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{"sheet":"Survey Set-Up","index":0,"n_rows":176,"n_cols":21,"rows_kept":176,"cut":false,"hidden":true,"merged":[[5,3,6,8],[175,0,175,13],[9,7,9,8]]}
["State:","Louisiana",null,"Year:",{"$f":"YEAR(DSH_Year_End)","v":2019},{"$f":"Year-1","v":2018},"Including Section L (provider tax form) in Part II?",null,null,null,"Yes",null,"Hospital Type","All Others",null,null,null,null,null,null,"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, K and L of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital. All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim. I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions. Detailed support exists for all amounts reported in the survey. These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested. "]
[null,null,null,null,"↑NOTE: DO NOT overwrite formula in cell above. Update DSH Year by entering begin/end dates on Sec. A.",null,null,null,null,null,null,null,"High Medicaid Pool Threshold",null,null,null,null,null,null,null,"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, and K of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital. All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim. I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions. Detailed support exists for all amounts reported in the survey. These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested. "]
[null,"Submission Information  (Flows to Checklist Sheet)",null,"Are you using the Myers and Stauffer DSH Web Portal?",null,null,null,null,"Yes",null,null,null,null,null,null,null,null,null,null,null,"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P, and the DSH Qualification section of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital. All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim. I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions. Detailed support exists for all amounts reported in the survey. These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested. "]
[null,"Myers and Stauffer LC",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P, and the DSH Qualification section of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital. All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim. I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions. Detailed support exists for all amounts reported in the survey. These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested. "]
[null,"ATTN:  DSH Examinations"]
[null,"700 W. 47th Street, Suite 1100",null,"After entering state, click on \"Run page setup\" below to set-up the headers and footers with the state name and year (in all sheets).  This is a slow process so be patient!",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The information provided above is true and accurate to the best of our ability, and supported by the financial and other records of the hospital.  I understand that a hospital that does not receive an interim DSH payment for a SFY will not be included in the independent DSH examination related to that SFY and will not be eligible for final DSH examination payment adjustments related to that SFY unless it submits a request to the MO HealthNet Division to be included in the independent DSH examination."]
[null,"Kansas City, Missouri 64112",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The information provided above is true and accurate to the best of our ability, and supported by the financial and other records of the hospital.  I understand that a hospital that does not receive an interim DSH payment for a SFY will not be included in the independent DSH examination related to that SFY and will not be eligible for final DSH examination payment adjustments related to that SFY."]
[null,"Fax:  (816) 945-5301"]
[null,"Phone:  (800) 374-6858",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"If you selected \"Yes\" above, you must fill out the days below.  CMS requires that the State of Missouri submit the MIUR for each hospital in the state that receives a Medicaid payment.  This information is necessary for the accurate reporting of the MIUR and may affect future federal funding."]
[null,"E-Mail: LADSH@mslc.com",null,null,null,null,null,"Output Directory:",null,"G:\\Data\\State Data\\Louisiana\\DSH Payment Calculation\\SFY 2019 UCC Analysis\\06 Uploads\\Survey Part I\\",null,null,null,null,null,null,null,null,null,null,"If you selected \"Yes\" above, you must fill out the days below.  CMS requires that the Department submit the MIUR for each hospital in the state that receives a Medicaid payment.  This information is necessary for the accurate reporting of the MIUR and may affect future federal funding."]
[]
[null,1,2,3,4,5,6,7,8,9,10,11,12,13,null,null,null,null,null,null,"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P, and the DSH Qualification section of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital. All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim. I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions. Detailed support exists for all amounts reported in the survey. These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested. I certify that the hospital elects not to receive an interim DSH payment for the SFY under review. I understand that a hospital that does not receive an interim DSH payment for a SFY will not be included in the independent DSH examination related to that SFY and will not be eligible for final DSH examination payment adjustments related to that SFY."]
[null,"Hospital Name","Medicaid Provider ID","Medicaid SubProvider1 ID","Medicaid SubProvider2 ID","Medicare Provider ID","Report Period From","Reporting Period To","Report Period From","Reporting Period To","Report Period From","Reporting Period To","Provider Pool Type","Ownership Type",null,null,null,null,null,null,"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P, and the DSH Qualification section of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital. All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim. I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions. Detailed support exists for all amounts reported in the survey. These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested. I certify that the hospital elects not to receive an DSH payment for the SFY under review. I understand that a hospital that does not receive an interim DSH payment for a SFY will not be included in the independent DSH examination related to that SFY and will not be eligible for final DSH examination payment adjustments related to that SFY."]
[null,"SELECT HOSPITAL NAME","M'Caid #","M'caid Sub 1 #","M'caid Sub 2 #","M'care #"]
[1,"Baton Rouge General",1720020,1705012,null,"190065","2017-10-01","2018-09-30",null,null,null,null,"LINCCA","Private"]
[{"$f":"A15+1","v":2},"Highland Medical Center",1744379,null,null,"190041","2017-07-01","2018-06-30",null,null,null,null,"LINCCA","Private"]
[3,"Ochsner Medical Center - North Shore",1744611,null,null,"190204","2017-04-01","2018-03-31",null,null,null,null,"LINCCA","Private"]
[4,"Regional Medical Center of Acadiana",1764981,null,null,"190205","2017-09-01","2018-08-31",null,null,null,null,"LINCCA","Private"]
[5,"Ochsner Medical Center - Kenner",1704385,null,null,"190274","2017-05-01","2018-04-30",null,null,null,null,"LINCCA","Private"]
[6,"Ochsner Medical Center - Baton Rouge",1700797,null,null,"190202","2017-10-01","2018-09-30",null,null,null,null,"LINCCA","Private"]
[7,"Rapides Regional Medical Center",1730106,null,null,"190026","2017-01-01","2017-12-31",null,null,null,null,"LINCCA","Private"]
[8,"Lakeview Regional Medical Center",1766836,null,null,"190177","2017-01-01","2017-12-31",null,null,null,null,"LINCCA"]
[9,"Ochsner Foundation Hospital",1730351,1705349,null,"190036","2017-01-01","2017-12-31",null,null,null,null,"LINCCA","Private"]
[10,"Tulane University Hospital",1763799,null,null,"190176","2017-01-01","2017-12-31",null,null,null,null,"LINCCA","Private"]
[11,"Willis Knighton - Bossier",1765058,null,null,"190236","2017-10-01","2018-09-30",null,null,null,null,"Major Medical (Central & Northern)","Private"]
[12,"Glenwood Regional Medical Center",1731382,1705845,null,"190160","2017-03-01","2018-02-28",null,null,null,null,"Major Medical (Central & Northern)","Private"]
[13,"St. Frances Cabrini Hospital",1720208,null,null,"190019","2017-07-01","2018-06-30",null,null,null,null,"LINCCA","Private"]
[14,"Willis-Knighton Health Systems",1747572,1705519,null,"190111","2017-10-01","2018-09-30",null,null,null,null,"Major Medical (Central & Northern)","Private"]
[15,"St. Francis Medical Center",1739570,null,null,"190125","2017-07-01","2018-06-30",null,null,null,null,"Major Medical (Central & Northern)","Private"]
[16,"North Oaks Medical Center",1720267,null,null,"190015","2017-07-01","2018-06-30",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[17,"Iberia Medical Center",1720330,2432192,null,"190054","2017-10-01","2018-09-30",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[18,"Lane Regional Medical Center",1720101,null,null,"190020","2017-07-01","2018-06-30",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[19,"Opelousas General Hospital",1720151,1704539,null,"190017","2017-07-01","2018-06-30",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[20,"Savoy Medical Center",1766062,1705772,null,"190025","2017-01-01","2017-12-31",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[21,"Slidell Memorial Hospital",1720313,null,null,"190040","2017-01-01","2017-12-31",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[22,"West Calcasieu Cameron Hospital",1730483,null,null,"190013","2017-01-01","2017-12-31",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[23,"North Oaks Rehabilitation Hospital",1702871,null,null,"193044","2017-07-01","2018-06-30",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[24,"St. Tammany Parish Hospital",1720259,null,null,"190045","2017-01-01","2017-12-31",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[25,"Terrebonne General Medical Center",1720275,null,null,"190008","2017-04-01","2018-03-31",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[26,"Thibodaux Regional Medical Center",1736848,null,null,"190004","2017-10-01","2018-09-30",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[27,"Christus Lake Area Medical Center",1767671,null,null,"190201","2017-07-01","2018-06-30",null,null,null,null,"LINCCA","Private"]
[28,"East Jefferson General Hospital",1735183,null,null,"190146","2017-01-01","2017-12-31",null,null,null,null,"Non-State Large Public (CPE)","Non-State Gov't"]
[29,"Our Lady of Lourdes Regional Medical Center",1720445,null,null,"190102","2017-07-01","2018-06-30",null,null,null,null,"Major Medical (Southwestern)","Private"]
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[{"$f":"A47+1","v":34}]
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["If more providers are needed, insert rows above this line. DO NOT delete this line and continue the list."]

{"sheet":"Instructions","index":1,"n_rows":23,"n_cols":3,"rows_kept":23,"cut":false,"hidden":true,"merged":[[23,0,23,2],[22,0,22,2]]}
["A. General Instructions and Identification of Cost Reports that Cover the DSH Year:"]
[]
["1.",null,"Select the \"Sec. A-C DSH Year Data\" tab in Excel workbook.  In row 1, select your facility from the drop-down menu provided (if not already populated).  When your facility is selected, the following fields will be populated: in-state Medicaid provider number and Medicare provider number.  Review information and indicate whether it is correct or incorrect.  If incorrect, provide correct information."]
[]
["2.",null,"Provide your cost reporting periods that are needed to completely cover the DSH year.  If the end date for cost report period 1 is before the end date of the DSH year, report your next cost reporting period (cost report 2).  If this cost report ends prior to the end of the DSH year, report your next cost reporting period (cost report 3).  The cost reporting periods must cover the entire DSH year. "]
[null,null,{"$f":"\"NOTE: For the \"&Year&\" DSH Survey, if your hospital completed the DSH survey for \"&PriorYear&\", the first cost report year should follow the last cost report year reported on the \"&PriorYear&\" DSH survey. The last cost report year on the \"&Year&\" survey must end on or after the end of the \"&Year&\" DSH year. If your hospital did not complete the \"&PriorYear&\" survey, your cost reports for \"&Year&\" must cover the entire \"&Year&\" DSH year.\"","v":"NOTE: For the 2019 DSH Survey, if your hospital completed the DSH survey for 2018, the first cost report year should follow the last cost report year reported on the 2018 DSH survey. The last cost report year on the 2019 survey must end on or after the end of the 2019 DSH year. If your hospital did not complete the 2018 survey, your cost reports for 2019 must cover the entire 2019 DSH year."}]
[]
["3.",null,"Supporting documentation for all data elements provided within the DSH survey must be maintained for a minimum of five years from the date of survey submission."]
["B. DSH OB Qualifying Information:"]
[]
["1.",null,"Answer \"B. DSH OB Qualifying Information\" questions 1, 2 and 3 to determine if your hospital is eligible to receive DSH payments."]
[]
["C. Disclosure of Other Medicaid Payments Received:"]
[]
["1.",null,"Medicaid supplemental payments should include UPL and Non-Claim Specific payments paid based on the state fiscal year. However, DSH payments should NOT be included."]
[]
["Certification:"]
[]
["1.",null,"The hospital CEO or CFO must certify the accuracy of the survey responses.  Provide hospital and outside preparer contacts who can respond to requests for additional information and answer questions related to the hospital's responses. "]
[]
[]
[]
[{"$f":"IF(TaxForm=\"No\", \"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-K included in the separate DSH survey Part II file.\", \"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-L included in the separate DSH Survey Part II file.\")","v":"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-L included in the separate DSH Survey Part II file."}]

{"sheet":"Instructions ","index":2,"n_rows":28,"n_cols":7,"rows_kept":28,"cut":false,"hidden":false,"merged":[[27,0,27,2],[28,0,28,2]]}
[{"$f":"IF(State=\"Missouri\",Missouri_Title,IF(State=\"Louisiana\",Louisiana_Title,\"\"))","v":"DSH Qualification"},null,null,null,null,"DSH Waiver & MIUR Data","A DSH Waiver & MIUR Data form is included in DSH Survey Part I. A hospital that did not receive an interim DSH payment for the year under examination and elects not to receive a Missouri Medicaid interim DSH payment for the upcoming interim DSH payment year must complete the DSH Waiver & MIUR Data form and indicate it elects not to receive an interim DSH payment.  The hospital must also complete the “Days” section on the DSH Waiver & MIUR Data form so the hospital’s MIUR may be calculated. However, the remainder of DSH Year Survey Part I and all of DSH Year Survey Part II do not need to be completed.  CMS requires the state of Missouri to submit the MIUR for each hospital in the state that receives a Medicaid payment.  It is important that the “Days” section is completed so the MIUR can be accurately reported to CMS as the MIUR data may affect future federal funding.    "]
[null,null,null,null,null,"DSH Qualification","In order for a hospital to be eligible to receive a DSH payment, the hospital must 1) have filed a year end cost report in accordance with Medicare filing guidelines, including extensions; 2) meet the qualification criteria as identified in the \"DSH Qualification\" tab; 3) have a minimum of 1% Medicaid days utilization percentage; and 4) meet obstetrical services criteria as identified in Section B of the \"Sec. A-C DSH Year Data\" tab."]
[{"$f":"IF(OR(State=\"Missouri\",State=\"Louisiana\"),1,\"\")","v":1},null,{"$f":"IF(State=\"Missouri\",Missouri_Instructions,IF(State=\"Louisiana\",Louisiana_Instructions,\"\"))","v":"In order for a hospital to be eligible to receive a DSH payment, the hospital must 1) have filed a year end cost report in accordance with Medicare filing guidelines, including extensions; 2) meet the qualification criteria as identified in the \"DSH Qualification\" tab; 3) have a minimum of 1% Medicaid days utilization percentage; and 4) meet obstetrical services criteria as identified in Section B of the \"Sec. A-C DSH Year Data\" tab."}]
[]
["A. General Instructions and Identification of Cost Reports that Cover the DSH Year:"]
[]
["1.",null,"Select the \"Sec. A-C DSH Year Data\" tab in Excel workbook.  In row 1, select your facility from the drop-down menu provided (if not already populated).  When your facility is selected, the following fields will be populated: in-state Medicaid provider number and Medicare provider number.  Review information and indicate whether it is correct or incorrect.  If incorrect, provide correct information."]
[]
["2.",null,"Provide your cost reporting periods that are needed to completely cover the DSH year.  If the end date for cost report period 1 is before the end date of the DSH year, report your next cost reporting period (cost report 2).  If this cost report ends prior to the end of the DSH year, report your next cost reporting period (cost report 3).  The cost reporting periods must cover the entire DSH year. "]
[null,null,{"$f":"\"NOTE: For the \"&Year&\" DSH Survey, if your hospital completed the DSH survey for \"&PriorYear&\", the first cost report year should follow the last cost report year reported on the \"&PriorYear&\" DSH survey. The last cost report year on the \"&Year&\" survey must end on or after the end of the \"&Year&\" DSH year. If your hospital did not complete the \"&PriorYear&\" survey, your cost reports for \"&Year&\" must cover the entire \"&Year&\" DSH year.\"","v":"NOTE: For the 2019 DSH Survey, if your hospital completed the DSH survey for 2018, the first cost report year should follow the last cost report year reported on the 2018 DSH survey. The last cost report year on the 2019 survey must end on or after the end of the 2019 DSH year. If your hospital did not complete the 2018 survey, your cost reports for 2019 must cover the entire 2019 DSH year."}]
[]
["3.",null,"Supporting documentation for all data elements provided within the DSH survey must be maintained for a minimum of five years from the date of survey submission."]
["B. DSH OB Qualifying Information:"]
[]
["1.",null,"The “Sec. A-C DSH Year Data” tab of DSH Year Survey Part I, Section B. DSH OB Qualifying Information, has two sets of OB questions. The first set of OB questions relates to the interim DSH payments which are the subject of the federal DSH examination. The second set of OB questions relates to the interim DSH payments for the upcoming SFY interim DSH payment calculation. You must complete the first set of OB questions if you are required to participate in the DSH examination. You must complete the second set of OB questions if you are electing to participate in the upcoming SFY interim DSH payment calculation."]
[]
["C. Disclosure of Other Medicaid Payments Received:"]
[]
["1.",null,{"$f":"'Sec. A-C DSH Year Data'!B69","v":"(Should include UPL and Non-Claim Specific payments paid based on the state fiscal year.  However, DSH payments should NOT be included.)"}]
[]
[]
["Certification:"]
[]
["1.",null,"The hospital CEO or CFO must certify the accuracy of the survey responses.  Provide hospital and outside preparer contacts who can respond to requests for additional information and answer questions related to the hospital's responses. "]
["Act 540 Questionnaire"]
["1.",null,"Hospitals in Act 540 must complete the attached Act 540 questionnaire and sign the additional certication statement."]
[]
[{"$f":"IF(TaxForm=\"No\", \"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-K included in the separate DSH survey Part II file.\", \"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-L included in the separate DSH Survey Part II file.\")","v":"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-L included in the separate DSH Survey Part II file."}]

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[]
["DSH Waiver & MIUR Data Form"]
[]
["General Information & DSH Waiver"]
[]
[1,"Hospital Name",null,null,{"$f":"HOSPITALNAME_ADJ","v":"SELECT HOSPITAL NAME"}]
[]
[2,{"$f":"IF(State=\"Missouri\",\"Missouri Medicaid Provider Number:\",\"Medicaid Provider Number:\")","v":"Medicaid Provider Number:"},null,null,{"$f":"McaidNum_ADJ","v":"M'Caid #"}]
[]
[]
[3,"Medicare Provider Number:",null,null,{"$f":"McareNum_ADJ","v":"M'care #"}]
[]
[4,"DSH Payment Year:",null,"From:","2018-07-01","To:","2019-06-30"]
[]
[null,{"$f":"CONCATENATE(\"Based on the hospital's projections, the above named hospital does not anticipate having uncompensated cost of care for Medicaid and the uninsured eligible for an interim DSH payment for SFY \",YEAR($G$13),\".  Therefore, this hospital elects not to receive an interim DSH payment for SFY \",YEAR($G$13),\".\")","v":"Based on the hospital's projections, the above named hospital does not anticipate having uncompensated cost of care for Medicaid and the uninsured eligible for an interim DSH payment for SFY 2019.  Therefore, this hospital elects not to receive an interim DSH payment for SFY 2019."}]
[]
[5,{"$f":"CONCATENATE(\"Waive interim DSH payment for SFY \",YEAR(DSH_Payment_Year_End),\"?\")","v":"Waive interim DSH payment for SFY 2019?"}]
[]
[null,{"$f":"IF(AND(State=\"Louisiana\",Louisiana_Pool=\"Small Rural\"),CONCATENATE(\"Even if your hospital chooses to waive receipt of a SFY \",YEAR(DSH_Payment_Year_End),\" DSH payment, you are still required to submit the required UCC surveys and supporting documentation.\"),IF(AND(State=\"Louisiana\",Louisiana_Pool=\"Act 540\"),CONCATENATE(\"Even if your hospital chooses to waive receipt of a SFY \",YEAR(DSH_Payment_Year_End),\" DSH payment, you are still required to complete and submit the required UCC surveys and supporting documentation for Act 540 reporting purposes.\"),\"\"))","v":""}]
["Required Federal Reporting of MIUR Data - Hospital Patient Days"]
["Note:","If you selected \"No\" above, you do not need to fill out the days or certification block below.",null,null,null,null,null,null,null,{"$f":"CONCATENATE(\"Cost Report Year (\", TEXT(MAX(FYB_1_ADJ,FYB_2_ADJ,FYB_3_ADJ),\"mm/dd/yy\"), \" - \", TEXT(MAX(FYE_1_ADJ,FYE_2_ADJ,FYE_3_ADJ),\"mm/dd/yy\"),\")\")","v":"Cost Report Year (01/00/00 - 01/00/00)"}]
[null,{"$f":"IF(State=\"Missouri\",MO_MIUR,MIUR)","v":"If you selected \"Yes\" above, you must fill out the days below.  CMS requires that the Department submit the MIUR for each hospital in the state that receives a Medicaid payment.  This information is necessary for the accurate reporting of the MIUR and may affect future federal funding."}]
[]
[6,{"$f":"IF(State=\"Missouri\",\"Missouri Total Paid Medicaid FFS Days \",\"Total Paid Medicaid FFS Days \")","v":"Total Paid Medicaid FFS Days "}]
[7,{"$f":"IF(State=\"Missouri\",\"Missouri Total Paid Medicaid Managed Care Days \",\"Total Paid Medicaid Managed Care Days \")","v":"Total Paid Medicaid Managed Care Days "}]
[8,{"$f":"IF(State=\"Missouri\",\"Missouri Total Paid Medicaid FFS Crossover Days \",\"Total Paid Medicaid FFS Crossover Days \")","v":"Total Paid Medicaid FFS Crossover Days "}]
[9,{"$f":"IF(State=\"Missouri\",\"Missouri Other Medicaid Eligible Days (No Medicaid Payment)\",\"Other Medicaid Eligible Days (No Medicaid Payment)\")","v":"Other Medicaid Eligible Days (No Medicaid Payment)"}]
[10,"Out-of-State Paid Medicaid Days  (Include FFS, Medicaid Managed Care, FFS Crossover, and Other Eligible)"]
[11,"Total Hospital Days Per Cost Report Excluding Swing-Bed (C/R, W/S S-3, Pt. I, Col. 8, Sum of Lns. 14, 16, 17, 18.xx less lines 5 & 6)"]
[12,"Total Medicaid Hospital Days Per Cost Report Excluding Swing Bed (W/S S-3, Pt. I, Col. 7, Sum of Lns. 2-4, 14, 16, 17, 18.xx less lines 5 & 6)"]
[13,{"$f":"IF(State=\"Missouri\",\"Unreconciled Medicaid Hospital Days (Primary Medicaid Days including Out-of-State less Cost Report Total) (please include explanation on Variance tab)\",\"Unreconciled Medicaid Hospital Days (Primary Medicaid Days including Out-of-State less Cost Report Total) (please include explanation with submission)\")","v":"Unreconciled Medicaid Hospital Days (Primary Medicaid Days including Out-of-State less Cost Report Total) (please include explanation with submission)"},null,null,null,null,null,null,null,{"$f":"J24+J25+J28-J30","v":0}]
[]
[]
[{"$f":"IF(State=\"Missouri\",\"Missouri Medicaid Inpatient Utilization Rate (MIUR) Calculation\",\"Medicaid Inpatient Utilization Rate (MIUR) Calculation\")","v":"Medicaid Inpatient Utilization Rate (MIUR) Calculation"}]
[]
[14,"Total Medicaid Eligible Days",null,null,"Sum of Line 6 thru Line 10",null,null,null,null,{"$f":"J24+J25+J26+J27+J28","v":0}]
[15,"Total Hospital Days (excludes swing-bed)",null,null,"Line 11",null,null,null,null,{"$f":"J29","v":0}]
[16,"MIUR",null,null,"Line 14 divided by Line 15",null,null,null,null,{"$f":"IF(J37>0,ROUND(J36/J37,4),0)","v":0}]
[]
[{"$f":"IF(State=\"Missouri\",\"Missouri DSH OB Qualifying Information\",\"DSH OB Qualifying Information\")","v":"DSH OB Qualifying Information"}]
[]
["Note:","If you selected \"No\" above, you do not need to fill out the OB responses or certification block below. Please complete the OB responses on \"Sec. A-C DSH Year Data\"."]
[null,"Questions 17-19, below, should be answered in the accordance with Sec. 1923(d) of the Social Security Act."]
[null,"During the Interim DSH Payment Year:",null,null,null,null,null,null,null,{"$f":"CONCATENATE(\"*Interim DSH Payment Year (\", TEXT(DSH_Payment_Year_Begin,\"mm/dd/yy\"), \" - \", TEXT(DSH_Payment_Year_End,\"mm/dd/yy\"),\")\")","v":"*Interim DSH Payment Year (07/01/18 - 06/30/19)"}]
[17,"Does the hospital have at least two obstetricians who have staff privileges at the hospital who have agreed to"]
[null,"provide obstetric services to Medicaid-eligible individuals during the DSH year?  (In the case of a hospital"]
[null,"located in a rural area, the term \"obstetrician\" includes any physician with staff privileges at the "]
[null,"hospital to perform nonemergency obstetric procedures.)  "]
[]
[null,"List the Names of the two Obstetricians (or case of rural hospital, Physicians) who have agreed to perform OB services:"]
[]
[]
[]
[18,"Is the hospital exempt from the requirement listed under #1 above because the hospital's "]
["","inpatients are predominantly under 18 years of age? "]
[]
[19,"Is the hospital exempt from the requirement listed under #1 above because it did not offer non-"]
[null,"emergency obstetric services to the general population when federal Medicaid DSH regulations"]
[null,"were enacted on December 22, 1987?  "]
[]
["19a.","Was the hospital open as of December 22, 1987?"]
[]
["19b.","What date did the hospital open?"]
[]
[]
["Certification"]
[]
[null,{"$f":"IF(State=\"Missouri\",MO_OptOut,OptOut)","v":"The information provided above is true and accurate to the best of our ability, and supported by the financial and other records of the hospital.  I understand that a hospital that does not receive an interim DSH payment for a SFY will not be included in the independent DSH examination related to that SFY and will not be eligible for final DSH examination payment adjustments related to that SFY."}]
[]
[]
[]
[]
[]
[]
[]
[null,"Signature of CEO or Other Authorized Person",null,null,null,null,"Date"]
[]
[]
[]
[null,"Print Name"]
[]
[]
[]
[null,"Title"]

{"sheet":"Variance","index":4,"n_rows":4,"n_cols":1,"rows_kept":4,"cut":false,"hidden":true,"merged":[[3,1,16,12]]}
[]
["Please explain variances below."]
[]
[13]

{"sheet":"DSH Qualification","index":5,"n_rows":213,"n_cols":12,"rows_kept":213,"cut":false,"hidden":false,"merged":[[14,0,18,9]]}
[]
["Louisiana DSH Pool-Specific Qualification Questionnaire"]
[]
["Small Rural Hospital Pool:"]
[]
["In order to determine eligibility for inclusion as a rural hospital under Act 1485 of the 1997 Louisiana Legislature, Act 1068 and Senate Concurrent "]
["Resolution 48 of the 1999 Louisiana Legislature, Act 1074 of the 2001 Legislature, Act 35 of the 2002 First Extraordinary Session of the Louisiana "]
["Legislature, Acts 526 and 1148 of the 2003 Legislature, Act 323 of the 2005 Legislature, Act 389 of the 2008 Legislature, Act 147 of the 2010 "]
["Legislature and our approved state plan, the Louisiana Department of Health and Hospitals requests that you provide the following data:"]
[]
[{"$f":"CONCATENATE(\"PLEASE NOTE: In order to qualify for FFY \",Year,\" Medicaid disproportionate share payments as a small rural hospital, the hospital must\")","v":"PLEASE NOTE: In order to qualify for FFY 2019 Medicaid disproportionate share payments as a small rural hospital, the hospital must"}]
["meet the statutory requirement at the 'Sec. A-C DSH Year Data' tab, have an affirmative reply to at least one of items 1 - 13 listed below, "]
["and have an affirmative reply to both items 14-15. "]
[]
[{"$f":"IF(OR($L$76=\"No\", $L$78=\"No\"),\"Per responses to questions 14 and 15 below, your facility does not qualify for a small rural DSH payment for SFY 2019. You are still required to complete the UCC survey and submit to Myers and Stauffer, along with all required supporting documentation.\",\"\")","v":""}]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"Answer (Yes/No)"]
[]
["1.","Facility is a general acute hospital licensed for sixty (60) beds or less and was licensed "]
[null,"for sixty or less beds on July 1, 1994 and is located in a parish of less than 50,000 or a"]
[null,"municipality of less than 20,000."]
[]
["2.","Facility meets the qualifications for a sole community hospital under 42 CFR §412.92(a) or met "]
[null,"the qualifications of a sole community hospital as of June 30, 2005 and subsequently converts to "]
[null,"critical access hospital status. Per RS 40:1300.143(7), a hospital that did not downsize to sixty beds "]
[null,"by May 16, 2003 and was not designated as rural hospital prior to July 1, 2003 does not qualify"]
[null,"under this provision."]
[]
["3.","Effective October 1, 1999, facility was licensed for no more than sixty hospital beds as of "]
[null,"July 1, 1999, and is located in a parish with a population, as measured by the 1990 census, "]
[null,"of less than 17,000. "]
[]
["4.","Effective October 1, 1999, facility was licensed for no more than sixty hospital beds as of "]
[null,"July 1, 1997, is a publicly owned and operated hospital, and is located in a parish of less"]
[null,"than 50,000 or a municipality of less than 20,000."]
[]
["5.","Effective August 8, 2001, has no more than sixty hospital beds as of June 30, 2000 and is located "]
[null,"in a municipality with a population of less than 20,000 as measured by the 1990 census."]
[]
["6.","Effective August 8, 2001, has no more than sixty hospital beds as of July 1, 1997 and is located "]
[null,"in a parish with a population of less than 50,000 as measured by the 1990 and 2000 census."]
[]
["7.","Effective August 8, 2001, was a facility licensed by the Department that had not more than sixty beds "]
[null,"as of July 1, 1994, which hospital facility has been in continuous operation since July 1, 1994, is"]
[null,"currently operating under a license issued by the Department, and is located in a parish with a"]
[null,"population of less than 50,000 as measured by the 1990 census. "]
[]
["8.","Effective August 5, 2002, has no more than sixty hospital beds or has notified the Department as of "]
[null,"March 7, 2002 of its intent to reduce its number of hospital beds to no more than sixty and is "]
[null,"located, as measured by the 2000 census, in a municipality with a population of less than 13,000"]
[null,"and in a parish with a population of less than 32,000."]
[]
["9.","Effective September 20, 2003, has no more than sixty hospital beds or has notified the Department "]
[null,"as of December 31, 2003 of its intent to reduce its number of hospital beds to no more than sixty"]
[null,"and is located, as measured by the 2000 census, in a municipality with a population of less than 7,000,"]
[null,"in a parish with a population of less than 53,000, and within ten miles of a United States military base."]
[]
["10.","Effective September 20, 2003, has no more than sixty hospital beds as of September 26, 2002 and is"]
[null,"located, as measured by the 2000 census, in a municipality with a population of less than 10,000 and "]
[null,"in a parish with a population of less than 33,000."]
[]
["11.","Effective September 20, 2003, has no more than sixty hospital beds as of January 1, 2003 and is "]
[null,"located, as measured by the 2000 census, in a municipality with a population of less than 11,000"]
[null,"and in a parish with a population of less than 90,000."]
[]
["12.","Effective August 15, 2005, has no more than forty hospital beds as of January 1, 2005 and is located,"]
[null,"as measured by the 2000 census, in a municipality with a population of less than 3,100 and in a "]
[null,"parish with a population of less than 15,000."]
[]
["13.","Effective September 20, 2012, has no more than sixty hospital beds as of November 1, 2013 and is"]
[null,"located, as measured by the 2000 census, in a municipality with a population of less than 33,000, "]
[null,"in a parish with a population of less than 15,000, and is located within three miles of Jackson Barracks."]
[]
["14.","Facility is public (Parish, Municipal or Other Governmental)."]
[]
["15.","Facility receives matching local governmental funding."]
[]
[]
["Non-State, Large Public (CPE) Pool:"]
[{"$f":"IF(DSHPool<>\"Non-State Large Public (CPE)\", \"N/A - This question does not apply to your facility.\",\"\")","v":"N/A - This question does not apply to your facility."}]
[null,{"$f":"\"In order to qualify for Disproportionate Share Payments for FFY \"&Year&\", we must verify that\"","v":"In order to qualify for Disproportionate Share Payments for FFY 2019, we must verify that"}]
[null,"your facility meets the qualifying criteria for a Non State, Large Public (CPE) Hospital:",null,null,null,null,null,null,null,null,null,"Answer (Yes/No)"]
[]
["1.","Meet the definition of a public non-rural community hospital as defined in 1.D.3.e. of the "]
[null,"Louisiana State Plan (below):"]
[]
[null,"A public, non-rural community hospital is defined as any non-state, non-rural hospital "]
[null,"(including hospitals with distinct part psychiatric units, long term care hospitals, rehabilitation, "]
[null,"and free standing psychiatric hospitals) that is owned by a parish, city, or other local government "]
[null,"agency or instrumentality; and meets the qualifying criteria for disproportionate share hospital "]
[null,"in 1.D.1 of the Louisiana State Plan."]
[]
[]
["Low-Income Needy Care Collaboration (LINCCA) Pool:"]
[{"$f":"IF(DSHPool<>\"LINCCA\", \"N/A - This question does not apply to your facility.\",\"\")","v":"N/A - This question does not apply to your facility."}]
[null,{"$f":"\"In order to qualify for Disproportionate Share Payments for FFY \"&Year&\", we must verify that\"","v":"In order to qualify for Disproportionate Share Payments for FFY 2019, we must verify that"}]
[null,"your facility meets the qualifying criteria for a DSH LINCCA Hospital:",null,null,null,null,null,null,null,null,null,"Answer (Yes/No)"]
[]
["1.","Effective for dates of service on or after January 21, 2010, be a hospital participating "]
[null,"in the Low Income and Needy Care Collaboration."]
[]
["2.","Facility has a LINCC Agreement on file with the LDH."]
[]
["Major Medical Center (Central & Northern):"]
[{"$f":"IF(DSHPool<>\"Major Medical (Central & Northern)\", \"N/A - This question does not apply to your facility.\",\"\")","v":"N/A - This question does not apply to your facility."}]
[null,{"$f":"\"In order to qualify for Disproportionate Share Payments for FFY \"&Year&\", we must verify that\"","v":"In order to qualify for Disproportionate Share Payments for FFY 2019, we must verify that"}]
[null,"your facility meets the qualifying criteria for a Major Medical Center:",null,null,null,null,null,null,null,null,null,"Answer (Yes/No)"]
[]
["1.","Effective for dates of service on or after June 30, 2016, hospitals qualifying for payments "]
[null,"as major medical centers located in the central and northern areas of the State shall meet "]
[null,"the following criteria (please check all applicable criteria the facility meets and provide "]
[null,"supporting documentation if applicable):"]
[]
[null,"a.","be a private, non-rural hospital located in Department of Health administrative"]
[null,null,"regions 6, 7, or 8"]
[]
[null,"b.","have at least 200 inpatient beds as reported on the Medicare/Medicaid cost report, "]
[null,null,"Worksheet S-3, column 2, lines 1-18, for the state fiscal year ending June 30, 2015. "]
[null,null,"For qualification purposes, inpatient beds shall exclude nursery and Medicare "]
[null,null,"designated distinct part psychiatric unit beds,"]
[]
[null,"c.","does not qualify as a Louisiana low-income academic hospital, and"]
[]
[null,"d.","such qualifying hospital (or its affiliate) does have a memorandum of understanding "]
[null,null,"executed on or after June 30, 2016, with Louisiana State University – School of "]
[null,null,"Medicine, the purpose of which is to maintain and improve access to quality care "]
[null,null,"for Medicaid patients in connection with the expansion of Medicaid in the state "]
[null,null,"through the promotion, expansion, and support of graduate medical education and training."]
[]
["Major Medical Center (Southwestern):"]
[{"$f":"IF(DSHPool<>\"Major Medical (Southwestern)\", \"N/A - This question does not apply to your facility.\",\"\")","v":"N/A - This question does not apply to your facility."}]
[null,{"$f":"\"In order to qualify for Disproportionate Share Payments for FFY \"&Year&\", we must verify that\"","v":"In order to qualify for Disproportionate Share Payments for FFY 2019, we must verify that"}]
[null,"your facility meets the qualifying criteria for a Major Medical Center (Southwestern):",null,null,null,null,null,null,null,null,null,"Answer (Yes/No)"]
[]
["1.","Effective for dates of service on or after June 30, 2018, hospitals qualifying for payments "]
[null,"as major medical centers located in the southwestern area of the State shall meet "]
[null,"the following criteria (please check all applicable criteria the facility meets and provide "]
[null,"supporting documentation if applicable):"]
[]
[null,"a.","be a private, non-rural hospital located in Louisiana Department of Health administrative"]
[null,null,"region 4"]
[]
[null,"b.","have at least 175 inpatient beds as reported on the Medicare/Medicaid cost report, "]
[null,null,"Worksheet S-3, column 2, lines 1-18, for the state fiscal year ending June 30, 2017. "]
[null,null,"For qualification purposes, inpatient beds shall exclude nursery and Medicare "]
[null,null,"designated distinct part psychiatric unit beds;"]
[]
[null,"c.","have a burn intensive care unit that is reported on the Medicare/Medicaid cost report,"]
[null,null,"Worksheet S-3, line 10, columns 1-8, for the state fiscal year ending June 30, 2017;"]
[]
[null,"d.","does not qualify as a Louisiana low-income academic hospital; and"]
[]
[null,"e.","does not qualify as a party to a low income and needy care collaboration agreement with "]
[null,null,"the Louisiana Department of Health"]
[]
["High Medicaid:"]
[null,"In order to qualify under federal statutory criteria as a hospital serving a disproportionate share of "]
[null,"indigent patients, specific criteria must be met.  These include certain staffing requirements as well "]
[null,"as utilization rates for Medicaid days and indigent days.  ",null,null,null,null,null,null,null,null,null,"Answer (Yes/No)"]
[]
["1.","Medicaid Inpatient Utilization Rate (based on Medicaid days to total days) is greater than the mean plus one "]
[null,"standard deviation of the Medicaid utilization rates for all hospitals in the state receiving payments; "]
[null,{"$f":"CONCATENATE(\"the qualifying percentage for the latest filed cost reporting period is \",TEXT(MIUR_Threshold,\"0.00%\"),\".\")","v":"the qualifying percentage for the latest filed cost reporting period is 0.00%."}]
[]
[null,"Medicaid Inpatient Utilization Rate (MIUR) Formula:"]
[]
[null,"Total Hospital Medicaid Eligible Days ÷ Total Hospital Days = MIUR"]
[]
[null,"Note: Medicaid days include nursery days. If the hospital has a distinct part unit, days for these are "]
[null,"included in the hospital’s total and are not calculated separately.  Total days include only hospital days, not "]
[null,"\"swing bed\" (nursing facility) days.  Per clarification received from the Centers for Medicare & Medicaid Services "]
[null,"(CMS), hospitals may count patient days for which the patient is eligible under a State plan (regardless of the "]
[null,{"$f":"CONCATENATE(\"available coverage). Hospitals that did not have at least \",TEXT(MIUR_Threshold,\"0.00%\"),\" Medicaid inpatient days’ utilization or qualify\")","v":"available coverage). Hospitals that did not have at least 0.00% Medicaid inpatient days’ utilization or qualify"}]
[null,"with 25% low income utilization revenue per the latest filed cost report period should review their inpatient days "]
[null,"for eligible Medicaid patients during this period whose stay was not covered by Medicaid to determine if there "]
[null,"is a sufficient number to qualify for disproportionate share payments. If so, please complete the attached form "]
[null,"detailing these patients and return to Myers and Stauffer, via the Myers and Stauffer web portal, along with the "]
[null,"other required documentation."]
[]
[null,"OR"]
[]
["2.","Low Income Utilization Rate (based on ratios of net Medicaid patient care revenues plus state subsidy to "]
[null,"net patient care revenues; and inpatient charges related to charity care as a percentage of total inpatient "]
[null,"charges) is greater than 25%."]
[]
[null,"Low Income Utilization Rate Formula:"]
[]
[null,"(Medicaid Hospital Patient Care Revenues + Hospital Patient Care Local/State Subsidies) ÷ Total Hospital Patient Care Revenues = Medicaid Fraction"]
[]
[null,"(Free Care Inpatient Hospital Charges - Inpatient Hospital Local/State Subsidies) ÷ Total Hospital Inpatient Charges = Charity Care Fraction"]
[]
[null,"LIUR = Medicaid Fraction + Charity Care Fraction"]
[]
[null,"Note: Revenues are defined as \"net revenues\" (gross revenues less contractual adjustments and discounts for"]
[null,"inpatient and outpatient hospital services).  Medicaid net revenues exclude disproportionate share payments.  "]
[null,"Hospital criteria for determining individuals who qualify for \"free care\" must be approved by the Department."]
[]
["2a.","In addition to the qualification criteria above, effective July 1, 1994, the qualifying disproportionate share "]
[null,"hospital must have a Medicaid inpatient utilization rate of at least 1%. "]
[]
[]
["LA ACT 540 Questionnaire"]
[]
[null,"Psychiatric Information:",null,null,null,null,null,null,null,null,null,"Answer Yes/No"]
[]
["1.","Does the hospital have a distinct part psychiatric unit?"]
[]
[{"$f":"A208+1&\".\"","v":"2."},"Is the hospital a freestanding psychiatric hospital?"]
[]
[{"$f":"A210+1&\".\"","v":"3."},"If yes, is hospital accredited by the Joint Commission on the Accreditation "]
[null,"of Healthcare Organizations?"]

{"sheet":"Sec. A-C DSH Year Data","index":6,"n_rows":105,"n_cols":31,"rows_kept":105,"cut":false,"hidden":false,"merged":[[104,2,104,5],[102,9,102,12],[67,1,67,4],[103,9,103,12],[101,2,101,5],[99,9,99,12],[84,1,84,13],[93,4,93,6],[88,1,88,10],[85,1,85,13],[83,2,83,13],[103,2,103,5],[102,2,102,5],[101,9,101,12],[90,4,90,6],[100,9,100,12],[99,2,99,5],[100,2,100,5],[93,10,93,12],[5,2,5,6],[66,1,66,4],[11,6,11,13],[12,6,12,13],[50,1,50,4],[51,1,51,4],[13,6,13,13],[60,1,60,4],[61,1,61,4],[16,2,16,4]]}
[null,null,null,null,null,null,null,null,"DSH Version",null,5.25,null,"2018-12-03",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"State","v":"Louisiana"},null,"Yes"]
["A.  General DSH Year Information",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Waiver_Response","v":0},null,"No"]
[null,null,"Begin",null,"End"]
["1.","DSH Year:","2018-07-01",null,"2019-06-30"]
[]
["2.","Select Your Facility from the Drop-Down Menu Provided:","SELECT HOSPITAL NAME"]
[]
[]
[null,"Identification of cost reports needed to cover the DSH Year:"]
[null,null,"Cost Report",null,"Cost Report"]
[null,null,"Begin Date(s)",null,"End Date(s)"]
["3.","Cost Report Year 1",{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,6,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,6,FALSE))","v":""},null,{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,7,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,7,FALSE))","v":""},null,{"$f":"IF(ISNUMBER(FYE_1),\"Must also complete a separate survey file for each cost report period listed - SEE DSH SURVEY PART II FILES\", \"\")","v":""}]
["4.","Cost Report Year 2 (if applicable)",{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,8,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,8,FALSE))","v":""},null,{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,9,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,9,FALSE))","v":""},null,{"$f":"IF(ISNUMBER(FYE_2),\"Must also complete a separate survey file for each cost report period listed - SEE DSH SURVEY PART II FILES\", \"\")","v":""}]
["5.","Cost Report Year 3 (if applicable)",{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,10,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,10,FALSE))","v":""},null,{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,11,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,11,FALSE))","v":""},null,{"$f":"IF(ISNUMBER(FYE_3),\"Must also complete a separate survey file for each cost report period listed - SEE DSH SURVEY PART II FILES\", \"\")","v":""}]
[]
[]
[null,null,"Data"]
["6.","Medicaid Provider Number:",null,null,{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,2,FALSE)","v":"M'Caid #"}]
["7.","   Medicaid Subprovider Number 1 (Psychiatric or Rehab):",null,null,{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,3,FALSE)","v":"M'caid Sub 1 #"}]
["8.","   Medicaid Subprovider Number 2 (Psychiatric or Rehab):",null,null,{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,4,FALSE)","v":"M'caid Sub 2 #"}]
["9.","Medicare Provider Number:",null,null,{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,5,FALSE)","v":"M'care #"}]
["10.","Owner/Operator (Private, State Gov't, Non-State Gov't)",null,null,{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,13,FALSE)","v":0},null,"Update if incorrect"]
["11.","DSH Pool Type (Small Rural, CPE, Major Medical, LINCCA)",null,null,{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,12,FALSE)","v":0},null,"Update if incorrect"]
[]
[]
["B.  DSH OB Qualifying Information"]
[null,"Questions 1-3, below, should be answered in the accordance with Sec. 1923(d) of the Social Security Act."]
[null,{"$f":"IF(State<>\"Louisiana\",\"During the DSH Examination Year:\",\"During the DSH Year:\")","v":"During the DSH Year:"},null,null,null,null,null,null,{"$f":"IF(State<>\"Louisiana\",CONCATENATE(\"DSH Examination Year (\",TEXT(DSH_Year_Begin,\"mm/dd/yy\"),\" - \",TEXT(DSH_Year_End,\"mm/dd/yy\"),\")\"),CONCATENATE(\"DSH Year (\",TEXT(DSH_Year_Begin,\"mm/dd/yy\"),\" - \",TEXT(DSH_Year_End,\"mm/dd/yy\"),\")\"))","v":"DSH Year (07/01/18 - 06/30/19)"}]
[1,"Did the hospital have at least two obstetricians who had staff privileges at the hospital that agreed to"]
[null,"provide obstetric services to Medicaid-eligible individuals during the DSH year?  (In the case of a hospital"]
[null,"located in a rural area, the term \"obstetrician\" includes any physician with staff privileges at the "]
[null,"hospital to perform nonemergency obstetric procedures.)  "]
[2,"Was the hospital exempt from the requirement listed under #1 above because the hospital's "]
["","inpatients are predominantly under 18 years of age? "]
[3,"Was the hospital exempt from the requirement listed under #1 above because it did not offer non-"]
[null,"emergency obstetric services to the general population when federal Medicaid DSH regulations"]
[null,"were enacted on December 22, 1987?  "]
[]
["3a.","Was the hospital open as of December 22, 1987?"]
[]
["3b.","What date did the hospital open?"]
[]
[null,"Questions 4-6, below, should be answered in the accordance with Sec. 1923(d) of the Social Security Act."]
[null,"During the Interim DSH Payment Year:",null,null,null,null,null,null,{"$f":"CONCATENATE(\"DSH Payment Year (\", TEXT(DSH_Payment_Year_Begin,\"mm/dd/yy\"), \" - \", TEXT(DSH_Payment_Year_End,\"mm/dd/yy\"),\")\")","v":"DSH Payment Year (07/01/18 - 06/30/19)"}]
[4,"Does the hospital have at least two obstetricians who have staff privileges at the hospital who have agreed to"]
[null,"provide obstetric services to Medicaid-eligible individuals during the DSH year?  (In the case of a hospital"]
[null,"located in a rural area, the term \"obstetrician\" includes any physician with staff privileges at the "]
[null,"hospital to perform nonemergency obstetric procedures.)  "]
[]
[null,"List the Names of the two Obstetricians (or case of rural hospital, Physicians) who have agreed to perform OB services:"]
[]
[]
[]
[5,"Is the hospital exempt from the requirement listed under #1 above because the hospital's "]
["","inpatients are predominantly under 18 years of age? "]
[6,"Is the hospital exempt from the requirement listed under #1 above because it did not offer non-"]
[null,"emergency obstetric services to the general population when federal Medicaid DSH regulations"]
[null,"were enacted on December 22, 1987?  "]
[]
[null,"List the Names of the two Obstetricians (or case of rural hospital, Physicians) who have agreed to perform OB services:",null,null,null,null,"OB License Number",null,"OB Medicaid Number"]
[]
[]
[]
[]
[]
["C.  Disclosure of Other Medicaid Payments Received:"]
[]
["1.",{"$f":"CONCATENATE(IF(State=\"Missouri\",\"Other Medicaid Payments for DSH Year \",\"Medicaid Supplemental Payments for DSH Year \"), TEXT(DSH_Year_Begin,\"mm/dd/yyy\"), \" - \", TEXT(DSH_Year_End,\"mm/dd/yyyy\"))","v":"Medicaid Supplemental Payments for DSH Year 07/01/2018 - 06/30/2019"}]
[null,{"$f":"IF(State=\"Missouri\",\"Should include all Non-Claim Specific payments paid based on the state fiscal year including Direct Medicaid, GME, UPL, Children's Outliers, etc.  However, DSH payments should NOT be included.\",\"(Should include UPL and Non-Claim Specific payments paid based on the state fiscal year.  However, DSH payments should NOT be included.)\")","v":"(Should include UPL and Non-Claim Specific payments paid based on the state fiscal year.  However, DSH payments should NOT be included.)"}]
[]
[]
[]
[]
[]
[]
[]
["Certification:"]
[null,null,null,null,null,null,null,null,"Answer"]
["1.","Was your hospital allowed to retain 100% of the DSH payment it received for this DSH year?"]
[null,"Matching the federal share with an IGT/CPE is not a basis for answering this question \"no\".  If your"]
[null,"hospital was not allowed to retain 100% of its DSH payments, please explain what circumstances were"]
[null,"present that prevented the hospital from retaining its payments."]
[]
[null,"Explanation for \"No\" answers:"]
[]
[]
[]
[null,"The following certification is to be completed by the hospital's CEO or CFO:"]
[null,{"$f":"IF(State=\"Louisiana\",IF(TaxForm=\"Yes\",IF(Waiver_Response=\"Yes\",LAWithTax_Waive, LAWithTax), IF(Waiver_Response=\"Yes\",LANoTax_Waive,LANoTax)),IF(TaxForm=\"Yes\",WithTax,NoTax))","v":"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P, and the DSH Qualification section of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital. All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim. I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions. Detailed support exists for all amounts reported in the survey. These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested. "}]
[]
[]
[null,"Hospital CEO or CFO Signature",null,null,"Title",null,null,null,null,null,"Date"]
[]
[]
[null,"Hospital CEO or CFO Printed Name",null,null,"Hospital CEO or CFO Telephone Number",null,null,null,null,null,"Hospital CEO or CFO E-Mail"]
[]
[null,"Contact Information for individuals authorized to respond to inquiries related to this survey:"]
[]
[null,"Hospital Contact:",null,null,null,null,null,null,"Outside Preparer:"]
[null,"Name",null,null,null,null,null,null,"Name"]
[null,"Title",null,null,null,null,null,null,"Title:"]
[null,"Telephone Number",null,null,null,null,null,null,"Firm Name:"]
[null,"E-Mail Address",null,null,null,null,null,null,"Telephone Number"]
[null,"Mailing Street Address",null,null,null,null,null,null,"E-Mail Address"]
[null,"Mailing City, State, Zip"]

{"sheet":"Sec. A-C DSH Year Data ADJ","index":7,"n_rows":105,"n_cols":31,"rows_kept":105,"cut":false,"hidden":true,"merged":[[100,2,100,5],[100,9,100,12],[90,4,90,6],[93,4,93,6],[93,8,93,10],[104,2,104,5],[101,2,101,5],[101,9,101,12],[102,2,102,5],[102,9,102,12],[103,2,103,5],[103,9,103,12],[85,1,85,13],[88,1,88,10],[60,1,60,4],[61,1,61,4],[99,2,99,5],[99,9,99,12],[84,1,84,13],[5,2,5,6],[16,2,16,4],[66,1,66,4],[67,1,67,4],[83,2,83,13],[50,1,50,4],[51,1,51,4]]}
[null,null,null,null,null,null,null,null,"DSH Version",null,{"$f":"Version","v":5.25},null,{"$f":"'Sec. A-C DSH Year Data'!M1","v":"2018-12-03"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"State","v":"Louisiana"}]
["A.  General DSH Year Information",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"IOWA",null,{"$f":"Waiver_Response","v":0}]
[null,null,"Begin",null,"End",null,null,null,"Workpaper #:",null,null,null,"Reviewer:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ARIZONA "]
["1.","DSH Year:",{"$f":"DSH_Year_Begin","v":"2018-07-01"},null,{"$f":"DSH_Year_End","v":"2019-06-30"},null,null,null,"Examiner:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ARKANSAS"]
[null,null,null,null,null,null,null,null,"Date:"]
["2.","Select Your Facility from the Drop-Down Menu Provided:",{"$f":"HOSPITALNAME","v":"SELECT HOSPITAL NAME"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALABAMA"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALASKA"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"COLORADO "]
[null,"Identification of cost reports needed to cover the DSH Year:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CONNECTICUT"]
[null,null,"Cost Report",null,"Cost Report"]
[null,null,"Begin Date(s)",null,"End Date(s)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DELAWARE"]
["3.","Cost Report Year 1",{"$f":"FYB_1","v":""},null,{"$f":"FYE_1","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DISTRICT OF COLUMBIA"]
["4.","Cost Report Year 2 (if applicable)",{"$f":"FYB_2","v":""},null,{"$f":"FYE_2","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FLORIDA"]
["5.","Cost Report Year 3 (if applicable)",{"$f":"FYB_3","v":""},null,{"$f":"FYE_3","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"GEORGIA"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"HAWAII"]
[null,null,"Data",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MAINE"]
["6.","Medicaid Provider Number:",null,null,{"$f":"McaidNum","v":"M'Caid #"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MASSACHUSETTS"]
["7.","   Medicaid Subprovider Number 1 (Psychiatric or Rehab):",null,null,{"$f":"SubNum1","v":"M'caid Sub 1 #"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MICHIGAN"]
["8.","   Medicaid Subprovider Number 2 (Psychiatric or Rehab):",null,null,{"$f":"SubNum2","v":"M'caid Sub 2 #"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MINNESOTA"]
["9.","Medicare Provider Number:",null,null,{"$f":"McareNum","v":"M'care #"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MISSISSIPPI"]
["10.","Owner/Operator (Private, State Gov't, Non-State Gov't)",null,null,{"$f":"OwnerType","v":0}]
["11.","DSH Pool Type (Small Rural, CPE, Major Medical, LINCCA)",null,null,{"$f":"DSHPool","v":0}]
[]
[]
["B.  DSH OB Qualifying Information"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B27","v":"Questions 1-3, below, should be answered in the accordance with Sec. 1923(d) of the Social Security Act."}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B28","v":"During the DSH Year:"},null,null,null,null,null,null,{"$f":"'Sec. A-C DSH Year Data'!I28","v":"DSH Year (07/01/18 - 06/30/19)"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MONTANA"]
[{"$f":"'Sec. A-C DSH Year Data'!A29","v":1},"Did the hospital have at least two obstetricians who had staff privileges at the hospital that agreed to",null,null,null,null,null,null,{"$f":"OBYes","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEBRASKA"]
[null,"provide obstetric services to Medicaid-eligible individuals during the DSH year?  (In the case of a hospital",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEVADA"]
[null,"located in a rural area, the term \"obstetrician\" includes any physician with staff privileges at the ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW HAMPSHIRE"]
[null,"hospital to perform nonemergency obstetric procedures.)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW JERSEY"]
[{"$f":"'Sec. A-C DSH Year Data'!A33","v":2},"Was the hospital exempt from the requirement listed under #1 above because the hospital's ",null,null,null,null,null,null,{"$f":"OBExempt1Yes","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW MEXICO"]
["","inpatients are predominantly under 18 years of age?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW YORK"]
[{"$f":"'Sec. A-C DSH Year Data'!A35","v":3},"Was the hospital exempt from the requirement listed under #1 above because it did not offer non-",null,null,null,null,null,null,{"$f":"OBExempt2Yes","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NORTH CAROLINA"]
[null,"emergency obstetric services to the general population when federal Medicaid DSH regulations",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NORTH DAKOTA"]
[null,"were enacted on December 22, 1987?  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OHIO"]
[]
[{"$f":"'Sec. A-C DSH Year Data'!A39","v":"3a."},"Was the hospital open as of December 22, 1987?",null,null,null,null,null,null,{"$f":"OpenAsOf_Exam","v":0}]
[]
[{"$f":"'Sec. A-C DSH Year Data'!A41","v":"3b."},"What date did the hospital open?",null,null,null,null,null,null,{"$f":"IF(OR(OpenDate_Exam=\"\",OpenDate_Exam=0),\"\",OpenDate_Exam)","v":""}]
[]
[null,{"$f":"'Sec. A-C DSH Year Data'!B43","v":"Questions 4-6, below, should be answered in the accordance with Sec. 1923(d) of the Social Security Act."}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B44","v":"During the Interim DSH Payment Year:"},null,null,null,null,null,null,{"$f":"'Sec. A-C DSH Year Data'!I44","v":"DSH Payment Year (07/01/18 - 06/30/19)"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MONTANA"]
[{"$f":"'Sec. A-C DSH Year Data'!A45","v":4},{"$f":"'Sec. A-C DSH Year Data'!B45","v":"Does the hospital have at least two obstetricians who have staff privileges at the hospital who have agreed to"},null,null,null,null,null,null,{"$f":"OBYes_Payment","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEBRASKA"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B46","v":"provide obstetric services to Medicaid-eligible individuals during the DSH year?  (In the case of a hospital"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEVADA"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B47","v":"located in a rural area, the term \"obstetrician\" includes any physician with staff privileges at the "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW HAMPSHIRE"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B48","v":"hospital to perform nonemergency obstetric procedures.)  "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW JERSEY"]
[]
[null,{"$f":"'Sec. A-C DSH Year Data'!B50","v":"List the Names of the two Obstetricians (or case of rural hospital, Physicians) who have agreed to perform OB services:"}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B51","v":0}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B52","v":0}]
[]
[{"$f":"'Sec. A-C DSH Year Data'!A54","v":5},{"$f":"'Sec. A-C DSH Year Data'!B54","v":"Is the hospital exempt from the requirement listed under #1 above because the hospital's "},null,null,null,null,null,null,{"$f":"OBExempt1Yes_Payment","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW MEXICO"]
["",{"$f":"'Sec. A-C DSH Year Data'!B55","v":"inpatients are predominantly under 18 years of age? "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW YORK"]
[{"$f":"'Sec. A-C DSH Year Data'!A56","v":6},{"$f":"'Sec. A-C DSH Year Data'!B56","v":"Is the hospital exempt from the requirement listed under #1 above because it did not offer non-"},null,null,null,null,null,null,{"$f":"OBExempt2Yes_Payment","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NORTH CAROLINA"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B57","v":"emergency obstetric services to the general population when federal Medicaid DSH regulations"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NORTH DAKOTA"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B58","v":"were enacted on December 22, 1987?  "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OHIO"]
[]
[null,{"$f":"'Sec. A-C DSH Year Data'!B60","v":"List the Names of the two Obstetricians (or case of rural hospital, Physicians) who have agreed to perform OB services:"},null,null,null,null,"OB License Number",null,"OB Medicaid Number"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B61","v":0},null,null,null,null,{"$f":"'Sec. A-C DSH Year Data'!G61","v":0},null,{"$f":"'Sec. A-C DSH Year Data'!I61","v":0}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B62","v":0},null,null,null,null,{"$f":"'Sec. A-C DSH Year Data'!G62","v":0},null,{"$f":"'Sec. A-C DSH Year Data'!I62","v":0}]
[]
[]
[]
["C.  Disclosure of Supplemental Medicaid Payments Received:"]
[]
["1.",{"$f":"CONCATENATE(IF(State=\"Missouri\",\"Other Medicaid Payments for DSH Year \",\"Medicaid Supplemental Payments for DSH Year \"), TEXT(DSH_Year_Begin,\"mm/dd/yyy\"), \" - \", TEXT(DSH_Year_End,\"mm/dd/yyyy\"))","v":"Medicaid Supplemental Payments for DSH Year 07/01/2018 - 06/30/2019"},null,null,null,null,null,null,{"$f":"UPL_Payments","v":0}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B69","v":"(Should include UPL and Non-Claim Specific payments paid based on the state fiscal year.  However, DSH payments should NOT be included.)"}]
[]
[]
[]
[]
[]
[]
[]
["Certification:"]
[null,null,null,null,null,null,null,null,"Answer"]
["1.","Was your hospital allowed to retain 100% of the DSH payment it received for this DSH year?",null,null,null,null,null,null,{"$f":"RetainDSHYes","v":0}]
[null,"Matching the federal share with an IGT/CPE is not a basis for answering this question \"no\".  If your"]
[null,"hospital was not allowed to retain 100% of its DSH payments, please explain what circumstances were"]
[null,"present that prevented the hospital from retaining its payments."]
[]
[null,"Explanation for \"No\" answers:",{"$f":"'Sec. A-C DSH Year Data'!C84","v":0}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B85","v":0}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B86","v":0}]
[]
[null,"The following certification is to be completed by the hospital's CEO or CFO:"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B89","v":"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P, and the DSH Qualification section of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital. All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim. I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions. Detailed support exists for all amounts reported in the survey. These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested. "}]
[]
[null,{"$f":"Signature","v":0},null,null,{"$f":"Signature_Title","v":0},null,null,null,null,null,{"$f":"IF(OR(Signature_Date=\"\",Signature_Date=0),\"\",Signature_Date)","v":""}]
[null,"Hospital CEO or CFO",null,null,"Title",null,null,null,null,null,"Date"]
[]
[null,{"$f":"Signature_Printed_Name","v":0},null,null,{"$f":"Signature_Telephone","v":0},null,null,null,{"$f":"Signature_EMail","v":0}]
[null,"Hospital CEO or CFO Printed Name",null,null,"Hospital CEO or CFO Telephone Number",null,null,null,"Hospital CEO or CFO E-Mail"]
[]
[null,"Contact Information for individuals authorized to respond to inquiries related to this survey:"]
[]
[null,"Hospital Contact:",null,null,null,null,null,null,"Outside Preparer:"]
[null,"Name",{"$f":"'Sec. A-C DSH Year Data'!C100","v":0},null,null,null,null,null,"Name",{"$f":"'Sec. A-C DSH Year Data'!J100","v":0}]
[null,"Title",{"$f":"'Sec. A-C DSH Year Data'!C101","v":0},null,null,null,null,null,"Title:",{"$f":"'Sec. A-C DSH Year Data'!J101","v":0}]
[null,"Telephone Number",{"$f":"'Sec. A-C DSH Year Data'!C102","v":0},null,null,null,null,null,"Firm Name:",{"$f":"'Sec. A-C DSH Year Data'!J102","v":0}]
[null,"E-Mail Address",{"$f":"'Sec. A-C DSH Year Data'!C103","v":0},null,null,null,null,null,"Telephone Number",{"$f":"'Sec. A-C DSH Year Data'!J103","v":0}]
[null,"Mailing Street Address",{"$f":"'Sec. A-C DSH Year Data'!C104","v":0},null,null,null,null,null,"E-Mail Address",{"$f":"'Sec. A-C DSH Year Data'!J104","v":0}]
[null,"Mailing City, State, Zip",{"$f":"'Sec. A-C DSH Year Data'!C105","v":0}]

{"sheet":"Checklist","index":8,"n_rows":41,"n_cols":11,"rows_kept":41,"cut":false,"hidden":false,"merged":[[40,4,40,14],[18,4,18,14],[32,4,32,13],[16,4,16,14],[23,4,23,14],[21,4,21,14],[22,4,22,14],[25,4,25,14],[24,4,24,14],[17,4,17,14],[19,4,19,14],[20,5,20,14],[15,4,15,14],[31,4,31,13],[7,5,7,14],[13,5,13,14],[12,4,12,14],[2,4,2,14],[30,4,30,13],[10,5,10,14],[27,4,27,14],[1,1,1,14],[26,4,26,14],[8,4,8,14],[11,4,11,14],[14,4,14,14],[6,1,7,1],[9,1,10,1],[12,1,13,1],[19,1,20,1],[3,4,3,14],[4,4,4,14],[5,4,5,14]]}
["DSH Survey Submission Checklist",null,null,null,null,null,null,null,null,null,"Act 540 only providers need only submit the highlighted items."]
[null,"Please indicate with an \"X\" each item included or a \"N/A\" if not included.  Consider a separate cover letter to explain any \"N/A\" answers to avoid additional documentation requests."]
[null,null,null,"1.",{"$f":"CONCATENATE(\"Electronic copy of the DSH Survey Part I - DSH Year Data -  \", TEXT(DSH_Year_Begin,\"mm/dd/yyyy\"), \" - \", TEXT(DSH_Year_End,\"mm/dd/yyyy\"))","v":"Electronic copy of the DSH Survey Part I - DSH Year Data -  07/01/2018 - 06/30/2019"}]
[null,null,null,"2.",{"$f":" CONCATENATE(\"Electronic copy of the DSH Survey Part II - Cost Report Data - Cost Report Year \", TEXT(FYB_1,\"mm/dd/yyyy\"), \" - \", TEXT(FYE_1,\"mm/dd/yyyy\"))","v":"Electronic copy of the DSH Survey Part II - Cost Report Data - Cost Report Year  - "}]
[null,null,null,"3.",{"$f":"CONCATENATE(\"Electronic copy of the RHC Survey - Cost Report Year \",TEXT(FYB_1,\"mm/dd/yyyy\"),\" - \",TEXT(FYE_1,\"mm/dd/yyyy\"),\" if applicable.\")","v":"Electronic copy of the RHC Survey - Cost Report Year  -  if applicable."}]
[null,null,null,"4.",{"$f":"IF(ISNUMBER('Sec. A-C DSH Year Data'!E14),CONCATENATE(\"Electronic copy of the DSH Survey Part II - Cost Report Data - Cost Report Year \", TEXT(FYB_3,\"mm/dd/yyyy\"), \" - \", TEXT(FYE_3,\"mm/dd/yyyy\")),\"N/A\")","v":"N/A"}]
[null,null,null,"5 (a).","Electronic copy of Exhibit A - Uninsured Charges / Days"]
[null,null,null,null,null,"- Must be in Excel (.xls or .xlsx) or CSV (.csv) using either a TAB or | (pipe symbol above the ENTER key)"]
[null,null,null,"5 (b).","Description of logic used to compile Exhibit A.  Include a copy of all financial classes and payer plan codes utilized during the cost report period and a description of which codes were included or excluded if applicable."]
[null,null,null,"6 (a).","Electronic copy of Exhibit B - Self-Pay Payments"]
[null,null,null,null,null,"- Must be in Excel (.xls or .xlsx) or CSV (.csv) using either a TAB or | (pipe symbol above the ENTER key)."]
[null,null,null,"6 (b).","Description of logic used to compile Exhibit B. Include a copy of all transaction codes utilized to post payments during the cost reporting period and a description of which codes were included or excluded if applicable."]
[null,null,null,"7 (a).","Electronic copy of Exhibit C for hospital-generated data (includes Medicaid eligibles, Medicare crossover, Medicaid MCO, or Out-Of-State Medicaid data that isn't supported by a state-provided or MCO-provided report)"]
[null,null,null,null,null,"- Must be in Excel (.xls or .xlsx) or CSV (.csv) using either a TAB or | (pipe symbol above the ENTER key)."]
[null,null,null,"7 (b).","Description of logic used to compile each Exhibit C. Include a copy of all financial classes and payer plan codes utilized during the cost report period and a description of which codes were included or excluded if applicable."]
[null,null,null,"8.","Copies of all out-of-state Medicaid fee-for-service PS&Rs (Remittance Advice Summary or Paid Claims Summary including crossovers)"]
[null,null,null,"9.","Copies of all out-of-state Medicaid managed care PS&Rs (Remittance Advice Summary or Paid Claims Summary including crossovers)"]
[null,null,null,"10.","Copies of in-state Medicaid managed care PS&Rs (Remittance Advice Summary or Paid Claims Summary including crossovers)"]
[null,null,null,"11.","Support for Section 1011 (Undocumented Alien) payments if not applied at patient level in Exhibit B"]
[null,null,null,"12.","Documentation supporting out-of-state DSH payments received"]
[null,null,null,null,null,"- Examples may include remittances, detailed general ledgers, or add-on rates."]
[null,null,null,"13.","Financial statements or other documentation to support total charity care charges and subsidies reported on Section F of DSH Survey Part II"]
[null,null,null,"14.","Revenue code cross-walk used to prepare cost report, or supporting grouping schedules"]
[null,null,null,"15a.","A detailed working trial balance used to prepare each cost report (including revenues)"]
[null,null,null,"15b.","A detailed revenue working trial balance by payer/contract.  The schedule should show charges, contractual adjustments, and revenues by payer plan and contract (e.g., Medicare, each Medicaid agency payer, each Medicaid Managed care contract)"]
[null,null,null,"16.","Electronic copy of all cost reports used to prepare each DSH Survey Part II"]
[null,null,null,"17.","Documentation supporting cost report payments calculated for Medicaid/Medicare cross-overs (dual eligible cost report payments)"]
[null,null,null,"18.","Documentation supporting Medicaid Managed Care Quality Incentive Payments, or any other Medicaid Managed Care lump sum payments"]
[]
[]
[null,null,null,null,"Please upload all checklist items above to the Myers and Stauffer Web Portal. If you are unable to access the Web Portal, please call or email. Web Portal Address:"]
[null,null,null,null,"https://dsh.mslc.com"]
[null,null,null,null,"All electronic (CD or DVD - CDs or DVDs must be encrypted and/or password protected) and paper documentation can be mailed (using certified or other traceable delivery) to:"]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B4","v":"Myers and Stauffer LC"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B5","v":"ATTN:  DSH Examinations"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B6","v":"700 W. 47th Street, Suite 1100"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B7","v":"Kansas City, Missouri 64112"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B8","v":"Fax:  (816) 945-5301"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B9","v":"Phone:  (800) 374-6858"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B10","v":"E-Mail: LADSH@mslc.com"}]
[null,null,null,null,"Please Call Myers and Stauffer if you have any questions on completing the DSH survey."]

{"sheet":"Exam Adjustments","index":9,"n_rows":26,"n_cols":11,"rows_kept":26,"cut":false,"hidden":true,"merged":[[6,0,6,9],[2,2,2,7],[0,0,0,9],[5,0,5,10]]}
["Medicaid DSH Survey Adjustments"]
[]
["PROVIDER:",null,{"$f":"'Sec. A-C DSH Year Data ADJ'!C6:G6","v":"SELECT HOSPITAL NAME"},null,null,null,null,null,"Mcaid Number:",{"$f":"McaidNum_ADJ","v":"M'Caid #"}]
["FROM:",null,{"$f":"DSH_Year_Begin","v":"2018-07-01"},null,"TO:",{"$f":"DSH_Year_End","v":"2019-06-30"},null,null,"Mcare Number:",{"$f":"McareNum_ADJ","v":"M'care #"}]
[]
["Myers and Stauffer DSH Survey Adjustments"]
[]
["Adj. #","Schedule","Line #","Line Description","Column","Column Description","Year","Explanation for Adjustment","Original Amount","Adjustment","Adjusted Total"]
[null,"Certification",1,"Retain 100% of DSH Payment?","1.00","Answer",{"$f":"DSH_Year_End","v":"2019-06-30"},"Adjust answer based on examination results.",{"$f":"RetainDSHYes","v":0},{"$f":"IF(K9<>I9,K9,0)","v":0},{"$f":"RetainDSHYes_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",1,"Have two OBs?","1.00","Answer","2019-06-30","Adjust answer based on examination results.",{"$f":"OBYes","v":0},0,{"$f":"OBYes_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",2,"Exempt to OB due to inpatients under age 18?","1.00","Answer","2019-06-30","Adjust answer based on examination results.",{"$f":"OBExempt1Yes","v":0},0,{"$f":"OBExempt1Yes_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",3,"Exempt to OB due to not offering OB on 12/22/87?","1.00","Answer","2019-06-30","Adjust answer based on examination results.",{"$f":"OBExempt2Yes","v":0},0,{"$f":"OBExempt2Yes_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information","3a","Was the hospital open as of 12/22/87?","1.00","Answer","2019-06-30","Adjust answer based on review results.",{"$f":"OpenAsOf_Exam","v":0},{"$f":"IF(K13<>I13,K13,0)","v":0},{"$f":"OpenAsOf_Exam_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information","3b","Year Hospital opened?","1.00","Answer","2019-06-30","Adjust answer based on review results.",{"$f":"IF(OR(OpenDate_Exam=\"\",OpenDate_Exam=0),\"\",OpenDate_Exam)","v":""},{"$f":"IF(K14<>I14,K14,0)","v":"00:00:00"},{"$f":"IF(OpenDate_Exam_ADJ=\"\",\"\",OpenDate_Exam_ADJ)","v":""}]
[null,"B - DSH OB Qualifying Information",4,"Have two OBs?","1.00","Answer",{"$f":"DSH_Payment_Year_End","v":"2019-06-30"},"Adjust answer based on review results.",{"$f":"OBYes_Payment","v":0},0,{"$f":"OBYes_Payment_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",5,"Exempt to OB due to inpatients under age 18?","1.00","Answer",{"$f":"DSH_Payment_Year_End","v":"2019-06-30"},"Adjust answer based on review results.",{"$f":"OBExempt1Yes_Payment","v":0},0,{"$f":"OBExempt1Yes_Payment_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",6,"Exempt to OB due to not offering OB on 12/22/87?","1.00","Answer",{"$f":"DSH_Payment_Year_End","v":"2019-06-30"},"Adjust answer based on review results.",{"$f":"OBExempt2Yes_Payment","v":0},0,{"$f":"OBExempt2Yes_Payment_ADJ","v":0}]
[null,"C - Disclosure of Other M'Caid Payments",1,"Medicaid Supplemental Payments for DSH Year","1.00","Answer",{"$f":"DSH_Year_End","v":"2019-06-30"},"Adjust to state's report.",{"$f":"UPL_Payments","v":0},{"$f":"K18-I18","v":0},{"$f":"UPL_Payments_ADJ","v":0}]
[null,"A - General DSH Year Information",10,"Ownership Type","1.00","Answer","2019-06-30","Adjust answer based on review results.",{"$f":"OwnerType","v":0},0,{"$f":"OwnerType_ADJ","v":0}]
[null,"A - General DSH Year Information",11,"DSH Pool Type","1.00","Answer","2019-06-30","Adjust answer based on review results.",{"$f":"DSHPool","v":0},0,{"$f":"DSHPool_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",4,"OB 1 Name","1.00","Answer","2019-06-30","Adjust answer based on review results.",{"$f":"LA_OBName1","v":0},0,{"$f":"LA_OBName1_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",4,"OB 2 Name","1.00","Answer","2019-06-30","Adjust answer based on review results.",{"$f":"LA_OBName2","v":0},0,{"$f":"LA_OBName2_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",4,"OB 1 License Number","1.00","Answer","2019-06-30","Adjust answer based on review results.",{"$f":"OBLicense_1","v":0},0,{"$f":"OBLicense_1_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",4,"OB 2 License Number","1.00","Answer","2019-06-30","Adjust answer based on review results.",{"$f":"OBLicense_2","v":0},0,{"$f":"OBLicense_2_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",4,"OB 1 Medicaid Number","1.00","Answer","2019-06-30","Adjust answer based on review results.",{"$f":"OBMedicaid_1","v":0},0,{"$f":"OBMedicaid_1_ADJ","v":0}]
[null,"B - DSH OB Qualifying Information",4,"OB 2 Medicaid Number","1.00","Answer","2019-06-30","Adjust answer based on review results.",{"$f":"OBMedicaid_2","v":0},0,{"$f":"OBMedicaid_2_ADJ","v":0}]

{"sheet":"Calculation","index":10,"n_rows":49,"n_cols":7,"rows_kept":49,"cut":false,"hidden":true,"merged":[[44,2,44,5],[45,2,45,5],[46,2,46,5],[47,2,47,5],[48,2,48,5]]}
[]
[{"$f":"CONCATENATE(\"SFY \",Year, \" Survey Shortfall/(Longfall) Preliminary Calculation\")","v":"SFY 2019 Survey Shortfall/(Longfall) Preliminary Calculation"},null,"All the data used here are ONLY for SFY claims falling within the cost report period."]
[]
[]
["Provider Information:"]
[]
[null,null,"Data"]
["1a.","Medicaid #",{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,2,FALSE)","v":"M'Caid #"}]
["1b.","Provider Name",{"$f":"HOSPITALNAME","v":"SELECT HOSPITAL NAME"}]
["1c.","Medicare #",{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,5,FALSE)","v":"M'care #"}]
["1d.","Is this a Municipal hospital?"]
[]
["Calculation of Uncompensated Care Cost (UCC):"]
[]
[null,null,null,null,"Cost Report Year 1",null,"Cost Report Year 2"]
[null,null,null,null,"Survey Part II",null,"Survey Part II"]
["2a.","In-State Medicaid Eligible UCC (Paid + Exhibit C SFY data)","Survey Part II, Section H, Ln. 145, Col. AV + AX",null,0,null,0]
["2b.","In-State Uninsured UCC (Exhibit A and B SFY data)","Survey Part II, Section H, Ln. 145, Col. AR + AT",null,0,null,0]
["2c.","OOS Medicaid Eligible UCC (Exhibit D SFY data)","Survey Part II, Section I, Ln. 143, Col. X + Z",null,0,null,0]
[2,"Total Medicaid Eligible and Uninsured UCC","2 = 2a + 2b + 2c",null,{"$f":"SUM(E17:E19)","v":0},null,{"$f":"SUM(G17:G19)","v":0}]
[]
[3,"1011 Payments (SFY basis)","Survey Part II, Section E, Ln. 7",null,0,null,0]
[4,"OOS DSH and OOS Supplemental Payments (SFY basis)","Survey Part II, Section E, Ln. 8 ",null,0,null,0]
[]
[5,"Tax Assessment Effect","Survey Part II, Section L, Ln. 25, Col. K",null,0,null,0]
[]
[6,"Medicaid Eligible and Uninsured UCC after all payments (GME to Crossover claims, 1011 and OOS DSH/Suppl, etc.) and Tax Assessment Effect","6 = 2 - 3 - 4 + 5",null,{"$f":"E20-E22-E23+E25","v":0},null,{"$f":"G20-G22-G23+G25","v":0}]
[]
[null,null,null,null,{"$f":"CONCATENATE(\"SFY \",Year)","v":"SFY 2019"}]
["7a.","SFY Managed Care HAF Payments","Survey Part I, Section C, 1a + 1b",null,0]
["7b.","SFY Managed Care Medical Education Payments ","Survey Part I, Section C, 2a + 2b",null,0]
[]
[8,{"$f":"CONCATENATE(\"SFY \", Year,\" Calculated Medicaid Eligible and Uninsured UCC\")","v":"SFY 2019 Calculated Medicaid Eligible and Uninsured UCC"},"8 = 6 - 7a - 7b",null,{"$f":"E27+G27-E30-E31","v":0}]
[]
[9,"Trended UCC (after all payments) for Municipal","If the above 1d is \"Yes\""]
[]
[10,{"$f":"CONCATENATE(\"SFY \", Year,\" DSH Payments\")","v":"SFY 2019 DSH Payments"},"State provided data",null,{"$f":"RetainDSHYes","v":0}]
[]
[]
["Confirmation:"]
[]
[null,{"$f":"CONCATENATE(\"We used all the information from submitted \", \"SFY \", Year,\" DSH Exam survey I and II to complete the above calculation, and the days, charges, and payments reported above are only for claims covering\")","v":"We used all the information from submitted SFY 2019 DSH Exam survey I and II to complete the above calculation, and the days, charges, and payments reported above are only for claims covering"}]
[null,{"$f":"CONCATENATE(\"SFY \", Year, \".\",\" We understand the above is a preliminary calculation only, and the final \", \"SFY \", Year,\" UCC is subject to Myers & Stauffer's review and adjustment.\")","v":"SFY 2019. We understand the above is a preliminary calculation only, and the final SFY 2019 UCC is subject to Myers & Stauffer's review and adjustment."}]
[]
[null,"Name:"]
[null,"Title:"]
[null,"Firm Name:"]
[null,"Telephone Number:"]
[null,"E-Mail Address:"]