State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References Adjustments Cost Report CEDARS-SINAI MEDICAL CENTER JULY 1, 2007 THROUGH JUNE 30, 2008 Explanation of Audit Adjustments HSC 30625F ADJUSTMENTS TO REPORTED PATIENT DAYS 6 4-1 D-1 I XIX 1.00 1 Subprovider I (Inpatient Days) 17,043 (17,043) 0 4-1 D-1 I XIX 4.00 1 Subprovider I (Semi-Private Room Days) 17,043 (17,043) 0 4, Contract 4 D-1 I XIX 1.00 1 Adults and Pediatrics (Inpatient Days) 206,861 17,043 223,904 * 4, Contract 4 D-1 I XIX 4.00 1 Adults and Pediatrics (Semi-Private Room Days) 206,861 17,043 223,904 * To reclassify Subprovider I (Psychiatric) total inpatient days to Adults and Pediatrics in conjunction with adjustment number 2. 42 CFR 413.20 and 413.50 / CMS Pub. 15-1, Section 2336.1 7 4-2 D-1 I XIX 1.00 1 Subprovider II (Inpatient Days) 8,598 (8,598) 0 4-2 D-1 I XIX 4.00 1 Subprovider II (Semi-Private Room Days) 8,598 (8,598) 0 4, Contract 4 D-1 I XIX 1.00 1 Adults and Pediatrics (Inpatient Days) * 223,904 8,598 232,502 4, Contract 4 D-1 I XIX 4.00 1 Adults and Pediatrics (Semi-Private Room Days) * 223,904 8,598 232,502 To reclassify Subprovider II (Rehabilitation) total inpatient days to Adults and Pediatrics in conjunction with adjustment number 2. 42 CFR 413.20 and 413.50 / CMS Pub. 15-1, Section 2336.1 *Balance carried forward from prior/to subsequent adjustments Page 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References Adjustments Cost Report CEDARS-SINAI MEDICAL CENTER JULY 1, 2007 THROUGH JUNE 30, 2008 Explanation of Audit Adjustments HSC 30625F ADJUSTMENTS TO REPORTED TOTAL CHARGES 8 4-1 D-1 I XIX 28.00 1 Subprovider I (General Inpatient Routine Service Charges) $60,363,671 ($60,363,671) $0 4-1 D-1 I XIX 30.00 1 Subprovider I (Semi-Private Room Charges) 60,363,671 (60,363,671) 0 4, Contract 4 D-1 I XIX 28.00 1 Adults and Pediatrics (General Inpatient Routine Service Charges) 749,552,889 60,363,371 809,916,260 * 4, Contract 4 D-1 I XIX 30.00 1 Adults and Pediatrics (Semi-Private Room Charges) 749,552,889 60,363,371 809,916,260 * To reclassify Subprovider I (Psychiatric) general inpatient routine service charges and semi-private room charges to Adults and Pediatrics in conjunction with adjustment number 2. 42 CFR 413.20 and 413.50 / CMS Pub. 15-1, Section 2336.1 9 4-2 D-1 I XIX 28.00 1 Subprovider II (General Inpatient Routine Service Charges) $24,816,770 ($24,816,770) $0 4-2 D-1 I XIX 30.00 1 Subprovider II (Semi-Private Room Charges) 24,816,770 (24,816,770) 0 4, Contract 4 D-1 I XIX 28.00 1 Adults and Pediatrics (General Inpatient Routine Service Charges) * 809,916,260 24,816,770 834,733,030 4, Contract 4 D-1 I XIX 30.00 1 Adults and Pediatrics (Semi-Private Room Charges) * 809,916,260 24,816,770 834,733,030 To reclassify Subprovider II (Rehabilitation) general inpatient routine service charges and semi-private room charges to Adults and Pediatrics in conjunction with adjustment number 2. 42 CFR 413.20 and 413.50 / CMS Pub. 15-1, Section 2336.1 *Balance carried forward from prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References Adjustments Cost Report CEDARS-SINAI MEDICAL CENTER JULY 1, 2007 THROUGH JUNE 30, 2008 Explanation of Audit Adjustments HSC 30625F ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT 10 4A Not Reported Medi-Cal Administrative Days (July 1, 2007 to July 31, 2007) 0 30 30 4A Not Reported Medi-Cal Administrative Day Rate (July 1, 2007 to July 31, 2007) $0.00 $310.68 $310.68 4A Not Reported Medi-Cal Administrative Days (August 1, 2007 to April 30, 2008) 0 96 96 4B Not Reported Medi-Cal Administrative Day Rate (August 1, 2007 to April 30, 2008) $0.00 $318.89 $318.89 4B Not Reported Medi-Cal Administrative Days (June 1, 2008 to June 30, 2008) 0 29 29 Medi-Cal Administrative Day Rate (June 1, 2008 to June 30, 2008) $0.00 $238.64 $238.64 11 6 Not Reported Medi-Cal Ancillary Charges - Radiology - Diagnostic $0 $9,574 $9,574 6 Not Reported Medi-Cal Ancillary Charges - Ultrasound 0 14,563 14,563 6 Not Reported Medi-Cal Ancillary Charges - Laboratory 0 643,608 643,608 6 Not Reported Medi-Cal Ancillary Charges - Physical Therapy 0 21,403 21,403 6 Not Reported Medi-Cal Ancillary Charges - Occupational Therapy 0 7,380 7,380 6 Not Reported Medi-Cal Ancillary Charges - Speech Pathology 0 2,806 2,806 6 Not Reported Medi-Cal Ancillary Charges - Drugs Charged to Patients 0 48,946 48,946 6 Not Reported Medi-Cal Ancillary Charges - Nuclear Medicine - Therapeutic 0 8,965 8,965 6 Not Reported Medi-Cal Ancillary Charges - Magnetic Resonance Imaging 0 296,745 296,745 6 Not Reported Medi-Cal Ancillary Charges - Total 0 1,053,990 1,053,990 12 2 Not Reported Medi-Cal Routine Service Charges $0 $631,176 $631,176 2 Not Reported Medi-Cal Ancillary Service Charges 0 1,053,990 1,053,990 13 3 Not Reported Medi-Cal Coinsurance $0 $24 $24 14 1 Not Reported Medi-Cal Interim Payments $0 $1,071,508 $1,071,508 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: September 29, 2011 Payment Period: July 1, 2007 through August 10, 2011 Service Period: July 1, 2007 through June 30, 2008 42 CFR 413.20, 413.50, 413.53, 413.60 and 413.64 CMS Pub. 15-1, Sections 2304 and 2408 Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References Adjustments Cost Report CEDARS-SINAI MEDICAL CENTER JULY 1, 2007 THROUGH JUNE 30, 2008 Explanation of Audit Adjustments HSC 30625F ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBPROVIDER I 15 4-1 D-1 I XIX 9.00 1 Medi-Cal Days - Subprovider I (Psychiatric) 2,574 (2,574) 0 16 6-1 D-4 XIX 40.00 2 Medi-Cal Ancillary Charges - Anesthesiology $72,066 ($72,066) $0 6-1 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 15,691 (15,691) 0 6-1 D-4 XIX 43.01 2 Medi-Cal Ancillary Charges - Ultrasound 1,906 (1,906) 0 6-1 D-4 XIX 43.02 2 Medi-Cal Ancillary Charges - CAT Scan 35,384 (35,384) 0 6-1 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 876,438 (876,438) 0 6-1 D-4 XIX 44.01 2 Medi-Cal Ancillary Charges - Laboratory - Pathological 2,350 (2,350) 0 6-1 D-4 XIX 44.02 2 Medi-Cal Ancillary Charges - HLA Lab 565 (565) 0 6-1 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 9,154 (9,154) 0 6-1 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 11,436 (11,436) 0 6-1 D-4 XIX 52.00 2 Medi-Cal Ancillary Charges - Speech Pathology 1,424 (1,424) 0 6-1 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 19,007 (19,007) 0 6-1 D-4 XIX 54.00 2 Medi-Cal Ancillary Charges - Electroencephalography 2,922 (2,922) 0 6-1 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 6,225 (6,225) 0 6-1 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 236,453 (236,453) 0 6-1 D-4 XIX 57.00 2 Medi-Cal Ancillary Charges - Renal Dialysis 2,235 (2,235) 0 6-1 D-4 XIX 59.00 2 Medi-Cal Ancillary Charges - Gastro Intestinal Services 3,138 (3,138) 0 6-1 D-4 XIX 59.03 2 Medi-Cal Ancillary Charges - Vascular Lab 4,321 (4,321) 0 6-1 D-4 XIX 59.04 2 Medi-Cal Ancillary Charges - Psychiatric/Psychological Services 37,369 (37,369) 0 6-1 D-4 XIX 59.06 2 Medi-Cal Ancillary Charges - Magnetic Resonance Imaging 16,958 (16,958) 0 6-1 D-4 XIX 61.00 2 Medi-Cal Ancillary Charges - Emergency 27,483 (27,483) 0 6-1 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 1,382,525 (1,382,525) 0 17 2-1 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges $9,032,552 ($9,032,552) $0 2-1 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 1,382,525 (1,382,525) 0 -Continued on next page- Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References Adjustments Cost Report CEDARS-SINAI MEDICAL CENTER JULY 1, 2007 THROUGH JUNE 30, 2008 Explanation of Audit Adjustments HSC 30625F ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBPROVIDER I -Continued from previous page- 18 1-1 E-3 III XIX 57.00 1 Medi-Cal Interim Payments $3,471,218 ($3,471,218) $0 To eliminate Medi-Cal Settlement Data associated with Subprovider I since the Psychiatric unit did not meet the requirements of a separate cost entity. 42 CFR 413.20, 413.24 and 413.53 (b) (c) CMS Pub. 15-1, Sections 2336.1, 2336.2, 2336.3 and 2306 Page 8 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References Adjustments Cost Report CEDARS-SINAI MEDICAL CENTER JULY 1, 2007 THROUGH JUNE 30, 2008 Explanation of Audit Adjustments HSC 30625F ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBPROVIDER II 19 4-2 D-1 I XIX 9.00 1 Medi-Cal Days - Subprovider II (Rehabilitation) 146 (146) 0 20 6-2 D-4 XIX 37.00 2 Medi-Cal Ancillary Charges - Operating Room $10,034 ($10,034) $0 6-2 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 4,998 (4,998) 0 6-2 D-4 XIX 43.02 2 Medi-Cal Ancillary Charges - CAT Scan 11,602 (11,602) 0 6-2 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 113,574 (113,574) 0 6-2 D-4 XIX 47.00 2 Medi-Cal Ancillary Charges - Blood Storing, Processing and Transfusion 1,573 (1,573) 0 6-2 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 17,756 (17,756) 0 6-2 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 95,372 (95,372) 0 6-2 D-4 XIX 51.00 2 Medi-Cal Ancillary Charges - Occupational Therapy 104,181 (104,181) 0 6-2 D-4 XIX 52.00 2 Medi-Cal Ancillary Charges - Speech Pathology 30,309 (30,309) 0 6-2 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 1,820 (1,820) 0 6-2 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 20,031 (20,031) 0 6-2 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 56,206 (56,206) 0 6-2 D-4 XIX 59.03 2 Medi-Cal Ancillary Charges - Vascular Lab 12,999 (12,999) 0 6-2 D-4 XIX 59.05 2 Medi-Cal Ancillary Charges - Nuclear Medicine - Therapeutic 4,677 (4,677) 0 6-2 D-4 XIX 59.06 2 Medi-Cal Ancillary Charges - Magnetic Resonance Imaging 19,959 (19,959) 0 6-2 D-4 XIX 59.08 2 Medi-Cal Ancillary Charges - Recreational Therapy 7,035 (7,035) 0 6-2 D-4 XIX 60.02 2 Medi-Cal Ancillary Charges - Medical Oncology 37,703 (37,703) 0 6-2 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 549,829 (549,829) 0 21 2-2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges $419,330 ($419,330) $0 2-2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 549,829 (549,829) 0 22 1-2 E-3 III XIX 57.00 1 Medi-Cal Interim Payments $292,277 ($292,277) $0 To eliminate Medi-Cal Settlement Data associated with Subprovider II since the Rehabilitation unit did not meet the requirements of a separate cost entity. 42 CFR 413.20, 413.24 and 413.53 (b) (c) CMS Pub. 15-1, Sections 2336.1, 2336.2, 2336.3 and 2306 Page 9 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References Adjustments Cost Report CEDARS-SINAI MEDICAL CENTER JULY 1, 2007 THROUGH JUNE 30, 2008 Explanation of Audit Adjustments HSC 30625F ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - CONTRACT 23 Contract 4 D-1 I XIX 9.00 1 Medi-Cal Days - Adults and Pediatrics 23,010 (2,860) 20,150 Contract 4A D-1 II XIX 42.00 4 Medi-Cal Days - Nursery 1,865 (364) 1,501 Contract 4A D-1 II XIX 43.00 4 Medi-Cal Days - Intensive Care Unit 1,394 125 1,519 Contract 4A D-1 II XIX 44.00 4 Medi-Cal Days - Coronary Care Unit 41 4 45 Contract 4A D-1 II XIX 46.00 4 Medi-Cal Days - Surgical Intensive Care Unit 696 62 758 Contract 4A D-1 II XIX 46.02 4 Medi-Cal Days - Surgical ICU - 8 1,066 95 1,161 Contract 4B D-1 II XIX 46.03 4 Medi-Cal Days - Pediatric Intensive Care Unit 923 (279) 644 Contract 4B D-1 II XIX 47.00 4 Medi-Cal Days - Neonatal Intensive Care Unit 3,373 66 3,439 24 Contract 6 D-4 XIX 37.00 2 Medi-Cal Ancillary Charges - Operating Room $29,374,396 $3,498,040 $32,872,436 Contract 6 D-4 XIX 39.00 2 Medi-Cal Ancillary Charges - Delivery and Labor Room 6,957,705 (2,867,546) 4,090,159 Contract 6 D-4 XIX 40.00 2 Medi-Cal Ancillary Charges - Anesthesiology 18,055,309 (5,982,132) 12,073,177 Contract 6 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 11,190,100 (2,132,882) 9,057,218 Contract 6 D-4 XIX 43.01 2 Medi-Cal Ancillary Charges - Ultrasound 1,537,588 3,683,751 5,221,339 Contract 6 D-4 XIX 43.02 2 Medi-Cal Ancillary Charges - CAT Scan 13,869,978 (851,805) 13,018,173 Contract 6 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 75,847,381 4,242,496 80,089,877 Contract 6 D-4 XIX 44.01 2 Medi-Cal Ancillary Charges - Laboratory - Pathological 2,117,121 263,927 2,381,048 Contract 6 D-4 XIX 44.02 2 Medi-Cal Ancillary Charges - HLA Lab 268,678 (268,678) 0 Contract 6 D-4 XIX 47.00 2 Medi-Cal Ancillary Charges - Blood Storing, Processing and Transfusion 4,925,935 538,624 5,464,559 Contract 6 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 46,191,718 (19,800,047) 26,391,671 Contract 6 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 1,824,592 32,912 1,857,504 Contract 6 D-4 XIX 51.00 2 Medi-Cal Ancillary Charges - Occupational Therapy 852,668 17,830 870,498 Contract 6 D-4 XIX 52.00 2 Medi-Cal Ancillary Charges - Speech Pathology 445,203 45,515 490,718 Contract 6 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 7,981,657 1,938,744 9,920,401 Contract 6 D-4 XIX 54.00 2 Medi-Cal Ancillary Charges - Electroencephalography 1,846,065 (491,473) 1,354,592 Contract 6 D-4 XIX 54.01 2 Medi-Cal Ancillary Charges - Electromyography 58,540 154,872 213,412 Contract 6 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 29,370,561 9,191,036 38,561,597 Contract 6 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 56,002,540 (470,262) 55,532,278 Contract 6 D-4 XIX 57.00 2 Medi-Cal Ancillary Charges - Renal Dialysis 3,991,880 (184,980) 3,806,900 Contract 6 D-4 XIX 59.00 2 Medi-Cal Ancillary Charges - Gastro Intestinal Services 1,415,038 (174,521) 1,240,517 Contract 6 D-4 XIX 59.02 2 Medi-Cal Ancillary Charges - Cardiac Catheterization Lab 4,384,761 1,351,479 5,736,240 Contract 6 D-4 XIX 59.03 2 Medi-Cal Ancillary Charges - Vascular Lab 3,689,266 (3,689,266) 0 -Continued on next page- Page 10 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References Adjustments Cost Report CEDARS-SINAI MEDICAL CENTER JULY 1, 2007 THROUGH JUNE 30, 2008 Explanation of Audit Adjustments HSC 30625F ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - CONTRACT -Continued from previous page- 24 Contract 6 D-4 XIX 59.05 2 Medi-Cal Ancillary Charges - Nuclear Medicine - Therapeutic $3,143,030 ($1,020,275) $2,122,755 Contract 6 D-4 XIX 59.06 2 Medi-Cal Ancillary Charges - Magnetic Resonance Imaging 5,780,291 (1,020,106) 4,760,185 Contract 6 D-4 XIX 59.07 2 Medi-Cal Ancillary Charges - Pulmonary Function Testing 96,564 239,667 336,231 Contract 6 D-4 XIX 60.00 2 Medi-Cal Ancillary Charges - Clinic 482 (482) 0 Contract 6 D-4 XIX 60.02 2 Medi-Cal Ancillary Charges - Medical Oncology 556,456 (556,456) 0 Contract 6 D-4 XIX 60.05 2 Medi-Cal Ancillary Charges - Clinic 3 - Neuro Surgical Institute 322 (322) 0 Contract 6 D-4 XIX 61.00 2 Medi-Cal Ancillary Charges - Emergency 14,476,332 (2,932,910) 11,543,422 Contract 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 346,252,157 (17,245,250) 329,006,907 25 Contract 2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges $203,045,096 ($9,220,284) $193,824,812 Contract 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 346,252,157 (17,245,250) 329,006,907 26 Contract 3 E-3 III XIX 33.00 1 Medi-Cal Deductibles $0 $1,640,687 $1,640,687 Contract 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance 0 71,410 71,410 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: August 12, 2011 Payment Period: July 1, 2007 through August 10, 2011 Service Period: July 1, 2007 through June 30, 2008 42 CFR 413.20, 413.50, 413.53, 413.60 and 413.64 CMS Pub. 15-1, Sections 2304 and 2408 Page 11 This is trial version www.adultpdf.com . State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work. prior/to subsequent adjustments Page 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work. prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 Adj. Audit Work