Pennsylvania Code
Title 61 - REVENUE
Part II - Auditor General
Subpart C - Audits of State-Aided Institutions
Chapter 521 - FINANCIAL REPORT TO COMMONWEALTH
Section 521.6 - Reporting forms
Current through Register Vol. 54, No. 44, November 2, 2024
Forms for determining reimbursable costs applicable to the Medical Assistance Program and the preparation of the report under either of the prescribed methods of apportionment are incorporated in the schedules and worksheets provided. All forms identified as Form AG12 "CD" shall be used by providers using either of the two prescribed methods of apportionment. Schedules B and B-1, identified as Form AG12 "C" Page 6 and Page 7, are required for use by Combination Method providers. Worksheets B and B-1, identified as Form AG12 "D" Page 6 and Page 7, are required for use by Departmental Method providers. These forms are detailed as follows:
(1) Schedule A-Reclassification and Adjustment of Trial Balance of Expenses ... AG12 CD PAGE 3.
(2) Schedule A-1-Adjustments to Expenses ... AG12 CD PAGE 4.
(3) Schedule A-2-Administrative and General Expenses Analysis ... AG12 CD PAGE 5.
(4) Schedule B-Cost Allocation-General Service Costs. For use of providers using COMBINATION METHOD ... AG 12 C PAGE 6.
(5) Schedule B-1-Cost Allocation-Statistical Basis COMBINATION METHOD (under 100 beds) ... AG12 C PAGE 7.
(6) Worksheet B-Cost Apportionment-General Services. For use of providers using DEPARTMENTAL METHOD ... AG12 D PAGE 6.
(7) Worksheet B-1-Cost Apportionment-Statistical Basis DEPARTMENTAL METHOD (over 99 beds) ... AG12 D PAGE 7.
(8) Schedule C-Departmental Distribution of Patient Care Costs ... AG12 CD PAGE 8.
(9) Schedule C-1-Departmental Distribution of PatientCare Charges ... AG12 CD PAGE 9.
