 Upload data submission or main menu Cost Report Initial Feedback Report Login ID 99991111 Current Facility MYERS AND STAUFFER LC Assigned File Name M499991111 01022002145235 Submission ID 6153 Batch Submission Type Excel File Report Date Time 01 02 2002 14 57 07
50. MA 11 COST REPORT SUBMISSION SYSTEM P End User Manual V4 0 Revised 08 26 2005 Department of Public Welfare and Myers and Stauffer LC Revised 08 26 2005 Contents SECTION 1 INTRODUCTION 1 ABOUT THIS MANUAL uou o E SE UR EBENEN aera aaa asa Sisa 1 HOW THIS MANUAL IS ORGANIZED rimedio ed pub tete eund 1 CONVENTIONS USED IN THIS MANUAL ttt 2 SECTION 2 QUICK GUIDE 3 SECTION 3 OVERVIEW 4 REPORTING REQUIREMENTS eben 4 MA 11 COST REPORT SUBMISSION SYSTEM WEB SITE 4 COST REPORT STANDARD HILE nevera mites plo umb 5 11 ACCEPTABILITY PROCESS u tbi anuo Aut pion ipi 5 SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY 7 INTRODUCTION d dns sedes eec nico ento EXCEL SPREADSHEET TEMPLATE DATA ENTRY SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 11 ESTABLISHING THE WEB SITE CONNECTION Internet Instructions sene Intranet Diakup Instructions u tenete tenter tenentes WEB SIFE OPTIONS ete senha ta n oett o e D e DEGREE RU Terminating the Communication Connection SUBMITTING COST REPORT STANDARD FILES Initial Feedback Report Final Validation Report Interpreting Initial Feedback Report and Final Validation Report 20 Certification Report na ede tete tU teer ebur Dep ee ee a et
51. N 2 QUICK GUIDE Glossary Terms Used In This Section Certification Report Cost Report Standard File Department Download Excel Spreadsheet Template Final Validation Report Initial Feedback Report MA 11 Cost Report Submission System Validation Web Site Definitions for these terms are found in Section 9 The following Quick Guide lists all of the steps necessary for a MA 11 cost report to be accepted You must complete all of the steps listed below for your facility s cost report to be accepted by the Department Refer to the section of this end user manual that is listed in each step for further instructions Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Complete the MA 11 Cost Report using the correct forms for the filing period Create a cost report standard file in one of two ways If using an MA 11 software program that creates the standard file for you follow the software instructions to create the standard file Otherwise download the standard Excel spreadsheet template following instructions starting in Section 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY on page 7 Submit the cost report standard file to the MA 11 Cost Report Submission System using the instructions starting in Section 5 ESTABLISHING THE WEB SITE CONNECTION on page 11 and wait to receive the Initial Feedback Report Re connect to the MA 11 Cost Report Submission System using the instructions starting in Section 5 Fi
52. ND MANAGEMENT Code NA as NA YES as 1 NO as 0 SCHEDULE MA 4 COMPLETED see instructions E 1344 PART Il BALANCE SHEET AT END OF PERIOD PART STATEMENT OF REVENUES EXPENDITURES amp CHANGES IN FUND BALANCE LINE DESCRIPTION LINE DESCRIPTION PERSONAL NO NO FUNDS 14 Payments to Facilty 1362 6 Other Expenditures 1364 8 17 N 1356 1368 21 TOTAL ASSETS 1369 LIABILITIES 2 Accounts Payable General 1370 N 25 Due to Commonwealth Escheats 1377 30 FUND BALANCE AT END OF PERIOD 31 TOTAL LIABILITIES amp FUND BALANCE 1379 PART COMPLIANCE QUESTIONS FOR FEDERAL REQUIREMENTS Code YES as 1 NO as 0 QUESTIONS YES nj 33 On what basis is interest allocated 34 Are accounting procedures established to assure that resident personal funds are not co mingled with facility funds 35 Are detailed resident personal fund ledgers available upon request 36 Are all personal funds of facility residents insured or covered by a surety bond 37 Are residents and the County Assistance Offices notified when the amount in an individual resident s personal account meets or exceeds MA specified levels APPENDIX D NUMBERED COST REPORT FORMS e 89 PRIVATE PAY AND Schedule MA 58 MEDICARE RATE CERTIFICATION STATEMENTS PART PRIVATE PAY RATE LINE QUESTION Code YES as 1 NO as 0 1
53. Part B Services Home Office Adjustment to Cost Compensation for Services of Sole Proprietors and Partners Cost of Major Movable Property Real Estate Taxes Legal Fees Excess Administrative Cost Schedule G Related Party Profit Schedule K Line 16 Attach Schedule Line 981 Line 882 Line 683 Line 684 1 a le I I I I NIN Aa py om 2 2 es ee ee eee e G eo w O D D D D C le le I he OO OO IO DO oo lt z gt rc gt r m Q o o O m m o SN Identify Housekeeping Plant Operation amp Maintenance Administrative Costs Real Estate Taxes N o COIN is ir O OTAL SCHEDULE ADJUSTMENTS N J APPENDIX D NUMBERED COST REPORT FORMS e 77 DEPRECIATION EQUIPMENT 1 Accumulated Method of Depreciation Cost or Depreciation Computing Expense For PROPERTY PLANT amp LINE Acquired Other Basis To Date Depreciation Period F s sont s roe aa 2 res 707 717 727 1735 743 s re mom rm um raa Other 694 roo 709 719 729 7 7 745 ron ram raor ej 05 7421 usu 11 s 716 726 752 1 Note that Schedule requires submission of a schedule of a
54. SECTION 6 MA 11 ACCEPTABILITY VALIDATIONS 28 Revised 08 26 2005 SEQUENCE Each data element is identified with a sequence number This determines the order that the data must be placed within the standard file and is displayed in the numbered cost report form in Appendix D The Sequence for each version of the cost report may be different SCHEDULE The cost report schedule on which the data element is found LINE The line number on which the data element is found on each cost report schedule The line for each version of the cost report may be different COLUMN The column name on which the data element is found on each cost report schedule Fields are also identified with a combination of schedule line and column For example sequence number 365 Version 4 0 is identified as SchC40E Schedule C line 40 column B FIELDNAME An abbreviated description of areas of the cost report schedules that cannot be identified solely by schedule line and column For example sequence number 1238 Version 4 0 is identified as SchL2identify Identify allowance for accounts and notes receivable listed on line 2 of Schedule L DESCRIPTION OF COST Description of the validation or the label for columns and lines as REPORT ELEMENT noted on the cost report schedules VALIDATION Description of the acceptable response s to individual items If the validation is exactly the same for concurrent sequence numbers the range of sequence numb
55. SS Line I0 must lines Se less lines 6 9e 1344 SchMA4 SchMA4completed Schedule MA 4 completed Valid answers NA 1 MA 4 completed or 0 separate reports 1345 1346 SchMA4 I Description statement of revenues expenditures amp changes May be blank If not blank must be whole number If SchMA4completed 0 pints mes rA mte I Description statement of revenues expenditures amp changes Line 1 2 must line 3 IfSchMA4completed 0 or NA must be blank i O 5 eee 755 5 MM Description statement of revenues expenditures amp changes May be blank If not blank must be whole number If SchMA4completed 0 Lines 4 6 must line 7 If SchMA4completed 0 or NA must be blank in fund balance E wo 1347 SchMA4 1348 1350 SchMA4 1351 SchMA4 1352 SchMA4 1353 1354 SchMA4 9 10 1355 1356 SchMA4 19 20 II Description statement of revenues expenditures amp changes Line 3 less line 7 must line 8 If SchMA4completed 0 or NA must be in fund balance blank Description statement of revenues expenditures amp changes If SchMa4completed 1 must not be blank IfSchMA4completed 0 or NA in fund balance must be blank Description balance sheet at end of period If Part II gt 0 must not be blank If SchMA4completed 0 or NA must be blank Description balance sheet at end of period If Part II gt 0 must not be blank If SchMA4completed 0 NA must be blank Resident persona
56. Save to Disk option and select the OK button After you have selected the OK button or if you did not receive the warning message the Save As window will appear Figure C 4 on page 69 Save As Actobat3 lotus Program Files J Archive My Documents Scratch MyFiles Timework Novell E Vip download Dasis32 Windows Drawin35 E Autoexec bat Pacrs40 Bootlog prv MA11 VLD20000501 doc All Files Figure C 4 Save As Window When this window appears the name of the file that you are downloading will appear in the File Name field Choose the directory where you would like to save this file and select the Save button After the Save button has been selected a status bar will appear tracking the progress of the download When the file has been successfully downloaded the status bar will disappear To view or use the downloaded file use the appropriate program to open the file It is very important that you remember where you saved the downloaded file so that you may find it later MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX C ACCEPTED 11 COST REPORT DATA e 69 Revised 08 26 2005 MULTIPLE COST REPORT FILES In order to view data from multiple cost report standard files that have been accepted by the Department from the Downloads option on the MA 11 Welcome Screen click your right mouse button on the MA 11 Accepted Data link and then select Save Link As from the pop up menu Depending on the Internet connec
57. Sch MA line 27 Schedule to support liabilities in excess of 1000 submitted on Schedule MA 4 line 27 If liabilities have been described elsewhere the supporting document for Schedule MA4 line 27 must state the location of this description ch ch ch h Sch MA line 28 Schedule to support liabilities in excess of 1000 submitted on Schedule MA 4 line 28 If liabilities have been described elsewhere the Required if SchMA4 28 gt 1000 00 S S S supporting document for Schedule MA4 line 28 must state the location of this description Sch MA4 line 32 Schedule to support response of NO submitted for Schedule MA 4 line 32 Required if Schedule MA 4 Completed 1 and SchMA4 32 0 S Completed 1 and SchMA4 34 0 i Required if Schedule MA 4 Completed 1 and SchMA4 35 0 Sch MA4 line 36 Schedule to support response of submitted for Schedule MA 4 line 36 Required if Schedule MA 4 MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA 11 ACCEPTABILITY VALIDATIONS 42 MA line 34 Schedule to support response of NO submitted for Schedule MA 4 line 34 Required if Schedule MA 4 Sch MA line 35 Schedule to support response of NO submitted for Schedule MA 4 line 35 SUPPORTING DOCUMENT VALIDATIONS Revised 08 26 2005 1 YES 0 NO ORDER LABEL DESCRIPTION OF DOCUMENT TYPE Completed 1 and SchMA4 36 0 Sch MA line 37 Schedule to support response of NO submitted for Sc
58. Submission Date Time 01 02 2002 14 57 07 Status Submission Received You must view your Final Validation Report to determine if this file has been rejected or if the file has invalid data Select Receive Validation Reports under the M 11 Cost Report Submissions main menu Figure 5 9 Initial Feedback Report MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 18 Revised 08 26 2005 The time it takes to generate and return the Initial Feedback Report may depend on the modem speed and system activity however you should remain on the MA 11 File Submission window until you receive the report The Initial Feedback Report will indicate that your submission was received Once you have received and reviewed the Initial Feedback Report you may choose to return to the cost report standard file submission process i e the MA 11 Cost Report File Submission screen or the MA 11 Cost Report Main Menu by pointing and clicking on either of the underlined options Final Validation Report The Final Validation Report will be generated after the submission of a cost report standard file Figure 5 10 on page 19 The report is created after the MA 11 Cost Report Submission System performs the MA 11 Acceptability Standard File Validations t Netscape 2 m http 10 3 1 4 reports MA33331111 M433331111 02022001104207 FINAL HTM F fl COST REPORT FINAL VALIDATION REPORT Page 1 of 1 Login ID
59. System PENNSYLVANIA Department of Public Welfare MAJ Cost Report Submissions Balletan Doanlogds Poasts of Costact PA NF Setenission rent Figure 5 3 MA 11 Cost Report Welcome Page There are six options available to you from this page They include MA 11 Cost Report Submissions accesses the MA 11 Cost Report Main Menu This option is only available to facilities with a non guest Login ID and password Accepted MA 11 Cost Reports contains the individual cost report data that have been accepted for each facility Refer to Appendix C for instructions on how to download this data This option is for public use Bulletins contains news from the Department and the Myers and Stauffer helpdesk This option is for public use Downloads contains files that may be downloaded and viewed or printed These files contain information on the MA 11 end user manual the standard spreadsheet template and multiple accepted cost report data Refer to Appendix B for instructions on how to download these files This option is for public use Points of Contact provides a list of contacts names addresses phone numbers and E mail addresses as applicable This option is for public use PA NF Submissions directs the user to the www PANFsubmit com website in order to complete the Resident Day Reporting Form for the NF Assessment Program Additional options may become available in the future You may point and click o
60. TO must Tine TT 1 79 sd c JAccumularddepressionisdae Mustbe column B IFnor Blank must be whole number 5 U JAccumularddepreciatontodae y E Emi sd 9 6 Accuslated depreciation tp date Must be lt column 17 must be whole mumber TH Aecumuiaeddeprecistiontodae be whole number ms sar Accumulated depreciation to dare 6 10 must ine TI 7757 7395 14 __ Met of computing depreciation f colum 0 must orbe bak 7730 732 Sci computing depreciation I colum 0 must norbe Blank Sei Si tic computing depreciation coloma s 0 must not be bak 55 57 sdE 4 ie rete Yio B0 mt te Bank 58 340 E Hie orae E columa T 0 must not be Blank Si 50 it ot 0 tt ak 743 745 2 C E Pesrciationexgenssforperiod lf colunm B 0 mustnot be Hank WFaor blanks mast be wholemumber
61. XXXXXXXXXXXXXXXXXXXXXXXXXXXXX MA 11 COST REPORT SUBMISSION SYSTEM REPORT FIELD Login ID DESCRIPTION A unique identifier for the facility submitting the cost report standard file This identifier is assigned by the Department VALUES Alphanumeric Current Facility Name The name of the facility for which the cost report standard file is being submitted Cost Report Period The period of time covered by the Date cost report standard file Validations Version The data specifications version that Current Version Number the MA 11 Cost Report Submission System is using for the Cost Report Period SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 21 Revised 08 26 2005 REPORTFIELD DESCRIPTION values FIELD DESCRIPTION VALUES Assigned Audit Number The OnT fete 2 5 _ _Vatves _ that will be used to LAS _ track an accepted cost report in the audit process This is assigned by the MA 11 Cost Report Submission System This field only appears on Final Validation Reports and Certification Reports Assigned File Name The file name assigned to the cost Alphanumeric report standard file by the MA 11 Cost Report Submission System Each cost report standard file submitted will be assigned a unique file name This is the Facility ID followed by the Date and the Time to the nearest second Submission ID A unique identification number for Integer this submission assigned by the MA 11 Cost Report Submission
62. a During the report period did the Medical Assistance rate charged to the Department exceed the usual and customary charges made to the general public for a room 1b If YES give all inclusive or room and board plus ancillary private pay rate If NO sign and date the following certification statement that will appear on the Certification Report I hereby certify that the facilitys usual and customary charges to the general public for a room during this reporting period exceeded the facility s Medical Assistance rate to the Department understand that any false claims statements or concealment of material fact may be prosecuted under applicable federal or state law understand that if do not sign this statement the Department will make any necessary gross adjustments to the facility s reimbursement in accordance with 62 P S 31406 b PART Il MEDICARE RATE LIN N QUESTION Code YES as 1 NO as 0 0 2 Indicate the Medicare rate that was in effect during the MA 11 report period attach schedule 2b Indicate the effective date of the Medicare rate YES NO 2c Indicate whether the Medicare rate is an audited rate pep If Medicare Rate 2a is completed sign and date the following certification statement that will appear on the Certification Report hereby certify that the above Medicare per diem rate was would have been the average Medicare rate as determined by the instructions to Sc
63. al Up Networking Note These instructions should be used if you do not have Netscape already installed on your PC you do not have Internet access and you plan to use the Intranet dial up method to connect These instructions are based on having your modem physically installed and the modem driver installed 1 A de o Select Start Programs Accessories and look for Dial Up Networking in your Accessories list If you downloaded Netscape from the Internet to this workstation Dial Up Networking should appear in this list If it does appear you can proceed to the Part II of these instructions Select Start Settings Control Panel Double click on the Add Remove Programs icon Select the Windows Setup tab or button Select Communications from the Components list A check will appear in the box next to Communications Select OK You may get a box stating you will need computer and workgroup names Select OK Then enter any name you desire for the workgroup name i e Cost Report and select Close You may need your Windows 95 Setup CD A copying files message box will appear showing the progress of this setup When you see the message box that Dial Up Networking Setup is complete and your system settings are reconfigured select OK You must restart Windows for Dial Up Networking settings to take effect PART II TCP IP If TCP IP appears in the list of network components installed you may proceed to Part III of the
64. an actual or preprint allocation is acceptable for Schedule C column K Fapplicable T applicable 57 Sch Schedule to support any additional lin es greater than 5 needed to complete the information Tor the facility If applicable 4 Participation Submit a copy of any approvals received under 55 Pa Code 1187 21 relating to nursing facility exception requests statement of policy If applicable Review Exception Request Replacement Beds Submit a copy of any approvals received under 55 Pa Code 1187 113a relating to nursing facility replacement beds statement of policy if not If applicable 54 5 5 O MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 11 ACCEPTABILITY VALIDATIONS 43 MANUAL REVIEW VALIDATIONS Revised 01 27 2003 1 YES 0 NO e PmpaerSigmuure iheprepamrssigmauredare present JI CERTprepsign not blank must l S Pivae Pay Rate Signature SSIs the administrator s signature date present 5 o Medicae Rate Signature Is the administrator s signature present If MAS8Za 0 mui T S MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA 11 ACCEPTABILITY VALIDATIONS 44 Revised 08 26 2005 SECTION 7 ALTERNATIVE STANDARD FILE METHODS Glossary Terms Used In This Section Cost Report Standard File Department Download Excel Spreadsheet Template MA 11 Cost Report S
65. artnership 26 1265 1298 en 112661 1767 Current year s operating profit loss Other R E account transactions ne Balance end of year Total Capital TOTAL LIABILITIES AND CAPITAL 1268 1269 1270 1301 1302 alan N N oO l mn pt pa 1 ele el 33 1272 APPENDIX D NUMBERED COST REPORT FORMS e 87 STATEMENT OF CHANGES IN FUNDED DEPRECIATION LINE DATE AMOUNT o nma INCREASE Investment Income 1327 Investment Income from interfund loans 1328 Monthly Deposits 1329 Other identify 1306 1316 1330 Other identify 1307 1331 Other identify 1308 1332 Other identify 1309 1333 Other identify 1310 1334 DECREASE Asset Purchases attach detailed schedule 1335 Mortgage or Bond Principal Payments 1336 Loans Receivable attach detailed schedule 1337 340 eo eo Other identify 11315 1342 9e ENDING BALANCE EI 1343 2 1 dH O o fen e oem e Oter gaem D13081 Sd Se o 2 e o oO 10 APPENDIX D NUMBERED COST REPORT FORMS e 88 hedule MA 4 ANNUAL FINANCIAL REPORT OF Schedule MA 4 RESIDENT PERSONAL FU
66. characters will be ignored MA 11 COST REPORT SUBMISSION SYSTEM SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY 8 Revised 08 26 2005 COLUMN NAME DESCRIPTION FIELD TYPE The type of field which the data submitted within the text file will be converted to by the submission system prior to validating the data Options are Character Date and Numeric Specific rules that apply to the text file for each field type are as follows Character Do not use hyphens or parentheses for phone numbers social security numbers or tax ID numbers When an MA 11 cost report date item field type is Character the item will be validated in the format in which it is submitted such as MM DD YYYY M DD YY or MM YY Date In the text file all fields with field type Date must be in the format MM DD YYYY Numeric In the text file do not use hyphens dollar signs or percent signs To start data entry into the template move the cursor to Column A Line 2 Leave row 1 as DATA V4 0 Enter the desired information into the field using the sequentially numbered cost report schedules in Appendix D as a guide In general the data is sequentially entered from the cost report forms starting at the top of the first column to the bottom of the first column then moving to the next column of the cost report schedules Use the Enter key or down arrow key to move the cursor from field to field Be very careful to enter information into the correct field T
67. chedule row 1b Data submitted in this manner does not result in a filed cost report and is not stored in any database Text File In this manual a term used to designate an alternative format for the cost report standard file The file is created using each sequentially numbered cost report item as a separate record within the file Title XIX Designation for the federal Medicaid regulations Uniform Resource Locator URL The global address of documents and other resources on the World Wide Web The first part of the address indicates what protocol to use and the second part specifies the IP address or the domain name where the resource is located MA 11 COST REPORT SUBMISSION SYSTEM SECTION 9 GLOSSARY 52 Revised 08 26 2005 URL see Uniform Resource Locator User Name see login ID Valid File see Valid Cost Report Standard File Valid Cost Report Standard File A cost report standard file submitted to the MA 11 Cost Report Submission System that has passed all Standard File Validations set forth in the MA 11 Acceptability Validations document The status on the Final Validation Report is Submission Received Valid The system then produces a Certification Report for download by the provider which delineates additional supporting documents required to be mailed with two copies of the signed Certification Report to the Department Validation An analysis of the MA 11 performed at three levels the Standard File
68. d 11 rat Reporte ARD nial xi Ch uev fpe e Deb be Sad webet 2 2 Dwa urasna dese o 1 zJ tiren 1 cord cM FILE ee 0S zc Accepted MA 11 Cost Reports Sam Modification Date OOM ONZA 5024916 AM 137 216 3 04 0X05 0945 16 AM 1392 4 05 21 2005 0207 34 AM 139 204 0152005 0223 00 1002564000013 00 2008 XL 139 976 4 20 2005 081031 1007732500000 00 2005 XLS 139 774 03 22 2005 0524 23 PM 6 Fibs Jeter to the 144 12 Cort Report Sytem Welcomes Page 2 e uw rw Figure C 2 Accepted MA 11 Cost Reports Each cost report standard file that has been accepted by the Department will appear as a separate file on this screen The files are named beginning with the provider s MA number followed by two digits and ending with the four digit cost reporting year Each file must be downloaded separately There is not a function in place to download multiple accepted cost report standard files at one time To download one of these files select the underlined file in the File Name column After selecting a file you may receive a warning message Figure C 3 on page 69 depending on how your system is configured MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX C ACCEPTED M11 COST REPORT DATA 68 Revised 08 26 2005 Warning here is a possible security hazard here 9 Figure C 3 Security Hazard Warning If you receive this warning message choose the
69. d 0 must be blank 1251 SchL 12 End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1252 Sh End of current period Line 11 less line 12 must line 13 If SchLcompleted 0 must be blank Ds 1254 r 5 les of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1255 Sh C u yQuT End of current period Line 6 13 14 15 must line 16 If SchLcompleted 0 must be blank use ps 1259 2n 84 of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1260 L A J Endofcurrent period Lines 17 20 must line 21 If SchLcompleted 0 must be blank 1261 1263 SchL 22 24 End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1264 Sh A Endofcurrent period Lines 21 24 must line 25 If SchLcompleted 0 must be blank gt 1270 X End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank gt Yi caren period ines 26 30 mast Tine 32 lrSchLeompleted must be Blank UU RH pe EE End of current pm LLL If S line 3 must not be blank Lines 25 32 must line 33 Line 33 must line 16 If SchLcompleted 0 must be blank
70. dback Report and the Final Validation Report follow the same format Each report begins with a header that displays general information The Final Validation Report header is followed by a report detail section that describes each error encountered in the cost report standard file The items on each line are tab delimited The format of the validation reports are as follows MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 20 Login ID Current Facility Name Assigned File Name Submission ID Batch Submission Type Report Date Time Submission Date Time Status Revised 08 26 2005 COST REPORT INITIAL FEEDBACK REPORT MAXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX MAXXXXXXXX yyyymmdd hhmmss XXXX Excel File Lotus File or Text File mm dd yyyy hh mm ss mm dd yyyy hh mm ss Submission Received Login ID Current Facility Name Cost Report Period Validations Version Assigned Audit Number Assigned File Name Submission ID Production Test Status Report Date Time Submission Date Time Status COST REPORT FINAL VALIDATION REPORT MAXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX mm dd yyyy mm dd yyyy 4 0 XXXXXXXX XX yyyy MAXXXXXXXX yyyymmdd hhmmss XXXX Production or Test mm dd yyyy hh mm ss mm dd yyyy hh mm ss Submission Received Invalid or Submission Received Valid Sequence Field Description Invalid Data Error s XXX XXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXX
71. dditions and deletions since the last report period 2 Difference between Column B and Column C must equal amount shown on Schedule L Line 13 3 Line 11 Column F must agree with amount shown on Schedule C Line 34 Column D APPENDIX D NUMBERED COST REPORT FORMS e 78 ADMINISTRATIVE COSTS SALARY FRINGE OTHER TOTAL LINE COST BENEFITS EXPENSES EXPENSES No A B C D Administrator 774 Office Personnel 775 795 Management Fees 3 776 Home Office Costs 777 Professional Services 5 778 798 Determination of 779 Advertising 781 801 Travel Entertainment 782 Telephone 783 Insurance 11 784 Other Interest 785 Legal Fees 13 786 Federal State Corporate Capital Stock 787 807 Office Supplies 15 788 Amortization Administrative Costs 789 Officers Life 17 790 Admin Minor Movable Property 791 811 Other If greater than 1 000 provide separate listing 19 792 Total Administrative Costs Schedule C Line 29 20 760 773 793 813 ADMINISTRATIVE ALLOWANCE COMPUTATION This computation should be made only after all other Schedule D and Schedule E adjustments Total Net Operating Schedule C Column F Line 30 Administrative Costs Schedule C Column F Line 29 Subtract Line 22 from Line 21 Limit on Administrative Line 23 divided by 88 Excess Administrative Subtract Line 24 from Line 21 Enter zero if answer is negative Ent
72. default destination directory of CAProgram FilesNNetscape Communicator You may leave those default settings and select the Next button If the C Program FilesWetscape Communicator directory does not exist you will be prompted to see if you want it to be created Select the Yes button APPENDIX A NETSCAPE INSTALLATION e 57 10 11 12 13 14 15 Revised 08 26 2005 A window will display asking you to identify a name for the program group Netscape Communicator is the default name Select the Next button to accept the default name for the folder A Start Copying Files window will appear showing the settings you have chosen Select the Install button A setup window will appear showing the progress of the installation This may take several minutes depending on the size of your PC and the speed of your CD ROM drive You may need your Windows 95 CD for this step A message box will appear asking if you want to view the readme txt You may select No to bypass this An information message box appears stating setup is complete Select the OK button A message box appears asking if you want to restart Windows You must restart Windows before you can use the Netscape Communicator The option Yes I want to restart my computer now is the default Select the OK button Note The Netscape installation has now been completed The remaining instructions will set up an account for Intranet dial up access to the MA 11 Cost
73. dicate the rejection error s and no further validation will take place If the cost report standard file is not rejected the detail section of the Final Validation Report indicates the type and number of errors encountered in the cost report standard file that was sent You may choose to exit the MA 11 Cost Report Submission System after receiving the Initial Feedback Report verifying acceptance of the cost report standard file and come back at a later time to access the Final Validation Re port MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 19 Revised 08 26 2005 Final Validation Reports are accessed from the MA 11 Cost Report Main Menu Simply point and click on Receive Validation Reports If you have initiated a new session you will access the MA 11 Cost Report Welcome Page and select MA 11 Cost Report Submissions The Login ID and Password Required window will appear for you to complete If you are continuing an ongoing session and have already completed a user log in the Validation Report Listing window will appear after you select Receive Validation Reports Figure 5 11 on page 20 Validation Report Listing Netscape Validation Reports MA99991111 02132001141014 FINAL HTM 02 13 2001 Ma99991111 02132001140941 FINAL HTM 02 13 2001 M 99991111 02132001141014 init htm 02 13 2001 M 99991111 02132001140941 init htm 02 13 2001 MA99991111 02132001121619 FINAL HTM 02 1
74. e Validation Definitions for these terms are found in Section 9 INTRODUCTION Cost report data submitted to the MA 11 Cost Report Submission System must be in the standard file format Some cost report preparers and or accounting firms that have MA 11 preparation software or spreadsheets have incorporated the standard file format into their existing program In these cases follow the instructions provided with the MA 11 program to create the cost report standard file and skip to the next section of this manual If programs of this type are not used to create the cost report schedules complete the cost report schedules manually and then data enter the results into the Excel spreadsheet template in order to create the cost report standard file This template may be downloaded by following the instructions in Appendix B Direct data entry into the Excel spreadsheet template is estimated to take less than two hours EXCEL SPREADSHEET TEMPLATE DATA ENTRY To use the Excel spreadsheet template to create a cost report standard file you must first download the template from the Cost Report Update Page found by clicking on the Downloads option on the MA 11 Cost Report Welcome Page After you have downloaded the template open it in either Lotus 1 2 3 or Microsoft Excel After the file has been opened the template will appear on the screen Figure 4 1 on page 8 MA 11 COST REPORT SUBMISSION SYSTEM SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY
75. e 6 when Schedule C column H line 30 0 or blank Identify the cost category basis Required if SchC30H 0 or blank of allocation and amount allocated for each line item if the allocations are not shown on Net Operating under the Residential amp Other column eT Columns H and J on Schedule C 22 Sch I line 11 Schedule of related parties to support response of YES on Schedule I line 11 Identify the name title function and SSN of related employe as Required if SchI11 1 BEEN d well as number of hours worked per week salaries wages fringe benefits and line of Schedule C on which this is recorded 23 Sch line 12 Schedule of specific details of personal expenses to support response of on Schedule I line 12 Include amounts and the Schedule and line Required if SchI12 0 24 Sch I line 13 Schedule of details of advances to officers attached to support response of YES on Schedule I line 13 Identify to whom amount and interest Required if SchI13 1 1 25 Sch I line 14 Schedule of details of advances from officers to support response of YES on Schedule I line 14 If these details have been included on the Required if SchI14 1 Classified Loan Schedule the supporting document for Schedule I line 14 should state the location of these details 26 Sch I line 18 Listing of components of the entire entity to support response of YES on Schedule I line 18 If the entity files
76. e audit process If the provider discovers an error on the Certification Report or supporting documents after they are mailed to the Department an amended Certification Report or supporting documents will only be accepted by the Department if the supporting document and manual review process has not begun If this process has begun the amended Certification Report and supporting documents will be returned to the provider The amended Certification Report and supporting documents may be maintained at the facility and should be given to the auditor for consideration at the time of audit ACCEPTABILITY PROCESS The signed Certification Report and all supporting documents are required to be received by the Department and must pass all Supporting Document and Manual Review validations for a cost report to be acceptable Submitting a valid cost report standard file is only part of the filing process To complete the process the facility administrator and the person who prepared the cost report if applicable must sign all areas of the Certification Report and mail the Certification Report and all the indicated supporting documents to the Department The Department must receive this package by the due date Two copies of the signed Certification Report and one copy of the supporting documents is required The Department will verify the supporting documents authenticity by comparison with the accompanying Certification Report The Department wi
77. eadsheet option an Excel spreadsheet template is available for download into either Excel or Lotus and is set up in the standard format The facility data enters the cost report information directly into this template and submits the file Many cost report preparers have incorporated this template into their existing programs negating the need to re data enter information into the template Alternatively cost report preparers may incorporate a standard text file format into their existing programs Instructions for creating a text file are included in TEXT FILE on page 46 The Excel spreadsheet template is not a program or tool to be used by a provider in completing the cost report and does not contain any formulas to aid in calculating totals or any edits to ascertain accuracy or completeness of the cost report The template also does not contain worksheets that resemble the paper cost report schedules It is assumed that facilities already have a program or procedures in place for completing the cost report The Excel spreadsheet template does not interfere with or replace these existing programs or procedures but simply allows the results of a completed cost report to be submitted in a manner that is common for all providers MA 11 ACCEPTABILITY PROCESS Do not mail a paper copy of the MA 11 cost report schedules to the Department Acceptability of the MA 11 is judged at three levels The first level is the validation of the data submi
78. ear showing the current modem selected If your modem was set up properly it should show up in the list box When you have selected your modem from the list select the Next arrow at the bottom of the window A window will appear asking for dialing settings for call waiting and access to an outside line The default for call waiting is the line doesn t have call waiting If a number s must be dialed to access an outside line enter that number s Select the appropriate radio button next to tone or pulse the default is tone Select the Next arrow at the bottom of the window A window will appear asking for your phone number You must enter your correct area code so the system will know if you are dialing long distance Select the Next arrow at the bottom of the window A window will appear stating you are done with the setup You may select the Connect Now icon at the bottom of the window to see if you can connect to the MA 11 Cost Report Submission System now or select the Done icon in the lower right corner of the window to try connecting later A shortcut is created on your desktop with the login ID used You may double click that shortcut then select the Connect button whenever you want to connect to the MA 11 Cost Report Submission System Refer to Section 5 for information on submitting cost report standard files APPENDIX A NETSCAPE INSTALLATION e 59 Revised 08 26 2005 INSTRUCTIONS FOR FREE VERSION SET UP PARTI Di
79. ed and leased items including term of rental or lease to and from dates property description imputed purchase price AHA Life annual straight line SL depreciaition annual lease or rental payments and reported amount Submit copies of invoices for property acquired under the Exceptional DME Grant Submit a classified loan schedule to support the other interest and interest on capital indebtedness expense reported on Schedules G and C This schedule should include the following information name of lender purpose of loan period of loan interest rate interest expense and balance of loan at end of report period Submit an organization chart for the facility of supervisory personnel with names inserted Submit a copy of any approvals received under 55 Pa Code 1187 21a relating to nursing facility exception requests statement of policy 1187 113a relating to nursing facility replacement beds statement of policy and or 55 Pa Code 1101 77a relating to termination for convenience and best interest of the Department statement of policy if not previously submitted with a prior cost report Submit copies of paid real estate tax bills NOTE refer to page 3 of the instructions for details APPENDIX D NUMBERED COST REPORT FORMS e 81 SUPPLEMENTAL INFORMATION AND QUESTIONNAIRE Code YES as 1 NO as 0 LINE LINE PART II UESTIONNAIRE 1 Has interest investment income from sources other than donor r
80. ed to each facility on the Password and Connectivity document mailed to the NF administrator This number is necessary to gain entry into the MA 11 Cost Report Submission System in order to submit the cost report standard file The same number is also the Login ID MA see Medical Assistance MA 11 Cost Report Submission System A web site developed by Myers and Stauffer under contract with the Department This web site performs edits on the submitted data provides feedback on the results of the validations process and acts as a repository for facility cost report data submitted by the facility or their cost report preparer Manual Review Validations A set of edits that have been designated by the Department to aid in obtaining completeness and accuracy of the Certification Report and its signature areas prior to acceptance of the cost report Medical Assistance MA Medical Assistance is a Federal and State program that pays for specific kinds of medical care and treatment for low income families Any payment made to a provider for services rendered is subject to the provisions of Title XIX of the Social Security Act and the Pennsylvania Public Welfare Code 55 PA Code Nursing Facility Services Handbook p 1 1 Modem An acronym for modulator demodulator A modem is a device or program that enables a computer to transmit data over telephone lines Computer information is stored digitally whereas information transmitted over telep
81. een received by the Department on or before the 120 day but the signatures and or some supporting documents are incorrect or missing the cost report is timely filed but not acceptable The facility has the latter of 30 days from the date of the not acceptable letter or 30 days following the due date of the cost report to correct and return the Certification Report and all supporting documents If these items are not received by the end of that time period and deemed acceptable by the Department the facility s rate will be adjusted downward according to Chapter 1187 80 The receipt date recognized by the Department is the date the Certification Report and supporting documents are received at P O Box 2675 or are received and stamped in by the Division of Nursing Home Rates as of the close of business at 5 P M MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 26 Revised 08 26 2005 When provider fails to submit any cost report standard file only a rejected cost report standard file s or only a test cost report standard file s to the MA 11 Cost Report Submission System within the first 120 days the rate will be adjusted downward according to Chapter 1187 80 The reduced rate period stops on the date the Certification Report and supporting documents are received by the Department but only after verifying that an acceptable Certification Report and supporting documents were received and deemed acceptab
82. emplate are included in Section 4 of this manual Questions and Answers for MA 11 v3 0 includes answers to questions submitted during development and implementation of Version 3 0 of the MA 11 effective for cost reporting periods beginning January 1 2001 Crosswalk V3 0 includes a crosswalk of the common MA 11 data elements between the MA 11 Version 3 0 and Version 2 0 MA 11 Accepted Data includes an all inclusive text file comma delimited of each accepted cost report See page 70 for further instructions Suggested Schedule C Line 32 Supporting Document Format includes an Excel file template that is suggested for use to support a response of other than blank or zero on Schedule C line 31 column G Major Movable Property Other update files may be available from time to time that will be useful in creating cost report standard files and interpreting validation reports To download one of these files select one of the underlined options After selecting an option you may receive a warning message Figure B 2 on page 66 depending on how your system is configured MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX B DOWNLOADS e 65 Revised 08 26 2005 Warning There is a possible security hazard here 9 Figure B 2 Security Hazard Warning If you receive this warning message choose the Save to Disk option and select the OK button After you have selected the OK button or if you did not receive the warn
83. en successfully created Select Finish You may double click on the new icon you created to connect to the MA 11 Cost Report Submission System at this time or you may close the Dial Up Networking windows and connect at another time Right mouse click on the new dialer you created and select Properties Select the Server Types tab or button For MA 11 Cost Report Submission System purposes only the Logon to network and TCP IP options should be checked If any other options are checked click on the box next to the option to remove the checkmark Select OK PART V Connecting to the MA 11 Cost Report Submission System Note The first time into Netscape you should select the Dial Properties button and enter the area code you are dialing from and any number or code required to access an outside line Then select the OK button l 2 3 Select Start Programs Accessories Dial Up Networking Double click on the Dialer icon you created i e Cost Report Enter the Login ID and password Select the Connect button On newer versions of Windows 95 the Dialup icon will display in the lower right corner of the screen while you are connected Refer to Section 5 for information on submitting cost report standard files INSTRUCTIONS FOR ACCOUNT SETUP ONLY PART I Account Setup Note These instructions should be used if you already have Netscape installed on your PC It does not matter whether or not you have Internet access F
84. entity If the entity files a Medicare Home Office cost report this report and the intermediary audit report with adjustments must be submitted with the MA 11 or as soon as each is available APPENDIX D NUMBERED COST REPORT FORMS e 83 SUPPLEMENTAL INFORMATION AND QUESTIONNAIRE LINE LINE NO PARTII QUESTIONNAIRE Continued NO List all managment companies utilized by the facility during the report period and the services provided TYPE OF SERVICE PROVIDED code number 1 Housekeeping 5 Therapy 2 Laundry 6 Administrative 3 Food Service 7 Fiscal 4 Grounds 8 Other IDENTIFY Type of Service Management Company Name code number Encode all Schedule data Part Il data in the standard file If any row of Line 19 is a type 8 service do not enter an 8 in Type of Service Instead specifically identify the type of service in this column Respond to all questions concerning your facility and cost report information APPENDIX D NUMBERED COST REPORT FORMS e 84 STATEMENT OF COMPENSATION Schedules OF OWNERS DIRECTORS AND RELATED INDIVIDUALS Code YES as 1 NO as 0 SCHEDULE J COMPLETED Time Devoted to Compensation Included Business Organization Nursing Facility Work in Allowable Cost ocia in owa par ticam ee ETE B C D E F G H I J NO 959 989 1004 1019 1034 1049 1064 1094 5 962 992 1052 1067 1097 963 9
85. er on Schedule E Line 19 APPENDIX D NUMBERED COST REPORT FORMS e 79 NURSING CARE STAFFING EMPLOYES Number of Full Time Employes Salary Fringe Hours or Equivalents Cost Fees Benefits Worked at Year End B D E A Licensed Practical Nurses 2 862 Orderlies Attendants 864 REGISTRY POOLED CONTRACT STAFF Registered Nurses 7 867 Licensed Practical Nurses 8 868 Nurse Aides 9 869 Orderlies Attendants 10 870 Other specify 815 11 871 Subtotal 12 872 Total Nursing Care 13 828 5 847 860 873 1 FTE equals forty 40 hours per week Round to the nearest whole number 2 Must agree to Schedule C Line 1 Column A 3 Must agree to Schedule C Line 1 Column B 4 Must agree to fees in general ledger included on Schedule C Line 1 Column C 5 Add Line 6 Column A Line 6 Column B and Line 12 Column A z z Pm POSITION d APPENDIX D NUMBERED COST REPORT FORMS e 80 SUPPLEMENTAL INFORMATION AND QUESTIONNAIRE PART SUPPLEMENTAL INFORMATION Certain documents and supporting schedules are required to be mailed with the Certification Report in order to complete the acceptance of your cost report The list of required supporting schedules is itemized on the Certification Report Submit copies of independent accountant financial statements Medicare cost reports and Medicare intermediary audit reports with adjustments for the report period with the MA
86. ers are listed for that validation in one row in order to consolidate this document Sequence numbers 19 30 and 38 refer to the available bed calculation An example of this calculation is as follows SCHEDULE LINE CHANGE DATE DAYS A 1 150 1 1 2001 1ba 15 3 15 2001 73 A 1bb 3 7 16 2001 123 A 1c 162 12 31 2001 169 A 2 58 623 73 150 123 165 169 162 365 INSTRUCTIONS FOR USE OF SUPPORTING DOCUMENT VALIDATIONS The Supporting Document Validations are a list of supporting documents schedules and worksheets that support the data submitted in the cost report standard file Some of the items are required depending on the data submitted in the standard file and others must be submitted when applicable All possible supporting documents are included in the list However only the required documents and the when applicable documents are listed on the Certification Report in order to help the provider determine what must be mailed with the Certification Report Package Each column in the Supporting Document Validations is described in the following table MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 11 ACCEPTABILITY VALIDATIONS 29 Revised 08 26 2005 COLUMN NAME DESCRIPTION ORDER Each validation is identified by an Order number This is the order that the documents must be arranged in the Certification Report Package LABEL The abbreviation of the cost report schedule column and line number to whic
87. ertification Report Package A bundle of documents mailed to the Department that contains two copies of the Certification Report with original signatures and one copy of supporting documents The documents in this package support the data submitted in the cost report standard file Contractor An entity working under contractual agreement with the Department to provide requested services e g Myers and Stauffer LC is the contractor that developed and manages the MA 11 Cost Report Submission System the NIS and the MA case mix reimbursement calculations Cost Report Standard File A standard file format to be used when submitting cost report data to the MA 11 Cost Report Submission System The cost report standard file format is best described as a column of data with each row or record MA 11 COST REPORT SUBMISSION SYSTEM SECTION 9 GLOSSARY 49 Revised 08 26 2005 containing the response to each question or data item on the MA 11 cost report schedules Department see Department of Public Welfare Department of Public Welfare Department The Department of Public Welfare is the Commonwealth agency designated as the single state agency responsible for the administration of the Commonwealth s Medical Assistance Program 1187 2 Dial Up Connection The ability to connect directly to the MA 11 Cost Report Submission System via a modem and phone line without having an Internet Service Provider Dialer A component
88. es allows you to correct information that may not be correct on this window Connect establishes the Intranet dial up communication connection to the MA 11 Cost Report Submission System 3 Once the Intranet dial up connection is established a small window will appear in the upper right hand corner of your screen or the dialer will minimize itself to the Minimized Dialer lower right corner of the screen If the dialer minimizes you may view it by double clicking on the icon of two linked computers in the lower right The only button you need to note is the Disconnect button When you log off of Netscape you will need to point and click on Disconnect to discontinue or exit the communication link to the MA 11 Cost Report Submission System Depending on your system configuration you will automatically access Netscape or L return to the Windows screen If you return to Windows double click on the Netscape Navigator Ink Netscape Navigator icon The Netscape window will appear Figure 5 2 on page 13 MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 12 Revised 08 26 2005 3 Netscape Elle Edit View Go Window Help Z 4 S 2 nmm w Beck Renard Kered Home Search Netscape Print Stop oes EL Bookmarks Jj Location whats Related Figure 5 2 Netscape Window There are a variety of configuration options you have when installing the requisite software on your system The Netscape wi
89. estricted specifically excluded 7 by Medical Assistance Regulations been offset on Schedule D Line 19 s 875 1 1 2 If please state amount of income not offset Have all costs for nonresident meals been deducted from dietary and food expense State number of meals Resident meals Employe meals Volunteer meals Visitor meals Other identify 882 Total all meals Has personal laundry expense for dry cleaning mending or other specialty laundry services been deducted from reported laundry expense If NO state total specialty laundry expense Have any capital assets with an acquisition cost of 500 or more been expensed in net operating costs If YES attach detail and identify Schedule C line item Have any administrative expenses been allocated to other allowable cost centers e g telephone expense to any other category such as Nursing If YES attach a schedule showing cost category basis of allocation and amount allocated for each line item Does the facility maintain any residential and other areas that have not been reported on this Cost Report Identify 889 If YES attach a schedule showing cost category basis of allocation and amount allocated for each line item if the allocations are not shown under Residential amp Other columns on Schedule C Do you have any nonallowable cost centers in the nursing facility such as a gift shop snack shop administrator s
90. ge 11 skip this section of the manual and go directly to WEB SITE OPTIONS on page 13 If you do not have Internet access you must access the system using a direct dial up method Correct installation and setup of all the hardware and software is essential to direct dial up access Appendix A includes instructions in addition to those found in your Netscape manual for setting up the Dialer icon Refer to both if you do not have a dialer icon visible when bringing up Windows When you double click on the dialer icon the Dialer Window will appear Figure 5 1 on page 12 Point and click on the User Name field and enter the Login ID provided to you by the Department You can tab to or point and click on the Password field to enter the password provided to you by the Department For guest users the Login ID is Guest and the Password field should be left blank However guest users can only access the public use area of the MA 11 Cost Report Submission System Connect To 3 1717 5415806 Default Location Cancel Figure 5 1 Dialer Window Both Phone Number and Dialing From should default to the correct entries The phone number should be 717 541 5806 which should appear after successful completion of the setup in Netscape Internet Access Edition or Windows 95 dialer setup This window has three buttons Connect Dial Properties and Cancel Select Cancel if you wish to terminate the dial in process Dial Properti
91. h the document applies or an abbreviation of the document itself The Label must also be clearly used to mark your supporting document prior to placing it in the Certification Report Package DESCRIPTION OF The written description of the document and any qualifiers as to when it is DOCUMENT a required document TYPE An indicator if the document is required or only must be mailed in the Certification Report Package when applicable INSTRUCTIONS FOR USE OF MANUAL REVIEW VALIDATIONS The Manual Review Validations are a list of requirements signatures dates and telephone numbers that are reviewed by the Department concerning the Certification Report Package In addition to passing the Standard File Validations and the Supporting Document Validations the Manual Review Validations must be met in order for the cost report to be acceptable Each column in the Manual Review Validations is described in the following table COLUMN NAME DESCRIPTION REVIEW A numeric identifier of each of the manual review processes CERTIFICATION REPORT AREA A description of which of the five areas of the Certification Report to which the validation refers DESCRIPTION OF THE The question to which the reviewer is responding CERTIFICATION REPORT ELEMENT VALIDATION This indicates the response required by the manual reviewer to pass the validation MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 11 ACCEPTABILITY VALIDATIONS 30 STANDARD FILE
92. he numbers contained in the SEQ column do not match the row numbers on the spreadsheet To make data entry less confusing you may remove the row and column headers on an Excel spreadsheet by 1 Select the TOOLS main menu option 2 Selectthe OPTIONS option from the TOOLS sub menu 3 Select the View tab 4 Inthe Windows Options section remove the checkmark from the Row amp Column Headers selection 5 Selectthe OK button You may remove the row and column headers on a Lotus spreadsheet by 1 Select the SHEET main menu option Select the SHEET PROPERTIES option from the SHEET sub menu Select the View tab Remove the checkmark from the Sheet Frame selection wa FY pP Close the Sheet Properties window All fields except for those that are to be left blank have to be data entered into the template including total fields No fields are calculated If you use formulas to calculate totals during data entry you must convert the formulas to values prior to submitting the template If the template is submitted with formulas in Column A DATA V4 0 the file may not be valid Any special data entry instructions for a field are contained in the MA 11 Instructions and Schedules that was published in the MA Bulletin Refer to these instructions for guidance when data entering the cost report information into the template Be sure to save each template created for a cost report period with a diffe rent name If using Lotus the file mus
93. hedule MA 4 line 37 Required if Schedule MA 4 Completed 1 and SchMA4 37 0 Sch MA 58 line Schedule to support Medicare rate submitted for Schedule MA 58 Part II line 2a See instruct ions to Schedule MA 58 for the correct format Required if SchMA58 2a lt gt blank or 2a 0 Independent Submit an Independent Accountant Report if applicable If applicable Accountant Report 48 Medicare Submit a Medicare Intermediary Audit Report if applicable If applicable Intermediary Audit Report Medicare Report Submit a Medicare Report if applicable If not completed at time of filing the Medicare report must be mailed when completed If applicable Financial Facility specific financial statements if available Schedule F line 11 Column B less Column C must equal the net book value on the financial Required if Schedule L Completed 45 46 47 49 50 Statements statements If the net book value does not agree an explanation of the discrepancy must be submitted with the financial statements 0 and SchAapprovedas lt gt 2 or 4 See Order 27 Otherwise submit if applicable 51 52 53 54 55 56 57 Submit a copy of any termination notices received under 55 Pa Code 1101 77 relating to termination for convenience and best interest of the If applicable Department statement of policy if not previously submited with a prior cost report Letter from the Department signifying that an allocation basis other th
94. hedule MA 58 for any Medicare resident had that Medicare resident been provided services during the MA 11 report period understand that any false claims statements or concealment of material fact may be prosecuted under applicable federal or state law PART Ill ADMINISTRATOR INFORMATION LINE UESTION NO 3 Administrator s Name 1391 3b Administrators Telephone Number 1 392 3c Administrators Fax Number 1393 APPENDIX D NUMBERED COST REPORT FORMS e 90
95. hone lines is transmitted in the form of analog waves A modem converts between these two forms Netscape Navigator Netscape communication s web browser that enables the user to view World Wide Web sites NF see Nursing Facility NIS see Nursing Facility Information System Numbered Cost Report A paper MA 11 cost report that has been overlaid with sequential numbers used to guide the placement of data in the cost report standard file Nursing Facility NF A general nursing facility hospital based or county nursing facility which is licensed by the Department of Health and enrolled in the MA Program 1187 2 Nursing Facility Information System NIS The comprehensive automated database of nursing facility resident and fiscal information needed to operate the Pennsylvania Case Mix Payment System 1187 2 The NIS stores accepted cost report data Nursing Facility Services Handbook A handbook issued by the Department s Medical Assistance Program for providers of NF Services containing all information necessary to participate in the Pennsylvania MA Program Password and Connectivity Document A document mailed to each new facility containing information needed to submit data to the MA 11 Cost Report Submission System The document is sent by certified mail to the NF administrator and must be forwarded to the cost report preparer if the preparer is responsible for the submission of the cost report sta
96. ick on the words main menu at the bottom of the MA 11 Cost Report File Submission screen to return to the MA 11 Cost Report Main Menu Once you select Send a Send Confirmation window will appear Figure 5 8 on page 17 10 3 1 4 JavaScript Application Q C cm Figure 5 8 Send Confirmation Window The Send Confirmation window serves as a reminder that the time required to generate the Initial Feedback Report will vary and that you should wait for the Initial Feedback Report which will indicate whether the submission was received prior to continuing with any other cost report or Netscape functions If for some reason you MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 17 Revised 08 26 2005 do not wish to wait for the Initial Feedback Report you may choose Cancel to discontinue the submission process However selecting Cancel will disrupt the submission of your file To confirm that you want to continue the process select OK Once you have confirmed the send command you should remain at the MA 11 File Submission window and not execute any additional cost report or Netscape functions until you receive an Initial Feedback Report The Initial Feedback Report indicates that the MA 11 Cost Report Submission System has received the cost report standard file The next section provides more detailed information about the validation process and reports INITIAL FEEDBACK REPORT FINA
97. ignatures must be originals on both copies If an active signature block appears in this section the facility officer or administrator must complete this section If this section is marked NO SIGNATURE REQUIRED no action is required If an active signature block appears in this section the facility officer or administrator must complete this section If this section is marked NO SIGNATURE REQUIRED no action is required of the supporting documents listed in this section must be submitted with the Certification Report Only one copy of these supporting documents should be mailed Label all supporting documents that are sent with the Certification Report The provider should use a check mark to indicate those items that are submitted with the Certification Report and complete the blank lines with a description of any other documents that the provider might wish to mail to support the cost report standard file Only one copy of these supporting documents should be mailed SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS e 25 Revised 08 26 2005 The MA 11 Cost Report Submission System does not require that a hard copy of the MA 11 cost report be submitted with the Certification Report Any hardcopy MA 11 cost reports that are submitted will be discarded Only the cost report standard file will be used for audit and rate calculations The Certification Report and all supporting documents should be mailed to
98. ill be displayed You may leave that information or delete it and leave those entries blank Select the Next arrow at the bottom of the window A window will appear asking for your provider s domain and DNS servers This is not needed for MA 11 Cost Report Submission System purposes You may leave this information blank Select the Next arrow at the bottom of the window A window will appear showing the current modem selected This should be the modem you selected earlier in these instructions Select the Next arrow at the bottom of the window APPENDIX A NETSCAPE INSTALLATION e 56 44 45 46 4T 48 49 Revised 08 26 2005 A window will appear asking for dialing settings for call waiting and access to an outside line The default for call waiting is the line doesn t have call waiting If a number s must be dialed to access an outside line enter that number s Select the appropriate radio button next to tone or pulse the default is tone Select the Next arrow at the bottom of the window A window will appear asking for your phone number You must enter your correct area code so the system will know if you are dialing long distance Select the Next arrow at the bottom of the window A window will appear stating you are done with the setup You may select the Connect Now icon at the bottom of the window to see if you can connect to the MA 11 Cost Report Submission System now or select the Done icon in the lower
99. ill match the header of the Final Validation Report generated for the cost report standard file This is the Part III Certification Statement area of the Certification Schedule of the cost report concerning the accuracy of the data This will appear on all Certification Reports In cost report standard files that indicate that the answer to Schedule MA 58 Line 1 is No this section will be active If the cost report standard file indicates that the answer to Schedule MA 58 Line la is Yes this section will indicate NO SIGNATURE REQUIRED In cost report standard files where the answer to Schedule MA 58 Line 2a is not blank or zero this section will be active If the cost report standard file indicates that the answer to Schedule MA 58 Line 2a is blank or zero this section will indicate NO SIGNATURE REQUIRED This section lists all supporting documents necessary to support the cost report standard file that was submitted to the M A 11 Cost Report Submission System The provider is reminded to label all supporting documents This section lists other supporting documents that may be submitted by the provider but the data within the cost report standard file cannot be used to indicate if the provider should be submitting the document Revised 08 26 2005 FACILITY ACTION No action is required The facility officer or administrator must complete this section The preparer must sign when applicable S
100. in Windows that allows you to connect your computer to the MA 11 Cost Report Submission System via a modem Direct Dial Up see Dial Up Connection Download To copy data usually an entire file from a main source to a peripheral device The term is used in this manual to describe the process of copying a file from the MA 11 Cost Report Submission System to one s own computer Excel Spreadsheet Template An Excel file that has been set up in the standard file format and is available for download into either Excel or Lotus The facility enters the cost report information directly into this template and submits the file Many cost report preparers have incorporated this template into their existing programs negating the need to re data enter information into the template Excel Template see Excel Spreadsheet Template Final Validation Report A report generated by the MA 11 Cost Report Submission System to display the results of the validations of the file structure and data content of the cost report standard file These validations are based on the Standard File Validations Guest A term used in this manual to indicate a Login ID that may be used by the general public to access certain areas or pages of the MA 11 Cost Report Submission System Initial Feedback Report A report indicating that the MA 11 Cost Report Submission System has received the cost report standard file Internet A global network connecting W
101. incorporate the creation of the standard file within their existing MA 11software along with suggestions on how to proceed with this endeavor These are only suggestions Myers and Stauffer or the Department does not guarantee the results since the MA 11 programs used by providers and their cost report preparers are outside of their areas of responsibility SPREADSHEET FILE For the spreadsheet format option an Excel spreadsheet template is provided by the Department and may be used as a pattern Refer to Appendix B for instructions on how to download this template The template may be linked to an existing MA 11 workbook whether as a separate file or as a separate worksheet within the existing MA 11 workbook The links would most likely be developed by beginning in Column A Row 2 of the spreadsheet template sequence number 1 Login ID Create a formula in this cell that points to the correct cell of the existing MA 11 MA 11 COST REPORT SUBMISSION SYSTEM SECTION 7 ALTERNATIVE STANDARD FILE METHODS e 45 TEXT FILE Revised 08 26 2005 workbook Create a formula for each of the remaining rows of the spreadsheet template Leave row 1 as DATA V4 0 After the links for each row are completed the formulas must be converted to values prior to saving the template and submitting the file to the MA 11 Cost Report Submission System This could be accomplished manually or through the use of a macro or program Extra care must be taken to main
102. ined the Cost Report data in file MA99991111 02092001102537 including any attached exhibits schedules forms and explanations to this Certification Report and found these to be true accurate and complete Expenses not related to nursing facility resident care have been appropriately identified or removed I understand that this information is submitted for the purpose of developing payment rates Figure 5 12 Certification Report The Certification Report will be produced only for cost report standard files that have a status of Received Valid on the Final Validation Report or that the Department has deemed to be valid The report will provide the necessary signature areas for the administrator and list all supporting documents that are required according to the responses in the cost report standard file for the cost report to be acceptable For instance all Certification Reports will have a Trial Balance as a Required Supporting Document However only Certification Reports for cost report standard files that indicate a Medicare rate on Schedule MA 58 will require a supporting document that ties to this rate Certification Reports are accessed from the MA 11 Cost Report Main Menu Simply point and click on Receive Validation Reports If you have initiated a new session you will access the MA 11 Cost Report Welcome Page and select MA 11 Cost MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS e 23 Rev
103. ing Cost Report data in file file name including any attached exhibits schedules forms and explanations and found these to be true accurate and complete Expenses not related to nursing facility resident care have been appropriately identified or removed understand that this information is submitted for the purpose of developing payment rates under the Pennsylvania Medical Assistance Program and that ultimate payment and satisfaction of claims will be based upon the information contained herein understand that any false claims statements or documents or concealment of material fact may be prosecuted under applicable federal or state law Declaration of preparer is based on all information of which the preparer has any knowledge PART IV MEDICARE INTERMEDIARY ris QUESTION NAME OF MEDICARE INTERMEDIARY 10 APPENDIX D NUMBERED COST REPORT FORM e 72 Schedule A SUMMARY PARTI TYPE OF FACILITY PART Il TYPE OF ORGANIZATION Approved as Type of Organization 12 Voluntary Non Profit Hospital Based Proprietary Individual Special Rehabilitation Proprietary Partnership County Proprietary Corporation 1 2 3 4 Proprietary Other Governmental NURSING RESIDENTIAL FE DATE OF PARTIII STATISTICAL DATA NO FACILITY amp OTHER TOTAL CHANGE A B G Beds available at beginning of period Changes in total beds during period Beds available at end of period Bed days available for
104. ing message the Save As window will appear Figure B 3 on page 66 Save C lotus Program Files My Documents Scratch Command C3 MyFiles Timework s Config sys Novell Vfp z Detlog old Dasis32 Windows Detlog t t E Orawin95 S Autoexec bat ffastun ffa E Pacrs40 a Bootlog prv z ffastun ffl MA11VLD 20000501 doc All Files Figure B 3 Save As Window When this window appears the name of the file that you are downloading will appear in the File Name field Choose the directory where you would like to save this file and select the Save button After the Save button has been selected a status bar will appear tracking the progress of the download When the file has been successfully downloaded the status bar will disappear To view or use the downloaded file use the appropriate program to open the file It is very important that you remember where you saved the downloaded file so that you may find it later MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX DOWNLOADS 66 Revised 08 26 2005 APPENDIX C ACCEPTED MA 11 COST REPORT DATA Glossary Terms Used In This Section Certification Report Cost Report Standard File Department Download MA MA 11 Cost Report Submission System Manual Review Validations Validation Definitions for these terms are found in Section 9 INDIVIDUAL COST REPORT FILES Once a cost report standard file has been successfully submitted to the MA 11 Cost Rep
105. iod May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1304 32 B End of prior period Lines 26 30 must line 32 If SchLcompleted 0 must be blank 1305 13361 End of prior period Line 32 25 must line 33 Line 33 must line 16 If SchLcompleted 0 MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 11 ACCEPTABILITY VALIDATIONS 38 gt STANDARD FILE VALIDATION Revised 08 26 2005 1 YES 0 NO Os 1306 130 sM ss lcommAmorbamk mastnot be blank 13 135 SchM 9x9 identity Oen deny fF column A not blank must not be blank 1316120 saM A Maybe blank If Other Identify not blank must nor be blank 13 135 sM o A Mare blank TF Other identify not blank must not be Blank i396 sm B o Am Maybeblklmotblank musbewholenumber i Amom Miybeblank I nor blank must be whole number 24 B 1330 1334 SchM 5a 5e Amount May be blank If Other Identify not blank must not be blank If not blank 335 1337 B o Amum o Maybe blank If not blank must be whole number 1338 1342 SchM 9 9 Amount May be blank If Other Identify not blank must not be blank If not blank must be whole number SchM wo s _ 1343 Amount S
106. ised 08 26 2005 Report Submissions The Login ID and Password Required window will appear for you to complete If you are continuing an ongoing session and have already completed a user log in move to the MA 11 Cost Report Main Menu and select the option The Validation Report Listing window will appear after you select Receive Validation Reports Figure 5 11 on page 20 This window lists all reports beginning with the most recently generated report The reports are identified by the Assigned File Name followed by FINAL for Final Validation Reports init for Initial Feedback Reports and CERT for Certification Reports In order to access a report simply point and click on the underlined file name When you are done you can point and click on main menu at the bottom of the window to return to the MA 11 Cost Report Main Menu The Certification Report must be printed since it must be completed and mailed to the Department Amending Submitted Data Immediately following the submission of a valid cost report standard file no more cost report standard files for that cost report period will be validated Cost report standard files submitted after a valid status has been obtained will be rejected If the facility discovers an error in a valid cost report standard file the correction may be forwarded by mail to the Department along with the Certification Report and the supporting documents The corrected information will be incorporated into th
107. itted on either or Schedule C line 35 or Schedule line 12 It should include the name of the Required if SchC35C lt gt 0 or blank or Ead dd purpose of the loan period of the loan interest rate interest expense and balance of the loan at the end of the report period if SchG12C lt gt 0 or blank Sch C line 31 Documentation to support an entry of other than blank or zero on Schedule C line 31 column G Required if SchC31G lt gt 0 or blank Include copies of the tax notices which identify the type of tax and taxing authority the location and description of the property the tax period and the tax amount Submit proof of any and all payments even if partial payments to the taxing authority in the form of copies of receipted bills or cancelled checks front and back Reasonable payment made in lieu of real estate taxes must be supported by proof of payment A copy of the agreement with the taxing authority must also be provided Submit a schedule reconciling the tax notices to the amount reported on Schedule C line 31 to include rebates and refunds of real estate taxes and amounts paid and or unpaid to date Sch C line 32 Schedule to support an entry of other than blank or zero on Schedule C Line 32 Include major movable property purchased item additions Required if SchC32G lt gt 0 or blank including date of acquisition description of property number of units description of property unit acquisition cost and total ac
108. k or 28 H __ Residential and other allocation dollars Lines 21 27 must line 28 43 Sh 2 H Residenialandotheralocaion dollars Mestbewholemumberblankor O 45 30 Residential and other allocation dollars Line20 28 29mus lin30 7 456 487 Scc 3132 H Residential and other allocation dollars whole mumber blankor C 458 463 1 3 facility allocation percent Must 1 0000 less column J If not blank or 0 must be rounded to 4 decimals 466 467 Schc ir L r __ Nursing facility allocation percen Must 1 0000 less column J If not blank or 0 must be rounded to 4 decimals MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 33 Nursing facility allocation dollars Column F less column H must column G m mpm STANDARD FILE VALIDATION Revised 08 26 2005 1 YES 0 NO 468 4744 1319 allocation pereent Must 1 0000 ess column 1 IF not blank or 0 must be rounded to 4 decimals 475 48 Scc 2127 r facility allocation percem 1 0000 less column J If not blank or 0 must be rounded to 4 decimas Shc 29 1 DNase facility allocation percem 1 0000 Tess column J IF not blank or 0 must be rounded to 4 decimals
109. l funds balance sheet at end of period May be blank If not blank must be whole number If SchMA4completed 0 or must be blank Resident personal funds balance sheet at end of period Lines 11 20 must line 21 If SchMA4completed 0 or NA must be blank Resident personal funds balance sheet at end of period May be blank If not blank must be whole number If SchMA4completed 0 or must be blank Resident personal funds balance sheet at end of period Lines 22 28 must line 29 If SchMA4completed 0 or NA must be blank Resident personal funds balance sheet at end of period Must SchMa410L If SchMA4completed 0 or NA must be blank Resident personal funds balance sheet at end of period Line 29 30 must line 31 Line 21 must line 31 If SchMA4completed Resident personal funds compliance questions If SchMa4completed 1 must not be blank Valid answer 0 1 or blank If Resident personal funds compliance questions If SchMa4completed 1 must not be blank If SchMA4completed 0 or NA III Lio n n If SchMa4completed 1 must not be blank Valid answers 0 1 or blank If SchMA4completed 0 or NA must be blank SchMA58 EMA rate exceed private pay rate Valid answer 0 or 1 be blank 1388 ScMMASS Maca May be blank TF not Blank must be rounded to 2 decimals 1389 SchMA58 2b Medicare rate effective date May be blank If MA58 2a gt 0 must be a valid date within 5 yea
110. lank chKcompleted Is Schedule K completed Valid answer 0 or 1 1079 1093 SchJ H9 sk To 1138 1150 SchK Schedule C line 29 Must 29 or LINE 29 or blank If SchKcompleted 0 must be blank i 0 mu Schedule C line number Must be valid Schedule C line number or blank IfSchKcompleted 0 must cop 7 Schedule C amount If column A not blank must be gt 0 If not blank must be whole number If 15 1 15 1 15 1 15 2 14 1 14 2 14 Amount of profit If column A not blank must be gt 0 If not blank must be whole number If SchKcompleted 0 must be blank 1151 SchK Additional Schedule K amount profit May be blank If not blank must be whole number If SchKcompleted 0 must be blank 1152 SchK 6 C Tota profit for all Schedule Must line 2 15 Must SchE20A 1153 aes Home Office Position service or supply If column A not blank must HOME OFFICE If SchKcompleted 0 must be blank Posiomsevieorsuply be blank If SchKcompleted 0 must be blank 1167 1180 Schk I E of related business Maybe blank IF SchKeompleted 0 mustbeblan Schk F ENwSSN May be blank If Sch Keompleted 0 mustbeblan 11951208 sak I G jOwmerofreatedbusmes IFSchKcompleted
111. lank must not be blank 19 Sh 3s IfSGhC38D nor blank must notbe a Sh 20 j A 21 2317 SdC 2 27 A zig 28 A Mayo Bms21 27mwizlm28 s o Must be whole number blank or 0 gt gt gt gt gt 3 9 2 Salary eost be whole number blank or0 seh a Salary cost Lines 20 28 and 29 must line 30 am 20 Syo Mome 222 240 5 1 319 B Fringe benefits Must be whole number blank or 0 20 8 benefis Lines 1 19 must Tine 20 242 248 21 27 B Fringe benefits Must be whole number blank or 0 38 sac 5 benefis Lines 21 27 must line 28 sac 39 Fringe benefits Must be whole number blank or 35i sent ss Finge benefits Linc 20 28 and 29 must line 30 32 s 49 8 Pins bencfis Linc 30 must line 40 253 27 Tio ther expenses be whole number Blank oro MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 32 gt gt STANDARD FILE VALIDATION Revised 08 26 2005 1 YES 0 NO 2m Sh 2 C Urepemes E T 25 359 Sec 2 27 C Other expenses
112. le by the Department If the Certification Report is incomplete or all supporting documents weren t submitted or acceptable the reduced rate is not lifted until all steps are completed valid cost report standard file complete Certification Report and all supporting documents are received and acceptable The receipt date recognized by the Department is the date the Certification Report and supporting documents are received at P O Box 2675 or are received and stamped in by the Division of Nursing Home Rates as of the close of business at 5 P M SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS e 27 MA 11 COST REPORT SUBMISSION SYSTEM Revised 08 26 2005 SECTION 6 MA 11 ACCEPTABILITY VALIDATIONS Glossary Terms Used In This Section 1187 Regulation Additional Supporting Documents Certification Report Certification Report Package Cost Report Standard File Department Internet Intranet MA MA 11 Cost Report Submission System Manual Review Validations Numbered Cost Report Nursing Facility Password and Connectivity Document Provider Number Required Supporting Document Sequence Number Standard File Validations Supporting Document Validations Validation Web Site Definitions for these terms are found in Section 9 INTRODUCTION Subchapter F Cost Reporting and Audit Requirements of Chapter 1187 requires nursing facilities to report costs to the MA Program by filing an acceptable MA 11 with the Department For MA 11 cost reports
113. ll also verify original signatures If the Certification Report and supporting documents pass all Supporting Document and Manual Review validations the cost report is accepted If the appropriate supporting documents have not been submitted or fully completed if the signatures are not complete or are not original or if only one Certification Report is received the Departnent will return the Certification Report Package and the cost report will be unacceptable The Certification Report consists of five areas plus the report header information While all sections will appear on every Certification Report not all sections will require action by the facility The sections that require action are based on the data submitted in the cost report standard file These items are described in the following table MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 24 MA 11 COST REPORT SUBMISSION SYSTEM SECTION Header Administrator Preparer Signature Private Pay Rate Signature Medicare Rate Signature Do not mark NA for any supporting document in the Required Supporting Documents area This will result in rejection of your cost report If you are unsure why a document was required contact the Myers and Stauffer helpdesk Required Supporting Documents Additional Supporting Documents DESCRIPTION This is general information for the cost report standard file that was submitted This header w
114. mets Bmsi I9mwtzne20 353 359 Scc 2127 FE Adwmes Mesbewholemumbrblnkor 36 28 E lAjwmess Hms21 27mwi lim28 3 amp Sh 2 E 362 30 363 384 ScC 322 E See lesi fes fesl fesi feol fesi m mi 374 sh 415 9 225 30 Allowable cost Column D E must column F Nursing facility allocation dollars Column F less column H must column G Nursing facility allocation dollars Column F less column H must column G Allowable cost Column D E must column F Nursing facility allocation dollars Lines 1 19 must line 20 SF Allowable cost Line 12 must 0 Column D E must column F Nursing facility allocation dollars Column F less column H must column G prz y s CY Cd CQ Ca Ca mnm 428 435 sheo 51 8 H 436 437 Schc 10341 H Residential and other allocation dollars Mustbewholemumberbankor0 438 44 Scc 1349 __ Residential and other allocation dollars J Mestbewholenumberblankor Sh j H Residential and other allocation dollars Limsi I9mux lime20 O C 446 483 Scc 2127 H Residenialand other allocation Must be whole number blan
115. n Amending Submitted Data n x ACCEPTABILITY PROCESS Reine E RU ERU EU E ERU Filing Deadlines ere ete e PO DI EU UR ERES SECTION 6 MA 11 ACCEPTABILITY VALIDATIONS 28 INTRODUCTION dno e eie p pee RR teens 28 INSTRUCTIONS FOR USE OF STANDARD FILE VALIDATIONS ee 28 INSTRUCTIONS FOR USE OF SUPPORTING DOCUMENT VALIDATIONS 29 INSTRUCTIONS FOR USE OF MANUAL REVIEW VALIDATIONS 30 SECTION 7 ALTERNATIVE STANDARD FILE METHODS 45 MA 11 COST REPORT SUBMISSION SYSTEM Contents i Revised 08 26 2005 INTRODUCTIDON E n UTR Dm c M d 45 SPREADSHEET PIB mud eden qai dte ge nth anita 45 TEXT BIEE e HI Rete tdv pag Tea ceti A 46 FILE NAMING CONVENTION setti ttti tt 46 SECTION 8 HELPDESK 47 MYERS AND STAUFFER 47 HELPDESK ASSISTANCE M ERA 48 PROBLEMS NOT SUPPORT ED abeo tonite tutae beer 48 SECTION 9 GLOSSARY 49 COMMON TERMS AND ABBREVIATIONS ettet 49 APPENDIX A NETSCAPE INSTALLATION 54 WINDOWS 3 X SET UP INSTRUCTIONS FOR NETSCAPE csset 54 WINDOWS 95 SET UP INSTRUCTIONS FOR NETSCAPE INSTRUCTIONS FOR FREE VERSION SET UP sss INSTRUCTIONS FOR ACCOUNT SETUP NETSCAPE PERSONAL EDITION OPTIONAL SETUP
116. n the underlined text option to go to the desired window Terminating the Communication Connection When you wish to exit the communication link to the MA 11 Cost Report Submission System and you are using an Internet connection simply exit Netscape MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS e 14 Revised 08 26 2005 select Exit from the File menu or double click on the small box at the top left corner of the window or select another address to view If you are using an Intranet dial up connection exit Netscape select Exitfrom the File menu or double click on the small box at the top left corner of the window and point and click on the Disconnect button on the dialer window SUBMITTING COST REPORT STANDARD FILES Selecting the MA 11 Cost Report Submissions option from the MA 11 Cost Report Welcome Page allows you access to the primary MA 11 Cost Report Submission System functions When you select MA 11 Cost Report Submissions a User Name and Password Required window will appear Figure 5 4 on page 15 Username and Password Required x Enter username for unknown prompt at 10 3 1 4 User Name Password Cancel Figure 5 4 Login ID and Password Required Window You must point and click in the first field User Name to begin entering the Login ID and password provided to you by the Department The Guest Login ID may not be used to submit cost report standard files Y
117. n provides definitions of terms and abbreviations used in this manual 1187 Regulation Medical Assistance Regulation Chapter 1187 Nursing Facility Services Case Mix Reimbursement System A specific provider regulation for nursing facility reimbursement This regulation may be found in the Nursing Facility Services Handbook Also referred to as 55 Pa Code 1187 Additional Supporting Documents Exhibits schedules forms and explanations that are required to be mailed to the Department if applicable to the cost report in order for the cost report to be accepted Some of these documents are listed on the Certification Report others may be listed on the blank lines of the Certification Report and mailed to the Department Assigned File Name The file name assigned to the cost report standard file by the MA 11 Cost Report Submission System Each cost report standard file submitted is assigned a unique file name which is the Facility ID followed by the Date and the Time to the nearest second Bookmark A feature of a web browser that allows the user to save the address URL of a web page so that the page can easily be revisited at a later date Browser see web browser Certification Report A report that is placed in the provider s directory on the MA 11 Cost Report Submission System after the status of Submission Received Valid has been achieved This report must be printed completed and mailed to the Department C
118. nal Validation Report on page 19 and view your Final Validation Report If the report indicates any errors repeat steps 2 and 3 If the report indicates that your cost report standard file was valid go to Step 5 View and print your Certification Report using the instructions starting in Section 5 Certification Report on page 23 Gather all supporting documents indicated on the Certification Report and label them using the document title on the Certification Report Put the documents in the order in which they appear on the Certification Report Make one copy of the Certification Report Sign the original and the copy in all applicable areas on the Certification Report for a total of two documents with original signatures Mail both copies of the signed Certification Report and one copy of all supporting documents to the address located in Section 5 Page 26 The package must be received by the Department on or before the cost reporting deadline MA 11 COST REPORT SUBMISSION SYSTEM SECTION 2 QUICK GUIDE 3 Revised 08 26 2005 SECTION 3 OVERVIEW Glossary Terms Used In This Section Additional Supporting Documents Browser Certification Report Cost Report Standard File Department Dial Up Connection Dialer Download Excel Spreadsheet Template Guest Internet Internet Explorer Internet Service Provider Login ID MA MA 11 Cost Report Submission System Manual Review Validations Medical Assistance Nursing Facility Spread
119. nd click on the Name of the Cost Report File field and simply type in the cost report standard file name including the complete path to the file e g C ACost Report myfile xxx The recommended method is to browse or review lists of files by pointing and clicking on the Browse button A File Upload window will appear to enable you to select from a list of files on the computer hard drive or from a floppy disk inserted into a different drive Figure 5 7 on page 17 File Upload 2 Look in a Program 7 El e ex Fiename Files of type HTML Files Cancel Figure 5 7 File Upload Window Select Files from the dropdown list in the Files of Type field so that you do not limit the types of files shown in the list Ensure that the correct drive is selected in the Look In field c for the computer hard drive and a or b for a floppy disk drive The list of file names will appear in the area above the File Name field To select a cost report standard file for submission you may point and click on a file name and then on Open or point and double click on the name of the cost report standard file you wish to submit The cost report standard file name will appear in the Name of the Cost Report File field on the MA 11 File Submission window Once you have selected a cost report standard file point and click on the Send button to submit the file If you decide not to submit a cost report standard file you may point and cl
120. ndard file MA 11 COST REPORT SUBMISSION SYSTEM SECTION 9 GLOSSARY 51 Revised 08 26 2005 PC Personal Computer Provider Number The eight digit number assigned to the nursing facility by the Department It can be found in the Provider Notice received shortly after enrolling in the Medical Assistance Program Public Use Area In this manual the public use area refers to the pages of the MA 11 Cost Report Submission System that may be viewed by the general public without a facility specific Login ID and password Rejected Cost Report Standard File A cost report standard file that is identified as REJECTED on the Final Validation Report The status on the Final Validation Report is Submission Received Invalid and the Error s listed will clearly state REJECTED In general a cost report standard file is rejected if the MA 11 Cost Report Submission System determines that the cost report standard file is not recognizable as a spreadsheet or text file if it cannot be determined for whom the cost report standard file is being submitted if the Test field is not completed with T or F if the Facility ID in the cost report standard file does not match the log in ID if the cost reporting periods are not correct or a valid cost report standard file has already been received for the cost reporting period Rejected File see Rejected Cost Report Standard File Required Supporting Document Exhibits schedules forms and ex
121. ndow has a single data entry field Location or Go To You must point and click on the field in order to type in the Uniform Resource Locator URL The URL for the MA 11 Cost Report Submission System is the following http 111 111 111 111 Once you press Enter Netscape will look for the specified URL There are configuration options within Netscape that can make accessing the MA 11 Cost Report Submission System easier in other words you can configure it so you do not have to type in the URL each time you access Netscape Appendix A contains instructions on setting the location to default to the MA 11 Cost Report Welcome Page or creating a Netscape bookmark WEB SITE OPTIONS The Department retains the Once you have connected to the system through the Internet or when Netscape finds right to limit the amount of the specified URL through the Intranet dial up connection the MA 11 Cost Report time that you are connected to Welcome Page will appear Figure 5 3 on page 14 the MA 11 Cost Report Submission System during a single session If necessary time limits will be imposed at a later date MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 13 Revised 08 26 2005 FJ Meli Weine Page Mkrowrt intersst tapiorer ajaj xj Ph b y yote Joh thb 14 out 3 Ue Greate Pete ue 22 Agiss 7 lt Welcome to the MA 11 Cost Report Submission
122. ne 34 583 591 ScD 19 B Revenues adjustments to Schedule C Must be whole number blank or 0 592 Sh 10 B Revenues adjustments to Schedule C If column A not blank or 0 must not be blank or 0 593 504 11 12 B Revenues adjustments to Schedule C Must be whole number blank or 0 595 609 14 30 B Revenues adjustments to Schedule C Must be whole number blank or 0 GO sdb S 5 Reemes adisment to Schedule Linc 30 must line 35 61 Sh 35 B Revenues adjustments to Schedule Must be whole number blank or 0 612 Sh 36 B Revenues adjustments to Schedule C Line 35a 35b and SchC40E must line 36 613 621 5 19 Schedule C line number If column B not blank or 0 must not be blank 622 623 11 12 C Schedule C line number If column B not blank or 0 must not be blank MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 34 z gt gt gt gt gt gt gt gt gt gt STANDARD FILE VALIDATION Revised 08 26 2005 1 YES 0 NO VALIDATION eres Sdb 1425 C ShueClnemmbr O coumsBnorblamkor must not be Blank 636 638 sab 2830 C Schedule Clinenumber Ireolumn not Blank or 0 must notbe Blank 69 8 Expems bank or O must not be Blank 60 Sh gt Ewems YRS ETA not blank o
123. notal beds during period Residential amp Other Must be gt 500 and lt 500 29 Sh J B Beds available at end of period Residential amp Other Must SchA1aB SchA1baB SchAIbbB SchATbcB SchA1bdB 0 Sh 2 B 4 Bed days available for period Residential amp Other Must be 1096 of available bed calculation See example 31 SchA 3 B Actuaresident days for period Residential amp Other Must be SchA2B 32 SchA J C Beds available at beginning of period Total Must SchA1aA SchA1aB 33 Ha C Changesin total beds during period Total Must SchA1baA SchA1baB 34 SchA C 4JChangesin total beds during period Total Must SchA1bbA SchATbbB 3 Sha C JChangesin total beds during period Total Must SchAT1bcA SchATbcB 36 Sch ma C Changes in total beds during period Total Must lt SchATbdA SchA Td 37 Must SchAlbdA SchAlbdB O SchA lc Beds available at end of period Total Must SchAlaC SchAlbaC SchAlbbC SchAlbcC SchA1bdC Must SCchA1cA SchA1cB 38 Sh 2 C available for period Total Must be 10 of available bed calculation See example E39 seh 3 Fra resident days for period Total Must SchASA SchA3B CERTbegdate and lt CERTenddate and CERTenddate 42 SchA lbc Date of Change for Total Beds during period If Sch
124. older or tag that allows you as with a book to go directly to a specific page where you have been before 1 2 3 MA 11 COST REPORT SUBMISSION SYSTEM Access Netscape Enter the correct URL in the Location or Go To field Click the Bookmarks button on the toolbar select File Bookmark and then select the folder where the bookmark should be added Once you have established this bookmark you can select this item by clicking the Bookmark button on the toolbar and selecting the item named Cost Report Welcome Page under the folder where you added it APPENDIX A NETSCAPE INSTALLATION 63 Revised 08 26 2005 APPENDIX B DOWNLOADS Glossary Terms Used In This Section Cost Report Standard File Download MA 11 Cost Report Submission System Validation Definitions for these terms are found in Section 9 DOWNLOADING COST REPORT UPDATE FILES In addition to this end user manual there are files available for download from the MA 11 Cost Report Submission System that will be useful in creating cost report standard files and interpreting validation reports To download these files connect to the MA 11 Cost Report Welcome Page as described in this end user manual From the MA 11 Cost Report Welcome Page select the Downloads link After Downloads has been selected the Cost Report Update Page will appear Figure B 1 on page 64 PERMITTI jaj xi Ph bh Yer Jo deb Sed Q 2 442 Qasa I 2 BE a
125. ollow these instructions if you plan to use the Intranet dial up method to connect These instructions are based on having your modem physically installed and the modem driver installed MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX A NETSCAPE INSTALLATION e 61 10 11 12 13 Revised 08 26 2005 Select Start Programs Accessories Dial Up Networking If you do not have Internet access you will get a window called Make New Connection If you do have Internet access double click on the Make New Connection icon Select the Next button You may enter a name for the computer you are dialing 1 Cost Report Select your modem from the drop down list Select the Next button Enter the area code and telephone number provided to you by the Department 717 541 5806 Select the Next button A message box will appear stating the connection has been successfully created Select Finish You may double click on the new icon you created to connect to the MA 11 Cost Report Submission System at this time or you may close the Dial Up Networking windows and connect at another time Right mouse click on the new dialer you created and select Properties Select the Server Types tab or button For MA 11 Cost Report Submission System purposes only the Logon to network and TCP IP options should be checked If any other options are checked click on the box next to the option to remove the checkmark Select OK PART II C
126. onnecting to the MA 11 Cost Report Submission System Note The first time into the dialer you should select the Dial Properties button and enter the area code you are dialing from and any number or code required to access an outside line Then select the OK button l 2 3 Select Start Programs Accessories Dial Up Networking Double click on the Dialer icon you created 1 Cost Report Enter the Login ID and password Select the Connect button On newer versions of Windows 95 the Dialup icon will display in the lower right corner of the screen while you are connected Refer to Section 5 for information on submitting cost report standard files NETSCAPE PERSONAL EDITION OPTIONAL SETUP You may set Netscape Personal Edition to automatically display the Cost Report Welcome Page as the first screen to appear when you access Netscape and eliminate the need to enter the URL each time you access Netscape To do so l 2 MA 11 COST REPORT SUBMISSION SYSTEM Access Netscape Move the cursor to the Options pull down menu APPENDIX A NETSCAPE INSTALLATION e 62 Revised 08 26 2005 Select General Preferences Click on the file tab for Appearance if necessary In the area labeled Startup ensure the Netscape Browser has an x in the box beside it In the field next to Browser Start With click the Home Page Location button and enter the URL specified in Section 5 of this manual This will be http 111 111 1
127. or other employe s living quarters and or other areas not related to resident care Identify 892 What is the total square footage of the non allowable cost centers 9 Have indirect costs applicable to nonallowable cost centers been eliminated on Schedule E m m slzls Encode all Schedule Part II data the standard file including the Identify designation for lines 2 6 and 8 Responses of YES must be encoded as 1 in the standard file NO must be encoded as O zero APPENDIX D NUMBERED COST REPORT FORMS e 82 SUPPLEMENTAL INFORMATION AND QUESTIONNAIRE Code YES as 1 NO as 0 LINE ts for th rt period for the followi I Fringe amounts the report period the Tollowing personne Administrator 895 903 Assistant Associate Administrator 896 912 Chief Dietitian 897 905 913 Chief of Fiscal Services 898 906 914 Director of Housekeeping 899 907 915 Director of Nursing 900 908 916 Facility Engineer 901 909 917 All Approved Feeding Assistants 91 0 91 8 while providing specific duties Does the facility employ any individuals who are related to the owner s or officers directors If YES attach a separate schedule identifying Name Title Function and SSN of related employe as well as number of hours worked per week salaries wages fringe benefits and line of Schedule C on which this is recorded
128. orconraced Mustbewholenumberblnkor Sh 1 Say empoy reed paies Valdamwer ori 9 sh gt T 1 lPesosexpmssexduded MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 36 STANDARD FILE VALIDATION Revised 08 26 2005 1 YES 0 NO 921 Schl 13 Loans notes or advances to officers employes BODs or Valid answers 0 1 or NA owners 922 Schl pow Loans notes or advances from officers employes BODs or Valid answers 0 1 or NA owners 35 Sd i Adjusmen made forexpenses disallowed in prior audits ValidamwersO IorNA 94 Sh 16 Faiy a Continuing Care retirement Community Valdanwer orl l sss 95 Sh j jReityhsadmisonie 95 Sh i jReWwpatorachun 97 sd Memtycun E 928 957 Mor ij Management company name lfcolumn B not blank or column C not Blank or 0 must not be Blank 958 947 Mor f j B Dwpeofservie onetypeofsericeperln fif column A not blank must not be blank SSCS 948 957 C PAmux lcolmnAnotblnk musbewholenumberor Schicomplted isSchedulelcompleed Validamswer ori IFO SchEISA musi orblmk A Nameofownerordiecior be blank
129. orld Wide Web sites There are a variety of ways to access the Internet Most online services such as America Online offer access to some Internet services It is also possible to gain access through a commercial Internet Service Provider ISP Internet Explorer Microsoft s web browser that enables the user to view World Wide Web sites Internet Service Provider A company that provides access to the Internet For a monthly fee the service provider gives you a software package Login ID password and access phone number Equipped with a modem you can then log on to the Internet and browse the World Wide Web Intranet A network based on an Internet belonging to an organization usually a corporation accessible only by the others with authorization An Intranet s web sites look and act just like any other web sites but the firewall surrounding an Intranet fends off unauthorized access Invalid File see Invalid Cost Report Standard File Invalid Cost Report Standard File A cost report standard file submitted to the MA 11 Cost Report Submission System that has not passed one or more Standard MA 11 COST REPORT SUBMISSION SYSTEM SECTION 9 GLOSSARY 50 Revised 08 26 2005 File Validations set forth in the MA 11 Acceptability Validations document The status on the Final Validation Report is Submission Received Invalid ISP see Internet Service Provider Login ID A number assigned by the Department and provid
130. ort Submission System and the Certification Report and all Supporting Document and Manual Review validations have been met the cost report will be deemed accepted Once a cost report has been accepted it will be made available for viewing and data analysis by the general public The accepted cost report data files may be downloaded from the MA 11 Cost Report Submission System To view a listing of these accepted cost reports download the first file listed 00000000 AcceptedMA 11s xls To download these files connect to the MA 11 Cost Report Welcome Page as described in this end user manual From the MA 11 Cost Report Welcome Page select the Accepted MA 11 Cost Reports link After Accepted MA 11 Cost Reports has been selected the Accepted MA 11 Cost Report Page will appear Figure C 1 on page 68 MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX C ACCEPTED MA11 COST REPORT DATA e 67 Revised 08 26 2005 T Au EU E 11 xi d Mev Peter Deb Hee vetet Q 2 2 Qa jte grees o 29 eJ obrem awa 1 Ch eor 27 B a Accepted MA 11 Cost Reports Yeu 2001 100 X mo x 04 Return to the MA Cort Resort S beraenos Sreern Walecere Dace Figure C 1 Accepted MA 11 Cost Report Page Each accepted cost report file is stored by year Select the cost reporting year and the subsequent MA 11 Accepted Cost Report Screen will appear as shown below T Accepte
131. ou may use the Tab key or point and click in the second field password to type in the password provided to you by the Department Once you have entered both a valid Login ID and password press Enter or point and click on OK You may select Cancel if you do not wish to proceed The Login ID and Password Required window will appear only when you initially access the cost report standard file submission process Once you have entered a correct Login ID and password and selected OK the MA 11 Cost Report Main Menu will appear Figure 5 5 on page 16 This window includes e Submit MA 11 Cost Report Data accesses the window for cost report standard file data submissions e Receive Validation Reports allows you to view and print Initial Feedback Reports Final Validation Reports and Certification Reports MA 11 COST REPORT SUBMISSION SYSTEM SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 15 Revised 08 26 2005 3 11 Main Menu Microsoft Internet Explorer Ee x hittp 10 3 1 4 ei mainhtml exe E 2 Welcoine to the Pennsylvania MA 11 Cost Report Submission System Use the links below to submit cost report data and to receive the latest validation reports on cost report submissions Submit 11 Cost Report Data Standard cost report file must be CLOSED before submission R c ive Validation Reports Return to the MA 11 Cost Report Submission System Welcome Page Figure 5 5 MA 11 Cost Report Main Menu
132. period CU EE lm Percent occupancy Line 3 Line 2 5 6 Round to 4 decimals Resident days at 90 occupancy 22 Line 2 X 90 Total MA resident days of care E APPENDIX D NUMBERED COST REPORT FORM e 73 SUMMARY OF RESIDENT CENSUS RECORDS Schedule B DAYS OF CARE C z m Nursing Nursing Nursing Nursing Nursing Nursing ma mamco wA LTCCAP MA Hospice Medicare Al Oer And Other m sa a nos nn ma nm ne e us sn e oa nor oa ros nem nen oa fo os m e om mo ms ner ner Pons sa m ms o waf nof nes e 68 1811 1941 1107 pg 120 1133 piei 146 i31 159 172 185 4 4 4 4 1 For line 13 Column B plus Column C plus Column D plus Column E plus Column plus Column must agree to Schedule A Line 3 Column g z ss T 2 N 13 ws 7 9 11 12 EN wo 2 Line 18 Column must agree to Schedule A Line 3 Column 3 Line 13 Column must agree to Schedule A Line 3 Column C 4 For Line 13 Column B plus Column C plus Column D plus Column E must agree to Schedule A Line 6 Column A APPENDIX D NUMBERED COST REPORT FORM e 74 COMPUTATION AND ALLOCATION OF ALLOWABLE COST Schedule C ALLOCATION ALLOCATION
133. planations that are required to be mailed to the Department in order for the cost report to be accepted These documents are listed on the Certification Report and are based on the data within the cost report standard file Sequence Number A number used to identify each area of the paper MA 11 cost report that is to be submitted in the cost report standard file The sequence number also identifies the order in which the data appears in the standard file Spreadsheet File In this manual a term used to designate the format of the cost report standard file The file may be created in either Excel or Lotus Standard File Validations A set of edits that have been designated by the Department to aid in obtaining completeness and accuracy of the data within the cost report standard file prior to generating a Certification Report Submission ID A unique identification number for a submission assigned by the MA 11 Cost Report Submission System This is a statewide sequential number tracking the number and order of cost report standard files that are submitted to the system Supporting Document Validations A set of edits that have been designated by the Department to aid in obtaining all the Required and Additional Supporting Documents listed on the Certification Report prior to acceptance of the cost report Test Cost Report Standard File A cost report standard file that does not contain F in sequence number 2 Certification S
134. quisition cost Include major movable property purchased item deletions including date of deletion number of units description of property original acquisition cost date of acquisition American Hospital Association AHA Life proceeds from sale or disposal remaining book value and total offset Include major movable property rented and leased items including term of rental or lease to and from dates description of property imputed purchase price AHA Life annual straight line SL depreciation annual lease or rental payments and reported amount Suggested format for supporting documentation of major movable property is located on Pennsylvania s MA 11 Cost Report Submission System website hhtp pamal 1 com downloads SchCline32 xls acad D line 10 Schedule to support an entry of other than blank or zero on Schedule D Line 10 Column A or B Indicate the source the amount and where the nacen Schedule C expenses appear Attach copies of invoices paid with the Exceptional DME Grant O or blank Sch D line 20 Schedule to support income greater than 500 reported on Schedule D line 20 Indicate the source the amount and where the related Schedule C Required if SchD20A gt 500 00 REM iE EE S prope I UU expenses appear Sch D line22 Schedule to support income greater than 500 reported on Schedule D line 22 Indicate the source the amount and where the related Schedule C Required if SchD22A gt 500 00 pee clc T 5 I eee ed e
135. rs of the cost report end date MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 39 1357 1358 SchMA4 27 28 1359 1368 SchMA4 11 20 1369 SchMA4 1370 1376 SchMA4 22 28 1377 SchMA4 29 1378 SchMA4 30 1379 SchMA4 31 i 1380 SchMA4 U 1381 SchMA4 U N o2 N 1382 1385 SchMA4 1386 1387 STANDARD FILE VALIDATION Revised 08 26 2005 1 YES 0 NO VALIDATION 1390 SchMA58 2e Audited Medicare rate Valid answers 0 1 or blank If MA58 2a gt 0 must not be blank IET SciMASS 3a Administrator s Name Must not be blank 1392 SchMA58 3b Administrator s Telephone Number Must be a 10 digit number 1393 SchMA58 J 1 Administrator s Fax Number May be blank If not blank must be a 10 digit number MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 40 SUPPORTING DOCUMENT VALIDATIONS Revised 08 26 2005 1 YES 0 NO ORDER LABEL DESCRIPTION OF DOCUMENT TYPE 1 Trial Balance Combining detail trial balance showing all general ledger account ending balances It must indicate the groupings of accounts to agree to the line Required item totals reported on Schedules C and D rJ Organization Chart Organization chart of supervisory personnel with names of personnel included Schedule Classified loan schedule to support costs subm
136. se instructions 1 2 3 4 Select Start Settings Control Panel Double click on the Network icon Under the Configuration tab select the Add button Highlight Protocol from the display list and select the Add button Select Microsoft from the list of manufacturers and then select TCP IP from the list of network protocols You may need your Windows 95 Setup CD Select the OK button on the Select Network Protocol window and again on the Network window You will need to restart windows for the TCP IP settings to take effect PART III Netscape Setup Install from a CD or download from the Internet and take all defaults See the web site www netscape com download for instructions on how to obtain the free progra m PART IV Account Setup MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX A NETSCAPE INSTALLATION e 60 10 11 12 13 Revised 08 26 2005 Select Start Programs Accessories Dial Up Networking If you do not have Internet access you will get a window called Make New Connection If you do have Internet access double click on the Make New Connection icon Select the Next button You may enter a name for the computer you are dialing 1 Cost Report Select your modem from the drop down list Select the Next button Enter the area code and telephone number provided to you by the Department 717 541 5806 Select the Next button A message box will appear stating the connection has be
137. sheet File Standard File Validations Text File Validation Web Browser Web Site Definitions for these terms are found in Section 9 REPORTING REQUIREMENTS The MA 11 is the Financial and Statistical Report for Nursing Facilities and Services under the Medical Assistance MA Program referred to in this end user manual as the cost report Each MA provider reports on either a January 1 through December 31 or July 1 through June 30 period as designated by the nursing facility The reporting period may only be changed in the event of the sale of the nursing facility to a new owner The annual reporting process requires the filing of the cost report within 120 days following the June 30 or December 31 period No extensions are granted except upon evidence of fraud or a breakdown in the Department s administrative process If the cost report is timely filed but is unacceptable the provider is notified of the corrections needed Corrections mu st be made and all supporting documents must be received by the Department by the correction deadline as described in Section 5 Filing Deadlines on page 26 MA 11 COST REPORT SUBMISSION SYSTEM WEB SITE The process of submitting and validating cost report data has been automated by the development of a web site the MA 11 Cost Report Submission System This web site performs edits on the submitted data provides feedback on the results of the validations process and acts as a repository for facility cost
138. sident days of care NF MA Hospice Line 13 must lines 1 12 Column B C D E must SchA6A Column B C D E F G must SchA3A 108 119 SchB 1 32 F Resident days of care NF Medicare Must be blank if column A is blank 120 Sh 13 F Resident days of care NF Medicare Line 13 must lines 1 12 Column B C D E F G must SchA3A 121 132 SchB 1 2 G Resident days of care NF All Other Must be blank if column A is blank 13 S amp B 13 J G Resident days of care NF All Other Line 13 must lines 1 12 Column B C D E F G must SchA3A 134 145 SchB 1 2 H Resident days of care Residential and Other Must be blank if column A is blank 146 Sh 13 H Resident days of care Residential and Other Line 13 must lines 1 12 Line 13 must SchA3B 147 158 ScB 1 12 I JjResidentdays of care total Must column B C D E F G H Resident days of care total Must column B C D E F G H Line 13 must lines 1 12 Line 13 must SchA3C 150171 O B Qo m Kon Kon wmm p OOo JMAhopiulkavedays MutbebankifcoummAisBa C Omerhospialawedays MutbeblnkitcoummAisBank Omerhoptaleaedays _ E i 26 KSehC2 DorSchC2 Enorblak must not be Blank ITSchCZ7D or SehC27E not b
139. support amount reported on Sch M line 8 Col B Required if SchM8B lt gt 0 or blank Sch MA4 Schedule to support a response of NO to Schedule MA 4 Completed The facility must attach separate and routine resident personal funds Required if Schedule MA 4 Resident Personal reports completed under generally accepted accounting principles and financial statement reporting requirements Completed 0 Funds 35 Sch MA line 18 Schedule to support assets in excess of 1000 submitted on Schedule MA 4 line 18 If assets have been described elsewhere the supporting Required if SchMA4 18 gt 1000 00 NE a document for Schedule MA 4 line 18 must state the location of this description pr MA4 line 19 Schedule to support assets in excess of 1000 submitted on Schedule MA 4 line 19 If assets have been described elsewhere the supporting document for Schedule MA 4 line 19 must state the location of this description MA4 line 20 Schedule to support assets in excess of 1000 submitted on Schedule MA 4 line 20 If assets have been described elsewhere the supporting Required if SchMA4 20 gt 1000 00 document for Schedule MA 4 line 20 must state the location of this description p MAG line 26 Schedule to support liabilities in excess of 1000 submitted on Schedule MA 4 line 26 If liabilities have been described elsewhere the supporting document for Schedule MA4 line 26 must state the location of this description 00 ch ch ch
140. t be saved as version or lower Lotus files with a MA 11 COST REPORT SUBMISSION SYSTEM SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY 9 Revised 08 26 2005 123 extension can not be validated Data entry will be easier if the original template is left blank MA 11 COST REPORT SUBMISSION SYSTEM SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY 10 Revised 08 26 2005 SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS Glossary Terms Used In This Section 1187 Regulation Additional Supporting Documents Assigned File Name Bookmark Browser Certification Report Certification Report Package Cost Report Standard File Department Department of Public Welfare Dialer Direct Dial Up Download Final Validation Report Guest Initial Feedback Report Internet Internet Explorer Internet Service Provider Intranet Invalid Cost Report Standard File Login ID MA 11 Cost Report Submission System Manual Review Validations Medical Assistance Modem Netscape Navigator PC Public Use Area Rejected Cost Report Standard File Required Supporting Document Sequence Number Standard File Validations Submission ID Test Cost Report Standard File Text File Uniform Resource Locator URL Valid Cost Report Standard File Validation Web Browser Web Site Definitions for these terms are found in Section 9 ESTABLISHING THE WEB SITE CONNECTION Internet Explorer can be used In order to connect to the MA 11 Cost Report Submission System you
141. t report file in Appendix D append each data item as a subsequent record in text format For example record 2 would be sequence number 1 Facility ID Record 3 would be sequence number 2 Test T or F and so forth If a data item is blank append a blank record as a placeholder When completed the table should contain only 1 393 records the number of records to create a text file for one provider s cost report Copy the table to an ASCII text file with the extension as txt Each record should be terminated with a carriage return and line feed characters Blank records should contain only the carriage return and line feed FILE NAMING CONVENTION Once the alternative standard cost report file has been created for a certain reporting year the file may be named in any convention created by the user or the software creating the file The file will be renamed by the submission system MA 11 COST REPORT SUBMISSION SYSTEM SECTION 7 ALTERNATIVE STANDARD FILE METHODS e 46 Revised 08 26 2005 SECTION 8 HELPDESK Glossary Terms Used In This Section Certification Report Cost Report Standard File Department Download Excel Spreadsheet Template Internet Internet Explorer MA MA 11 Cost Report Submission System Modem NIS Numbered Cost Report Validation Definitions for these terms are found in Section 9 MYERS AND STAUFFER HELPDESK Myers and Stauffer is a Department consultant contracted to administer the MA 11 Cost Report Submission Sys
142. tain the correct required format for each cell in the submission file The correct format requirements may be found in the Excel spreadsheet template or in the Standard File Validation descriptions The standard file may be saved as either an Excel or Lotus file If Lotus is used save as a Wk4 or lower version 123 cannot be used at this time Only Row A of the standard file must be submitted to the MA 11 Cost Report Submission System However the submission of additional columns rows or worksheets will not lead to a rejected file but the additional information will be ignored by the system If a provider is submitting a workbook to the MA 11 Cost Report Submission System the standard file described above must be placed as the first worksheet in the workbook Submitting the entire workbook rather than just the standard file results in a longer wait for the user while submitting due to the size of the workbook compared to the size of the standard file worksheet only The text file option was created for use by software vendors whose MA 11 program can be modified to create a text file from the tables used by the MA 11 program to store cost report data For the text file option create a table with one field The size for the field should be 100 characters the greatest maximum field size in the standard spreadsheet template Record 1 should contain DATA V4 0 Following the sequence of data in the Excel spreadsheet template or the numbered cos
143. tem the NIS calculate MA Case Mix Reimbursement rates and provide technical support for the submission of records to the CMS MDS 2 0 Data Collection System The Myers and Stauffer Helpdesk is available for questions from providers and cost report preparers concerning the submission of the cost report standard file and interpretation of the validation reports When contacting the helpdesk please indicate that you have a question concerning the MA 11 cost report MA 11 COST REPORT SUBMISSION SYSTEM The phone number for the helpdesk is 717 541 5809 If the staff is unable to answer your call directly due to heavy call volume or during non business hours leave a voice mail message with your name the facility name or organization name and the phone number It is also important to indicate that the question concerns the MA 11 cost report since the helpdesk staff also support MDS submis sions The amount of space in the voice mail account is limited so we ask that callers only leave the minimum amount of information necessary to identify the caller the facility the telephone number with area code and extension and 11 question This will allow as many callers as possible to leave messages before the voice mail account is full and will not accept any more messages The voice mail account will be checked by the helpdesk frequently during business hours to avoid having the account become full However during non business hours
144. tion this file may take a significant amount of time to generate The format of the comma delimited file is one row for each data element within each accepted cost report standard file An example of the first three rows for a complete cost report set is shown below 00000000003241 MA99994444 1 CERTla Facility ID 00000000003241 F 2 CERT1b Test T or 00000000003241 SAMPLE FACILITY 3 CERT1c Facility name Each row is formatted as follows ELEMENT DESCRIPTION ASSIGNED AUDIT The unique audit number assigned for each submitted cost NUMBER report DATA The data submitted by the provider except for Social Security Numbers that may have been submitted for Schedule K If no data was required the item will appear as blank or NULL SEQUENCE NUMBER The sequence number that is assigned to each field on the sequentially numbered cost report schedules that corresponds to the cost reporting period SCH LINE COLUMN The schedule line and column location of the field on the cost report schedule DESCRIPTION The full name of the field on the cost report schedule MA 11 COST REPORT SUBMISSION SYSTEM APPENDIX C ACCEPTED M11 COST REPORT DATA 70 Revised 08 26 2005 APPENDIX D NUMBERED COST REPORT FORM Glossary Terms Used In This Section Certification Report Depart ment Excel Spreadsheet Template Numbered Cost Report Nursing Facility Sequence Number Standard File Validations Validation
145. tted in the standard file format to the MA 11 Cost Report Submission System Once received at the web site the cost report standard file is analyzed for inconsistencies and a report is generated for the provider The analysis is based on the Standard File validations beginning on page 28 Once all the MA 11 COST REPORT SUBMISSION SYSTEM SECTION 3 OVERVIEW 5 Revised 08 26 2005 Standard File validations are met the file is valid and the system produces a Certification Report for download by the provider which delineates additional supporting documents required to be mailed with two copies of the signed Certification Report to the Department These documents are then reviewed by the Department and must pass the Supporting Document and Manual Review validations which are the second and third levels of acceptability The Supporting Document and Manual Review validations begin on page 29 In order for the MA 11 to be accepted all three validation types must be met The submission of the supporting documents and the signature process is described in Section 6 ACCEPTABILITY VALIDATIONS on page 28 MA 11 COST REPORT SUBMISSION SYSTEM SECTION 3 OVERVIEW 6 Revised 08 26 2005 SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY Glossary Terms Used In This Section Cost Report Standard File Download Excel Spreadsheet Template MA MA 11 Cost Report Submission System Numbered Cost Report Sequence Number Standard File Validations Text Fil
146. ual its organization and document conventions Section 2 Quick Guide lists the steps that must be completed for a cost report to be accepted by the Department of Public Welfare the Department Section 3 Overview introduces the MA 11 Cost Report Submission System Section 4 Excel Spreadsheet Template Data Entry describes how to data enter cost report information into the Excel spreadsheet template Section 5 Submission and Acceptability Process describes the three basic system functions which include establishing the web site connection submitting cost report standard files and retrieving and interpreting the validation and Certification reports This section also provides procedures for completing the acceptability process Section 6 MA 11 Acceptability Validations describes the validations for the cost report fields the supporting documents and the manual review process SECTION 1 INTRODUCTION 1 Revised 08 26 2005 Section 7 Alternative Standard File Methods describes how to create a cost report standard file for users that choose not to use the Excel spreadsheet template e Section 8 Helpdesk describes how to contact the Myers and Stauffer helpdesk for support e Section 9 Glossary defines some commons terms that are used in this manual e Appendix A Netscape Installation provides some general Netscape installation and configuration instructions to assist you in establishing access to the system
147. ubmission System Numbered Cost Report Rejected File Sequence Number Spreadsheet File Text File Validation Definitions for these terms are found in Section 9 INTRODUCTION Alternate standard file methods are only recommended for cost report preparers who complete numerous cost reports for each cost reporting period The cost report standard file may be incorporated into a provider s accountant s or software vendor s existing MA 11 software or spreadsheet program in order to avoid duplicate data entry into the Excel spreadsheet template This section provides suggestions on how this may be accomplished However since the process of incorporating the standard file into existing programs could conceivably take many hours it would only be cost effective to attempt this task if the cost report preparer completes numerous cost reports for each reporting period Otherwise the process of data entering completed cost report information directly into the Excel spreadsheet template is recommended rather than this alternative method Direct data entry into the Excel spreadsheet template should take less than two hours The process of incorporating the standard file into existing programs could take 20 or more hours in addition to the time spent to test for accuracy The alternate data file may be created in one of two standardized file types a spreadsheet format or a text format This section describes both types of files for those who wish to
148. when the account is not being checked it may become full and no longer accept any messages If you are unable to leave a voice mail message because the account is full you may choose to fax your question as described below Messages that are left in the voice mail account will be answered in the order that they are received The FAX number for the helpdesk is 717 541 5802 Please be as descriptive as possible so that the helpdesk representative may research your question prior to calling you When faxing a question please include your name and the provider name and MA number if applicable The help desk will contact you as soon as possible please do not fax the same message multiple times SECTION 8 HELPDESK 47 Revised 08 26 2005 The hours and days of operation for the helpdesk are Monday through Friday from 8 30 a m to 4 30 p m Periodically the helpdesk posts bulletins on the MA 11 Cost Report Submission System These bulletins may be accessed by selecting the Bulletins link on the Welcome page HELPDESK ASSISTANCE The following types of problems will be supported by the Myers and Stauffer Helpdesk Accessing the MA 11 Cost Report Submission System and navigating the site Assistance in completing the Excel spreadsheet template using the numbered cost report Assistance in interpreting validation reports and Certification Reports Identifying steps to be taken to complete necessary corrections in the cost report
149. with years ending 12 31 2001 and after the Department obtains cost report data electronically via submission to an Internet Intranet web site As cost report standard files are submitted to the MA 11 Cost Report Submission System the fields included in the file are validated as a first step in determining acceptability Instructions for submitting the cost report standard file are found in Section 5 of this manual The validations for the cost report fields are included in this section of the manual The validations for the manual review of the Certification Report and the list of supporting documents are also included in this section of the manual beginning on page 28 In order for a cost report to be determined acceptable all validations must be met and two copies of the Certification Report and one copy of all required supporting documents makes up the Certification Report Package must be received by the Department by the filing date referenced at 1187 73 for annual cost reports and 1187 75 for final cost reports These validations and processes will be required for all full year and partial year cost reports with years ending 12 31 2001 and after INSTRUCTIONS FOR USE OF STANDARD FILE VALIDATIONS The Standard File Validations provide details for each element used in the acceptability processing of the MA 11 cost report standard file A description of each element is contained in the following table MA 11 COST REPORT SUBMISSION SYSTEM
150. xpenses appear 11 Sch D line24 Schedule to support income greater than 500 reported on Schedule D line 24 Indicate the source the amount and where the related Schedule C Required if SchD24A gt 500 00 ll rl expenses appear T applicable D of additions and deletions to PiN plant and equipment to aren the difference in costs submitted on Schedule L column A line 11 and Schedule L column B line 11 For additions include item description date acquired cost or other depreciable basis current annual 1 and SchL11A not equal to SchLIIB depreciation and life and method of computing depreciation Sch line 19 Schedule to support costs greater than 1 000 reported on Schedule line 19 Required if SchG19C gt 1000 00 19 Sch Lline4 Schedule to support response of YES to capital assets with an acquisition cost of 500 or more that have been expensed in net operating costs Required if SchI4 1 on Schedule I line 4 Schedule to support response of YES to administrative cost allocated to other cost center on Schedule I line 5 Show cost category basis of MA 11 COST REPORT SUBMISSION SYSTEM SECTION 6 MA 11 ACCEPTABILITY VALIDATIONS e 41 SUPPORTING DOCUMENT VALIDATIONS Revised 08 26 2005 1 YES 0 NO ORDER LABEL DESCRIPTION OF DOCUMENT TYPE l a Q C allocation and amount allocated for each line item lg 5 77 x2 21 Sch I line 6 Schedule to support response of YES on Schedule I lin

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