SCHEDULE 5 PROGRAM: NON CONTRACT SCHEDULE OF MEDICAL ANCILLARY COSTS_part7 potx

State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT 16 4A Not Reported Medi-Cal Administrative Days (September 1, 2006 - March 31, 2007) 0 14 14 4A Not Reported Medi-Cal Administrative Day Rate (September 1, 2006 - March 31, 2007) $0 $310.68 $310.68 17 6 Not Reported Medi-Cal Ancillary Charges - Radiology - Diagnostic $0 $230 $230 6 Not Reported Medi-Cal Ancillary Charges - Laboratory 0 2,798 2,798 6 Not Reported Medi-Cal Ancillary Charges - Physical Therapy 0 129 129 6 Not Reported Medi-Cal Ancillary Charges - Drugs Charged to Patients 0 9,616 9,616 6 Not Reported Medi-Cal Ancillary Charges - Total 0 12,773 12,773 18 2 Not Reported Medi-Cal Routine Charges $0 $20,050 $20,050 2 Not Reported Medi-Cal Ancillary Charges 0 12,773 12,773 19 3 Not Reported Medi-Cal Deductibles $0 $106 $106 20 1 Not Reported Medi-Cal Interim Payments $0 $8,331 $8,331 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: June 9, 2008 Payment Period: July 1, 2006 through June 9, 2008 Service Period: July 1, 2006 through June 30, 2007 42 CFR 413.20, 413.24, 413.50, 413.53, 413.60, 413.64, and 433.139 CMS Pub. 15-1, Sections 2304, 2404, and 2408 CCR, Title 22, Section 51541 Page 8 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report ADJUSTMENT TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBPROVIDER (REHABILITATION) 21 4-1 D-1 I XIX 9.00 3 Medi-Cal Days - Rehabilitation 194 (194) 0 To eliminate the reported Subprovider I (Rehabilitation) Medi-Cal settlement data since the unit did not meet the criteria to be reported as a separate level of care. 42CFR 413.50 and 413.53(b)(c) / CMS Pub. 15-1, Section 2336.1 Page 9 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - CONTRACT 22 Contract 4 D-1 I XIX 9.00 1 Medi-Cal Days - Adults & Pediatrics 3,913 427 4,340 Contract 4A D-1 II XIX 43.00 4 Medi-Cal Days - Intensive Care Unit 611 98 709 23 Contract 6 D-4 XIX 37.00 2 Medi-Cal Ancillary Charges - Operating Room $736,018 ($310,492) $425,526 Contract 6 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 1,145,081 213,163 1,358,244 Contract 6 D-4 XIX 43.00 2 Medi-Cal Ancillary Charges - Radioisotope 303,623 (45,903) 257,720 Contract 6 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 2,374,752 684,975 3,059,727 Contract 6 D-4 XIX 46.00 2 Medi-Cal Ancillary Charges - Whole Blood and Packed Red Blood Cells 146,399 (499) 145,900 Contract 6 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 3,594,122 (418,312) 3,175,810 Contract 6 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 70,457 144,347 214,804 Contract 6 D-4 XIX 52.00 2 Medi-Cal Ancillary Charges - Speech Pathology 24,160 40,356 64,516 Contract 6 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 692,442 89,993 782,435 Contract 6 D-4 XIX 54.00 2 Medi-Cal Ancillary Charges - Electroencephalography 0 17,798 17,798 Contract 6 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1,030,893 632,202 1,663,095 Contract 6 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4,499,013 470,561 4,969,574 Contract 6 D-4 XIX 57.00 2 Medi-Cal Ancillary Charges - Renal Dialysis 354,888 (2,922) 351,966 Contract 6 D-4 XIX 61.00 2 Medi-Cal Ancillary Charges - Emergency 499,261 (80,872) 418,389 Contract 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 15,471,109 1,434,395 16,905,504 24 Contract 2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges $11,257,102 ($2,657,878) $8,599,224 Contract 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 15,471,109 1,434,395 16,905,504 25 Contract 3 E-3 III XIX 33.00 1 Medi-Cal Deductibles $0 $3,809 $3,809 Contract 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance 0 272,303 272,303 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: June 9, 2008 Payment Period: July 1, 2006 through June 9, 2008 Service Period: July 1, 2006 through June 30, 2007 42 CFR 413.20, 413.24, 413.50, 413.53, 413.60, 413.64, and 433.139 CMS Pub. 15-1, Sections 2304, 2404, and 2408 CCR, Title 22, Section 51541 Page 10 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - ADULT SUBACUTE 26 AS 1 Not Reported Medi-Cal Adult Subacute Days - Ventilator 0 4,212 4,212 AS 1 D-1 I XIX 9.00 1 Medi-Cal Adult Subacute Days - Total 8,937 (85) 8,852 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: June 9, 2008 Payment Period: July 1, 2006 through June 9, 2008 Service Period: July 1, 2006 through June 30, 2007 42 CFR 413.20, 413.24, 413.50, 413.53, 413.60, 413.64, and 433.139 CMS Pub. 15-1, Sections 2304, 2404, and 2408 CCR, Title 22, Section 51541 27 AS 1 Not Reported Total Adult Subacute Days - Ventilator 0 4,325 4,325 AS 1 Not Reported Total Adult Subacute Days - Nonventilator 0 4,764 4,764 To reflect total Adult Subacute ventilator and nonventilator days in the audit report. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 28 AS 1 Not Reported Subacute - Ventilator Equipment Cost $0 $32,438 $32,438 To reflect total ventilator equipment expense in the audit report. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 Page 11 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - ADULT SUBACUTE 29 AS 4 D-4 XIX 41.00 2 Adult Subacute Ancillary Charges - Radiology - Diagnostic $32,687 $19,495 $52,182 AS 4 D-4 XIX 44.00 2 Adult Subacute Ancillary Charges - Laboratory 272,618 22,522 295,140 AS 4 D-4 XIX 49.00 2 Adult Subacute Ancillary Charges - Respiratory Therapy 5,177,220 142,539 5,319,759 AS 4 D-4 XIX 50.00 2 Adult Subacute Ancillary Charges - Physical Therapy 35,044 9,983 45,027 AS 4 D-4 XIX 52.00 2 Adult Subacute Ancillary Charges - Speech Therapy 0 15,960 15,960 AS 4 D-4 XIX 55.00 2 Adult Subacute Ancillary Charges - Medical Supplies Charged To Patients 1,355,230 16,665 1,371,895 AS 4 D-4 XIX 56.00 2 Adult Subacute Ancillary Charges - Drugs Charged To Patients 3,607,747 98,259 3,706,006 AS 5 D-4 XIX 101.00 2 Adult Subacute Ancillary Charges - Total 10,480,546 325,423 10,805,969 To adjust allowable Subacute ancillary charges to agree with the provider's general ledger. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Section 2300 and 2304 Page 12 This is trial version www.adultpdf.com . Routine Service Charges $11, 257 ,102 ($2, 657 ,878) $8 ,59 9,224 Contract 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 15, 471,109 1,434,3 95 16,9 05, 504 25 Contract 3 E-3 III XIX 33.00 1. XIX 56 .00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4,499,013 470 ,56 1 4,969 ,57 4 Contract 6 D-4 XIX 57 .00 2 Medi-Cal Ancillary Charges - Renal Dialysis 354 ,888 (2,922) 351 ,966 Contract. 142 ,53 9 5, 319, 759 AS 4 D-4 XIX 50 .00 2 Adult Subacute Ancillary Charges - Physical Therapy 35, 044 9,983 45, 027 AS 4 D-4 XIX 52 .00 2 Adult Subacute Ancillary Charges - Speech Therapy 0 15, 960 15, 960 AS