IRF PPS PS & R and Claims Issues
TK P R O V I D E R S T A T I S T I C A L A N D R E I M B U R S E M E N T S Y S T E M
PROGRAM ID: MD430502 - V28.0 PAGE: 421
PAID DATES: 01/01/02 THRU 04/15/03 PROVIDER SUMMARY REPORT REPORT #: OD44203
RUN DATE: 04/23/03 INPATIENT REHABILITATION - PART A REPORT TYPE: 11R
PROVIDER FYE: 12/31 PROSPECTIVE PAYMENT PROVIDER
PROVIDER NUMBER: 00T000 Rehabilitation Hosp
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REVENUE SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD
CODE DESCRIPTION 01/01/02 - 12/31/02 00/00/00 - 00/00/00 00/00/00 - 00/00/00 00/00/00 - 00/00/00
UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES
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TOTAL CHARGES $609,680.45 $.00 $.00 $.00
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________________ ________________ ________________ ________________
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FEDERAL SPECIFIC $257,119.33 $.00 $.00 $.00
COST OUTLIER $634.99 $.00 $.00 $.00
LIP PAYMENTS $2,216.15 $.00 $.00 $.00
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FEDERAL PAYMENTS $259,970.47 $.00 $.00 $.00
HOSPITAL SPECIFIC $110,477.08 $.00 $.00 $.00
GROSS REIMBURSEMENT $370,447.55 $.00 $.00 $.00
LESS:
CASH DEDUCTIBLE $2,436.00 $.00 $.00 $.00
BLOOD DEDUCTIBLE $.00 $.00 $.00 $.00
COINSURANCE $.00 $.00 $.00 $.00
NET PRIMARY PAYOR
PAYMENTS MADE UNDER MSP $.00 $.00 $.00 $.00
OTHER (1) $17,775.80- $.00 $.00 $.00
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NET REIMBURSEMENT $385,787.35 $.00 $.00 $.00
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________________ ________________ ________________ ________________
INFORMATIONAL ONLY:
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INTEREST PAYMENTS $.00 $.00 $.00 $.00
PENALTY AMOUNT $.00 $.00 $.00 $.00
CMG DISCHARGE FRACTION 0.0000 0.0000 0.0000 0.0000
CMG WEIGHT 0.0000 0.0000 0.0000 0.0000
CMG WEIGHT FRACTION 0.0000 0.0000 0.0000 0.0000
Page Last Updated: Wednesday, 31-Dec-2008 10:49:08 CST
