UNCOMPENSATED COST REPORT
HOSPITAL: Centennial Hills Hospital Period: 2018
Line PART II -   Calculate Uncompensated Care
1 EPSI Master Pivot
1 Adjusted RCC from Part I 9.3% 2 NHQR - Tab Columns
Billed Charges From Hospital Records Cost = Charges X RCC Patient & 3rd Party Payments Uncompensated Cost IP OP IP OP Cells
2 State and Local Assistance Programs (H)  $      2,687,697  $         249,394  $           22,532  $          226,861 (facility reports)   1,463,949   1,223,748             200        22,332  B6  B10 E6 E10
3 Self-Pay / Uninsured Patients (I)  $    62,755,408  $      5,823,127  $         698,509  $       5,124,618 A02 & A03 PrivatePay + Charity (NHQR/facility reports) ######### #########      255,840      442,669 A02 I+J A03 I+J E5 E9
4 Underinsured Patients (J)  $    22,492,498  $      2,087,098  $      1,742,141  $          344,957 (facility reports) #########   4,724,731   1,391,672      350,468 B7 B11 E7 E11
5      Subtotal Uninsured Care  = "U"  $    87,935,603  $      8,159,618  $      2,463,182  $       5,696,436
6 Medicaid - Title XIX  = "M" (K)  $   488,427,261  $    45,321,574  $    39,223,931  $       6,097,643 A02 & A03 Medicaid (NHQR) ######### ######### ######### ######### A02 C+D A03 C+D M13-A02 M+N N13-A03 M+N
7 Total Uncompensated Care  M + U  $   576,362,864  $    53,481,192  $    41,687,113  $     11,794,079
8 Cost Directly Assigned to Uninsured Patients (L)            $       4,458,822
9 Less: Payments Related to Directly Assigned Cost (M)            $                    -
10 Total Uncompensated Cost Based on Charges            $     16,252,901
11 Medicare Uncompensated Costs  $                    - A02 & A03 Medicare (NHQR) ######### ######### ######### ######### A02 E+F A03 E+F M18-A02 O+P N18-A03 O+P
(H) Includes all charges billed to County Social Services, Indigent Accident Fund, Victims of Crime, and community based charity programs.
   Exclude SIIS, Indian Health Services, and other non-indigency based programs from this line.
   Exclude from payments, amounts received directly from state or local governments (e.g. IAF, county Supplemental Fund) other than for Medicaid.  
(I) Includes accounts for which there is no 3rd party pay source even if pending Medicaid or County approval.
     Exclude those accounts where patient payments exceeds the cost of providing the care. 
(J) Refers to those accounts where payments are less than cost of  providing care calculated based on application of above RCC.
     Exclude Medicaid, SCHIP, Medicare, prisoners, all contracted payers, and  accounts already reflected in the other uninsured categories.  
(K) Include all Title XIX ( Out-of-State, HMO, demonstration wavers, etc) except for SCHIP programs. Medicaid payments include UPL but Exclude DSH & GME.
(L) Must reconcile to amounts excluded in Part I,  and be directly related to indigent care.  See notes (3), (4), & (5) 
(M) Include Medicaid & Medicare direct GME payments for medical education cost and any other revenues specific to directly assigned cost .
Note: The following patient populations should not be included in the uncompensated cost reporting in any category: 
    Prisoner programs, SCHIP, Medicare, and all contracted payers.