Spreadsheet: 0b105e96-a0d9-4f18-a321-b3c40605430a
Sheet: Sheet1

For patient days, do not use days related to swing beds, long-term care beds, residential treatment center beds, home health, nursing facilities, the treatment of patients on a leave of absence from the facility, patients being observed for the need of admission, or patients who receive services during the day but are not housed at the facility at midnight.  Include Psych and [NAME] days at your facility, including sub-acute if the patient has been in the hospital at least 24 hours. | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6
 | Data Element | Description | Enter Your Data Here
1 | Managed Care Days | Consumers with managed care plans are generally restricted to a specified or preferred network of providers.  (See the attached list of major Colorado managed care plans) *
2 | Non-Managed Care Days | Consumers with non-managed care plans are generally free to utilize the services of any provider without additional costs.  (See the attached list of major Colorado non-managed care plans) *
3 | [NAME]  (normal DRG Medicaid payment billed to the State, non-managed care) | These days may be derived using the same methodology used to populate the CMS Medicare Cost Report 2552-96 Worksheet S-3, Part I, Column 5, Line 12 minus [NAME] (Swing Bed Days-SNF) minus [NAME] (Swing Bed Days-NF) minus [NAME] (Nursery Days).
4 | Medicaid Nursery Days | These days may be derived using the same methodology used to populate the CMS Medicare Cost Report 2552-96 Worksheet S-3, Part I, Column 5, Line 11.  Includes Medicaid Nursery Days for fee for service and HMO enrolled clients.
5 | Medicaid Managed Care Days | These days may be derived using the same methodology used to populate the CMS Medicare Cost Report 2552-96 Worksheet S-3, Part I, Column 5, Line 2.
6 | Medicaid Rehabilitation Days | These days may be derived using the same methodology used to populate the CMS Medicare Cost Report 2552-96 Worksheet S-3, Part I, Line 14.01, Column 5 (Medicaid).
7 | Medicare Fee-for-Service Days (normal DRG, non-managed care) | These days may be derived using the same methodology used to populate the CMS Medicare Cost Report 2552-96 Worksheet S-3, Part I, Column 4, Lines 12, plus any psych and rehab subprovider amounts for the hospital reported on Line 14; minus [NAME] (Swing Bed Days-SNF) minus [NAME] (Swing Bed Days-NF).
8 | Medicare HMO Days | These days may be derived using the same methodology used to populate the CMS Medicare Cost Report 2552-96 Worksheet S-3, Part I, Column 4, Line 2.
9 | Colorado Indigent Care Program (CICP) Days | Report patient days for those in the CICP (CICP is either primary or secondary).
10 | Charity Care Days | Patients in hospital's charity care program (does not include CICP). Health services for which hospital policies determine the patient is unable to pay. Charity care results from a provider’s policy to provide health care services free of charge or where only partial payment is expected to individuals who meet certain financial criteria.
11 | Uninsured/Self Pay Days | Days for self pay clients and those with no third party coverage.
12 | Other Payers Days | These are days not included in numbers 1 – 11 above. *
13 | Total Days | The Total Days as reported on the 2009 Patient Census.  This should reconcile to Total Days derived using the same methodology used to populate the CMS Medicare Cost Report 2552-96 Worksheet S-3, Part I, Column 6, Line 12 for Acute Care Days and Line 14 for Subprovider (Psychiatric and Rehabilitation) Days.
14 | Charity Care Write-Off Charges | Health services for which hospital policies determine the patient is unable to pay. Charity care results from a provider’s policy to provide health care services free of charge or where only partial payment is expected (not to include contractual allowances for otherwise insured patients) to individuals who meet certain financial criteria. For the purpose of uncompensated care, charity care is measured on the basis of revenue forgone, at full-established rates. Charity care does not include bad debt nor CICP charges.
15 | Bad Debt, EXCLUDING MEDICARE BAD DEBT | The current period charge for actual or expected doubtful accounts resulting from the extension of credit.  [NAME].
16 | Uninsured/Self Pay Write-Off  Charges | Charges for self pay clients and those with no third party coverage less patient payment.
17 | Medicare-Medicaid Dual Eligible Days | Report days for patients with Medicare primary and Medicaid secondary (Including Medicare Managed Care).
18 | Third Party-Medicaid Days | Report days for patients with Third Party coverage (other than Medicare) primary and Medicaid secondary.
19 | Distinct Psychiatric Unit | Does your facility have a currently active psychiatric unit?
20 | Distinct Psychiatric Unit Beds | If "Yes" on question 19, report number of psychiatric beds.
21 | Distinct Pschiatric Unit [NAME] | If "Yes" on question 19 please report psych days using the same methodology used to populate the CMS Medicare Cost Report 2552-96 Worksheet S-3, Part I, Line 14, Column 5 (Medicaid).
22 | Psychiatric Care With No Distinct Unit | If "No" on question 19, do you use Med-Surg beds for psychiatric patients?
23 | Psychiatric Care With No Distinct Unit Redords | If "Yes" on question 22, do you have record of inpatient Medicaid psych days (where psych is the primary diagnosis)?
24 | Psychiatric Care With No Distinct Unit Days | If "Yes" on question 23, please report number of inpatient Medicaid psych days.
25 | DSH OB Requirement | Per Social Security Act - Sec. 1923 [42 U.S.C. 1396r-4] (d), to qualify for Disproportionate Share Hospital payments, report 2 obstetricians with staff  privileges at the hospital who agree to provide nonemergency obstetric services to Medicaid clients. |  |  | 1 | 0
 |  |  |  |  | 0 | 0
 | Contact Information
 | [NAME]
 | CFO Name
 | CFO Address
 | CFO City, State Zip
 | CFO Phone
 | CFO Email
 | Please return the completed survey no later then April 15, 2011 to:
 | Department of Health Care Policy and Financing
 | Safety Net Section
 | Attention: Weston Lander
 | 1570 Grant Street
 | Denver, CO 80203
 | [NAME]