STATE OF CALIFORNIA CONTRACT SCH 2Provider No: HSC 30625F REASONABLE COST OF MEDI-CAL INPATIENT SERVICES CHARGES FOR MEDI-CAL INPATIENT SERVICES 5.. Excess of Reasonable Cost Over Custom
Trang 1STATE OF CALIFORNIA CONTRACT SCH 2
Provider No:
HSC 30625F
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
CHARGES FOR MEDI-CAL INPATIENT SERVICES
5 Excess of Customary Charges Over Reasonable Cost
6 Excess of Reasonable Cost Over Customary Charges
(To Contract Sch 1)
* If charges exceed reasonable cost, no further calculation necessary for this schedule
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
This is trial version www.adultpdf.com
Trang 2STATE OF CALIFORNIA CONTRACT SCH 3
Provider No:
HSC 30625F
3 Medi-Cal Inpatient Hospital Based Physician
7 Medi-Cal Inpatient Hospital Based Physician
(To Contract Sch 2)
11 Net Cost of Covered Services Rendered to Medi-Cal
(To Contract Sch 1)
COMPUTATION OF MEDI-CAL NET COST OF COVERED SERVICES
This is trial version www.adultpdf.com
Trang 3STATE OF CALIFORNIA CONTRACT SCH 4
Provider No:
HSC 30625F
GENERAL SERVICE UNIT NET OF SWING-BEDS COSTS
INPATIENT DAYS
SWING-BED ADJUSTMENT
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
PROGRAM INPATIENT OPERATING COST
(To Contract Sch 3)
MEDI-CAL INPATIENT ROUTINE SERVICE COST
COMPUTATION OF
This is trial version www.adultpdf.com
Trang 4STATE OF CALIFORNIA CONTRACT SCH 4A
Provider No:
HSC 30625F
NURSERY
INTENSIVE CARE UNIT
CORONARY CARE UNIT
SURGICAL INTENSIVE CARE UNIT
SURGICAL ICU-7
SURGICAL ICU-8
(To Contract Sch 4)
MEDI-CAL INPATIENT ROUTINE SERVICE COST
COMPUTATION OF
This is trial version www.adultpdf.com
Trang 5STATE OF CALIFORNIA CONTRACT SCH 4B
Provider No:
HSC 30625F
PEDIATRIC INTENSIVE CARE UNIT
NEONATAL INTENSIVE CARE UNIT
N/A
N/A
N/A
N/A
(To Contract Sch 4)
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
This is trial version www.adultpdf.com
Trang 6STATE OF CALIFORNIA CONTRACT SCH 5
Provider No:
HSC 30625F
RATIO COST TO CHARGES ANCILLARY COST CENTERS
37.00 Operating Room $ 95,710,199 $ 585,456,449 0.163480 $ 32,872,436 $ 5,373,973 39.00 Delivery Room and Labor Room 29,518,483 75,488,257 0.391034 4,090,159 1,599,392 40.00 Anesthesiology 55,602,856 446,285,096 0.124590 12,073,177 1,504,202 41.00 Radiology-Diagnostic 49,746,582 193,969,630 0.256466 9,057,218 2,322,867 43.01 Ultrasound 4,215,379 29,801,839 0.141447 5,221,339 738,542 43.02 CAT Scan 12,997,062 201,731,626 0.064427 13,018,173 838,728 44.00 Laboratory 81,858,827 694,170,211 0.117923 80,089,877 9,444,461 44.01 Laboratory-Pathological 25,512,941 62,236,846 0.409933 2,381,048 976,070 44.02 HLA Lab 4,969,551 11,666,069 0.425983 0 0 47.00 Blood Storing, Processing & Trans 25,970,759 39,817,972 0.652237 5,464,559 3,564,188 49.00 Respiratory Therapy 29,840,758 292,629,267 0.101975 26,391,671 2,691,281 50.00 Physical Therapy 11,777,981 41,779,821 0.281906 1,857,504 523,641 51.00 Occupational Therapy 4,439,833 22,511,543 0.197225 870,498 171,684 52.00 Speech Pathology 1,689,666 8,339,831 0.202602 490,718 99,420 53.00 Electrocardiology 13,588,420 98,869,613 0.137438 9,920,401 1,363,438 54.00 Electroencephalography 4,408,169 21,049,131 0.209423 1,354,592 283,683 54.01 Electromyography 166,799 1,342,237 0.124269 213,412 26,521 55.00 Medical Supplies Charged to Patients 125,543,810 522,478,410 0.240285 38,561,597 9,265,780 56.00 Drugs Charged to Patients 93,304,736 462,202,429 0.201870 55,532,278 11,210,293 57.00 Renal Dialysis 8,102,366 31,845,109 0.254430 3,806,900 968,591 59.00 Gastro Intestinal Services 17,677,073 51,780,517 0.341385 1,240,517 423,493 59.01 Eye Laboratory 116,474 643,684 0.180950 0 0 59.02 Cardiac Catheterization Laboratory 10,383,847 81,800,167 0.126942 5,736,240 728,168 59.03 Vascular Laboratory 4,491,186 49,819,261 0.090150 0 0 59.04 Psychiatric/Psychological Services 948,688 4,444,067 0.213473 0 0 59.05 Nuclear Medicine - Therapeutic 14,418,226 116,313,021 0.123961 2,122,755 263,138 59.06 Magnetic Resonance Imaging 15,976,382 140,454,524 0.113748 4,760,185 541,460 59.07 Pulmonary Function Testing 1,901,599 3,728,114 0.510070 336,231 171,501 59.08 Recreational Therapy 139,834 833,837 0.167700 0 0 60.00 Clinic 5,867,508 3,544,413 1.655425 0 0 60.01 Psychiatric Clinic 4,048,115 6,939,317 0.583359 0 0 60.02 Medical Oncology 101,988,606 315,812,474 0.322940 0 0 60.03 Psych - Partial Hospitalization 894,863 2,902,036 0.308357 0 0 60.04 Clinic 2 - Gen Risk Center 406,378 124,968 3.251855 0 0 60.05 Clinic 3 - Neuro Surgical Institute 5,137,193 1,367,847 3.755678 0 0 60.06 Clinic 4 - Prostate Cancer Program 463,111 194,947 2.375574 0 0 60.07 Clinic 5 -Endocrinology Center 1,082,093 973,406 1.111657 0 0 60.08 Clinic 6 - Spine Injury Institute 4,253,159 2,992,983 1.421044 0 0 60.09 Clinic 7 - Pediatric Center 2,929,172 1,490,379 1.965387 0 0 61.00 Emergency 38,372,548 260,197,483 0.147475 11,543,422 1,702,363
TOTAL $ 910,461,233 $ 4,890,028,831 $ 329,006,907 $ 56,796,878
(To Contract Sch 3)
* From Schedule 8, Column 27
(Contract Sch 6)
MEDI-CAL TOTAL
ANCILLARY COST*
TOTAL ANCILLARY CHARGES (Adj )
MEDI-CAL CHARGES COST SCHEDULE OF MEDI-CAL ANCILLARY COSTS
This is trial version www.adultpdf.com
Trang 7STATE OF CALIFORNIA CONTRACT SCH 6
Provider No:
HSC 30625F
ANCILLARY CHARGES
(To Contract Sch 5)
AUDITED ADJUSTMENTS
REPORTED
(Adj 24) ADJUSTMENTS TO MEDI-CAL CHARGES
This is trial version www.adultpdf.com
Trang 8STATE OF CALIFORNIA CONTRACT SCH 7
Provider No:
HSC 30625F
PROFESSIONAL
SERVICE COST CENTERS
40.00 Anesthesiology $ 0 $ 0 0.000000 $ $ 0 41.00 Radiology - Diagnostic 0 0 0.000000 0 43.00 Radioisotope 0 0 0.000000 0 44.00 Laboratory 0 0 0.000000 0 53.00 Electrocardiology 0 0 0.000000 0 54.00 Electroencephalography 0 0 0.000000 0 61.00 Emergency 0 0 0.000000 0
TOTAL $ 0 $ 0 $ 0 $ 0
(To Contract Sch 3)
TO ALL PATIENTS
RATIO OF REMUNERATION
MEDI-CAL COST CHARGES
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
REMUNERATION
(Adj )
PHYSICIAN'S REMUNERATION
TO CHARGES
MEDI-CAL
This is trial version www.adultpdf.com
Trang 9This is trial version www.adultpdf.com
Trang 10This is trial version www.adultpdf.com
Trang 114 4 4 4 4 4 4 4 4 5.
0 0
This is trial version www.adultpdf.com