Được kiểm toán Chi phí trung bình mỗi ngày 1 Medi-Cal. 2. 3. 4. 5. Medi-Cal Chi phí dịch vụ Bao (Bảng 3, Line 8) Trừ: Chi phí Medi-Cal hành chính ngày (Bảng 4A, dòng 28 và 31) Tổng số chi phí Medi-Cal Dịch vụ Bao Theo giảm (1 trừ dòng 2) được kiểm toán ngày Medi-Cal (Danh mục 4, 4A, 4B, không bao gồm ngày hành chính) đã được kiểm toán Medi-Cal Chi phí mỗi ngày (3 ÷ dòng 4) $ $ 0 $ | STATE OF CALIFORNIA SCHEDULE A-4 PROGRAM NONCONTRACT COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT HFPAs WITH LESS THAN 3 HOSPITALS AB 5 10 REDUCTION FOR SERVICES FROM JULY 1 2008 THROUGH JUNE 30 2009 Provider Name MARIAN MEDICAL CENTER Provider No. ZZT30107H Fiscal Period Ended JUNE 30 2009 Audited Medi-Cal Cost Per Day 1. Medi-Cal Cost of Covered Services Schedule 3 Line 8 2. Less Medi-Cal Administrative Day Cost Schedule 4A Lines 28 and 31 3. Total Medi-Cal Cost of Covered Services Subject to Reductions Line 1 minus Line 2 0 4. Total Audited Medi-Cal Days Schedules 4 4A and 4B excludes Administrative Days 5. Audited Medi-Cal Cost Per Day Line 3 Line 4 10 Cost Reduction For Services From 07 01 08 Through 06 30 2009 6. Audited Medi-Cal Days of Service from 07 01 08 - 06 30 2009 excludes Administrative Days 7. Audited Medi-Cal Cost Per Day for 07 01 08 - 06 30 2009 Line 5 X Line 6 0 8. 10 Cost Reduction for 07 01 08 - 06 30 2009 Line 7 X 10 0 To Schedule A Ln 4 This is trial version STATE OF CALIFORNIA SCHEDULE A-5 RURAL HEALTH PROGRAM NONCONTRAcT COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT RURAL HEALTH HOSPITALS AB 5 10 REDUCTION FOR SERVICES FROM JULY 1 2008 THROUGH OCTOBER 31 2008 Provider Name MARIAN MEDICAL CENTER Provider No. ZZT30107H Fiscal Period Ended JUNE 30 2009 Audited Medi-Cal Cost Per Day 1. Medi-Cal Cost of Covered Services Schedule 3 Line 8 2. Less Medi-Cal Administrative Day Cost Schedule 4A Lines 28 and 31 3. Total Medi-Cal Cost of Covered Services Subject to Reductions Line 1 minus Line 2 0 4. Total Audited Medi-Cal Days Schedules 4 4A and 4B excludes Administrative Days 5. Audited Medi-Cal Cost Per Day Line 3 Line 4 10 Cost Reduction For Services From 07 01 08 Through 10 31 0 6. Audited Medi-Cal Days of Service from 07 1 08 - 10 31 08 excluding Administrative Days 7. Audited Medi-Cal Cost Per Day for 07 01 08 - 10 31 08 Line 5 X Line 6 0 8. 10 Cost Reduction for 07 01 08 - 10 31 08 Line 7 X 10 0 To Schedule A
