LỊCH CHƯƠNG TRÌNH 4B: tính toán NONCONTRACT CỦA CHI PHÍ DỊCH VỤ MEDI-CAL bệnh nhân nội trú thường lệ Nhà cung cấp Tên: SAN FRANCISCO CHUNG BỆNH VIỆN cung cấp số ZZR00228W đơn vị CHĂM SÓC ĐẶC BIỆT 1. Tổng số bệnh nhân nội trú thường xuyên Chi phí (8 Sch, Line , Col 27) 2. Tổng số bệnh nhân nội trú ngày (adj) 3. Trung bình mỗi Diệm Chi phí 4. Medi-Cal bệnh nhân nội trú ngày (adj) 5. Chi phí áp dụng cho Medi-Cal. | STATE OF CALIFORNIA Provider Name SCHEDULE 4B PROGRAM NONCONTRACT COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST Fiscal Period Ended SAN FRANCISCO GENERAL HOSPITAL JUNE 30 2009 Provider No. ZZR00228W SPECIAL CARE UNITS REPORTED AUDITED 1. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 2. Total Inpatient Days Adj 0 0 3. Average Per Diem Cost 4. Medi-Cal Inpatient Days Adj 0 5. Cost Applicable to Medi-Cal 0 0 6. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 7. Total Inpatient Days Adj 0 0 8. Average Per Diem Cost 9. Medi-Cal Inpatient Days Adj 0 10. Cost Applicable to Medi-Cal 0 0 11. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 12. Total Inpatient Days Adj 0 0 13. Average Per Diem Cost 14. Medi-Cal Inpatient Days Adj 0 15. Cost Applicable to Medi-Cal 0 0 16. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 17. Total Inpatient Days Adj 0 0 18. Average Per Diem Cost 19. Medi-Cal Inpatient Days Adj 0 20. Cost Applicable to Medi-Cal 0 0 21. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 22. Total Inpatient Days Adj 0 0 23. Average Per Diem Cost 24. Medi-Cal Inpatient Days Adj 0 25. Cost Applicable to Medi-Cal 0 0 26. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 27. Total Inpatient Days Adj 0 0 28. Average Per Diem Cost 29. Medi-Cal Inpatient Days Adj 0 30. Cost Applicable to Medi-Cal 0 0 31. Medi-Cal Routine Cost Sum of Lines 5 10 15 20 25 30 0 0 This is trial version To Schedule 4 STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT SCHEDULE OF MEDI-CAL ANCILLARY COSTS Provider Name SAN FRANCISCO GENERAL HOSPITAL Fiscal Period Ended JUNE 30 2009 Provider No ZZR00228W TOTAL ANCILLARY COST TOTAL ANCILLARY CHARGES Adj 20 RATIO COST TO CHARGES MEDI-CAL CHARGES From Schedule 6 MEDI-CAL COST ANCILLARY COST CENTERS Operating Room 40 164 281 77 824 637 0 0 Delivery Room and Labor Room 6 753 212 4 642 051 0 0 Anesthesiology 8 903 388
