**1.0 A/R CONVERSION AND RECONCILIATION OVERVIEW**

**1.1 Purpose**

Providing useful, accurate, and reliable financial data is the top
priority for the Accounts Receivable data conversion. In order to
implement and support the financial activities within UFMS, the data
converted from RPMS needs to be current (within two years of the October
1, 2007 Go Live date) and reconciled with the general ledger. This
document addresses strategies and methodologies for systematic clean-up
and reconciliation of converted accounts receivable data.

Reconciliation means to bring into agreement two or more financial
records or reports that represent the same business information. The
Accounts Receivable Conversion activities are necessary to 1)
authenticate that converted financial data is accurate and 2) validate
that no financial transactions have been lost or duplicated.

This document is intended as a working document that will be enhanced
and modified as additional reconciliations activities are executed and
identified. It may be used as a supplement to the IHS UFMS Conversion
Strategy document, which addresses the conversion and data validation
strategies.

**2.0 Data Clean-up Process Activities**

**2.1 Tax ID Process**

Prior to conversion to UFMS, all federal sites must begin the process of
identifying the tax ID numbers for the Third Party Payers. UFMS will use
this unique identifier for the RPMS to create customer files for the
RPMS patient accounts for payment purposes. This information needs to be
captured in the federal sites RPMS databases by March 31, 2007. To
facilitate this process, each Area Business Office coordinator will:

1\. Accumulate all of the 1099 forms that were received by their
facilities or their Finance Office to the current date and for the next
year. Within these forms are the names and addresses of the payers as
well as the Tax ID number. These Tax ID numbers need to be populated
into RPMS. Because the Third Party and Patient Registration modules in
RPMS have not been modified to allow for the entry of these numbers,
Appendix A provides a Fileman report for Area/Sites to use to populate
these numbers; or

2\. Run an RPMS Fileman report to identify payers for each facility
location that have been billed back to October 1, 2005. The listing that
is printed from each site should be converted to an Excel spreadsheet
that should be accumulated at the Area Office and submitted to Sandra
Lahi or Sharon Sorrell for further accumulation into the master
spreadsheet, Appendix B is provided for guidance.

There will be methods that can be shared across the Areas and facilities
on existing Tax ID numbers that are currently available. If the Area has
a listing that they need assistance with, they can contact Sandra Lahi
or Sharon Sorrell, who will research and locate those numbers for the
Area and provide the information for input into RPMS.

**2.2 Accounts Receivable Clean-up \> Two Years**

Prior to conversion to UFMS, all sites must complete the process of
accounts receivable data clean-up. This data clean-up pertains to
federal sites RPMS databases and must be completed by April 30, 2007.
Each site must clear all accounts with balances that are older than
10/1/05. To facilitate this process an auto-write off (AWO) tool for
receivables, prior to October 1, 2005, is available in RPMS, Appendix
C.. This auto-write off must be compliant with the Debt Management
Policy.

Alternatively, sites can post/adjust these old accounts manually or
contract for this service to be done for them via an outside contractor.
However, all clean-up must be completed by April 30, 2007.

After the sites run the AWO key, it is important for each site to run a
report of all accounts written off to make sure the proper accounts were
written off. The Detailed Fileman report is available and is optional if
the site wishes to do this step to confirm the data, Appendix D.

The Summary Fileman report by Insurer will provide information by each
Insurance company of all of the accounts that were written off with the
AWO key, Appendix E. This report is to be printed and attached to the
Debt Management letter to verify that the total dollar amounts were less
than the delegated authority for write offs as designated for the CEO or
Area Director. These documents should remain on file at the facility
and/or Area Office.

**2.3 Accounts Receivable Clean-up \< Two Years**

Prior to conversion to UFMS, all sites must complete the process of
accounts receivable data clean-up for accounts less than 2 years old.
This data clean-up pertains to federal site's RPMS databases and must be
completed by May 25, 2007. To facilitate this process, each site must:

1\. Post all payments received to the appropriate accounts and adjust
any remaining uncollectible balances.

2\. At close of business on May 31, 2007, run an ASM report and forward
to the Area FMO for summarization in the attached spreadsheet, Appendix
F.

3\. On the last day of each month, from June 2007 to September 2007, run
an ASM report for that month and forward to the Area FMO for
summarization.

**3.0 Reconciliation Process Activities**

1.  **Data Extraction**

Beginning May 31, 2007 and ending September 30, 2007, the FMO for each
area will summarize the ASMs from each server on the attached
spreadsheet and also detail the balance in CORE for each payer type. A
copy of the spreadsheet is to be sent to Sandra Winfrey or Ron Grinnell
at the Headquarters Office of Finance and Accounting as well as to
Sandra Lahi.

If the data extracts between RPMS and CORE do not balance, Headquarters
will reverse the CORE balance and post the correct RPMS balance to CORE.

**4.0 Reconciliation Documentation**

It is critical to the success of any data conversion to have a complete
reconciliation plan including standardized reconciliation worksheet. A
standard Accounts Receivable Reconciliation Worksheet will be used to
support the reconciliation process. This worksheet will document the
reconciliation of the CORE balances and the RPMS balances reconciliation
and is designated as the audit document.

**Fileman Template for Printing a Listing of Active Insurances with
Addresses**

When you print ACTIVE INSURER: (do not forget to put the colon) after so
the system can go to the insurer File. 

Use a "\^" as a delimiter so the report can [load into
Excel]{.underline} and then filter to find the unique insurers. 

NUMBER: 2266                            NAME: AZPDPBUFMSCUST

  DATE CREATED: DEC 19, 2006@07:58      READ ACCESS: @

  FILE: 3P BILL                         USER #: 1286

  WRITE ACCESS: @                       DATE LAST USED: FEB 14, 2007

  SUB-HEADER SUPPRESSED: YES

  HEADER (c): @

  FIRST PRINT INSURER FIELD: ACTIVE INSURER://

  THEN PRINT INSURER FIELD: NAME;C1;L45;\"\"//

  THEN PRINT INSURER FIELD: \"\^\";C46;L1//

  THEN PRINT INSURER FIELD: STREET;C47;L20;\"\"//

  THEN PRINT INSURER FIELD: \"\^\";C67;L1//

  THEN PRINT INSURER FIELD: CITY;C68;L25;\"\"//

  THEN PRINT INSURER FIELD: \"\^\";C93;L1//

  THEN PRINT INSURER FIELD: STATE;C94;L20;\"\"//

  THEN PRINT INSURER FIELD: \"\^\";C114;L1//

  THEN PRINT INSURER FIELD: ZIP;C115;L10;\"\"//

  THEN PRINT INSURER FIELD: \"\^\";C125;L1//

  THEN PRINT INSURER FIELD: PHONE;C126;L14;\"\"//

  THEN PRINT INSURER FIELD: \"\^\";C140;L1//

  THEN PRINT INSURER FIELD: CONTACT PERSON;C141;L25;\"\"//

  THEN PRINT INSURER FIELD: \"\^\";C166;L1//

**  THEN PRINT INSURER FIELD: FEDERAL TAX ID #;C167;L9;\"\"//**

  THEN PRINT INSURER FIELD: \"\^\";C176;L1//

  THEN PRINT INSURER FIELD: //

THEN PRINT FIELD: //

  COMPILED (c): NO

Below is the Search template. The system searched for bills that were
approved in the time frame given.  It then sorted by the active insurer
and at the first print Field, it used the print template.  This is then
saved off and loaded into an Excel document. You can then run reports on
this data.

Select VA FileMan Option: SEARCH File Entries

OUTPUT FROM WHAT FILE: PRINT TEMPLATE// 3P BILL    (143044 entries)

  -A- SEARCH FOR 3P BILL FIELD: DATE/TIME APPROVED 

  -A- CONDITION: \>  GREATER THAN

  -A- GREATER THAN DATE: 09302005  (SEP 30, 2005)

  -B- SEARCH FOR 3P BILL FIELD:

IF: A//   

              DATE/TIME APPROVED GREATER THAN the entire day SEP 30,2005
(09302005)

STORE RESULTS OF SEARCH IN TEMPLATE:

SORT BY: BILL NUMBER// ACTIVE INSURER 

START WITH ACTIVE INSURER: FIRST//

  WITHIN ACTIVE INSURER, SORT BY:

FIRST PRINT FIELD: AZPDPBUFMSCUST

WANT TO EDIT \'AZPDPBUFMSCUST\' TEMPLATE? No//   (No)

Heading (S/C): @//

DEVICE: ;150;90000

**ENTERING THE PAYER TAX ID \# VIA FILEMAN**

\*\*\* The User will need the \# character populated in the User's
Fileman Access Code to enter this information.

\*\*\* This menu should only be followed by a person who fully
understands the Fileman system to allow protection of the files.   See
Below:

Select IHS Kernel Option: va  VA FileMan

          VA FileMan Version 22.0

          Enter or Edit File Entries

          Print File Entries

          Search File Entries

          Modify File Attributes

          Inquire to File Entries

          Utility Functions \...

          Data Dictionary Utilities \...

          Transfer Entries

          Other Options \...

Select VA FileMan Option: ENTER or Edit File Entries

INPUT TO WHAT FILE: INSURER//

EDIT WHICH FIELD: ALL// .11  FEDERAL TAX ID \#

THEN EDIT FIELD:

Select INSURER NAME: WASHINGTON MEDICAID

WASHINGTON MEDICAID                  - 1220 SW 3RD AVENUE

                                       PORTLAND, WA 97204

 OK? Y//

**FEDERAL TAX ID #: 911050000**

Select INSURER NAME:

          Enter or Edit File Entries

          Print File Entries

          Search File Entries

          Modify File Attributes

          Inquire to File Entries

          Utility Functions \...

          Data Dictionary Utilities \...

          Transfer Entries

          Other Options \...

SEE RESULTS BELOW:

NUMBER: 694                             NAME: WASHINGTON MEDICAID

  STREET: 1220 SW 3RD AVENUE            CITY: PORTLAND

  STATE: WASHINGTON                     ZIP: 97204

  PHONE: (360)384-0464                  CONTACT PERSON: JOE SMOE

**  FEDERAL TAX ID #: 911050000**           STATUS: BILLABLE

  TYPE OF INSURER: MEDICAID FI          ALL INCLUSIVE BILLING (Y/N): NO

  RX BILLING STATUS: BILLED POINT OF SALE

  BACKBILLING LIMIT (MONTHS): 12        OLD DFN: 1440

  LONG NAME: WASHINGTON MEDICAID

**STEP 1 -- Preparing to run the Automatic Write Off (AWO) option.**

1.  First, complete the following requirements in preparation for the
    AWO:

> a\) Rollback (ROL) the A/R bills to Third Party. Use this feature if
> you are not using the option to rollback immediately after hitting (P)
> for post on the account. Most sites are rolling back as soon as they
> post the individual account.
>
> b\) Bill File Error Scan (BES) -- this option scans the A/R bill file
> for problems BY A DATE OF SERVICE DATE RANGE (there is no report
> printout) and it will show you the date of the last time the BES was
> run. In RPMS, run the BES date that displays on your system.
> (Reminder: the (BES) has to be run first before any of the following
> reports can be generated)

c)  Generate the Aged Summary (ASM) Report

d)  Generate the Negative Balance (NEG) Report

e)  Generate the Small Balance (SB) Report

f)  Generate the Ages Open Items (AOI) Report

-   Review the AOI for patient accounts that have a date of service
    (DOS) up to and including 9/30/05. \*REMEMBER, BILLS WITH A NEGATIVE
    BALANCE WILL NOT BE WRITTEN OFF BY THE AWO.

-   Correct ALL negative balances in these patient accounts

-   If you have fractional amounts, refer to your Site Manager for
    assistance on these accounts. They may need to contact the OIT Help
    Desk for assistance.

2.  Once you are sure that the patient accounts up to and including
    9/30/05 are corrected, then prepare to run the AWO option.

**\*\*\*REMINDER! IT IS IMPORTANT NOT TO DO ANY BILLING OR POSTING WHILE
THE AWO OPTION IS RUNNING\*\*\***

3.  **RUNNING THE AWO** **OPTION**

> With this option, you will write off bills with dates of service up to
> and including 9/30/05. So in RPMS at the date prompt, enter the DOS up
> to and including 9/30/05. All Bills found within the specified DOS are
> written off to code 503 Write Off 2007.

4.  **POST -- AWO option steps:**

> a\. Run the BES again --(back to 10/1/2001) this is to ensure that the
> system will identify any problems that may have occurred during the
> AWO process.
>
> b\. Generate the AOI report for comparison purposes to the previously
> run reports
>
> c\. Generate the ASM report and submit to your Finance Office.
>
> d\. Use the Fileman report attached that can be used to list the
> accounts that were posted with the AWO 916 Write Off 2007 adjustment
> code.
>
> 5\. For patient accounts with open balances and with DOS after
> September 30, 2005 must be researched and posted according to the
> Remittance Advice documents received on site.

***[REMEMBER]{.underline}*:** The AWO option is only available in RPMS
until April 30, 2007. The outstanding receivables that will be booked
into CORE must be reasonable amounts and must be supported in case of a
financial audit.

# 

Select VA FileMan Option: **[SEARCH]{.underline}** File Entries

OUTPUT FROM WHAT FILE: **[A/R TRANSACTIONS/IHS]{.underline}**

-A- SEARCH FOR A/R TRANSACTIONS/IHS FIELD: **[ADJUSTMENT
TYPE]{.underline}**

-A- CONDITION: **[EQUALS]{.underline}**

-A- EQUALS A/R TABLE ENTRY/IHS: ­**[916]{.underline}** AUTO WRITE-OFF
2007

-B- SEARCH FOR A/R TRANSACTIONS/IHS FIELD:

IF: A// ADJUSTMENT TYPE EQUALS 916 (AUTO WRITE-OFF 2007)

STORE RESULTS OF SEARCH IN TEMPLATE:

SORT BY: DATE/TIME// **[VISIT LOCATION+]{.underline}**

START WITH VISIT LOCATION: FIRST//

WITHIN VISIT LOCATION, SORT BY: **[A/R ACCOUNT:]{.underline}**

A/R ACCOUNTS/IHS FIELD: **[VP INSURER TYPE;S1]{.underline}**

START WITH VP INSURER TYPE: FIRST//

WITHIN VP INSURER TYPE, SORT BY: **[A/R ACCOUNT;S1+]{.underline}**

START WITH A/R ACCOUNT: FIRST//

WITHIN A/R ACCOUNT, SORT BY:

STORE IN \'SORT\' TEMPLATE:

FIRST PRINT FIELD: **[A/R ACCOUNT;N]{.underline}**

THEN PRINT FIELD: **[BILL (A/R)!]{.underline}**

THEN PRINT FIELD: **[CREDIT;R10&]{.underline}**

1 CREDIT

2 CREDIT - DEBIT

CHOOSE 1-2: **[1]{.underline}** CREDIT

THEN PRINT FIELD:

Heading (S/C): A/R TRANSACTIONS/IHS STATISTICS Replace
**[\...]{.underline}** With **[2007 AUTO WRITE OFF REPORT]{.underline}**

Replace

2007 AUTO WRITE OFF REPORT

DEVICE:

2007 AUTO WRITE OFF REPORT MAR 13,2007 15:32 PAGE 1

A/R ACCOUNT BILL (A/R) CREDIT

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

VISIT LOCATION: INDIAN HEALTH HOSPITAL

VP INSURER TYPE: MEDICAID FI

CIMARRON SALUD 14648B-JSU 48.00

14948A-JSU 85.94

14857B-JSU 105.00

14648B-JSU -48.00

14948A-JSU -85.94

14857B-JSU -105.00

14648B-JSU -48.00

14948A-JSU -85.94

14857B-JSU -105.00

14648B-JSU 48.00

14948A-JSU 85.94

14857B-JSU 105.00

14648B-JSU -48.00

14948A-JSU -85.94

14857B-JSU -105.00

14648B-JSU 48.00

14948A-JSU 85.94

14857B-JSU 105.00

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--SUBTOTAL
0.00

SUBCOUNT 18

LOVELACE SALUD 17041A-JSU 95.00

15866A-JSU 322.00

15921A-JSU 16.00

17041A-JSU -95.00

15866A-JSU -322.00

15921A-JSU -16.00

17041A-JSU -95.00

15866A-JSU -322.00

15921A-JSU -16.00

17041A-JSU 95.00

15866A-JSU 322.00

15921A-JSU 16.00

17041A-JSU -95.00

A/R ACCOUNT BILL (A/R) CREDIT

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

15866A-JSU -322.00

15921A-JSU -16.00

17041A-JSU 95.00

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

SUBTOTAL -338.00

SUBCOUNT 16

Select VA FileMan Option: **[SEARCH]{.underline}** File Entries

OUTPUT FROM WHAT FILE: **[A/R TRANSACTIONS/IHS]{.underline}**

-A- SEARCH FOR A/R TRANSACTIONS/IHS FIELD: **[ADJUSTMENT
TYPE]{.underline}**

-A- CONDITION: **[EQUALS]{.underline}**

-A- EQUALS A/R TABLE ENTRY/IHS: ­**[916]{.underline}** AUTO WRITE-OFF
2007

-B- SEARCH FOR A/R TRANSACTIONS/IHS FIELD:

IF: A// ADJUSTMENT TYPE EQUALS 916 (AUTO WRITE-OFF 2007)

STORE RESULTS OF SEARCH IN TEMPLATE:

SORT BY: DATE/TIME// **[VISIT LOCATION+]{.underline}**

START WITH VISIT LOCATION: FIRST//

WITHIN VISIT LOCATION, SORT BY: **[A/R ACCOUNT:]{.underline}**

A/R ACCOUNTS/IHS FIELD: **[VP INSURER TYPE;S1]{.underline}**

START WITH VP INSURER TYPE: FIRST//

WITHIN VP INSURER TYPE, SORT BY: **[A/R ACCOUNT+]{.underline}**

START WITH A/R ACCOUNT: FIRST//

WITHIN A/R ACCOUNT, SORT BY:

STORE IN \'SORT\' TEMPLATE:

FIRST PRINT FIELD: **[BILL (A/R)!]{.underline}**

THEN PRINT FIELD: **[CREDIT;R10&]{.underline}**

1 CREDIT

2 CREDIT - DEBIT

CHOOSE 1-2: **[1]{.underline}** CREDIT

THEN PRINT FIELD:

Heading (S/C): A/R TRANSACTIONS/IHS STATISTICS Replace
**[\...]{.underline}** With **[2007 AUTO WRITE OFF REPORT]{.underline}**

Replace

2007 AUTO WRITE OFF REPORT

DEVICE:

2007 AUTO WRITE OFF REPORT MAR 13,2007 15:32 PAGE 1

BILL (A/R) CREDIT

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

VISIT LOCATION: INDIAN HEALTH HOSPITAL

VP INSURER TYPE: MEDICAID FI

A/R ACCOUNT: CIMARRON SALUD

SUBTOTAL 0.00

SUBCOUNT 18

A/R ACCOUNT: LOVELACE SALUD

SUBTOTAL -338.00

SUBCOUNT 16

A/R ACCOUNT: NEW MEXICO MEDICAID

SUBTOTAL -2448.00

SUBCOUNT 314

A/R ACCOUNT: PRESBYTERIAN SALUD

SUBTOTAL -169.53

SUBCOUNT 58

SUBTOTAL -2955.53

SUBCOUNT 406

VP INSURER TYPE: PRIVATE

A/R ACCOUNT: AETNA LIFE INSURANCE

SUBTOTAL 0.00

SUBCOUNT 6

A/R ACCOUNT: BC/BS OF OKLAHOMA

SUBTOTAL -5.49

SUBCOUNT 41

A/R ACCOUNT: BCBS OF ARIZONA

SUBTOTAL 0.00

SUBCOUNT 12

A/R ACCOUNT: BCBS OF NEW MEXICO

SUBTOTAL -654.90

SUBCOUNT 316

A/R ACCOUNT: BCBS OF NEW MEXICO (FEP)

SUBTOTAL -354.16

SUBCOUNT 152

A/R ACCOUNT: BCBS OF NEW MEXICO (NMPSIA)

SUBTOTAL -170.70

SUBCOUNT 164

A/R ACCOUNT: BCBS OF NEW MEXICO - ITS

SUBTOTAL -44.00

SUBCOUNT 5

2007 AUTO WRITE OFF REPORT MAR 13,2007 15:32 PAGE 1

BILL (A/R) CREDIT

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

A/R ACCOUNT: CIGNA

SUBTOTAL -125.52

SUBCOUNT 120

A/R ACCOUNT: DELTA DENTAL OF NEW MEXICO INC

SUBTOTAL -78.00

SUBCOUNT 23

A/R ACCOUNT: LIFE COURSE

SUBTOTAL 0.00

SUBCOUNT 12

A/R ACCOUNT: LOVELACE HEALTH PLAN

SUBTOTAL -95.48

SUBCOUNT 70

A/R ACCOUNT: MAIL HANDLERS BENEFIT PLAN

SUBTOTAL 0.00

SUBCOUNT 6

A/R ACCOUNT: PRESBYTERIAN HEALTH PLAN

SUBTOTAL -116.60

SUBCOUNT 29

A/R ACCOUNT: UNITED HEALTH CARE

SUBTOTAL 0.00

SUBCOUNT 18

SUBTOTAL -1644.85

SUBCOUNT 974

VP INSURER TYPE: WORKMEN\'S COMP

A/R ACCOUNT: AETNA LIFE AND CASUALTY

SUBTOTAL -259.59

SUBCOUNT 62

SUBTOTAL -259.59

SUBCOUNT 62

SUBTOTAL -4859.97

SUBCOUNT 1442

TOTAL -4859.97

COUNT 1442

1442 MATCHES FOUND.

  ----------------- --------------- -- ----------------- -- -----------------
                    **Accounts                              
                    Receivable**                            

                    **5/31/2007**      **5/31/2007**        

  **Server Site**   **Total A/R**      **CORE Balance**     **Difference**

                    **per ASM**                             

  **Facility 1**                                            

  Schip                                                     \$ -

  Medicaid                                                  \$ -

  Medicare                                                  \$ -

  Private Insurance                                         \$ -

  Other                                                     \$ -

  **Facility 1      **\$ -**           **\$ -**             **\$ -**
  Total**                                                   

                                                            

                                                            

  **Facility 2**                                            

  Schip                                                     \$ -

  Medicaid                                                  \$ -

  Medicare                                                  \$ -

  Private Insurance                                         \$ -

  Other                                                     \$ -

  **Facility 2      **\$ -**           **\$ -**             **\$ -**
  Total**                                                   

                                                            

                                                            

  **Facility 3**                                            

  Schip                                                     \$ -

  Medicaid                                                  \$ -

  Medicare                                                  \$ -

  Private Insurance                                         \$ -

  Other                                                     \$ -
  ----------------- --------------- -- ----------------- -- -----------------

  ----------------- -------------- -- ----------------- -- -----------------
  **Server Site**   **Total A/R**     **CORE Balance**     **Difference**

                    **per ASM**                            

  **Facility 3      **\$ -**          **\$ -**             **\$ -**
  Total**                                                  

                                                           

                                                           

  **Facility 4**                                           

  Schip                                                    \$ -

  Medicaid                                                 \$ -

  Medicare                                                 \$ -

  Private Insurance                                        \$ -

  Other                                                    \$ -

  **Facility 4      **\$ -**          **\$ -**             **\$ -**
  Total**                                                  

                                                           

                                                           

  **Facility 5**                                           

  Schip                                                    \$ -

  Medicaid                                                 \$ -

  Medicare                                                 \$ -

  Private Insurance                                        \$ -

  Other                                                    \$ -

  **Facility 5      **\$ -**          **\$ -**             **\$ -**
  Total**                                                  

                                                           

                                                           

  **Facility 6**                                           

  Schip                                                    \$ -

  Medicaid                                                 \$ -

  Medicare                                                 \$ -

  Private Insurance                                        \$ -

  Other                                                    \$ -

  **Server Site**   **Total A/R**     **CORE Balance**     **Difference**

                    **per ASM**                            

  **Facility 6      **\$ -**          **\$ -**             **\$ -**
  Total**                                                  

                                                           

                                                           

  **Facility 7**                                           

  Schip                                                    \$ -

  Medicaid                                                 \$ -

  Medicare                                                 \$ -

  Private Insurance                                        \$ -

  Other                                                    \$ -

  **Facility 7      **\$ -**          **\$ -**             **\$ -**
  Total**                                                  

                                                           

                                                           

  **Facility 8**                                           

  Schip                                                    \$ -

  Medicaid                                                 \$ -

  Medicare                                                 \$ -

  Private Insurance                                        \$ -

  Other                                                    \$ -

  **Facility 8      **\$ -**          **\$ -**             **\$ -**
  Total**                                                  

                                                           

                                                           

  **Facility 9**                                           

  Schip                                                    \$ -

  Medicaid                                                 \$ -

  Medicare                                                 \$ -

  Private Insurance                                        \$ -

  Other                                                    \$ -
  ----------------- -------------- -- ----------------- -- -----------------

  ----------------- -------------- -- ----------------- -- -----------------
  **Server Site**   **Total A/R**     **CORE Balance**     **Difference**

                    **per ASM**                            

  **Facility 9      **\$ -**          **\$ -**             **\$ -**
  Total**                                                  

                                                           

                                                           

  **Facility 10**                                          

  Schip                                                    \$ -

  Medicaid                                                 \$ -

  Medicare                                                 \$ -

  Private Insurance                                        \$ -

  Other                                                    \$ -

  **Facility 10     **\$ -**          **\$ -**             **\$ -**
  Total**                                                  

                                                           

                                                           

  **Facility 11**                                          

  Schip                                                    \$ -

  Medicaid                                                 \$ -

  Medicare                                                 \$ -

  Private Insurance                                        \$ -

  Other                                                    \$ -

  **Facility 11     **\$ -**          **\$ -**             **\$ -**
  Total**                                                  

                                                           

                                                           

  **Facility 12**                                          

  Schip                                                    \$ -

  Medicaid                                                 \$ -

  Medicare                                                 \$ -

  Private Insurance                                        \$ -

  Other                                                    \$ -

  **Server Site**   **Total A/R**     **CORE Balance**     **Difference**

                    **per ASM**                            

  **Facility 12     **\$ -**          **\$ -**             **\$ -**
  Total**                                                  

                                                           

                                                           

  **Total**                                                

  Schip             \$ -              \$ -                 \$ -

  Medicaid          \$ -              \$ -                 \$ -

  Medicare          \$ -              \$ -                 \$ -

  Private Insurance \$ -              \$ -                 \$ -

  Other             \$ -              \$ -                 \$ -

  **Area Total**    \$ -              \$ -                 **\$ -**
  ----------------- -------------- -- ----------------- -- -----------------