4/19/04 Instructions for completing the 2003 RHCF report.

April 19, 2004

Dear Client,

As part of our continuing service, the following documentation will to assist you in completing the N.Y. State RHCF-IV, annual cost report.

Except as noted otherwise, all reports are produced by program PMGEN.

Instructions are based on the latest version of Part I - Statistical Data.

Print the census reports for the entire year by specifying the range of dates from 1/1/03 - 12/31/03 before running the following reports. (Note: You can now run this report once for the entire year by specifying a range of dates from 1/1/03 - 12/31/03.)

Sincerely,

Reliable Health Systems, Inc.

encl.

Page 3, Part 1-3, Lines 10-11(Scr: 1-2-2) Number of Days of Care Total Medicaid Days - (Not)/Eligible Part B

Run program ARGEN2 [AR, 5, 10] from any menu and press ENTER. Run the report as shown. Items that are in bold need are not initialized and need to be entered. Verify (Y/N): N All Billing Types Level of Care: Budget Ancillary _ Medicaid Medicare Pvt VA Other =============== ================ ================== X MEDICAID MA MEDICARE MC PRIVATE PVT _ NYS ADD ON =========================================================================== Report on Billing/ Cash Receipt/Outstanding (B/C/O): B Residents: A - ZZ Processing Order: S Report Type: G Report Order By: 1 (P)-By Posting Date P- Pat.total R- Regular 1- Resident 2- Date (S)-By Service Date S- Subtotal G- Grand Ttl 3- Denial# 4- Bill DATES --- Ancillaries --- Posted : 12/31/2099 Billed/Not Billed: YY No. 9999999 Service: 01/01/2003 12/31/2003 User ID: ZZZ Bill types: Logon : 12/31/2099 Amounts: -99999.99 99999.99 Ancl.Class: Billed : 12/31/2099 Source (credit) : ZZ Attend Dr.: ZZZ Record Types : YNYY YY Rec.Type YYYY (Reg./X/V/A) Diag.: Reg/Coin/Elg/NonElg Bh/Thr Denial No.: 99999 Receiv.From: Room Category : Z Set to Bill Z Pending: Z Type : Z Subtype(Mc: 9999 Resident Participation Include in Open Items Print Only Part. : Credits : Bill Types(credit): - 99 Overpayment: Report Header: Print Option: S The breakdown of days appear on the last line of the report: GRAND TOTALS 281 ELIG.B DAYS 185 NON ELIG.B DAYS(INCL BH) 96

Part 1-3 B8, line 18 Number of Bed Reservations established during year.
Add the total hospital and therapeutic bed hold days shown in the following two reports:

Title: THERAPEUTIC BH ESTABLISHED From Resident:A To: ZZ Activity Info. From Date:01/01/03 To:12/31/2003 Detail/Master(A/M):A Active as of Latest Bill Code: Print Option: P Field From Range To Range sort 1)47 2) Print if All/Any fields are applicable (All/Any) :ANY --------------------------------------------------------------------------- DEMO Company THERAPEUTIC BH ESTABLISHED ID PATIENT NAME THER BH ACTIVITY-DATE ----- ------------------------ ---------------- ------------- 10000 Axxx,bbb THER BH 02 03/18/03 10006 Bxxx,ddddd THER BH 01 12/31/03 10009 Cxxxx,eeeee THER BH 03 03/18/03 THER BH 04 04/04/03 THER BH 01 07/17/03 THER BH 07 08/06/03 10007 Dxxx,rrrrr THER BH 02 02/14/03 THER BH 02 05/10/03 THER BH 03 05/16/03 THER BH 01 06/30/03 THER BH 04 07/03/03 THER BH 05 07/15/03 THER BH 03 10/17/03 10008 Exxxx,xxxx THER BH 01 began before ‘03 10087 Fxxxx,fffff THER BH 01 04/07/03 11101 Gxxxx,ccccc THER BH 03 04/18/03 THER BH 03 04/25/03 THER BH 03 05/09/03 10053 Hxxxx,wewewe THER BH 01 10/11/03 THER BH 01 11/15/03 THER BH 01 11/27/03 ----- ------------------------ ---------------- ------------- 00008 21 52 20.00 <---- PATIENTS ON MORE THAN ONE BH IN COL.01 4 Therapeutic bedhold 08 = Number of residents 21 = Number of occurrences 52 = Days used in the 33 occurrences 20 = Times Therapeutic BH established in current year <----

Title: HOSPITAL BH ESTABLISHED From Resident: A To: ZZ Activity Info. From Date:01/01/03 To:12/31/2003 Detail/Master(A/M): A Active as of Latest Bill Code: Print Option: P Field From Range To Range sort 1)154 2) 3) 4) 5) 6) 7) 10) Print if All/Any fields are applicable (All/Any) :ANY ------------------------------------------------------------------------- DEMO NURSING HOME HOSPITAL BH ESTABLISHED ID PATIENT NAME HOSP BH ACTIVITY-DATE ----- ------------------------- ---------------- ------------- 21252 xxxxxx,MARIA HOSP BH 20 09/10/03 10002 xxxxxx,JOSEPH HOSP BH 21 08/10/03 10005 xxxxxx,HARRY HOSP BH 11 12/01/03 80009 xxxxxx,JOE HOSP BH 01 10/02/03 10024 xxxxxx,JENNIE HOSP BH 10 02/10/03 10206 xxxxxx,MOZELLE HOSP BH 09 01/01/03 88888 xxxxxx,MEDICARE HOSP BH 10 12/20/03 23513 xxxxxx,ROSE HOSP BH 356 01/10/03 ----- ------------------------- ---------------- ------------ 00008 8 438 8.00 <---- HOSPITAL bedhold 08 = Number of residents 08 = Number of occurrences 438 = Days used in the 08 occurrences 08 = Times Hospital BH established in current year <----

Note: Add the total in the previous report (20) to the total in this report (8) and insert the number in line 18.

Page 3, Part 1-3, Lines 19-21 (scr: 1-2-3)
Bed Reservations established and days

PATIENT RANGE : A-ZZ FROM DATE : 01/01/2003 TO DATE : 12/31/2003 ACTIVITY MASTER : A ACTIVE A/O : LEAVE BLANK PRINT OPTION : P FIELD FROM RANGE TO RANGE SORT ----- ---------- -------- ---- 1) 46 2) 47 3) 46 11 20 4) 47 11 20 ALL/ANY : ANY --------------------------------------------------------------------------

Report Generator ID PATIENT NAME HOSP BH THER BH HOSP BH THER BH ----- ------------ ------------- ------------ -------------- ------- 30888 AGARS,GEORGE HOSP.BH - 09 THER.BH - 02 HOSP.BH - 09 HOSP.BH - 24 HOSP.BH - 24 30004 DOE,SAM HOSP.BH - 07 31005 BETH,SARAH HOSP.BH - 02 HOSP.BH - 02 ----- ------------ ------------- ------------ -------------- ------- 00003 4 42 1 2 3 35 0 PATIENTS ON MORE THAN ONE BH IN COL.01 1 PATIENTS ON MORE THAN ONE BH IN COL.03 1 The above report provides the answers to the following: 8 ) Bed Reservations: Total = 5 8a) Days = 44 (Hospital + Therapeutic) 8b) Medicaid Bedhold: Total = 35 8c) Days = 0 (Therapeutic)

Page 5, Part 1-5, Lines 3-10 (Scr: 1-3-1)
Admissions during reporting period

PATIENT RANGE : A-ZZ FROM DATE : 01/01/2003 TO DATE : 12/31/2003 ACTIVITY MASTER : A ACTIVE A/O : LEAVE BLANK PRINT OPTION : P FIELD FROM RANGE TO RANGE SORT ----- ---------- -------- ---- 1) 85 1 skip at break - Y - ----------------- 2) 52 ALL/ANY : ALL --- -------------------------------------------------------------------------- Report Generator ID PATIENT NAME HOSP TYPE ADMISSION ACTIVITY-DATE ----- ----------------- --------- ------------------ ------------- 10234 BEICHLE,E. 01 HOPKIN 04/10/95 04/10/96 10213 BIRUM,STAN 01 HOME 05/01/95 05/01/96 10243 BREWSTER,F 01 HOPKIN 04/03/95 04/03/96 10244 BREWSTER,S 01 HOPKIN 01/24/95 01/24/96 [ 4 ] 10006 BACCHIERI,FAUSTINA 02 JOHN JAY 10/17/95 10/17/96 10009 BEASLEY,RUTH 02 JOHN JAY 10/30/95 10/30/96 10010 BENTLEY,MARY 02 JOHN JAY 11/28/95 11/28/96 [ 3 ] ----- ---------------- --------- ------------------ ----------- 00007 7 7 7.00 --------------------------------------------------------------------------- Note : Hosp. Types (01) HOME = 04 (02) HOSPITAL = 3 (03) SNF = 0 (04) HRF = 0 (05) OTHER = 0 (00) FACILITY NOT ENTERED IN HOSPITAL TABLE

Page 5, Part 1-5, Lines 14-21 (Scr: 1-3-2)
Discharges during reporting period

PATIENT RANGE : A-ZZ FROM DATE : 01/01/2003 TO DATE : 12/31/2003 ACTIVITY MASTER : A ACTIVE A/O : LEAVE BLANK PRINT OPTION : P FIELD FROM RANGE TO RANGE SORT ----- ---------- -------- ---- 1) 85 1 skip at break - Y - ----------------- 2) 86 ALL/ANY : ALL --- --------------------------------------------------------------------------- Report Generator ID PATIENT NAME HOSP TYPE FINAL DISCH DATE ----- -------------------- --------- -------------------- -------- 10008 BALDI,MARIE 00 EXPIRED-HOME2641 08/01/96 [ 1 ] 10011 BERG,ANNA 01 EXPIRED-OUT 559 01/10/96 10213 DIRNDAUM,EVA 01 NO BEDHOLD 93 08/01/96 [ 2 ] 10007 BAKTAY,EMERY 02 BH-RELEASE 5513 11/20/96 [ 1 ] ----- -------------------- --------- -------------------- -------- 00004 4 4 4.00 DAYS ON BH PRIOR TO RELEASE FOR COL.02 28 Note : Hosp. Types (01) HOME = 2 (02) HOSPITAL = 1 (03) SNF = 0 (04) HRF = 0 (05) OTHER = 0 (00) FACILITY NOT ENTERED IN HOSPITAL TABLE = 1

Page 6, Part 1-6, Lines 1-11 (Scr: 1-4-1)
Ages of Patients

PATIENT RANGE : A-ZZ FROM DATE : 01/01/2003 TO DATE : 12/31/2003 ACTIVITY MASTER : M ACTIVE A/O : 12/31/2003 - 12/31/2003 PRINT OPTION : P FIELD FROM TO SORT ----- ---- -- ---- 1) 18 M MZ 2) 139 16 20 3) 139 21 54 4) 139 55 64 5) 139 65 69 6) 139 70 74 7) 139 75 79 8) 139 80 84 9) 139 85 89 10) 139 90 ALL/ANY : ANY MUST INCLUDE FIELD: 1 -------------------------------------------------------------------------- Rerun the same report for females changing the first range to : FIELD FROM TO SORT ----- ---- -- ---- 1) 18 F FZ -------------------------------------------------------------------------- Note: If there are any resident in your facility in the age range of 0 - 15 you will need to rerun this report another 2 times as follows: FIELD FROM TO SORT ----- ---- -- ---- 1) 18 M MZ 2) 139 0 15 FIELD FROM TO SORT ----- ---- -- ---- 1) 18 F FZ 2) 139 0 15

Page 7, Part 1-7, Line 19 (Scr: 1-4-3)
Patients Previously Private

Note: For lines 12 - 17 use the figures on the 12/31/2003 census report.

PATIENT RANGE : A-ZZ FROM DATE : 01/01/70 TO DATE : 12/31/2003 ACTIVITY MASTER : M ACTIVE A/O : 12/31/2003 - 12/31/2003 Latest Bill Code : 11 PRINT OPTION : P FIELD FROM RANGE TO RANGE SORT ----- ---------- -------- ---- 1) 53 31 ALL/ANY : ANY Note: If you have multiple Medicaid bill types other than type '11' you should run this report as follows (and remove the '11' from Latest Bill Code above): 1) 53 31 2) 120 1 1 ALL/ANY : ALL

Page 8, Part 1-8, Lines 20-25 (Scr: 1-4-5)
New Admissions Payors

PATIENT RANGE : A-ZZ FROM DATE : 01/01/2003 TO DATE : 12/31/2003 ACTIVITY MASTER : A ACTIVE A/O : LEAVE BLANK PRINT OPTION : P FIELD FROM RANGE TO RANGE SORT ----- ---------- -------- ---- 1) 53 11 20 2) 53 * 21 30 3) 53 31 40 4) 53 41 *Facilities that have different codes for MC/Medicaid & MC/Pvt may add another line to separate them. ALL/ANY : ANY

Page 9, Part 1-9, Lines 26-50 (Scr: 1-5-1)
Length of Stay

From any screen type LENOFSTY or [GM, 2, 10] for the Length of Stay report. Enter 01/01/2003-12/31/2003 for the range of dates. The following is a sample printout. ------------------------------------------------------------------------------ LENGTH OF STAY ID PATIENT NAME HOSP.TYPE DAYS DISCHARGE INFO. ------ --------------------- --------- ---- ------------------ 31029 FOX,SALLY 06 31 EXPIRED-HOME [ 1 FOR 01 + MONTHS ] 31030 GREENE,TIMOTHY 01 121 NO BEDHOLD [ 1 FOR 04 + MONTHS ] ------ --------------------- --------- ---- ------------------ 2 ------------------------------------------------------------------------------- Note : Each Category is separated by Length of stay and facility [ 1 FOR 01 + MONTHS ] = 1 patient for the 1+ Month category for 'expired in facility'. [ 1 FOR 04 + MONTHS ] = 1 patient for the 4+ Month category for 'To Home' discharge. Hosp Types : 06 - Expired in facility See page 5 for other codes.

Page 10, Part 1-10, Lines 1-41 (Scr: 1-6-1)
Patient origin by county

PATIENT RANGE : A-ZZ FROM DATE : 12/31/2003 TO DATE : 12/31/2003 ACTIVITY MASTER : M ACTIVE A/O : 12/31/2003-12/31/2003 PRINT OPTION : P FIELD FROM RANGE TO RANGE SORT ----- ---------- -------- ---- 1) 42 1 Skip at Break Y 2) 13 2 3) 10 ALL/ANY : ANY