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End User Manual V3.0 - MA

1. 45 Medicare Submit a Medicare Intermediary Audit Report if applicable If applicable 46 46 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 SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 41 SUPPORTING DOCUMENT VALIDATIONS Revised 01 27 2003 1 YES 0 NO ORDER LABEL DESCRIPTION OF DOCUMENT TYPE 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 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 23 Otherwise submit if applicable 48 Participation Submit a copy of any approvals received under 55 Pa Code 331187 21a 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 previously submitted with a prior cost report Submit a copy of any termination notices received under 55 Pa Code 31101 77a relating to termination for convenience and best interest of the If
2. 25 Sho 390 o ota expenses B C must column D Lines 20 28 and 29 must Tine 30 24 330 Scc 3137 D Total expenses Column Cust columaD SSCS SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 32 a ec Olerexpenes Lines 20 28 and 29 must line 30 a STANDARD FILE VALIDATION Revised 01 27 2003 1 YES 0 NO VALIDATION oi Sho 38 D pulexess Column Crust column D Lines 31 37 must linc 38 25 se 39 D ____ Total expenses SSCS Column A B C column Line 3038mus line3 35 31 Shc i49 E dAjumexs Must be whole number blankor0 zm sho 29 E jAdwmes Dmsi i9mwtze20 z5 59 Sac 2t27 E jAdwmems Mesbewholemumbrbankor 3 sShc Adjustments Hms21 27mwt linm28 59 sho 29 E Adjustments Mestbewhoemmberbankor 2 Sho 39 E Adustmemts Dme2028ax29metzlne30 335 28 Scc 3 32 E Adjustments Mast be whole number blank or x5 Ssmo 39 E jAdwmexs EEEE E T E Ne E eooo er n
3. GEM VT in fund balance or NA must be blank Description statement of revenues expenditures amp changes Lines 4 6 must line 7 If SchMA4completed 0 or NA must be blank 7 CC RM Description statement of revenues expenditures amp changes Line 3 less line 7 must line 8 If SchMA4completed 0 or NA must be pT Finnie STS LU doo o fe NEN meten n TP in fund balance must be blank SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 38 1269 1270 SEQUENCE SCHEDULE LINE 1271 1272 SchMA4 19 20 1273 1274 SchMA4 27 28 1275 1284 SchMA4 11 20 1285 SchMAd 1286 1292 SchMA4 22 28 1293 SchMA4 1294 SchMA4 1297 SchMA4 1298 1301 SchMA4 34 37 1302 SchMASS Ta 1303 SchMA58 1304 SchMASS 1305 SchMASS 1306 SchMASS Sch ae 1307 chMASS 1308 SchMASS 3b h h h h h h 2 9 i C 1 1 1 b a wj Go 1309 SchMA58 STANDARD FILE VALIDATION Revised 01 27 2003 1 YES 0 NO COLUMN FIELDNAME II Description balance sheet at end of period If Part II gt 0 must not be blank If SchMA4completed 0 or NA must be blank II desript Description balance sheet at end of period If Part II gt 0 must not be blank If SchMA4completed 0 or NA must be blank II I I Resident personal funds balance sheet at end of period May be blank If not blank must be whole number If SchMA4completed 0 or NA m
4. eee o s 936 950 SchJ 1 15 E 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 decimals If SchJcompleted 0 must be blank 566 980 Seats __ Number of nursing facility hours worked per week If column A not blank must lt 168 If SchJeompleted 0 must be blank 981 995 SchJ 1 15 H nursing facility time worked per week If column A not blank must be gt 0 lt 1 0000 If not blank or 0 must be 996 1010 SchJ 1 15 LANE 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 blank SchKcompleted Is Schedule K completed Valid answer 0 or 1 Schedule C line number Must be valid Schedule C line number or blank If SchKcompleted 0 must ee May be blank If not blank must be whole number If SchKcompleted 0 must be blank rit eon We ass 0 Vortlank IrSchKcompleted 0 mus c a Position service or supply May be blank If SchKcompleted 0 must be blank Name of related business May be blank If SchKcompleted 0 must be blank 1011 1025 SchJ 1 15 1026 1041 1054 SchK I 1154 2 C E m l P P EIN or SSN May be blank If SchKcompleted 0 must be blank Owner of
5. Endofprior period Lies 1 5 TES line 6 If SchLcompleted 0 must be blank 1195 1198 SchL End of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 119 End of prior period Lines 7 10 must line 11 If SchLcompleted 0 must be blank gt 3 e of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1201 End of prior period Line 11 less line 12 must line 13 If SchLcompleted 0 must be blank 1202 1203 SchL ar 5 End of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 120 SchL End of prior period Line 6 13 14 15 must line 16 If SchLcompleted 0 must be blank EN 1208 __ 35 of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1209 SchL 1 End of prior period Lines 17 20 must line 21 If SchLcompleted 0 must be blank aS 1212 at aL of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1213 B 4 J JEndofprior period Lines 21 24 must line 25 If SchLcompleted 0 must be blank 1214 1219 SchL 2631 End of prior period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 120 Ss End of prior period Lines 26
6. Revenue cost center F column A or column B not Blank or 0 must not be Blank C s 30 e o JRevene cost center column A or column B not Blank or 0 must not be Blank 4695 480 Sdb i i A General edger S number Blankor0 SSCS Sh 1 A jGmemlegr JEDmsi iI2mwtzlinii 482 493 Sdb 1425 A General edger Mesbewholemumbrblnkor 494 26 A General ledger Lmeli 25mut lme26 45 Shb 27 jGmemlehe Dmsiit2 mwtzlme27 4965 498 Sd 2830 A jGemmlldgr Mesbewholemumbrbankor gt gt eee io ie 45 Smp 3 A ____ General ledger E EE E E 30 Shp 33 jGmemleer Dm33metzSdCD sy sdb 34 A jGemwmlldgr Lme32leslin33mus lne3 sdb 19 B __ Revenues adjustments to Schedule Mast be whole number blank or0 si s o B O Revenues adjustments to Schedule fif column A not blank or 0 must not be blank or0 33 531 Sdb Iii B Revenues adjustments to Schedule C Mustbe whole number blankor0 SSC
7. 60 sh 5 C Accumulated depreciation to date Lms2 4mut lmesS eH e3 SshF 8 C Accumulated depreciation to dae Must be lt column B If not blank mustbewholemumbor 64 645 sar 3 00 C Accumulated depreciation to dae jMustbewholemumberbunkor O y 66 SF 1 C jAecmwlreddeprecatoniodae Line Sand 6 10 must line 11 5 65 ShF 24 D Method of computing depreciation fif column B 50 mustnotbe blank 650 6532 SchF es D Method of computing depreciation lcoumnBs0 mutnobeblak o 63 634 Schk 39 10 D Mehodofcompuinedeprction Maybeba SSCS 65 65 ShF 24 E llieome fWchmnBs mumobeba 65 660 sa 6 8 E lieorme O elmnBs mutmobeban 68 662 Sc 39 10 E llieome T T 663 665 sar 24 r Dereca onexpemeforperod Ifcolumn B gt 0 must not be blank If not blank must be whole number 66 Sh 5 F Depreciation expenseforperiod Lm2 4mut lmes SSCS 667 669 Sc 68 F 670 671 sa 3 0 F EM Depreciation expense for period Line 11 must line 5 and 6 10 Line 11 must be lt column B Line 11 must Pp i SchC33D 95 69 7 A _ 5 29 jBay
8. L NINN NINN TD DI by SS NNT n 55 NPN Py DANIAN NNN SYS SSN Ge 4 C OQ l pt NAN EI oS e ele N IS Ios f dj IN pm pani SJSN Co vvu SNNN QIN IS EM Fe NI GG Ge SSS Go DO m Ge Co ro Go __ Beauty and Barber Services RC Minor Movable Property Nurse Aide Training 108 0 E z E 5 i E T i i E E E i E 364 a 5 55 1 5 mm T S E E N E E EN N 25 w N N SI O3 Un EE EE Go edu e E 3 a a jan one love yu ee NINNIN 19 Y 95 Hl Ni 336 307 308 9 1559 370 311 371 312 313 373 314 402 Total Npa Joe s E 316 347 377 404 431 sa Ft 46Qgal N 5 Co Go 5 5 NIA N TO 35 36 37 274 275 276 166 138 239 139 240 140 241 172 281 197 Ren Rod Food we NIN Eo FAEERE NINININI e NIA ali ds Aje Oya NUN v 3333 3 9 3 Plant Operation amp Maintenance ORR Minor Movable Property 110 To ss N Mz 278 279 280 Go
9. 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 will 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 la 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 f
10. 30 must line 32 If SchLcompleted 0 must be blank 5 of prior period Line 32 25 must line 33 Line 33 must line 16 If SchLcompleted 0 be blank 127 136 sM eX We Oe Identity fir column A nor blank mastnot be blank O o 1277 93 sM 99e identify lcoumm A not blank mustnotbe blank De ps sm ss A paie e ie iie thn BT TBs Baa ScM o A Du SSS May be blank Tf Other identify not blank must not be Blank i ee RN NT 8 mum May be bank Inot blanke mustbewholemmber 1246 1250 SchM Amount May be blank If Other Identify not blank must not be blank If not blank must be whole number I251 1253 8 mom Maybe blank If not blank must be whole number 1254 1258 SchM Amount May be blank If Other Identify not blank must not be blank If not blank must be whole number D Pa Ene es ner 9e 1260 TE IM sic SchMA4completed Schedule MA completed Valid answers NA 1 MA 4 completed or 0 Separate reports eee innate SN ENS VC in fund balance or NA must be blank 1263 Description statement of revenues expenditures amp changes Line 1 2 must line 3 If SchMA4completed 0 or NA must be blank
11. A ExemeadwsmenstoScheddeC Mesbewholemumberbunkor 59 s 27 A ______ Expense adjustments to Schedule C Limesl 26musi line27andmus SchDHSbB s5 s mE 2 12 B Schede C Tinemune column A not blank or 0 must not be blank 60 613 se 15 26 B Schedule Cine number lcoummAnotblankor musnotbeblnk 6H Sh 4 Wepion Property plant amp equipment column F not blank or 0 must not be blank 61 616 sa 9 10 description Properyplan amp equipmem lfcolumnFmorblamkor musmorbeblak e7 60 sw L4 A o jDwexqied fchumnB mutnobeban SshF 6 8 A Date acquired IF column B gt 0 must not be Blank G4 605 Schr 9 0 A Dwewaeied Maybhak G6 69 sw L4 B Owtorohebais Mast be whole number blank or sh 3 B jOsteomerbss E E Gi 63 sar 6 10 B jCwtorohebais O blank or O o 6 ii B A or other basis Lines 5 and 6 10 must line TT SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 34 i gt gt STANDARD FILE VALIDATION Revised 01 27 2003 1 YES 0 NO VALIDATION 637 639 s 24 C Accumulated depreciation to date Musi be lt column Irnot blank mustbewholemumber
12. The MA 11 Cost Report Submission System may be accessed using one of two methods For users that have access to the Internet the facility may transmit a cost report standard file using a web browser to access and to login to the Internet web site If a user does not have an Internet service provider the web site may be accessed directly using a dial up connection and web browser Either method of access to the MA 11 Cost Report Submission System is acceptable SECTION 3 OVERVIEW 4 Revised 01 27 2003 To submit a cost report standard file the user is issued a User Name and password by the Department These User Names 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 User Name and password information to that party In addition to providing the ability to electronically submit the cost report standard file the MA 11 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 User
13. 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 SECTION 9 GLOSSARY 50 Revised 01 27 2003 forwarded to the cost report preparer if the preparer is responsible for the submission of the cost report standard file 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 User Name 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
14. Volunteer Services Pharmacy Prescription Drugs Over the Counter Drugs Medical Supplies Laboratory and X rays Physical Occupational amp Speech Therap Oxygen Beauty and Barber Services RC Minor Movable Propert Nurse Aide Training 108 otal Resident Care Costs ll OTHER RESIDENT RELATED COSTS Dietary and Food aundry and Linens Housekeeping NI Unj UN r2 os p pm f pams 5 NIN UN ER J NI 1 H mA NIN i ae E eM N I oC oC EB T E WR E E E Hn gs aa al pal E t E oec oo z NI Uf UN Ni N N N lo i E E a H E E E EI amp Qi AY Q Sa es Resid TI TT 9 2 B W pami pe pam j N ee oe oe oc oe Cy 3 3 F9 e ve x E SEE H ce GN F z cel 00 oc B E EE E g E E p N NIN WINI NI NOJS Un ES o2 r3 e Hj m Aju a B E E E B i E i E E N ko SEBEEE PR EERE um S oo E oo N Sinn Sjo N Mz oo N Nj O3 Io i Un SLIGO on Aino lt 13 5 I Ge N pen o 19 a DL Au I El Co vuu ujua ANNON VUn t SIS E E E
15. Select the appropriate radio button next to tone or puls e 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 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 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 l
16. blank or 0 Om sem s a sslar costes Lines 5 and SchCIA mist Ine 6 742 746 SchH 7 34 A Salay cost fees Must be whole number blank or 0 747 SehH 12 a J Salarycost fees Lines 7 11 must line 12 If line 12 not blank must be lt SchC1C ns sei Bry costes Linc 6 17 SehHOB must c linc 13 749 753 ShH 15 B Fringe benefits Must be whole number blank or 0 7 Sent 8 Fringe benefits Lines 5 and SehCIB must line 6 24 685 SchG 25 Excess administrative costs If line 21 less line 24 0 then must be 0 else must line 21 less line 24 SchE19A must line 25 20 Hewspid on Anoba mustnotbe blank Hewspid Lmsi 5mwi lm6 ours paid Sf ofan nt Blank must not be blank 766 Hewspid Lms7 limwt lnei o Hewspid 78 72 Sch 15 D Howwokd Must Be tocolumn C m sa 6 D ____ Hours worked Lines 1 5 mut Hine 6 Th T8 ShH 7 3 D Howwokd 75 Sen 1 1 D ours worked Ums7 limwi lm 2 SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 35 STANDARD FILE VALIDATION Revised 01 27 2003 1 YES 0 NO 78
17. ex lt j Files of type HTML Files Cancel Figure 5 7 File Upload Window Select All 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 click 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 whe
18. 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 Supporting Documents and Manual Review These validations are created by the Department in order to provide consistency completeness and greater accuracy in reporting All 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 Sub
19. 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 45 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 submitted 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
20. 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 LAU I hereby certify that I have read the above statement and that I have examined 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 c
21. 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 indicate 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 Report SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 19 Revised 01 27 2003 Final Validation Reports are accessed from the MA 11 Cost Report Main Menu Simply point and
22. 2 Round to 4 decimals rm 9 o S f o EN Resident days at 9096 occupancy Line 2 X 90 1a 1c 2 3 4 5 6 Total MA resident days of care APPENDIX D NUMBERED COST REPORT FORM e 71 SUMMARY OF Schedule B RESIDENT CENSUS RECORDS LINE Nursing Facility Nursing and TOTAL NE i A B E E sa m 1 Line 13 Column B plus Line 13 Column C must agree to Schedule A Line 3 Column A 2 Line 13 Column D must agree to Schedule A Line 3 Column B z o plalz JEH 70 83 96 71 97 72 85 98 73 74 87 100 75 88 101 76 102 77 103 78 91 104 SE E BH 79 92 105 6 7 8 10 Le 11 106 D 3 Line 13 Column E must agree to Schedule A Line 3 Column C 4 Must agree to Schedule A Line 6 APPENDIX D NUMBERED COST REPORT FORM e 72 COMPUTATION AND ALLOCATION OF ALLOWABLE COST Schedule C Rounded to Nearest Dollar ALLOCATION Fringe Other Total Allowable i identi Benefits Expenses Expensesb Adjustments Cost Pacing Residential COST CENTERS B C E F G H l RESIDENT CARE COSTS ur _ 1214 E E E 250 515 l E E 5 545 349 350 40 0 7 Director of Nursing Related Clerical Staff Practitioners Medical Director Social Services Resident Activities
23. 3 55 What is the total square footage of the non allowable cost centers Have indirect costs applicable to nonallowable cost centers been eliminated on Schedule E mm eo Encode all Schedule I Part Il data in 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 0 zero APPENDIX D NUMBERED COST REPORT FORMS 80 SUPPLEMENTAL INFORMATION AND QUESTIONNAIRE Code YES as 1 NO as 0 LINE PART Il QUESTIONNAIRE Continued YES List the annual gross salaries wages and fringe benefits and or contracted amounts for the report period for the following personnel Fringe Salary Benefits Contracted Administrator Assistant Associate Administrator Chief Dietitian Chief of Fiscal Services Director of Housekeeping Director of Nursing 820 827 834 Facility Engineer 821 828 835 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 N 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
24. 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 explanations 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 c
25. Once all the SECTION 3 OVERVIEW 5 Revised 01 27 2003 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 INTRODUCTION on page 28 SECTION 3 OVERVIEW 6 Revised 01 27 2003 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 File 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
26. 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 69 The code for the field in error Form Location Code error Invalid Data The actual data value submitted SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 22 Revised 01 27 2003 REPORT FIELD DESCRIPTION VALUES 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 Netscape CERTIFICATION REPORT Page
27. 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 APPENDIX B DOWNLOADS 65 Revised 01 27 2003 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 Once a cost report standard file has been successfully submitted to the MA 11 Cost Report 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 w
28. 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 PARTIV MEDICARE INTERMEDIARY MO QUESTION NAME OF MEDICARE INTERMEDIARY 10 APPENDIX D NUMBERED COST REPORT FORM e 70 SUMMARY PARTI TYPE OF FACILITY PART Il Approved as 11 General 2 Hospital Based 3 Special Rehabilitation County PART Ill STATISTICAL DATA LINE NURSING N FACILITY A Schedule A TYPE OF ORGANIZATION Type of Organization 12 Voluntary Non Profit Proprietary Individual Proprietary Partnership Proprietary Corporation Proprietary Other Governmental RESIDENTIAL amp OTHER TOTAL B C DATE OF CHANGE Beds available at beginning of period Changes in total beds during period Beds available at end of period Bed days available for period Actual resident days for period SEE INSTRUCTIONS Percent occupancy Line 3 Line
29. applicable Department statement of policy if not previously submitted with a prior cost report Letter from the Department signifying that an allocation basis other than actual or preprint allocation is acceptable for Schedule C column K SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 42 MANUAL REVIEW VALIDATIONS Revised 01 27 2003 1 YES 0 NO 6 Preparer Signature ls the preparers signature date present i CERTprepsign not blank must 1 ____ Private Pay Rate Signature SSIS the administrator s signature date present t MAS amp laz0 mus l o Medicare Rate Signature Is the administrator s signature present I MAS8Za 0 muu T SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 43 Revised 01 27 2003 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 Submission 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
30. 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 Feedback 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 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 01 27 2003 COST REPORT INITIAL FEEDBACK REPORT MAXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX MAXXXXXXXX yyyymmdd hhmmss XX
31. 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 User Name 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 A 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 13 2001 M 99991111 02132001121619 init htm 02 13 2001 Ma99991111 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
32. 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 SECTION 6 M 11 ACCEPTABILITY VALIDATIONS 28 Revised 01 27 2003 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 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 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 285 is identified as SchC39E Schedule C line 39 column E 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 1154 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
33. maintains residential and other areas not reported on Valid answer 0 or 1 If SchI6identify not blank must be 1 cost report 89 Sh Sidenty __PTentify resident and other areas ISchi amp i musmobebank san eg Ls p sm ona ost ents 77 JvaMamwer or 82 Sh 8 de kemitymomalowablecostcemes Sehl8 i mesmobeblank E imi cec ugue foosge fasse conne HOMI domare E 814 Schl Indirect costs for nonallowable cost centers maed on Valid answers Bd lor NA Schedule E SiS E Semis A Admismtorsiuy Musbewhoemumberblnkor sa ooe B Administrator fringe benefit Mustbewholemumberblkor0 O O 825 835 Sc 1 Ig C Administrator contracted Mustbewhoemumberblmkor0 6 sh S Relempoyrltedpates jValdamwer orl 85 Sh 12 Pesomdexpensesexduded Validanwem0TorNA 838 Schl 13 Loans notes or advances to officers employes BODs or Valid answers 0 1 or NA owners ee eae ee Loans notes or advances from officers employes BODs or Valid answers 0 1 or NA owners Sh o __ Adjustment made Tor expenses disallowed im prior audits Validanswes0 lorNA SSCS a_i Care retirement Community Vali
34. 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 the 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
35. 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 SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 15 Revised 01 27 2003 3 MA 11 Main Menu Microsoft Internet Explorer Ee x LONE http 10 3 1 4 cgi mainhtmlexe 5 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 MA 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 To submit your cost report standard file point and clic k 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 MA 11 Cost Report File Submission Select the COST REPORT file to su
36. 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 incorporate the creation of the standard file within their existing MA 1 software 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 Departm
37. related business May be blank If SchKcompleted 0 must be blank 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 EE ae ee 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 M aga NR oa cana Identify allowance for accounts and notes receivable May be blank If SchLcompleted 0 must be blank 1155 Sh 353 Identify inventories priced at If SchL3A not blank must not be blank If SchLcompleted 0 must be blank SchL 3 1156 1160 1 5 End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1161 ShL 6 End of current period Lines 5 must line 6 If SchLcompleted 0 must be blank 1162 1165 SchL 7 10 End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1166 A End of current period Lines 7 10 must line 11 If SchLcompleted 0 must be blank 1167 SchL 12 End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1168 SchL B As End of current period Line 11 less line 12 must line 13 If SchLcompleted 0 must be blank 1169 1170 SchL 14 15 End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank pA 1171 End o
38. 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 will 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 SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 24
39. 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 All 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 1111 Current Facility Name 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 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 SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 18 Revised 01 27 2003 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
40. 0 ShH B D Howwokd 78 785 SdH 15 E __ Number of FTES or equivalents at yearend May be blank TF not blank must be whole number C m sent Jt oT orequivatents at yearend Jhines T Smast Tine sno E _ __ Namber of FTEs or equivalents at yearend May be blank blank must be whole number x shH 1 Naber of FTES or equivalents at yearend Lms7 limut lmell Lm p sm 7p 8 LE ero FTESoregiemssQeren fines 65 must e pepe eee Valid answers 0 Tor NA Tor NA E585 set 1 318 e eo ir SCIL 0 mist not Pe ER TER sr eoe ume 76 Sd 2 removed Valdamwes0lorNA 797 801 Shi ux _ Reienmuls SSCS Maybe T 89 Sh 2e identity ther identity lSdijes0mutmobcba s a E reihmeais a AS 0 L9 Pent Perna a pense removed vaMamwesUToNA 805 Schl If 3 If SchI3 or NA must eS blank or 0 If SchI3 0 must be gt 0 If not blank must be whole number eT Sr Re Walid answers 0 LorNA 807 Sch 5 1 Administrative expenses in other cost centers Valid answers 0 Lor NA 0 00 0 000000000 Facility
41. 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 1 6 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 COST REPORT FINAL VALIDATION REPORT Page 1 of 1 MA99991111 MYERS AND STAUFFER LC 01 01 1999 12 31 1999 1 00 99991111 00 1999 M 99991111 02022001104207 5361 Production 02 02 2001 10 43 16 02 02 2001 10 42 07 Submission Received Invalid 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 Sequence Field Description Invalid Data Error 5 SchCERT1C Facility Name MY NURSING HOME 539 The Provider Name must match the one on the Password and Connectivity document Sequence Field Description Invalid Data Error s All costs for nonresident meals removed
42. 1690 1e tr Le 1591 tes 759 ea iea mo 721 722 723 ra 725 726 727 728 725 730 rs Other If greater than 1 000 provide separate listing 19 732 Total Administrative Costs Schedule C Line 29 20 650 693 713 733 ADMINISTRATIVE ALLOWANCE COMPUTATION This computation should be made only after all other Schedule D and Schedule E adjustments Management Fees Home Office Costs Professional Services Determination of Eligibility Gift Shop Advertising et SS Cd lt FS TS I NT gE Travel Entertainment e a Telephone Insurance Other Interest k m wo Legal Fees Federal State Corporate Capital Stock Tax c AR wa Office Supplies k O aS Amortization Administrative Costs M J Officers Life Insurance co Admin Minor Movable Property Being legai Fess B Total Net Operating Cost Schedule C Column F Line 30 21 681 Administrative Costs 22 Schedule C Column F Line 29 22 Subtract Line 22 from Line 21 23 Limit on Administrative Costs Line 23 divided by 88 24 684 25 Excess Administrative Costs Subtract Line 24 from Line 21 Enter zero if answer is negative Enter on Schedule E Line 19 APPENDIX D NUMBERED COST REPORT FORMS e 77 NURSIN
43. 17 18 19 20 21 Revised 01 27 2003 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 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 yo
44. 25 5d Other identity 1226 5e DECREASE Asset Purchases attach detailed schedule 6 Mortgage or Bond Principal Payments Loans Receivable attach detailed schedule Other identify 1227 9a Other identify 1228 m Other identify 1229 9c Other identify 1230 o z o uH z O N lt C2 d a co N d Other identity 1231 9 o 2 18 e 10 APPENDIX D NUMBERED COST REPORT FORMS 86 ANNUAL FINANCIAL REPORT OF Schedule MA 4 RESIDENT PERSONAL FUND MANAGEMENT Code NA as NA YES as 1 NO as 0 Yes No SCHEDULE MA 4 COMPLETED see instructions E PART Il BALANCE SHEET AT END OF PERIOD PARTI STATEMENT OF REVENUES EXPENDITURES amp CHANGES IN FUND BALANCE LINE DESCRIPTION PERSONA LINE DESCRIPTION PERSONAL NO FUNDS NO FUNDS ASSETS 2 1262 an 4 Payments to Facility 5 Resident Expenditures 1278 6 Other Expenditures 7 TOTAL EXPENDITURES 1280 3 1284 21 1285 LIABILITIES Accounts Payable General 1286 23 5 veo Cormoran Eses T1289 ES 28 1293 FUND BALANCE AT END OF PERIOD 1294 31 TOTAL LIABILITIES amp FUND BALANCE 1295 PART Ill COMPLIANCE QUESTIONS FOR FEDERAL REQUIREMENTS Code YES as 1 NO as 0 34 Are accounting procedures established to assure that resident personal funds are not co
45. 5 36 37 38 39 40 41 42 43 Revised 01 27 2003 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 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 De
46. Assigned Audit Number The _ that will be used to LL AES 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 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
47. Edd RI N m m E A num H C qum m EA A r3 eC r k m m a la oa 3 jm APPENDIX D NUMBERED COST REPORT FORMS 84 Schedule L Code YES as 1 NO as 0 SCHEDULE L COMPLETED COMPARATIVE BALANCE SHEET END OF END OF LINE CURRENT PERIOD PRIOR PERIOD CURRENT ASSETS 1 T 2 Inventories priced at 35 4 1193 PROPERTY PLANT AND EQUIPMENT i95 Buildings O ues 3 Total property plantand equipment Jan pio OTHER ASSETS 16 CURRENT LIABILITIES 1205 Notespayable nos Accrued salaries wages fees payabe i pna j Total Current Liabilities et nep ng LONG TERM LIABILITIES 22 CAPITAL Owner s equly proprelaryorpamnershipy 5 mer 7214 Capital stock outstanding corporation Retained earnings R E beginning of year 28 Gd 60 Total Capital 187 1220 33 Lz APPENDIX D NUMBERED COST REPORT FORMS 85 STATEMENT OF CHANGES IN FUNDED DEPRECIATION LINE DATE AMOUNT LINE B 1 BEGINNING BALANCE ay 1242 1 INCREASE Investment Income Other identify 1222 5a Other identify 1223 5b Other identify 1224 5c Other identity 12
48. G CARE STAFFING EMPLOYES Number of Full Time Employes Salary Fringe Hours or Equivalents Cost Fees Benefits Worked at Year End A B D E 736 749 781 7411 e 754 760 7731 1786 p 788 744 789 745 790 746 747 9 gm Lr POSITION z o Registered Nurses Licensed Practical Nurses Nurse Aides Orderlies Attendants Other specify 734 Subtotal REGISTRY POOLED CONTRACT STAFF N Registered Nurses Licensed Practical Nurses Nurse Aides Orderlies Attendants 5 Other specify 735 11 Subtotal 12 Total Nursing Care 13 748 5 791 793 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 APPENDIX D NUMBERED COST REPORT FORMS e 78 SUPPLEMENTAL INFORMATION AND QUESTIONNAIRE PARTI 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 repor
49. Go 55 c 5 AR m INS rS S Il ADMINISTRATIVE COSTS istrative Schedule G otal Net Operating NO Costs V CAPITAL COSTS D gt a E 5 E gt e lt 5 v Q Q a oO 5 Ps 0 e e oO 3 wD D Rv 1 e C o e E N N L 141 4 04 T 2 283 por pam 2 Major Movable Property Depreciation nterest on Capital Indebtedness ent of Facilit mortization Capital Costs e 3 o5 585 c3 o3 Ola g Ni od eie e cA S E EIE SIE BRE N pmi pamm pam ae vN N N Un ZA SO z 3 T 9 otal Capital Costs otal All Costs 39 143 174 APPENDIX D NUMBERED COST REPORT FORMS 73 Schedule D REVENUES AND ADJUSTMENTS TO REVENUES REVENUE GENERAL ADJUSTMENTS SCHEDULE C LEDGER TO SCHEDULE C LINE NUMBER REVENUES A B C z o RESIDENT CARE Nursing Care Practitioners Pharmacy Prescription Drugs Over the Counter Drugs Medical Supplies Laboratory and X rays Physical Occupational amp Speech Therap Oxygen Beauty and Barber Services Exceptional DME Grant Payments 461 Subtotal Resident Care ll OTHER INCOME Guest and Employe Meals Discounts Vending Machines Telephone Television Gift shop Unrestricted Interest Investment Income Miscellaneous If any line 20 25 greater than 500 provide separate detail with source amp amo
50. ITION OPTIONAL SETUP sets 61 NETSCAPE COMMUNICATOR OPTIONAL 62 APPENDIX B DOWNLOADS 63 DOWNLOADING COST REPORT UPDATE 5 63 APPENDIX C ACCEPTED MA 11 COST REPORT DATA 66 APPENDIX D NUMBERED COST REPORT FORM 69 Contents ii Revised 01 27 2003 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 NFs This system enables you to connect electronically to the submission web site transmit cost report standard files and receive feedback via the system This 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 Section 1 Introduction provides general information about this manual its organization and document conventions Section 2 Quick Guide lists th
51. MA 11 COST REPORT SUBMISSION SYSTEM P Lie Lt End User Manual V3 0 Revised 01 27 2003 Department of Public Welfare and Myers and Stauffer LC Revised 01 27 2003 Contents SECTION 1 INTRODUCTION 1 ABOUT THIS MANUAL UR EBENEN aera E 1 HOW THIS MANUAL IS ORGAN ZBD vioi tipp rimedio ed pub tete eund dd 1 CONVENTIONS USED IN THIS 2 SECTION 2 QUICK GUIDE 3 SECTION 3 OVERVIEW 4 REPORTING REQUIREMENTS 2 pite deleto aut Ue eben 4 MA 11 COST REPORT SUBMISSION SYSTEM WEB SITE 4 COST REPORT STANDARD HILE s eisopetpevia pits tao bk br uibem 5 MA 11 ACCEPTABILITY PROCESS 5 SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY 7 INTRODUCTION sedes E EXCEL SPREADSHEET TEMPLATE DATA ENTRY SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 11 ESTABLISHING THE WEB SITE CONNECTION Internet Instructions eese Intranet Diakup Instructions eeeeeeseseeeeeseenenete tenente tente tenente tenete tenente tenentes WEB SITE OPTIONS eter poteet oett D en ERU Rs 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 ce ettet bete t eter eiue Dp Ree ee eR es Amending
52. N Code YES as 1 NO as 0 Indicate the Medicare rate that was in effect during the MA 11 report period attach schedule N 2a 2b Indicate the effective date of the Medicare rate YES O 2c Indicate whether the Medicare rate is an audited rate mo 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 Schedule 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 QUESTION NO 3a Administrators Name 1307 3b Administrator s Telephone Number 1 308 80 Administrators Fax Number 1309 APPENDIX D NUMBERED COST REPORT FORMS 88
53. Name 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 User Name for the dialer window is Guest leave the password field blank When accessing the system through the Internet you do not need a User Name 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 spreadsheet 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
54. REPORT ELEMENT VALIDATION This indicates the response required by the manual reviewer to pass the validation SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 30 STANDARD FILE VALIDATION Revised 01 27 2003 1 YES 0 NO SEQUENCE SCHEDULE COLUMN FIELDNAME DESCRIPTION OF COST REPORT ELEMENT VALIDATION CERT la J FaciityID Must be valid facility ID as listed on the Password and Connectivity document CRT we J 3 Rr ic wpowam Facility name Mustbe name as listed on the Password and Connectivity document document 5 cH i ese Rept begin date MusbevaiddaecCERTendda 7 6 cr it fee Repstenddue Must be valid date gt CERThegdate and Tess than todays dae 7 cmr 2a msn Cost repon preparedby jMaybebak 3 Hr 25 ummme Pepmeshmmam Maye blank 9 X fee Fmteephonemumber May be blank TF CERTHirmname not blank must be a I0 digi number oo CERT m ieman Name of Medicare intermediary May be blank If MAS8 2anot blank or 0 must not be blank 1 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 type 35 12 SchA typeorg Type of organization Must be 1 6 If SchAapprovedas 4 must 6 If SchAapprovedas 1 2 or 3 must not 6 13 la Beds
55. S 515 526 Sdb 1425 B RevmusadusmensioSchedueC Must be whole number Blank or 327 529 Sch 2830 B Revenues adjustments to Schedule C Mustbewholeumberblnkor 53 adjustments to Schedule C lLimeI 30 mus llne3a 34 Shb 35b B Revenues adjustments to Schedule C Must be whole number blank or 0 53 Sab 36 B RevemesadjsimenstoScheduleC Line3Sa 3Sband SchC39E mus linc36 O 553 54 Sab 1 9 C O Schede Cline number column B not blank or 0 must not be blank 33 333 sab m C SehedieClnemmber fif column B not blank or O must not be Blank 54 555 Sdb 1425 C O SeedueClinemmber lrcolumsBnorblankor musnotbeblam 556 558 Sc 2830 C SehedeClinemmber O column B not blank or 0 must notbe Blank so sm 8 id iY penises WSehEBAmobunkor must not be Blank 3 1 SS Ewme SehEBAmobankor mutnobebnk s amp se 29 O Exeme SEDA not blank oF 0 mustmorbeblank sg smE 21 l s WSehEZAmoblankor must not be Blank 3 SsmE 36 dT Exeme SehE26A not blank oO must not be Blank 5684 589 SdE 126
56. Submitted Data ihe ACCEPTABILITY PROCESS eei nee RUE p ER CE a R R Filing Deadlines ere eet rede reo Dn ee UT Te REM SECTION 6 MA 11 ACCEPTABILITY VALIDATIONS 28 INTRODUCTION 3 5 dno e eie p ped RR Ute 28 INSTRUCTIONS FOR USE OF STANDARD FILE VALIDATIONS e 28 INSTRUCTIONS FOR USE OF SUPPORTING DOCUMENT VALIDATIONS 29 INSTRUCTIONS FOR USE OF MANUAL REVIEW VALIDATIONS 30 SECTION 7 ALTERNATIVE STANDARD FILE METHODS 44 Contents i Revised 01 27 2003 cent UR Dm 44 SPREADSHEET PIEE 5 eden qaid E tet 44 ipd T sa as hea ora TN E 45 FILE NAMING 45 SECTION 8 HELPDESK 46 MYERS AND STAUFFER HELPDESK 46 HEEPDESRSASSISTANCE Ute E cM M MA MU A IU RAT 47 PROBLEMS N T SUPPORTED detecte ers ia i nte NM dd 47 SECTION 9 GLOSSARY 48 COMMON TERMS AND 48 APPENDIX A NETSCAPE INSTALLATION 53 WINDOWS 3 X SET UP INSTRUCTIONS FOR 53 WINDOWS 95 SET UP INSTRUCTIONS FOR sse 56 INSTRUCTIONS FOR FREE VERSION 5 59 INSTRUCTIONS FOR ACCOUNT SETUP ONLY sette 60 NETSCAPE PERSONAL ED
57. XX 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 3 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 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 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 01 27 2003 REPORTFIELD DESCRIPTION values FIELD DESCRIPTION VALUES
58. alidation is identified by an Order number This is the order that the documents must be placed in the Certification Report Package LABEL The abbreviation of the cost report schedule column and line number to which 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
59. andard file Only one copy of these supporting documents should be mailed SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 25 Revised 01 27 2003 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 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 will 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 o
60. arers 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 User Name 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 World 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 User Name 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 bas
61. assword 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 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
62. ated for a cost report period with a different name If using Lotus the file must be saved as version WK4 or lower Lotus files with a SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY 9 Revised 01 27 2003 123 extension can not be validated Data entry will be easier if the original template is left blank SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY 10 Revised 01 27 2003 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 User Name 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 Submis
63. ation dollars Must be whole number blankor0 3 Sec 29 H Residential and other allocation dollars LimsI l9must line20 O 366 372 Scc 2127 A Mustbewholenumber blnkor 358 se 28 H Residential and other allocation dollars Lins2 27muxzine2 amp O 3u Sac 29 H O Residential and other allocation dollars Mustbewholenumberblmkor x5 Sc 30 A Residential and other allocation dollars jLine2028 29mut lin3 O7 S 376 37 Scc 3 32 H Residential and other allocation dollars Musi be whole number Blank or 38 38 Scc L8 Nursing facility allocation percem Must 1 0000 less column J IF not blank or 0 must be rounded to 4 decimals 386 387 Scc 1931 1 __ Nursing facility allocation pereent_ Must 1 0000 Tess column J IF not Blank or 0 must be rounded to 4 decimals 388 394 Scc 1319 __ Nursing facility allocation percent Must 1 0000 Tess column J If not blank or 0 must be rounded to 4 decimals 395 401 Scc 2127 1 _____ Nursing facility allocation percem Must 1 0000 less column J If not blank or 0 must be rounded to 4 decimas 105 H Hi 5 YY YY 5 QQ QD QQ QL Ql a 10 11 220 451 31 32 Pp Pp Residential and other allocation percent 0 lt co
64. available at beginning of period Nursing Facility Must be 1500 Changes in total beds during period Nursing Facility Must be gt 500 and lt 500 15 SchA ibb As Changes in total beds during period Nursing Facility Must be gt 500 and lt 500 16 SchA Ibe A Changes in total beds during period Nursing Facility Must be gt 500 and lt 500 17 SchA ibd A Ts Changes in total beds during period Nursing Facility Must be gt 500 and lt 500 18 lc Beds available at end of period Nursing Facility Must SchA1aA SchAlbaA SchA1bbA SchATbcA SchA1bdA 19 2 Bed days available for period Nursing Facility Must be 10 of available bed calculation See example 20 s a 3 A Jj Actulresident days for period Nursing Facility Must be lt SchA2A sha 4 A jrewmtexwwxy Must SA SARA rounded 3 decimals ex 9545 22 sha 5 Resident days at 90 occupancy May be blank or whole number If not blank must SchA2A X 90 53 Ss Ftd MA resident days of care Must be lt SchA3A 24 SchA la Beds available at beginning of period Residential and Must be lt 1500 Other B gt Changes in total beds during period Residential Other Must be gt 500 and lt 500 26 SchA lb B JjChangesintotal beds during pe
65. ber Name of Medicare intermediary Approved as Type of organization Revised 01 27 2003 VALIDATION Must be valid facility ID as listed on Connectivity document Must T or F Must be name as listed on the Pass Connectivity document Must be the provider number as liste Password and Connectivity documel Must be valid date lt CERTenddate Must be valid date gt CERTbegdate today s date May be blank May be blank May be blank If CERTfirmname n 10 characters May be blank If MA58 2a not blank blank Must be 1 4 If SchAapprovedas Hospital based for case mix rates SchAapprovedas 4 must be pro Must be 1 6 If SchAapprovedas SchAapprovedas 1 2 or 3 must The following table describes the columns that make up the template COLUMN NAME DESCRIPTION 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 character
66. bmission 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 follo wing instructions starting in Section 4 EXCEL SPREADSHEET TEMPLATE DATA E 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 Final 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 an
67. bmit 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 the system and check back for your full Validation Report later To get your validation report select Receive Validation Reports from the MA 11 Cost Report Submissions main menu Name ofthe Cost Report Fis Retum to MA 11 Cost Report Submissions main menu Figure 5 6 MA 11 File Submission Window SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 16 Be sure and save your file prior to selecting it for submission Revised 01 27 2003 You have two options for entering a cost report standard file name If you know the cost report standard file name you may point and 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 x Look in E Program El e
68. c ios Hes Bes mes 2865 293 Scc 1 8 ea CS a ee Allowable cost Line9 must 0 Column D E must column F 355 39 Scc 191i F n Allowable cost Column D E must column F F Allowable cost Line 12 must 0 Column D E must column F 298 317 13 32 F Allowable cost Column D E must column F Q 2185325 e a 365 327 sae f 1911 38 34 se 1 1 G Nusimgfaliyalocaiondolars CoummFlescolmnHmust coumnG 35 se 29 SG Nursing facility allocation dollars DmesI l9mwst line20 SSCS 355 342 Scc 2127 G Nusimgfadhtyalocaiondolars ColmmFlescolummHmus coumnG 3x Seh 28 G Nusiefai yalocaiondolas Lims21 27mus hne28 34 Ssmo 29 G Nursing Facility allocation dollars ColmmFlescolumnHmus coumnG 35 30 o __ Nursing facility allocation dollars Line 20 28 29 must line 30 Mstbes0 36 347 se 3 32 G Nusimgfadhiyalcaiondolars CoummFlescolumnHmus coumnG 348 355 Scc L8 H O Residential and other allocation dollas Mustbewholenumberblnkor 356 357 saco 19 1 H Residential and other allocation dollars Must be whole number blank or0 358 364 Scc 1319 n Residential and other alloc
69. ce 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 APPENDIX A NETSCAPE INSTALLATION e 57 27 28 29 30 3 92 33 34 35 36 37 38 39 40 41 42 43 Revised 01 27 2003 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 informat
70. cx Tine 20 IrSchAaprovedas lt 2 ines TT must z line 20 e s 2i A ___J Total net operating cost SchC30F ISchElPA mus Tme2 p SchG 22 Administrative costs SehCJSF SchElSA mus le2 6 SaG 23 A __ Net operating cost less administrative costs Line 21 Tess Tine 22 must tine 233 sen 1 24 Line 237 88 rounded to places must Tine 24 eri i T gt gt gt gt gt gt gt 686 602 ShG 17 B Fringe benefits Must be whole number blank or 0 693 SchG 20 B Fringe benefits SchC29B must line 20 IfSchAaprovedas lt gt 2 lines 7 must line 20 64 712 Sen ther expenses Mustbe whole numiber Blank or Cm seh 29 tr expenses ScRCJ9C must ine 20 WSchAapprovedas S2 lines T must Te 20 TaT rota expenses Jan B Ct con TU H2 se 819 tal expenses Foor C must z colum D 29 5 reat espenses Eom A B C and Sch COD mus c column D 5 Sei 5 sition E ScRHSA s 0 must noi be bank 585 S88 11 S Pesitio i 8 0 mist ot Bank 736 740 SchH 15 Salary cost fees Must be whole number
71. d 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 SECTION 2 QUICK GUIDE 3 Revised 01 27 2003 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 MA MA 11 Cost Report Submission System Manual Review Validations Medical Assistance Nursing Facility Spreadsheet File Standard File Validations Text File User Name 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 M
72. d to field Be very careful to enter information into the correct field The 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 Select the 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 Select the 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 FF WY pP Close the Sheet Properties window All fields except for those that are to be left blank have to be data entered into the temp late 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 V3 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 cre
73. danswerO orl 8p Sh 1 J cility maintain Tite care contracts Valdamwer ori 3 Sh 18 O jReityhsadmisonfe Valdamwer ori Bd Sh 19 __ Facility maintains funded depreciation account Valdanser orl 5 851 MGT 2m 2j A Management company name MF column B not blank or column C not Blank or 0 must not be blank 555 864 mor 2m 0j B lDwmeofsevie onetypeofservicepern fif column A not blank musmotbebak L3 p Moro p mexp o0 lo Hesum Ame msbe wl 0000000 ws S Jima fis Schedule completed Vslid answer Oor T ITO SchETSA masi zD orbe S8 LEE a fRmestsssererdissr ei sn feompleted m Bak 3 891 905 SchJ pedi Social security number If column AA not blank must not bel blank T SchJ completed 0 must be blank 906 920 Title function If column A not blank must not be blank If SchJcompleted 0 must be blank 921 935 1 315 D J Propretorship 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 SECTION 6 MA 11 ACCEPTABILITY VALIDATIONS 36 STANDARD FILE VALIDATION Revised 01 27 2003 1 YES 0 NO VALIDATION 00000 Seheompleed O mustbe Blank
74. dule 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 Sch MA line 6 Schedule to support expenditures in excess of 500 submitted on Schedule MA 4 line 6 Required if SchMA4 6 gt 500 00 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 document for Schedule MA 4 line 18 must state the location of this description ch MA 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 Required if SchMA4 19 gt 1000 00 document for Schedule MA 4 line 19 must state the location of this description Sch MA 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 Sch MA line 26 Schedule to support liabilities in excess of 1000 submitted on Schedule MA 4 line 26 If liabilities have been described elsewhere the Required if SchMA4 26 gt 1000 00 supporting document for Schedule MA4 line 26 must state t
75. e E39 Sd 3 Acus 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 SchA1bcA or SchA1bcB not blank or 0 must be valid date gt SchA1bbD pre qp e a SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 31 STANDARD FILE VALIDATION Revised 01 27 2003 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 SchA1beD and lt CERTenddate 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 SchB 1 2 B Resident days of care non MA Must be blank if column A is blank L 68 sen 13 8 Resident days of care non MA Line 13 must ines 1 12 69 80 SchB 1 2 C Resident days of care MA Must be blank if column A is blank ie te ee Resident days of care MA Line 13 must lines 1 12 Line 13 must SchA6A Column B C must SchA3A 82 93 SchB 1 2 D Resident days of care Residential and Other Must be blank if column A is blank 94 S amp B 13 D Resident days of care Residential and Other Line 13 must lines 1 12 Line 13 mu
76. e 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 SECTION 7 ALTERNATIVE STANDARD FILE METHODS e 45 Revised 01 27 2003 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 System 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 The phone number for the helpdesk is 717 541 5809 If the staff i
77. e C Required if SchD21A gt 500 00 al T Sch D line 22 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 o um ec en expenses appear expenses appear Sch E line 1 Schedule to support costs reported on Schedule E column A line 1 Required if SchELA lt gt 0 or blank 12 Sch D line 25 Schedule to support income greater than 500 reported on Schedule D line 25 Indicate the source the amount and where the related Schedule C Required if SchD25A gt 500 00 expenses appear Sch E line 16 chedule to support expenditures in excess of Exceptional DME Grant If applicable PPE Schedule of additions and deletions to property plant and equipment to support the difference in costs submitted on Schedule L column A line Required if Schedule L completed 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 toSchL11B depreciation and life and method of computing depreciation S S Sch E line 14 Schedule to support costs reported on Schedule E column A line 14 Required if SchE14A lt gt 0 or blank 3 5 i S ch G line 19 Schedule to support costs greater than 1 000 reported on Schedule G line 19 Required if SchG19C gt 1000 00 Sch Lline4 Sch
78. e 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 Icons Icons for specific software functions are used where applicable and available e g the Netscape Navigator icon SECTION 1 INTRODUCTION 2 Revised 01 27 2003 SECTION 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 Su
79. e 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 01 27 2003 9 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 e Appendix B Downloads contains instructions for downloading cost report updat
80. ease 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 CD 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 The Setup 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 APPENDIX A NETSCAPE INSTALLATION e 53 10 11 12 13 14 15 16
81. ed Loan Schedule the supporting document for Schedule I line 14 should state the location of these details 25 Sch K column C Schedule to support a response of YES or NO even if zero included in the reported costs and any adjustments to remove the profit from the Required if any SchK1C SchK14C D reported allowable costs At a minimum provide amount of profit for each completed line even if profit has been removed and any adjustment that was made to remove the profit 26 Financial Facility specific financial statements to support a response of NO 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 0 and SchAapprovedas lt gt 2 or 4 with the financial statements MI 27 Sch L line 30 Schedule to support other R E account transactions on Schedule L line 30 Required if SchL30A lt gt O or blank and Schedule L Completed and SchAapprovedas 2 or 4 Sch M line 6 Schedule of detailed list of assets purchased to support amount reported on Sch M line 6 Col B Required if SchM6B 0 or blank Sch M line 8 Schedule of specific details of loans receivable to support amount reported on Sch M line 8 Col B Required if SchM8B lt 0 or blank Sch MA4 Schedule to support a response of NO to Sche
82. ed 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 SECTION 9 GLOSSARY 49 Revised 01 27 2003 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 provided 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 User Name 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 ha
83. edical 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 must 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 Internet Explorer can be used in place of Netscape as a browser when submitting cost report standard files However instructions for Internet Explorer are not provided with this manual The process of submitting and validating costreport 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 report data submitted by the facility or their cost report preparer
84. edule to support response of YES to capital assets with an acquisition cos of 500 00 or more expensed in net operating costs on Schedule Required if Schl4 1 L line 4 20 Sch I line 5 Schedule to support response of YES to administrative cost allocated to other cost center on Schedule I line 5 Show cost category basis of Required if SchI5 1 allocation and amount allocated for each line item 17 i 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 eee well as number of hours worked per week salaries wages fringe benefits and line of Schedule C on which this is recorded pepe we os Schedule of specific details of personal expenses to support response of NO on Schedule I line 12 Include amounts and the Schedule and line on which this is recorded SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 40 SUPPORTING DOCUMENT VALIDATIONS Revised 01 27 2003 1 YES 0 NO ORDER LABEL DESCRIPTION OF DOCUMENT TYPE 23 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 during the report period 1 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 Classifi
85. efits Dms21 27muizhme28 amp i sc 29 B Siig benefits Mast be whole number Blank or 3 se 30 B O Fimseteefts Lms2628ani29must lin30 Sho 39 B Pmebmfs Dm3omwtzie39 a 15 13 se 1 19 C Oerexenes Mesbewholemumbrbankor i4 20 C jOerexpemes Bmsi I mut line20 15 20 2127 C lOrexpenes Mexbewholenumbrblnkor 28 Oeexenmes Lme21 27mwt lime28 x Seki 9 C jOmerexenmes Mast be whole number Blank or pl ine 30 n sehe EST 22 se 38 C SS OSS ef 339 563 74 233 se 1 19 D Total expenses SSCS Coltri AB Crust column DSSS 5 sShc 30 otal expenses Colt A B C must column D Lines T 19 must Tie 20 35 340 Shc 2127 D Wexwems OwmA B CmwtzchmnD zi se 28 D Tealewenes Column A B C must column D Lines 21 27 must line 28 258 sho 29 D mulepess OhmnA B Cmwtzchmnb
86. ent 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 Facility ID Create a formula in this cell that points to the correct cell of the existing MA 11 SECTION 7 ALTERNATIVE STANDARD FILE METHODS e 44 TEXT FILE Revised 01 27 2003 workbook Create a formula for each of the remaining rows of the spreadsheet template Leave row 1 as DATA V3 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 maintain 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 colu mns rows or work
87. eo Ww Ge N E mA eo V U N E mA BE s m HH Az E H un N E Ss m A 55 N E fhe m m A A 45 E e m wo Hin 19 E e A e N m wo E m N A Go E APPENDIX D NUMBERED COST REPORT FORMS 83 FACILITY TRANSACTIONS WITH RELATED PARTIES Code YES as 1 NO as 0 TRANSACTIONS WITH RELATED PARTIES ARE INCLUDED IN Profit EIN Owner s LINE Schedule C Removed pater UE or of Related NO Line Amount Yes Supply Name of Related Business SSN Business A B D F G H 1027 1041 1055 1069 1083 112 1028 1042 1056 1070 1084 1126 meer TMT nem ms m 1030 1044 1458 1072 1086 1128 1031 1045 1059 10731 1087 1129 1032 1046 1074 1088 1130 1033 1047 1075 1089 1131 1034 1048 1062 1076 1090 1132 0351 049 ndes 1077 1091 1133 1036 toso 038 1092 1134 1037 1051 fides 1079 1093 1135 1038 1052 1066 1080 1094 1136 1039 1053 nden tosi 1095 1137 1040 posa f ades 1082 1096 1138 1152 LINE 5 z o E E X I Mz z S 42 N lt
88. er 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 Follow 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 APPENDIX A NETSCAPE INSTALLATION e 60 Revised 01 27 2003 1 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 2 Select the Next button 3 You may enter a name for the computer you are dialing i e Cost Report 4 Select your modem from the drop down list 5 Select the Next button 6 Enterthe area code and telephone number providedto you by the Department 717 541 5806 7 Select the Next button 8 Amessage box will appear stating the connection has been successfully created 9 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 con
89. etter 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 default destination directory of C Program Files Netscape 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 56 10 11 12 13 14 15 Revised 01 27 2003 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 aski
90. f current period Line 6 13 14 15 must line 16 If SchLcompleted 0 must be blank 1172 1175 SchL 17 20 End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 2 A 1176 End of current period Lines 17 20 must line 21 If SchLcompleted 0 must be blank 1177 1179 SchL 22 24 End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank 1180 25 J Endofcurentperiod Lines 21 24 must line 25 If SchLcompleted 0 must be blank 1181 1186 SchL 26 31 End of current period May be blank If not blank must be whole number If SchLcompleted 0 must be blank SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 37 gt gt gt gt gt gt gt gt gt gt gt E STANDARD FILE VALIDATION Revised 01 27 2003 1 YES 0 NO SEQUENCE SCHEDULE ee Niles an FIELDNAME DESCRIPTION OF COST REPORT ELEMENT VALIDATION 1187 A Endofcurrent period Lines 26 30 must line 32 If SchLcompleted 0 must be blank a Le Essi End of current Eu E If SchLcompleted 1 line 33 must not be blank Lines 25 32 must line 33 Line 33 must line 16 If SchLcompleted 0 must be blank 1189 1193 SchL End of prior period May be blank If not blank must be whole number If SchLcompleted 0 LEE EM 1194 it BT
91. fically excluded 1a 2 by Medical Assistance Regulations been offset on Schedule D Line 19 If NO please state amount of income not offset Have all costs for nonresident meals been deducted from dietary and food expense If NO please state number of meals Resident meals Employe meals Volunteer meals Visitor meals Other identify 802 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 6 Does the facility maintain any residential and other areas that have not been reported on this Cost Report Identify 809 What is the total square footage of the facility used for nursing facility services Do you have any nonallowable cost centers in the nursing facility such as a gift shop snack shop administrator s or other employe s living quarters and or other areas not related to resident care Identify 812 lt E
92. he location of this description 36 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 Required if SchMA4 27 gt 1000 00 supporting document for Schedule MA4 line 27 must state the location of this description 37 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 supporting document for Schedule MA4 line 28 must state the location of this description Sch ch i ch i ch h M M M M Completed 1 and SchMA4 32 0 M 5 A M M M S 39 S A4 line 34 Schedule to support response of NO submitted for Schedule MA 4 line 34 Required if Schedule MA 4 eee eee impii a SehMAM aet 40 S A4 line 35 Schedule to support response of NO submitted for Schedule MA 4 line 35 Required if Schedule MA 4 e o atta 21 ma 50 Completed 1 and SchMA4 36 0 42 Schedule to support response of NO submitted for Schedule MA 4 line 37 Required if Schedule MA 4 Completed 1 and SchMA4 37 0 43 Sch MA 58 line Schedule to support Medicare rate submitted for Schedule MA 58 Part II line 2a See instructions to Schedule MA 58 for the correct format 2a 0 44 Independent Submit an Independent Accountant Report if applicable If applicable CHEN
93. icare rate Valid answers 0 1 or blank If MA58 2a gt 0 must not be blank I I I I II II II I Must not be blank Administrator s Telephone Number Must be a 10 digit number Administrator s Fax Number May be blank If not blank must be a 10 digit number SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 39 SUPPORTING DOCUMENT VALIDATIONS Revised 01 27 2003 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 2 Organization Chart Organization chart of supervisory personnel with names of personnel included If the facility is part of a larger entity submit a listing of the Required components of the entire 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 at audit or when available 3 Loan Schedule Classified loan schedule to support costs submitted on either or Schedule C line 34 or Schedule G line 12 It should include the name of the Required if SchC34C lt gt 0 or blank or lender 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 4 Sch C line 31 Documentation t
94. if applicable The help desk will contact you as soon as possible please do not fax the same message multiple times SECTION 8 HELPDESK 46 Revised 01 27 2003 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 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 othe
95. ile 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 01 27 2003 FACILITY ACTION No action is required The facility officer or administrator must complete this section The preparer must sign when applicable Signatures 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 All 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 st
96. ill appear Figure C 1 on page 66 Sj Accepted MA 11 Cost Report Microsoft Internet Explorer Accepted MA 1 Cost Report File Name Size bytes Modification Date 00000000 AcceptedMA 11s xls 54272 8 20 02 10 18 03 AM 00575770 39 2001 xls 143360 6 4 02 11 43 30 AM 00576202 65 2001 xls 142848 5 10 02 4 15 32 PM 00576310 06 2001 xls 141824 7 18 02 2 58 35 PM 00583842 14 2001 xls 180736 6 4 02 11 47 36 AM 00633739 00 2001 xls 143360 8 1 02 11 26 08 AM 00744872 22 2001 xls 143360 6 4 02 12 21 44 PM Figure C 1 Accepted MA 11 Cost Report Page APPENDIX C ACCEPTED MA 11 COST REPORT DATA 66 Revised 01 27 2003 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 2 on page 67 depending on how your system is configured Warning There is a possible security hazard here 9 Figure C 2 Security Hazard Warning If you receive this warning message choose the Save to Disk option and select the OK button Afte
97. ion 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 appear showing the current modemselected 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
98. l of the property 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 If the facility is part of a larger entity submit a listing of the components of the entire 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 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 79 SUPPLEMENTAL INFORMATION AND QUESTIONNAIRE Code YES as 1 NO as 0 NO PART Il QUESTIONNAIRE 1 Has interest investment income from sources other than donor restricted or speci
99. 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 numbers are listed for that validation in one row in order to consolidate this document Sequence numbers 19 30 and 38 refer to the Aavailable bed calculation An example of this calculation is as follows SCHEDULE LINE CHANGE DATE DAYS A la 150 1 1 2001 A 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 SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 29 Revised 01 27 2003 COLUMN NAME DESCRIPTION ORDER Each v
100. lumn J lt 1 0000 If not blank or 0 must be rounded to 4 decimals Residential and other allocation percent lt column J lt 1 0000 If not blank or 0 must be rounded to 4 decimals 9 7 432 438 i Allocation basis column F gt 0 and column I or column J is not 1 0000 must not be blank Allocation basis ust not be blank 1 2 1 17 49 se 8 i 0 1 mus i s i 5 If is Mus 1 SECTION 6 MA11 ACCEPTABILITY VALIDATIONS 33 STANDARD FILE VALIDATION Revised 01 27 2003 1 YES 0 NO VALIDATION 459 450 Scc 18 19 K J Alsionbais lrcolumnF 0 and column T or column T is not 1 0000 must not be blank 43 432 Scc 2122 K jAlewintwis Metmahbebak 48 sShc 233 K Alsinbwis Sco 0 and column Tor columnis nor 1 0000 must not be blank 54 455 Sch 24235 K jAMheconbais MeswbeeiherSQFTorACIUAL Cd 456 457 Scc 2627 K Allocation basis Ifcolumn F0 and column Tor column Tis not 1 0000 must nor be blank 48 Shc 29 K Alesintwis MwtbeTOTALNOCOST 459 460 Scc 3132 K Allocation basis Must be either SQFT or ACTUAL 46 462 Sdb 12 Revmecoxcee column A or column B not blank or 0 must not be blank 4683 46 Sdb 2125
101. 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 87 PRIVATE PAY AND Schedule MA 58 MEDICARE RATE CERTIFICATION STATEMENTS PART Il PRIVATE PAY RATE LINE NO QUESTION Code YES as 1 NO as 0 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 If YES give all inclusive or room and board plus ancillary private pay rate 1 303 If NO sign and date the following certification statement that will appear on the Certification Report hereby certify that the facility s 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 1406 b PART II MEDICARE RATE LINE 0 QUESTIO
102. mission 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 SECTION 9 GLOSSARY 52 Revised 01 27 2003 APPENDIX A NETSCAPE INSTALLATION Glossary Terms Used In This Section 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 User Name 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 pl
103. n 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 been 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 SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 26 Revised 01 27 2003 When a provider fails to submit any cost
104. n page 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 User Name 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 User Name 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 E Connect To 3 1717 5415806 Default Location Connect 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 Pro
105. n 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 Certification 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 forma
106. nect at another time 10 Right mouse click on the new dialer you created and select Properties 11 Select the Server Types tab or button 12 ForMA 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 13 Select OK PART II Connecting 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 1 Select Start Programs Accessories Dial Up Networking 2 Double click on the Dialer icon you created i e Cost Report 3 Enter the User Name and password 4 Selectthe 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 Access Netscape 2 Move the cursor to the Options pull down menu APPENDIX A NETSCAPE INSTALLATION e 61 Revised 01 27 2003 Selec
107. ng data into the template are included in Section 4 of this manual e 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 64 depending on how your system is configured 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 warning message the Save As window will appear Figure B 3 on page 65 APPENDIX B DOWNLOADS 64 Revised 01 27 2003 Actobat3 C lotus Program Files Archive C My Documents Scratch E MyFiles Timework E Novell Vip CJ Dasis32 Windows C3 Drawings S Autoexec bat E Pacrs40 fa Bootlog prv MA11VLD20000501 doc Files Figure B 3 Save As Window E Command s Config sys ai Detlog old Detlog t t E ffastun ffa 58 ffastun ffl 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
108. ng 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 16 17 18 19 20 21 22 23 24 25 26 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 Servi
109. nternet 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 6 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 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 1 2 3 Select Start Programs Accessories Dial Up Networking Double click on the Dialer icon you created i e Cost Report Enter the User Name and password Select the Connect button On new
110. o support an entry of other than blank or zero on Schedule C line 31 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 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 to date 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 Schedule to support an entry of other than blank or zero on Schedule C Line 32 Include major movable property additions and deletions including date description of property and proceeds from sale or disposal Sch 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 Required if SchD10A or SchD10B lt gt related Schedule C expenses appear Attach copies of invoices paid with the Exceptional DME Grant expenses appear Sch D line 21 Schedule to support income greater than 500 reported on Schedule D line 21 Indicate the source the amount and where the related Schedul
111. ompleteness 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 Schedule 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 SECTION 9 GLOSSARY 51 Revised 01 27 2003 protocol to use and the second part specifies the IP address or the domain name where the resource is located URL
112. 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 SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 13 Revised 01 27 2003 http 10 3 1 4 Welcome to the MA 11 Cost Report Submission System PENNSYLVANIA Department of Public Welfare MA 11 Cost Report Submissions Accepted MA 1 Cost Reports Bulletins Downloads Points of Contact Figure 5 3 MA 11 Cost Report Welcome Page There are five options available to you f
113. ort 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 these instructions 1 2 3 4 3 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 program PART IV Account Setup APPENDIX A NETSCAPE INSTALLATION e 59 10 11 12 13 Revised 01 27 2003 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 I
114. ost 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 SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 23 Revised 01 27 2003 Report Submissions The User Name 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
115. p 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 SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 14 Revised 01 27 2003 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 User Name and Password Required Window You must point and click in the first field User Name to begin entering the required information provided to you by the Department The Guest User Name may not be used to submit cost report standard files You 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 User Name and password press Enter or point and click on OK You may select Cancel if you do not wish to proceed The User Name and Password Required window will appear only when you initially access the cost report standard file submission process Once you have entered a correct User Name and
116. partment Enter your login name and password 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 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 55 44 45 46 4T 48 49 Revised 01 27 2003 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
117. personal portion of company car trips conventions meals and lodging phone entertainment etc 12 If NO please provide specific details including amounts Schedule and line on which this is recorded ak ao k C3 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 If YES attach a separate schedule identifying to whom amount and interest during report period Were there any loans notes or advances from officers employes members of the Board of Directors or owners due from the facility during the report period AR 4 _ If YES identify on the schedule submitted under Schedule I Part item 4 Has an adjustment been made for those types of expenses that were disallowed in prior audits or are otherwise nonallowable Is the facility a Continuing Care Retirement Community CCRC 15 19 i N o Does the facility maintain life care contracts 18 Is it the formal or informal policy of the facility to require an admission fee on or before the date of admission 19 Does the facility maintain a funded depreciation account A APPENDIX D NUMBERED COST REPORT FORMS 81 SUPPLEMENTAL INFORMATION AND QUESTIONNAIRE LINE PARTII QUESTIONNAIRE Continued NO List all managment companies utilized by the facility during the repo
118. perties 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 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 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 SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 12 Revised 01 27 2003 Depending on your system configuration you will automatically access Netscape or S 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 3 Netscape Elle Edi View Go Window Help 43 5 A se a Back For penadi Home Search Netscape rir Security J L Bookmarks 4 Location v I What s 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 window has a single data entry field Location
119. quence 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 APPENDIX D NUMBERED COST REPORT FORM 69 FINANCIAL AND STATISTICAL REPORT FOR NURSING FACILITIES AND SERVICES UNDER THE MEDICAL ASSISTANCE PROGRAM OF THE Certification Schedule DEPARTMENT OF PUBLIC WELFARE COMMONWEALTH OF PENNSYLVANIA PART I COST REPORT AND FACILITY INFORMATION LINE z 58 DESCRIPTION 1a FACILITY ID LL dm LL LL LI TEST T or F o a 1c FACILITY NAME 3 MAN REPORT BEGIN DATE 5 REPORT END DATE PART II PREPARER INFORMATION LINE QUESTION z 55 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 hereby certify that have read the above statement and that have examined the accompanying Cost Report data in file file name including any attached exhibits schedules forms and explanations
120. r Services of Sole Proprietors and Partners Cost of Major Movable Property Real Estate Taxes Legal Fees Excess Administrative Cost Schedule G Attach Schedule Attach Schedule Line 802 Line 603 Line 604 Line f805 2 D B Eb O E5 ro ri o D D 2 607 608 m wm V NONALLOWABLE COST CENTERS Identify Housekeeping Plant Operation amp Maintenance Administrative Costs Real Estate Taxes B09 Line 0 Linet25 n Co 09 OO e N C2 mo O b D Owe oh ok OTAL SCHEDULE E ADJUSTMENTS APPENDIX D NUMBERED COST REPORT FORMS e 75 DEPRECIATION Depreciation Expense For PROPERTY PLANT amp i i Period EQUIPMENT 1 Buildings Fixed Equipment Other 614 Subtotal Movable Property Other Movable specify Transportation Equipment 671 672 1 Note that Schedule requires submission of a schedule of additions 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 33 Column D APPENDIX D NUMBERED COST REPORT FORMS 76 ADMINISTRATIVE COSTS SALARY FRINGE OTHER TOTAL LINE COST BENEFITS EXPENSES EXPENSES NO A B C D Adminstrator a 673 686 694 Office Personnel 674 687 695 715 697 ur ies n7 ieran
121. r entities or are outside of the cost report standard file submission arena 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 47 Revised 01 27 2003 SECTION 9 GLOSSARY COMMON TERMS AND ABBREVIATIONS This manual section 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 o
122. r you have selected the OK button or if you did not receive the warning message the Save As window will appear Figure C 3 on page 67 lotus Program Files My Documents Scratch E Command MyFiles Timework 9 Config sys Novell Vip a Detlog old Dasis32 Windows Detlog txt Orawin95 S Autoexec bat j ffastun ffa Pacrs40 a Bootlog prv ffastun ffl MATTVLD20000501 doc All Files E Figure C 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 APPENDIX C ACCEPTED MA11 COST REPORT DATA 67 Revised 01 27 2003 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 APPENDIX C ACCEPTED M11 COST REPORT DATA 68 Revised 01 27 2003 APPENDIX D NUMBERED COST REPORT FORM Glossary Terms Used In This Section Certification Report Department Excel Spreadsheet Template Numbered Cost Report Nursing Facility Sequence Number Standard File Validations Validation Definitions for these terms are found in Section 9 This appendix displays the se
123. 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 acceptable 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 27 Revised 01 27 2003 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 P
124. riod Residential amp Other Must be gt 500 and lt 500 27 SchA ibe B Changes in total beds during period Residential amp Other Must be gt 500 and lt 500 28 Sha bd B JChangesinotal beds during period Residential amp Other _ Must be gt 500 and lt 500 29 SchA lc B Beds available at end of period Residential amp Other Must SchA1aB SchA1baB SchAIbbB SchA1bcB SchA 1baB 30 SchA 2 B Bed days available for period Residential amp Other Must be 10 of available bed calculation See example 31 SchA 3 B Actuaresident days for period Residential amp Other Must be SchA2B 32 SchA la C Beds available at beginning of period Total Must SchA1aA SchA1aB 33 SchA C JChansesin total beds during period Total Must SchA1baA SchA1baB 34 SchA C Changesintotal beds during period Total Must SchA1bbA SchATbbB 535 sei Tbe Changes in total beds during period Tota Must SchATheA SchAfbcH 36 se ba Changes in total beds during period Total Mist SchATbdA SchATbdE 37 Must SchAlbdA SchAlbdB O SchA lc Beds available at end of period Total Must SchAlaC SchAlbaC SchAlbbC SchAlbcC SchA1bdC Must be SCchA1cA SchA1cB 38 Shaa 2 C dJ JVBeddsys available for period Total Must be 10 of available bed calculation See exampl
125. rom this page They include e Cost Report Submissions accesses the MA 11 Cost Report Main Menu This option is only available to facilities with a non guest User Name and password e 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 e Bulletins contains news from the Department and the Myers and Stauffer helpdesk This option is for public use e Downloads contains files that may be downloaded and viewed or printed These files contain information on the MA 11 end user manual and the standard spreadsheet template 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 Additional options may become available in the future You may point and click on 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 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 u
126. rt 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 Code YES as 1 NO as 0 Currently Type of Utilized Service Management Company Name code number ki 855 8 856 8 85 8 ssa 8 859 8 860 8 861 18 3621 8 tees 8 E pm M Encode all Schedule data Part II data in the standard file If any row of Line 20 is a type 8 service do not enter an 8 in Type of Service Instead specifically identify the type of service in this column Responses of YES must be encoded as 1 in the standard file NO must be encoded as 0 zero Respond to all questions concerning your facility and cost report information APPENDIX D NUMBERED COST REPORT FORMS 82 Schedule J Code YES as 1 NO as 0 SCHEDULE J COMPLETED Time Devoted to Compensation Included Business Organization Nursing Facility Work in Allowable Cost ocia A dued peu uo Er B G H I J Css er ms 5 9581 973 1018 9611 976 noz a STATEMENT OF COMPENSATION OF OWNERS AND DIRECTORS NO i A 876 m m ii Un p N Il n lt C2 oS M2 Un d n D o M2 Un bz mA m
127. s 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 submissions 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 MA 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 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
128. s 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 63 http 111 111 111 111 mal Tupdat html Welcome to the Cost Report Update Page This page is provided to assist you in keeping the MA 11 Automation System up to date The links below contain information and downloadable files MA 11 Cost Report Submission System End User Manual Excel SpreadSheet Template Figure B 1 Cost Report Update Page There are two options available on this page Other downloadable items may be available in the future e MA 1I Cost Report Submission System End User Manual includes instructions for electronically submitting the cost report standard file APPENDIX B DOWNLOADS 63 Revised 01 27 2003 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 e 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 enteri
129. s may be entered into the template field only the number of characters specified will be saved The remaining characters will be ignored SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY 8 Revised 01 27 2003 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 as DATA V3 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 fiel
130. sheets 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 V3 0 Following the sequence of data in the Excel spreadsheet template or the numbered cost 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 1 310 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 b
131. sion System you 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 All 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 pamal1 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 SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 11 Minimized Dialer Revised 01 27 2003 Intranet Dial up Instructions If you have an Internet service provider and have already completed Internet Instructions o
132. st SchA3B 35 19 sch Resident days of cre iota Musi column B C XD dl eee Resident days of care total Must column B C D Line 13 must lines 1 12 Line 13 must SchA3C i Sdc 1 ow at centers i9 Scc 19 ser Cost centers orSchCi9Enorblak must not be Blank i19 Sc 26 ser Costcemter lSehC26D or Se C26Enot blank mustmotbeblank ii Sho 27 joww Centers Se C27 or SehC27Enot blank must not be blank i 357 Joost Costcmes E 13 I4 se i 9 A SWaycs o beoe mmber bonkoro im sho 29 A mayo Bwsi bmwi ln3 13 19 sae 2127 A yos i Smc 28 A jSMaycs A d Sho 29 A JS lary cost Mast be whole number Blank or 2 se 30 A SMaycsw Lines 20 28 and 29 must Tine 30 3 Sho 39 A Wave Bm3omwtzhe39 i i Shc i49 B Fmebeh MesBewhoemumbrblnkor i sse o B ____ Fringe benefits Hmsi l mwt lne20 Sdhc 2127 B jRimebemfts Mesbewhoemumberbunkor wi sic 28 B ring Ben
133. t General Preferences Click on the file tab for Appearance if necessary wom 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 111 111 111 111 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 Once you have established this bookmark you can select this item by choosing Cost Report Welcome Page 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 but
134. t 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 SECTION 9 GLOSSARY 48 Revised 01 27 2003 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 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 prep
135. 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 58 Revised 01 27 2003 INSTRUCTIONS FOR FREE VERSION SET UP PART I Dial 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 c NS 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 Rep
136. ther the submission was received prior to continuing with any other cost report or Netscape functions If for some reason you SECTION 5 SUBMISSION AND ACCEPTABILITY PROCESS 17 Revised 01 27 2003 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 FINAL 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
137. 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 SECTION 4 EXCEL SPREADSHEET TEMPLATE DATA ENTRY 7 N Microsoft Excel MA11Template_version3 xls SEQ SCH LINE COLUMN 1 CERTla CERT1b CERTic CERTId CERTIe CERTIf CERT2a CERT2b CERT2c CERT4a Approvedas Atypeorg Figure 4 1 MA 11 Spreadsheet Template DESCRIPTION Facility ID Test T or F Facility name MA number Report begin date Report end date Cost report prepared by Preparer s firm name Firm telephone num
138. ton 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 to save 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 placeholder or tag that allows you as with a book to go directly to a specific page where you have been before 1 2 3 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 e 62 Revised 01 27 2003 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 thi
139. ts and Medicare intermediary audit reports with adjustments for the report period with the MA 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 additions including the date of the addition the acquisition cost and a description of the addition Submit copies of invoices for property acquired under the Exceptional DME Grant Major movable property deletions including the deletion date a description of the property and any proceeds from the sale or disposa
140. unts 463 464 E ake CO D O Co cloc SSRIS lA e mo 11 Lid tpi Attach Schedule mS LA LB e hs hs DO Ss IB DO DO ar wo hs OO ee OO N B T T B pe e hs OO OO a NS eo e 3 Ci oh N IA ES k co 61 j Subtotal Resident Care 9 IL OTHERINCOME GuestandEmplyeMeals 14 Discounts 4 Vending Machines 49 Telephone Television SE Unrestricted interestinvestment income ine me NIN eu E OO DIES 467 Subtotal Other Income TOTAL GROSS REVENUES Add Lines 13 amp 26 DEDUCTIONS FROM REVENUES Uncollectible Accounts Contractual Adjustments To S9 D o oo EE gere 8 D A eo z wo beri Subtotal Deductions NET REVENUE Line 27 minus Line 31 LESS EXPENSES Sch C Line 39 Column D NET INCOME LOSS TOTAL SCHEDULE D ADJUSTMENTS TOTAL SCHEDULE E ADJUSTMENTS TOTAL ADJUSTMENTS T S APPENDIX D NUMBERED COST REPORT FORMS 74 ADJUSTMENTS TO EXPENSES EXPENSE ADJUSTMENTS SCHEDULE C TO SCHEDULE C LINE NUMBER 542 23 575 Il EXPENSE ADJUSTMENTS Part B Services Services and Supplies from Related Parties Adjustment to Cost Compensation fo
141. ur 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 s ettings Select the Finish button if you are satisfied with the settings you selected 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 Report Submission System 22 After logging back into your computer and accessing Windows double click on the Netscape Communicator program group APPENDIX A NETSCAPE INSTALLATION e 54 23 24 25 26 27 28 29 30 31 32 33 34 3
142. ust 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 NA must be blank Pp 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 SchMa410I 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 Sch MA4completed Resident personal funds compliance questions If SchMa4completed 1 must not be blank Valid answer 0 1 or blank If Peete eee SchMA4completed 0 or NA must be blank Resident personal funds compliance questions If SchMa4completed 1 must not be blank If SchMA4completed 0 or NA If SchMa4completed 1 must not be blank Valid answers 0 1 or blank If SchMA4completed 0 or NA must be blank MA rate exceed private pay rate Valid answer 0 or 1 Valid answer 0 or If SchMA58 1a 1 must be rounded to 2 decimals If SchMA58 1a 0 must be blank May be blank If not blank must be rounded to 2 decimals Medicare rate effective date May be blank If MA58 2a gt 0 must be a valid date within 5 years of the cost report end date Audited Med
143. ve 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 I 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 telephone 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

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