{"text_format":"1","workbook":"xlsx","n_sheets":14,"sheets":["Provider Information","Trial Balance","Trial Balance Reclassifications","Trial Balance Adjustments","Anticipated Costs","Indirect Cost Allocation","Allocation Descriptions","Daily Visits","Monthly Visits","Services Provided","Comments","CC PPS-1 Rate","CC PPS-2 Rate","Certification"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":54,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Provider Information","index":0,"n_rows":88,"n_cols":11,"rows_kept":88,"cut":false,"hidden":false,"merged":[[0,0,0,10],[15,5,15,6],[16,2,16,10],[15,2,15,3],[39,7,39,8],[7,0,7,2],[15,8,15,10],[14,8,14,10],[17,3,17,10],[13,2,13,10],[14,2,14,6],[25,1,25,9],[31,7,31,10],[20,6,20,10],[8,0,8,10],[33,7,33,8],[34,7,34,8],[35,7,35,8],[32,0,32,10],[4,6,4,10],[5,6,5,10],[7,3,7,10],[10,0,10,2],[10,3,10,10],[87,0,87,10],[2,3,2,10],[3,3,3,10],[3,0,3,2],[4,0,4,2],[5,0,5,2],[6,0,6,2],[6,3,6,10],[12,0,12,10],[55,0,55,10],[22,0,22,9],[18,3,18,10],[66,5,66,10],[54,0,54,10],[40,7,40,8],[43,7,43,8],[37,7,37,8],[29,0,29,5],[30,0,30,4],[57,0,57,1],[34,0,34,6],[83,7,83,8],[2,0,2,2],[18,0,18,2],[19,0,19,5],[20,0,20,5],[21,0,21,10],[51,0,51,8],[44,7,44,8],[41,0,41,10],[33,0,33,6],[42,0,42,6],[30,5,30,10],[28,0,28,10],[23,1,23,9],[24,1,24,9],[26,1,26,9],[27,1,27,9],[29,6,29,10],[85,0,85,6],[43,0,43,6],[44,0,44,6],[45,0,45,6],[46,0,46,6],[47,0,47,6],[48,0,48,6],[49,0,49,6],[70,0,70,6],[71,0,71,6],[72,0,72,6],[73,0,73,6],[74,0,74,6],[75,0,75,6],[76,0,76,6],[78,0,78,6],[61,3,61,10],[85,7,85,8],[79,7,79,8],[80,7,80,8],[58,8,58,10],[69,0,69,6],[79,0,79,6],[81,0,81,6],[83,0,83,6],[84,0,84,6],[77,0,77,10],[31,0,31,6],[66,0,66,4],[65,0,65,5],[64,0,64,5],[63,0,63,5],[61,0,61,2],[60,0,60,1],[62,0,62,2],[64,6,64,10],[80,0,80,6],[76,7,76,8],[67,7,67,10],[75,7,75,8],[74,7,74,8],[73,7,73,8],[84,7,84,8],[50,7,50,10],[50,1,50,6],[65,6,65,10],[82,0,82,6],[81,7,81,8],[13,0,13,1],[82,7,82,8],[78,7,78,8],[58,0,58,1],[59,0,59,1],[39,0,39,6],[36,0,36,6],[35,0,35,6],[40,0,40,6],[37,0,37,6],[38,0,38,6],[57,2,57,10],[58,2,58,6],[46,7,46,8],[36,7,36,8],[38,7,38,8],[42,7,42,8],[45,7,45,8],[19,6,19,10],[63,6,63,10],[14,0,14,1],[15,0,15,1],[16,0,16,1],[17,0,17,2],[86,0,86,10],[11,0,11,10],[1,0,1,10],[53,0,53,10],[72,7,72,8],[71,7,71,8],[70,7,70,8],[69,7,69,8],[68,0,68,10],[67,0,67,6],[51,9,51,10],[47,7,47,8],[48,7,48,8],[49,7,49,8],[56,0,56,9],[62,3,62,10],[60,2,60,10],[59,8,59,10],[59,2,59,3],[59,5,59,6],[52,0,52,5],[52,6,52,10],[9,7,9,10],[9,0,9,3]]}
["CCBHC Cost Report"]
["This top section is for Medicaid ID, NPI, reporting period, and rate period, and will be automatically populated in all other tabs. Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:"]
["NPI:"]
["REPORTING PERIOD:",null,null,"From:",null,"To:"]
["RATE PERIOD:",null,null,"From:",null,"To:"]
["WORKSHEET:",null,null,"Provider Information"]
["PPS METHODOLOGY:"]
["This box for state use only - LEAVE BLANK"]
["Select type of oversight:",null,null,null,null," Audited ",null,"Desk Reviewed"]
["Date reviewed:"]
["Part 1 is for single site or consolidated information.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1 - PROVIDER INFORMATION (Consolidated)"]
["1.      Name:"]
["2.      Street:",null,null,null,null,null,null,"P.O. Box: "]
["3.        City:",null,null,null,"State: ",null,null,"Zip Code:"]
["4.        County:"]
["5.        Medicaid ID:",null,null,{"$f":"IF(D3=\"\",\"\",D3)","v":""}]
["6.        NPI:",null,null,{"$f":"IF(D4=\"\",\"\",D4)","v":""}]
["7.        Location designation (see Cost Report Instructions):"]
["8.        Organizational authority (see Cost Report Instructions):"]
["9.        Behavioral health professionals (see Cost Report Instructions):"]
["Name\n    1",null,null,null,null,null,null,null,null,null,"NPI\n2"]
["9a"]
["9b"]
["9c"]
["9d"]
["9e"]
[]
["10.      Is the CCBHC dually certified as a 1905(a)(9) clinic?"]
["11.      Does the site operate as other than CCBHC? "]
["12.      If line 11 is \"Yes\" specify the type of operation (e.g., clinic, FQHC, other):"]
["13.      Identify days and hours the site operates as a CCBHC by listing the time next to the applicable day:"]
["Days",null,null,null,null,null,null,"Hours of Operation \nFrom",null,"Hours of Operation \nTo","Total Hours"]
["13a                     Sunday"]
["13b                     Monday"]
["13c                     Tuesday"]
["13d                     Wednesday"]
["13e                     Thursday"]
["13f                       Friday"]
["13g                     Saturday"]
["14.      Identify days and hours the site operates as other than a CCBHC by listing the time next to the applicable day:"]
["Days",null,null,null,null,null,null,"Hours of Operation \nFrom",null,"Hours of Operation \nTo","Total Hours"]
["14a                     Sunday"]
["14b                     Monday"]
["14c                     Tuesday"]
["14d                     Wednesday"]
["14e                     Thursday"]
["14f                       Friday"]
["14g                     Saturday"]
[15,"List any excluded satellite facilities and reasons for exclusion. Use the Comments Sheet for additional details."]
["16.      Is this site filing a consolidated cost report for multiple locations?  If yes, see Cost Report Instructions. "]
["17.      How many sites are reported for the consolidated entity?",null,null,null,null,null," "]
["Part 2 is for reporting specific information for each site.  Copy and complete this section for each site reported and include as an attachment.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2 - PROVIDER INFORMATION FOR CLINICS FILING UNDER CONSOLIDATED COST REPORTING (For additional satellite sites, create new tab and copy and paste Part 2 for each additional site included)"]
["Site-Specific Information"]
["1.        Was this site in existence before April 1, 2014?  (No payment will be made to satellite facilities of CCBHCs established \n            after April 1, 2014)."]
["2.        Name:"]
["3.        Street:",null,null,null,null,null,null,"P.O. Box: "]
["4.        City:",null,null,null,"State: ",null,null,"Zip Code:"]
["5.        County:"]
["6.        Medicaid ID:"]
["7.        NPI:"]
["8.        Location designation (see Cost Report Instructions):"]
["9.        Organizational authority  (see Cost Report Instructions):"]
["10.      Is the CCBHC dually certified as a 1905(a)(9) clinic?"]
["11.      Does the site operate as other than CCBHC? "]
["12.      If line 11 is \"Yes\", specify the type of operation (e.g., clinic, FQHC, other):"]
["13.      Identify days and hours the site operates as a CCBHC by listing the time next to the applicable day"]
["Days",null,null,null,null,null,null,"Hours of Operation \nFrom",null,"Hours of Operation \nTo","Total Hours"]
["13a                     Sunday"]
["13b                     Monday"]
["13c                     Tuesday"]
["13d                     Wednesday"]
["13e                     Thursday"]
["13f                       Friday"]
["13g                     Saturday"]
["14.      Identify days and hours the site operates as other than a CCBHC by listing the time next to the applicable day"]
["Days",null,null,null,null,null,null,"Hours of Operation \nFrom",null,"Hours of Operation \nTo","Total Hours"]
["14a                     Sunday"]
["14b                     Monday"]
["14c                     Tuesday"]
["14d                     Wednesday"]
["14e                     Thursday"]
["14f                       Friday"]
["14g                     Saturday"]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Trial Balance","index":1,"n_rows":103,"n_cols":12,"rows_kept":103,"cut":false,"hidden":false,"merged":[[64,0,64,2],[73,0,73,2],[74,0,74,2],[75,0,75,2],[54,0,54,11],[63,0,63,2],[65,0,65,2],[48,0,48,11],[49,1,49,2],[50,0,50,11],[67,1,67,2],[70,0,70,11],[69,0,69,2],[62,0,62,2],[58,0,58,2],[59,0,59,2],[60,0,60,2],[61,0,61,2],[77,0,77,2],[72,0,72,2],[80,0,80,11],[97,1,97,2],[66,0,66,11],[96,0,96,11],[68,0,68,11],[90,0,90,11],[76,0,76,2],[100,0,100,2],[99,0,99,2],[78,0,78,2],[79,0,79,2],[83,0,83,2],[84,0,84,2],[85,0,85,11],[87,0,87,11],[93,0,93,11],[82,0,82,11],[81,1,81,2],[91,1,91,2],[92,0,92,11],[98,0,98,11],[95,0,95,2],[88,0,88,11],[18,0,18,2],[19,0,19,2],[10,0,10,11],[0,0,0,11],[8,0,8,11],[2,2,2,11],[3,2,3,11],[6,2,6,11],[4,5,4,11],[5,5,5,11],[1,0,1,11],[7,0,7,11],[102,0,102,11],[11,0,11,2],[94,0,94,11],[33,0,33,11],[41,0,41,11],[57,0,57,2],[56,0,56,11],[71,0,71,11],[89,0,89,2],[51,0,51,2],[52,0,52,2],[39,0,39,2],[86,0,86,11],[23,0,23,2],[43,0,43,2],[20,0,20,2],[21,0,21,2],[25,0,25,2],[24,0,24,2],[22,0,22,2],[34,0,34,2],[42,0,42,2],[26,0,26,2],[27,0,27,2],[101,0,101,11],[29,1,29,2],[28,0,28,11],[36,0,36,11],[37,1,37,2],[38,0,38,11],[9,0,9,11],[40,0,40,11],[53,0,53,11],[55,0,55,11],[44,0,44,2],[45,0,45,2],[46,0,46,2],[47,0,47,2],[31,0,31,2],[32,0,32,11],[30,0,30,11],[35,0,35,2],[12,0,12,2],[13,0,13,2],[14,0,14,2],[15,0,15,2],[16,0,16,2],[17,0,17,2]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",null,{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",null,{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:",null,"From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:",null,"From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:",null,"Trial Balance"]
["Part 1 is for entering direct costs for CCBHC services.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1 - DIRECT CCBHC EXPENSES"]
["Part 1A is for entering direct CCBHC staff costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1A - CCBHC STAFF COSTS"]
["Description",null,null,"\nCompensation\n\n1","\nOther\n\n2","Total\n(Col. 1 + 2)\n\n3","Reclassifications\n\n4","Reclassified Trial Balance \n(Col. 3 + 4)\n5","Adjustments\nIncreases\n(Decreases)\n6","Adjusted Amount\n(Col. 5 + 6)\n7","Adjustments for Anticipated Cost Changes\n8","Net \nExpenses\n(Col. 7 + 8)\n9"]
["1.         Psychiatrist",null,null,null,null,{"$f":"SUM(D13:E13)","v":0},null,{"$f":"F13+G13","v":0},null,{"$f":"H13+I13","v":0},null,{"$f":"J13+K13","v":0}]
["2.         Psychiatric nurse",null,null,null,null,0,null,0,null,0,null,0]
["3.         Child psychiatrist",null,null,null,null,0,null,0,null,0,null,0]
["4.         Adolescent psychiatrist",null,null,null,null,0,null,0,null,0,null,0]
["5.         Substance abuse specialist",null,null,null,null,0,null,0,null,0,null,0]
["6.         Case manager",null,null,null,null,0,null,0,null,0,null,0]
["7.         Recovery coach",null,null,null,null,0,null,0,null,0,null,0]
["8.         Peer specialist",null,null,null,null,0,null,0,null,0,null,0]
["9.         Family support specialist",null,null,null,null,0,null,0,null,0,null,0]
["10.       Licensed clinical social worker",null,null,null,null,0,null,0,null,0,null,0]
["11.       Licensed mental health counselor",null,null,null,null,0,null,0,null,0,null,0]
["12.       Mental health professional (trained \n             and credentialed for psychological \n             testing)",null,null,null,null,0,null,0,null,0,null,0]
["13.       Licensed marriage and family \n             therapist",null,null,null,null,0,null,0,null,0,null,0]
["14.       Occupational therapist",null,null,null,null,0,null,0,null,0,null,0]
["15.       Interpreter or linguistic counselor",null,null,null,null,0,null,0,null,0,null,0]
["16.       General practice (performing \n             CCBHC services)",null,null,null,null,0,null,0,null,0,null,0]
["17.       Other staff costs (specify details below)"]
["17a",null,null,null,null,{"$f":"SUM(D30:E30)","v":0},null,{"$f":"F30+G30","v":0},null,{"$f":"H30+I30","v":0},null,{"$f":"J30+K30","v":0}]
["      "]
["18.       Subtotal staff costs \n             (sum of lines 1-17)",null,null,{"$f":"SUM(D13:D31)","v":0},0,0,0,0,0,0,0,0]
["Part 1B is for entering direct CCBHC costs under agreement.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1B - CCBHC COSTS UNDER AGREEMENT"]
["Description",null,null,"\nCompensation\n\n1","\nOther\n\n2","Total\n(Col. 1 + 2)\n\n3","\nReclassifications\n\n4","Reclassified Trial Balance \n(Col. 3 + 4)\n5","Adjustments\nIncreases\n(Decreases)\n6","Adjusted Amount\n(Col. 5 + 6)\n7","Adjustments for Anticipated Cost Changes\n8","Net \nExpenses\n(Col. 7 + 8)\n9"]
["19.       CCBHC costs from DCO",null,null,"This cell is left intentionally blank.",null,{"$f":"SUM(D36:E36)","v":0},null,{"$f":"F36+G36","v":0},null,{"$f":"H36+I36","v":0},null,{"$f":"J36+K36","v":0}]
["20.       Other CCBHC costs (specify details below)",null,null,"This cell is left intentionally blank.",null,{"$f":"SUM(D37:E37)","v":0},null,{"$f":"F37+G37","v":0},null,{"$f":"H37+I37","v":0},null,{"$f":"J37+K37","v":0}]
["20a",null,null,null,null,{"$f":"SUM(D38:E38)","v":0},null,{"$f":"F38+G38","v":0},null,{"$f":"H38+I38","v":0},null,{"$f":"J38+K38","v":0}]
["      "]
["21.       Subtotal costs under agreement \n             (sum of lines 19-20)",null,null,"This cell is left intentionally blank.",{"$f":"SUM(E36:E39)","v":0},0,0,0,0,0,0,0]
["Part 1C is for entering other direct CCBHC costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1C - OTHER DIRECT CCBHC COSTS"]
["Description",null,null,"\nCompensation\n\n1","\nOther\n\n2","Total\n(Col. 1 + 2)\n\n3","\nReclassifications\n\n4","Reclassified Trial Balance \n(Col. 3 + 4)\n5","Adjustments\nIncreases\n(Decreases)\n6","Adjusted Amount\n(Col. 5 + 6)\n7","Adjustments for Anticipated Cost Changes\n8","Net \nExpenses\n(Col. 7 + 8)\n9"]
["22.       Medical supplies",null,null,"This cell is left intentionally blank.",null,{"$f":"SUM(D44:E44)","v":0},null,{"$f":"F44+G44","v":0},null,{"$f":"H44+I44","v":0},null,{"$f":"J44+K44","v":0}]
["23.       Transportation (health care staff)",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["24.       Depreciation - medical equipment",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["25.       Professional liability insurance",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["26.       Telehealth ",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["27.       Other direct costs not already included (specify details below)",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["27a",null,null,"This cell is left intentionally blank.",null,{"$f":"SUM(D50:E50)","v":0},null,{"$f":"F50+G50","v":0},null,{"$f":"H50+I50","v":0},null,0]
["      "]
["28.       Subtotal other direct CCBHC \n             costs (sum of lines 22-27)",null,null,"This cell is left intentionally blank.",{"$f":"SUM(E44:E51)","v":0},0,0,0,0,0,0,0]
["29.       Total cost of CCBHC services \n             (other than overhead)\n             (sum of lines 18, 21, and 28)",null,null,{"$f":"SUM(D32,D40,D52)","v":0},0,0,0,0,0,0,0,0]
["Part 2 is for entering indirect costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2 - INDIRECT COSTS"]
["Part 2A is for entering indirect facility costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2A - SITE COSTS"]
["Description",null,null,"\nCompensation\n\n1","\nOther\n\n2","Total\n(Col. 1 + 2)\n\n3","\nReclassifications\n\n4","Reclassified Trial Balance \n(Col. 3 + 4)\n5","Adjustments\nIncreases\n(Decreases)\n6","Adjusted Amount\n(Col. 5 + 6)\n7","Adjustments for Anticipated Cost Changes\n8","Net \nExpenses\n(Col. 7 + 8)\n9"]
["30.       Rent",null,null,"This cell is left intentionally blank.",null,{"$f":"SUM(D59:E59)","v":0},null,{"$f":"F59+G59","v":0},null,{"$f":"H59+I59","v":0},null,{"$f":"J59+K59","v":0}]
["31.       Insurance",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["32.       Interest on mortgage or loans",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["33.       Utilities",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["34.       Depreciation - buildings and fixtures",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["35.       Depreciation - equipment",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["36.       Housekeeping and maintenance",null,null,null,null,0,null,0,null,0,null,0]
["37.       Property tax",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["38.       Other site costs (specify details below)",null,null,null,null,0,null,0,null,0,null,0]
["38a",null,null,null,null,{"$f":"SUM(D68:E68)","v":0},null,{"$f":"F68+G68","v":0},null,{"$f":"H68+I68","v":0},null,{"$f":"J68+K68","v":0}]
[]
["39.       Subtotal site costs \n             (sum of lines 30-38)",null,null,{"$f":"SUM(D59:D69)","v":0},0,0,0,0,0,0,0,0]
["Part 2B is for entering indirect administrative costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2B - ADMINISTRATIVE COSTS"]
["Description",null,null,"\nCompensation\n\n1","\nOther\n\n2","Total\n(Col. 1 + 2)\n\n3","\nReclassifications\n\n4","Reclassified Trial Balance \n(Col. 3 + 4)\n5","Adjustments\nIncreases\n(Decreases)\n6","Adjusted Amount\n(Col. 5 + 6)\n7","Adjustments for Anticipated Cost Changes\n8","Net \nExpenses\n(Col. 7 + 8)\n9"]
["40.       Office salaries ",null,null,null,null,{"$f":"SUM(D74:E74)","v":0},null,{"$f":"F74+G74","v":0},null,{"$f":"H74+I74","v":0},null,{"$f":"J74+K74","v":0}]
["41.       Depreciation - office equipment",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["42.       Office supplies",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["43.       Legal",null,null,null,null,0,null,0,null,0,null,0]
["44.       Accounting",null,null,null,null,0,null,0,null,0,null,0]
["45.       Insurance",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["46.       Telephone",null,null,"This cell is left intentionally blank.",null,0,null,0,null,0,null,0]
["47.       Other administrative costs (specify details below)",null,null,null,null,0,null,0,null,0,null,0]
["47a",null,null,null,null,{"$f":"SUM(D82:E82)","v":0},null,{"$f":"F82+G82","v":0},null,{"$f":"H82+I82","v":0},null,{"$f":"J82+K82","v":0}]
[]
["48.       Subtotal administrative costs \n             (sum of lines 40-47)",null,null,{"$f":"SUM(D74:D83)","v":0},0,0,0,0,0,0,0,0]
["49.       Total overhead \n             (sum of lines 39 and 48)",null,null,{"$f":"SUM(D70,D84)","v":0},0,0,0,0,0,0,0,0]
["Part 3 is for entering direct costs for non-CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 3 - DIRECT COSTS FOR NON-CCBHC SERVICES"]
["Part 3A is for entering direct costs for non-CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 3A - DIRECT COSTS FOR SERVICES OTHER THAN CCHBC SERVICES"]
["Description",null,null,"\nCompensation\n\n1","\nOther\n\n2","Total\n(Col. 1 + 2)\n\n3","\nReclassifications\n\n4","Reclassified Trial Balance \n(Col. 3 + 4)\n5","Adjustments\nIncreases\n(Decreases)\n6","Adjusted Amount\n(Col. 5 + 6)\n7","Adjustments for Anticipated Cost Changes\n8","Net \nExpenses\n(Col. 7 + 8)\n9"]
["50.       Direct costs for non-CCBHC services covered by Medicaid  (specify details below)",null,null,null,null,{"$f":"SUM(D91:E91)","v":0},null,{"$f":"F91+G91","v":0},null,{"$f":"H91+I91","v":0},null,{"$f":"J91+K91","v":0}]
["50a",null,null,null,null,{"$f":"SUM(D92:E92)","v":0},null,{"$f":"F92+G92","v":0},null,{"$f":"H92+I92","v":0},null,{"$f":"J92+K92","v":0}]
[]
["Part 3B is for entering direct costs that are for non-reimbursable services. Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 3B - NON-REIMBURSABLE COSTS"]
["Description",null,null,"\nCompensation\n\n1","\nOther\n\n2","Total\n(Col. 1 + 2)\n\n3","\nReclassifications\n\n4","Reclassified Trial Balance \n(Col. 3 + 4)\n5","Adjustments\nIncreases\n(Decreases)\n6","Adjusted Amount\n(Col. 5 + 6)\n7","Adjustments for Anticipated Cost Changes\n8","Net \nExpenses\n(Col. 7 + 8)\n9"]
["51.       Direct costs for non-CCBHC services not covered by Medicaid (specify details below)",null,null,null,null,{"$f":"SUM(D97:E97)","v":0},null,{"$f":"F97+G97","v":0},null,{"$f":"H97+I97","v":0},null,{"$f":"J97+K97","v":0}]
["51a",null,null,null,null,{"$f":"SUM(D98:E98)","v":0},null,{"$f":"F98+G98","v":0},null,{"$f":"H98+I98","v":0},null,{"$f":"J98+K98","v":0}]
[]
["52.       Total costs for non-CCBHC services \n             (sum of lines 50-51)",null,null,{"$f":"SUM(D91:D99)","v":0},0,0,0,0,0,0,0,0]
["53.       Total costs \n             (sum of lines 29, 49, and 52)",null,null,{"$f":"+D100+D85+D53","v":0},0,0,0,0,0,0,0,0]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Trial Balance Reclassifications","index":2,"n_rows":49,"n_cols":10,"rows_kept":49,"cut":false,"hidden":false,"merged":[[44,0,44,9],[43,1,43,3],[45,0,45,3],[26,1,26,3],[33,1,33,3],[42,1,42,3],[41,1,41,3],[40,1,40,3],[39,1,39,3],[38,1,38,3],[27,1,27,3],[32,1,32,3],[31,1,31,3],[30,1,30,3],[29,1,29,3],[28,1,28,3],[48,0,48,9],[2,0,2,1],[46,0,46,9],[11,1,11,3],[12,1,12,3],[13,1,13,3],[14,1,14,3],[15,1,15,3],[9,1,9,3],[10,1,10,3],[8,0,8,3],[16,1,16,3],[17,1,17,3],[7,0,7,9],[18,1,18,3],[19,1,19,3],[2,2,2,9],[3,2,3,9],[4,5,4,9],[5,5,5,9],[0,0,0,9],[1,0,1,9],[47,0,47,9],[20,1,20,3],[3,0,3,1],[4,0,4,1],[5,0,5,1],[6,0,6,1],[6,2,6,9],[37,1,37,3],[21,1,21,3],[22,1,22,3],[23,1,23,3],[24,1,24,3],[25,1,25,3],[36,1,36,3],[35,1,35,3],[34,1,34,3]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",null,{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",null,{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:",null,"From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:",null,"From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:",null,"Trial Balance Reclassifications"]
["The bottom section is for entering detail to support the reclassification of expenses.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["Explanation of Entry",null,null,null,"Increase: Expense Category \n1","Increase: \n\nLine Number\n2","Increase: \n\nAmount*\n3","Decrease: \nExpense Category \n4","Decrease: \n\nLine Number\n5","Decrease: \n\nAmount*\n6"]
["1."]
["2."]
["3."]
["4."]
["5."]
["6."]
["7."]
["8."]
["9."]
["10."]
["11."]
["12."]
["13."]
["14."]
["15."]
["16."]
["17."]
["18."]
["19."]
["20."]
["21."]
["22."]
["23."]
["24."]
["25."]
["26."]
["27."]
["28."]
["29."]
["30."]
["31."]
["32."]
["33."]
["34."]
["35a"]
[]
["36.       Total reclassifications \n             (sum of column 3 must equal sum of column 6)",null,null,null,"This cell is left intentionally blank.","This cell is left intentionally blank.",{"$f":"SUM(G10:G45)","v":0},"This cell is left intentionally blank.","This cell is left intentionally blank.",{"$f":"SUM(J10:J45)","v":0}]
["* Transfer to Trial Balance worksheet, column 4 as appropriate"]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Trial Balance Adjustments","index":3,"n_rows":46,"n_cols":8,"rows_kept":46,"cut":false,"hidden":false,"merged":[[0,0,0,7],[9,0,9,3],[10,0,10,3],[2,2,2,7],[3,2,3,7],[4,5,4,7],[5,5,5,7],[6,2,6,7],[3,0,3,1],[4,0,4,1],[2,0,2,1],[5,0,5,1],[6,0,6,1],[8,0,8,7],[11,0,11,3],[21,1,21,3],[1,0,1,7],[7,0,7,7],[45,0,45,7],[41,0,41,7],[26,0,26,3],[15,0,15,3],[40,0,40,3],[29,0,29,3],[24,0,24,7],[42,0,42,7],[38,0,38,7],[36,0,36,7],[37,1,37,3],[43,0,43,7],[12,0,12,3],[16,0,16,3],[17,0,17,3],[35,0,35,3],[34,0,34,3],[33,0,33,3],[32,0,32,3],[31,0,31,3],[30,0,30,3],[27,0,27,3],[28,0,28,3],[14,0,14,3],[20,0,20,7],[22,0,22,7],[25,0,25,7],[44,0,44,7],[23,0,23,3],[13,0,13,3],[18,0,18,3],[19,0,19,3],[39,0,39,3]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",null,{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",null,{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:",null,"From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:",null,"From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:",null,"Trial Balance Adjustments"]
["Part 1 is for entering common adjustments.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1 - COMMON ADJUSTMENTS"]
["Description",null,null,null,"Basis for Adjustment*\n\n1","Amount**\n\n2","Expense Classification***\n\n3","Line Number\n\n4"]
["1.         Investment income on commingled restricted and \n             unrestricted funds"]
["2.         Trade, quantity, and time discounts on purchases"]
["3.         Rebates and refunds of expenses"]
["4.         Rental of building or office space to others"]
["5.         Home office costs"]
["6.         Adjustment resulting from transactions with related \n             organizations"]
["7.         Vending machines"]
["8.         Practitioner assigned by National Health Service Corps"]
["9.         Depreciation - buildings and fixtures"]
["10.       Depreciation - equipment"]
["11.       Other common adjustments (specify details below)"]
["11a"]
[]
["12.       Subtotal of common adjustments (sum of lines 1-11)",null,null,null,"This cell is left intentionally blank.",{"$f":"SUM(F11:F23)","v":0},"This cell is left intentionally blank.","This cell is left intentionally blank."]
["Part 2 is for entering costs not allowed.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2 - COSTS  NOT ALLOWED (Must be removed from allowable costs)"]
["Description",null,null,null,"Basis for Adjustment*\n\n1","Amount**\n\n2","Expense Classification***\n\n3","Line Number\n\n4"]
["13.       Bad debts",null,null,null,"A"]
["14.       Charitable contributions",null,null,null,"A"]
["15.       Entertainment costs, including costs of alcoholic \n             beverages",null,null,null,"A"]
["16.       Federal, state, or local sanctions or fines",null,null,null,"A"]
["17.       Fund-raising costs",null,null,null,"A"]
["18.       Goodwill, organization costs, or other amortization",null,null,null,"A"]
["19.       Legal fees related to criminal investigations",null,null,null,"A"]
["20.       Lobbying costs",null,null,null,"A"]
["21.       Selling and marketing costs",null,null,null,"A"]
["22.       Subtotal of other costs not allowed (specify details below)",null,null,null,"A",null,"This cell is left intentionally blank.","This cell is left intentionally blank."]
["22a",null,null,null,{"$f":"E28","v":"A"}]
[]
["23.       Subtotal of costs not allowed \n             (sum of lines 13-22)",null,null,null,"A",{"$f":"SUM(F28:F39)","v":0},"This cell is left intentionally blank.","This cell is left intentionally blank."]
["24.       Total Adjustments (sum of lines 12 and 23)",null,null,null,"This cell is left intentionally blank.",{"$f":"F40+F24","v":0},"This cell is left intentionally blank.","This cell is left intentionally blank."]
["*Basis for adjustment\nA. Costs - if cost (including applicable overhead) can be determined\nB. Amount received - if cost cannot be determined"]
["** Transfer to Trial Balance worksheet, column 6 as appropriate"]
["*** Expense classification on Trial Balance worksheet from which amount is to be deducted or to which the amount is to be added"]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Anticipated Costs","index":4,"n_rows":104,"n_cols":7,"rows_kept":104,"cut":false,"hidden":false,"merged":[[66,0,66,6],[49,1,49,2],[67,1,67,2],[82,0,82,6],[80,0,80,6],[81,1,81,2],[38,0,38,6],[36,0,36,6],[37,1,37,2],[50,0,50,6],[48,0,48,6],[69,0,69,2],[73,0,73,2],[74,0,74,2],[71,0,71,6],[72,0,72,2],[62,0,62,2],[63,0,63,2],[64,0,64,2],[65,0,65,2],[45,0,45,2],[58,0,58,2],[59,0,59,2],[93,0,93,6],[92,0,92,6],[90,0,90,6],[91,1,91,2],[98,0,98,6],[96,0,96,6],[99,0,99,2],[97,1,97,2],[68,0,68,6],[13,0,13,2],[14,0,14,2],[15,0,15,2],[16,0,16,2],[1,0,1,6],[7,0,7,6],[9,0,9,6],[60,0,60,2],[61,0,61,2],[52,0,52,2],[51,0,51,2],[39,0,39,2],[17,0,17,2],[18,0,18,2],[19,0,19,2],[20,0,20,2],[21,0,21,2],[25,0,25,2],[26,0,26,2],[27,0,27,2],[31,0,31,2],[30,0,30,6],[29,1,29,2],[28,0,28,6],[0,0,0,6],[8,0,8,6],[11,0,11,2],[10,0,10,6],[22,0,22,2],[23,0,23,2],[24,0,24,2],[12,0,12,2],[103,0,103,6],[101,0,101,6],[88,0,88,6],[95,0,95,2],[70,0,70,6],[57,0,57,2],[56,0,56,6],[41,0,41,6],[34,0,34,2],[42,0,42,2],[35,0,35,2],[46,0,46,2],[47,0,47,2],[54,0,54,6],[43,0,43,2],[44,0,44,2],[102,0,102,6],[86,0,86,6],[33,0,33,6],[6,2,6,6],[2,2,2,6],[3,2,3,6],[4,5,4,6],[5,5,5,6],[75,0,75,2],[76,0,76,2],[77,0,77,2],[78,0,78,2],[32,0,32,6],[40,0,40,6],[53,0,53,6],[55,0,55,6],[100,0,100,2],[79,0,79,2],[83,0,83,2],[84,0,84,2],[89,0,89,2],[94,0,94,6],[85,0,85,6],[87,0,87,6]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",null,{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",null,{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:",null,"From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:",null,"From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:",null,"Anticipated Costs"]
["Part 1 is for entering direct CCBHC expenses.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1 - DIRECT CCBHC EXPENSES"]
["Part 1A is for entering anticipated direct CCBHC staff costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1A - CCBHC STAFF COSTS"]
["Description",null,null,"Additional Required \nFull-Time Equivalent (FTE) Staff\n\n1","Additional Expense Amount\n\n2","Reduced Expense Amount\n\n3","Anticipated Changes in Costs Due to Addition of CCBHC Services*\n(Col. 2 - 3)\n\n4"]
["1.         Psychiatrist",null,null,null,null,null,{"$f":"E13-F13","v":0}]
["2.         Psychiatric nurse",null,null,null,null,null,{"$f":"E14-F14","v":0}]
["3.         Child psychiatrist",null,null,null,null,null,0]
["4.         Adolescent psychiatrist",null,null,null,null,null,0]
["5.         Substance abuse specialist",null,null,null,null,null,0]
["6.         Case manager",null,null,null,null,null,0]
["7.         Recovery coach",null,null,null,null,null,0]
["8.         Peer specialist",null,null,null,null,null,0]
["9.         Family support specialist",null,null,null,null,null,0]
["10.       Licensed clinical social worker",null,null,null,null,null,0]
["11.       Licensed mental health counselor",null,null,null,null,null,0]
["12.       Mental health professional (trained \n             and credentialed for psychological \n             testing)",null,null,null,null,null,0]
["13.       Licensed marriage and family \n             therapist",null,null,null,null,null,0]
["14.       Occupational therapist",null,null,null,null,null,0]
["15.       Interpreters or linguistic counselor",null,null,null,null,null,0]
["16.       General practice (performing \n             CCBHC services)",null,null,null,null,null,0]
["17.       Other staff costs (specify details below)"]
["17a",{"$f":"IF('Trial Balance'!B30=\"\",\"\",'Trial Balance'!B30)","v":""},null,null,null,null,0]
["Additional lines inserted via Trial Balance tab"]
["18.       Subtotal staff costs \n             (sum of lines 1-17)",null,null,{"$f":"SUM(D13:D31)","v":0},{"$f":"SUM(E13:E31)","v":0},{"$f":"SUM(F13:F31)","v":0},{"$f":"SUM(G13:G31)","v":0}]
["Part 1B is for entering anticipated direct CCBHC costs under agreement.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1B - CCBHC COSTS UNDER AGREEMENT"]
["Description",null,null,"Additional Required \nFull-Time Equivalent (FTE) Staff\n\n1","Additional Expense Amount\n\n2","Reduced Expense Amount\n\n3","Anticipated Changes in Costs Due to Addition of CCBHC Services*\n(Col. 2 - 3)\n\n4"]
["19.       CCBHC costs from DCO",null,null,"This cell is left intentionally blank.",null,null,{"$f":"E36-F36","v":0}]
["20.       Other CCBHC costs (specify details below)",null,null,"This cell is left intentionally blank.",null,null,{"$f":"E37-F37","v":0}]
["20a",{"$f":"IF('Trial Balance'!B38=\"\",\"\",'Trial Balance'!B38)","v":""},null,"This cell is left intentionally blank.",null,null,{"$f":"E38-F38","v":0}]
["Additional lines inserted via Trial Balance tab"]
["21.       Subtotal costs under agreement \n             (sum of lines 19-20)",null,null,"This cell is left intentionally blank.",{"$f":"SUM(E36:E39)","v":0},{"$f":"SUM(F36:F39)","v":0},{"$f":"SUM(G36:G39)","v":0}]
["Part 1C is for entering anticipated other direct CCBHC costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1C - OTHER DIRECT CCBHC COSTS"]
["Description",null,null,"Additional Required \nFull-Time Equivalent (FTE) Staff\n\n1","Additional Expense Amount\n\n2","Reduced Expense Amount\n\n3","Anticipated Changes in Costs Due to Addition of CCBHC Services*\n(Col. 2 - 3)\n\n4"]
["22.       Medical supplies",null,null,"This cell is left intentionally blank.",null,null,{"$f":"E44-F44","v":0}]
["23.       Transportation (health care staff)",null,null,"This cell is left intentionally blank.",null,null,0]
["24.       Depreciation - medical equipment",null,null,"This cell is left intentionally blank.",null,null,0]
["25.       Professional liability insurance",null,null,"This cell is left intentionally blank.",null,null,0]
["26.       Telehealth ",null,null,"This cell is left intentionally blank.",null,null,0]
["27.       Other direct costs not already included (specify details below)"]
["27a",{"$f":"IF('Trial Balance'!B50=\"\",\"\",'Trial Balance'!B50)","v":""},null,null,null,null,{"$f":"E50-F50","v":0}]
["Additional lines inserted via Trial Balance tab"]
["28.       Subtotal other direct CCBHC \n             costs (sum of lines 22-27)",null,null,"This cell is left intentionally blank.",{"$f":"SUM(E44:E51)","v":0},{"$f":"SUM(F44:F51)","v":0},{"$f":"SUM(G44:G51)","v":0}]
["29.       Total cost of CCBHC services \n             (other than overhead)\n             (sum of lines 18, 21, and 28)",null,null,{"$f":"SUM(D32,D40,D52)","v":0},{"$f":"SUM(E32,E40,E52)","v":0},{"$f":"SUM(F32,F40,F52)","v":0},{"$f":"SUM(G32,G40,G52)","v":0}]
["Part 2 is for entering indirect costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2 - INDIRECT COSTS"]
["Part 2A is for entering anticipated indirect facility costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2A - SITE COSTS"]
["Description",null,null,"Additional Required \nFull-Time Equivalent (FTE) Staff\n\n1","Additional Expense Amount\n\n2","Reduced Expense Amount\n\n3","Anticipated Changes in Costs Due to Addition of CCBHC Services*\n(Col. 2 - 3)\n\n4"]
["30.       Rent",null,null,"This cell is left intentionally blank.",null,null,{"$f":"E59-F59","v":0}]
["31.       Insurance",null,null,"This cell is left intentionally blank.",null,null,0]
["32.       Interest on mortgage or loans",null,null,"This cell is left intentionally blank.",null,null,0]
["33.       Utilities",null,null,"This cell is left intentionally blank.",null,null,0]
["34.       Depreciation - buildings and fixtures",null,null,"This cell is left intentionally blank.",null,null,0]
["35.       Depreciation - equipment",null,null,"This cell is left intentionally blank.",null,null,0]
["36.       Housekeeping and maintenance",null,null,"This cell is left intentionally blank.",null,null,0]
["37.       Property tax",null,null,"This cell is left intentionally blank.",null,null,0]
["38.       Other site costs (specify details below)",null,null,"This cell is left intentionally blank.",null,null,0]
["38a",{"$f":"IF('Trial Balance'!B68=\"\",\"\",'Trial Balance'!B68)","v":""},null,"This cell is left intentionally blank.",null,null,0]
["Additional lines inserted via Trial Balance tab"]
["39.       Subtotal site costs \n             (sum of lines 30-38)",null,null,"This cell is left intentionally blank.",{"$f":"SUM(E59:E69)","v":0},{"$f":"SUM(F59:F69)","v":0},{"$f":"SUM(G59:G69)","v":0}]
["Part 2B is for entering anticipated indirect administrative costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2B - ADMINISTRATIVE COSTS"]
["Description",null,null,"Additional Required \nFull-Time Equivalent (FTE) Staff\n\n1","Additional Expense Amount\n\n2","Reduced Expense Amount\n\n3","Anticipated Changes in Costs Due to Addition of CCBHC Services*\n(Col. 2 - 3)\n\n4"]
["40.       Office salaries ",null,null,"This cell is left intentionally blank.",null,null,{"$f":"E74-F74","v":0}]
["41.       Depreciation - office equipment",null,null,"This cell is left intentionally blank.",null,null,{"$f":"E75-F75","v":0}]
["42.       Office supplies",null,null,"This cell is left intentionally blank.",null,null,0]
["43.       Legal",null,null,"This cell is left intentionally blank.",null,null,0]
["44.       Accounting",null,null,"This cell is left intentionally blank.",null,null,0]
["45.       Insurance",null,null,"This cell is left intentionally blank.",null,null,0]
["46.       Telephone",null,null,"This cell is left intentionally blank.",null,null,0]
["47.       Other administrative costs (specify details below)"]
["47a",{"$f":"IF('Trial Balance'!B82=\"\",\"\",'Trial Balance'!B82)","v":""},null,"This cell is left intentionally blank.",null,null,0]
["Additional lines inserted via Trial Balance tab"]
["48.       Subtotal administrative costs \n             (sum of lines 40-47)",null,null,"This cell is left intentionally blank.",{"$f":"SUM(E74:E83)","v":0},{"$f":"SUM(F74:F83)","v":0},{"$f":"SUM(G74:G83)","v":0}]
["49.       Total overhead \n             (sum of lines 39 and 48)",null,null,"This cell is left intentionally blank.",{"$f":"E70+E84","v":0},{"$f":"F70+F84","v":0},{"$f":"G70+G84","v":0}]
["Part 3 is for entering anticipated direct costs for non-CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 3 - DIRECT COSTS FOR NON-CCBHC SERVICES"]
["Part 3a is for entering anticipated direct costs for non-CCBHC services. Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 3A - DIRECT COSTS FOR SERVICES OTHER THAN CCHBC SERVICES"]
["Description",null,null,"Additional Required \nFull-Time Equivalent (FTE) Staff\n\n1","Additional Expense Amount\n\n2","Reduced Expense Amount\n\n3","Anticipated Changes in Costs Due to Addition of CCBHC Services*\n(Col. 2 - 3)\n\n4"]
["50.       Direct costs for non-CCBHC services covered by Medicaid (specify details below)"]
["50a",{"$f":"IF('Trial Balance'!B92=\"\",\"\",'Trial Balance'!B92)","v":""},null,null,null,null,{"$f":"E92-F92","v":0}]
["Additional lines inserted via Trial Balance tab"]
["Part 3B is for entering anticipated direct costs that are for non-reimbursable services. Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 3B - NON-REIMBURSABLE COSTS"]
["Description",null,null,"Additional Required \nFull-Time Equivalent (FTE) Staff\n\n1","Additional Expense Amount\n\n2","Reduced Expense Amount\n\n3","Anticipated Changes in Costs Due to Addition of CCBHC Services*\n(Col. 2 - 3)\n\n4"]
["51.       Direct costs for non-CCBHC services not covered by Medicaid (specify details below)"]
["51a",{"$f":"IF('Trial Balance'!B98=\"\",\"\",'Trial Balance'!B98)","v":""},null,null,null,null,{"$f":"E98-F98","v":0}]
["Additional lines inserted via Trial Balance tab"]
["52.       Subtotal costs for non-CCBHC \n             services (sum of 50-51)",null,null,"This cell is left intentionally blank.",{"$f":"SUM(E91:E93,E97:E99)","v":0},{"$f":"SUM(F91:F93,F97:F99)","v":0},{"$f":"SUM(G91:G93,G97:G99)","v":0}]
["53.       Total costs \n             (sum of lines 29, 49, and 52)",null,null,{"$f":"SUM(D100,D85,D53)","v":0},{"$f":"+E100+E85+E53","v":0},{"$f":"+F100+F85+F53","v":0},{"$f":"+G100+G85+G53","v":0}]
["* Transfer to Trial Balance worksheet, column 8 as appropriate"]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Indirect Cost Allocation","index":5,"n_rows":27,"n_cols":8,"rows_kept":27,"cut":false,"hidden":false,"merged":[[5,0,5,1],[6,2,6,7],[6,0,6,1],[12,0,12,6],[13,0,13,6],[5,5,5,7],[7,0,7,7],[8,0,8,6],[9,0,9,6],[11,0,11,4],[2,2,2,7],[3,2,3,7],[4,5,4,7],[0,0,0,7],[2,0,2,1],[3,0,3,1],[1,0,1,7],[4,0,4,1],[14,0,14,6],[15,0,15,6],[25,0,25,7],[26,0,26,7],[10,0,10,3],[10,4,10,7],[11,5,11,7],[16,0,16,6],[17,0,17,6],[18,0,18,6],[19,0,19,6],[20,0,20,6],[21,0,21,6],[23,0,23,6],[24,0,24,6],[22,0,22,6]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",null,{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",null,{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:",null,"From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:",null,"From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:",null,"Indirect Cost Allocation"]
["The bottom section is used for identifying the method for allocating indirect costs.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["Description",null,null,null,null,null,null,"This cell is left intentionally blank."]
["1.         Does the CCBHC have a indirect cost rate approved by a cognizant agency (see Cost  \n             Report Instructions)?  If no, go to line 7. "]
["2.         Which cognizant agency approved the rate?"]
["3.         Describe the base rate with respect to the indirect cost rate. "]
["4.         Enter the basis amount subject to the rate agreement"]
["5.         Enter the approved rate amount"]
["6.         Calculated indirect costs allocable to CCBHC services (line 4 multiplied by line 5)",null,null,null,null,null,null,{"$f":"IF(H10=\"Yes\",+H13*H14,0)","v":0}]
["7.         Does the CCBHC qualify to use the federal minimum rate and elect to use the rate for all \n             federal awards?  See instructions for qualifications.  If no, go to line 11."]
["8.         Direct costs for CCBHC services (Trial Balance, column 9, line 29)",null,null,null,null,null,null,{"$f":"IF(H16=\"Yes\",'Trial Balance'!L53,0)","v":0}]
["9.         Minimum rate",null,null,null,null,null,null,0.1]
["10.       Calculated indirect costs allocable to CCBHC services (line 8 multiplied by line 9)",null,null,null,null,null,null,{"$f":"IF(H16=\"Yes\",+H17*H18,0)","v":0}]
["11.       Will the CCBHC allocate indirect costs proportionally by the percentage of direct costs \n             for CCBHC services versus total allowable costs less indirect costs?  If no, go to line 15."]
["12.       Percentage of direct costs versus total allowable direct costs (Trial Balance, column 9, \n             line 29 divided by the sum of Trial Balance, column 9, line 29 and Trial Balance, \n             column 9, line 52)",null,null,null,null,null,null,{"$f":"IF(H20=\"Yes\",IF(SUM('Trial Balance'!L53+'Trial Balance'!L100)=0,0,'Trial Balance'!L53/SUM('Trial Balance'!L53+'Trial Balance'!L100)),0)","v":0}]
["13.       Indirect costs to be allocated (Trial Balance, column 9, line 49)",null,null,null,null,null,null,{"$f":"+'Trial Balance'!L85","v":0}]
["14.       Calculated indirect costs allocable to CCBHC services (line 12 multiplied by line 13)",null,null,null,null,null,null,{"$f":"IF(H20=\"Yes\",H21*H22,0)","v":0}]
["15.       If none of the lines 1, 7, or 11 are entered as Yes, provide a thorough description \n             of the cost allocation method used. Include attachments for descriptions and calculations.  \n             Include references to line items included in the Trial Balance tab.  Enter the amount of \n             indirect costs allocated to providing CCBHC services here."]
["16.       Total indirect costs allocated to CCBHC services",null,null,null,null,null,null,{"$f":"IF(H10=\"Yes\", H15,IF(H16=\"Yes\",H19,IF(H20=\"Yes\",H23,H24)))","v":0}]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Allocation Descriptions","index":6,"n_rows":41,"n_cols":5,"rows_kept":41,"cut":false,"hidden":false,"merged":[[40,0,40,8],[10,0,38,8],[9,0,9,8],[0,0,0,8],[8,0,8,8],[2,1,2,8],[3,1,3,8],[4,4,4,8],[5,4,5,8],[6,1,6,8],[1,0,1,8],[7,0,7,8],[39,0,39,8]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:","From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:","From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:","Allocation Descriptions"]
["The bottom section is used for entering the description of allocations.  The descriptions should include the tab in which the allocation is referenced, the method for allocation and the amounts allocated.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PLEASE EXPLAIN METHODS USED FOR ALLOCATING RESOURCES TO DIRECT OR INDIRECT COSTS"]
["Justification for allocation:"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Daily Visits","index":7,"n_rows":16,"n_cols":8,"rows_kept":16,"cut":false,"hidden":false,"merged":[[4,0,4,1],[4,5,4,7],[5,0,5,1],[5,5,5,7],[6,0,6,1],[6,2,6,7],[0,0,0,7],[2,2,2,7],[2,0,2,1],[3,0,3,1],[3,2,3,7],[1,0,1,7],[7,0,7,7],[8,0,8,7],[15,0,15,7],[9,0,9,6],[10,0,10,6],[11,0,11,6],[13,0,13,6],[12,0,12,6],[14,0,14,7]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",null,{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",null,{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:",null,"From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:",null,"From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:",null,"Daily Visits"]
["The bottom section is used for identifying the number of days patients received CCBHC services.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PATIENT DEMOGRAPHICS CONSOLIDATED"]
["Include ALL visits for CCBHC services; do not limit it to those covered by Medicaid.",null,null,null,null,null,null,"Total Daily\nPatient Visits\n1"]
["1.       Number of daily visits for patients receiving CCBHC services provided directly from staff"]
["2.       Number of daily visits for patients receiving CCBHC services directly from DCO \n          (not included above)"]
["3.       Number of additional anticipated daily visits for patients receiving CCBHC services"]
["4.       Total daily visits for patients receiving CCBHC services (sum of lines 1-3)",null,null,null,null,null,null,{"$f":"SUM(H11:H13)","v":0}]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Monthly Visits","index":8,"n_rows":18,"n_cols":10,"rows_kept":18,"cut":false,"hidden":false,"merged":[[17,0,17,9],[8,0,8,9],[10,0,10,1],[11,0,11,1],[12,0,12,1],[13,0,13,1],[15,0,15,1],[14,0,14,1],[10,8,15,8],[16,0,16,9],[0,0,0,9],[9,0,9,9],[2,1,2,9],[3,1,3,9],[5,4,5,9],[4,4,4,9],[6,1,6,9],[1,0,1,9],[7,0,7,9]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:","From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:","From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:","Monthly Visits"]
["The bottom section is used for identifying the number of months each patient received CCBHC services.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PATIENT DEMOGRAPHICS CONSOLIDATED"]
["Patient demographics should be analyzed to identify Certain Conditions.  Because CC PPS-2 requires monthly detail, patient data must be aggregated by patient by month to determine eligibility for Certain Conditions.  Months should be captured for ALL CCBHC services provided; do not limit the information to Medicaid members."]
["Description",null,"Standard Population\nVisit Months\nAll\n1a","Standard Population\nVisit Months\nAbove the Outlier Threshold\n1b","Certain Conditions 1\nVisit Months\nAll\n2a","Certain Conditions 1\nVisit Months\nAbove the Outlier Threshold\n2b","Certain Conditions 2\nVisit Months\nAll\n3a","Certain Conditions 2\nVisit Months\nAbove the Outlier Threshold\n3b",null,"Monthly\nPatient Visit\n(Sum of col. a's)\n\nTotal"]
["1.       Describe population\n\n",null,"This cell is left intentionally blank.","This cell is left intentionally blank.",null,"This cell is left intentionally blank.",null,"This cell is left intentionally blank.",null,"This cell is left intentionally blank."]
["2.       Number of months patients \n           received CCBHC services directly \n           from staff",null,null,null,null,null,null,null,null,{"$f":"SUMPRODUCT((MOD(COLUMN(C13:I13),2)>0)*(C13:I13))","v":0}]
["3.       Number of months patients \n           received CCBHC services directly \n           from DCO (not included above)",null,null,null,null,null,null,null,null,{"$f":"SUMPRODUCT((MOD(COLUMN(C14:I14),2)>0)*(C14:I14))","v":0}]
["4.       Number of additional anticipated \n          months patients received CCBHC\n          services (not included above)",null,null,null,null,null,null,null,null,{"$f":"SUMPRODUCT((MOD(COLUMN(C15:I15),2)>0)*(C15:I15))","v":0}]
["5.       Total months patients \n           received CCBHC services \n           (sum of lines 2-4)",null,{"$f":"SUM(C13:C15)","v":0},{"$f":"SUM(D13:D15)","v":0},{"$f":"SUM(E13:E15)","v":0},{"$f":"SUM(F13:F15)","v":0},{"$f":"SUM(G13:G15)","v":0},{"$f":"SUM(H13:H15)","v":0},null,{"$f":"SUM(J13:J15)","v":0}]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Services Provided","index":9,"n_rows":78,"n_cols":9,"rows_kept":78,"cut":false,"hidden":false,"merged":[[77,0,77,4],[42,0,42,4],[44,0,44,4],[45,0,45,2],[62,0,62,2],[61,0,61,2],[73,0,73,4],[64,1,64,2],[72,1,72,2],[50,0,50,2],[55,0,55,2],[56,0,56,2],[46,0,46,2],[70,0,70,2],[68,0,68,4],[74,0,74,2],[75,0,75,2],[69,0,69,2],[19,0,19,2],[20,0,20,2],[21,0,21,2],[60,0,60,2],[26,0,26,2],[34,0,34,2],[53,0,53,2],[27,0,27,2],[57,0,57,2],[58,0,58,2],[47,0,47,2],[24,0,24,2],[25,0,25,2],[35,0,35,2],[13,0,13,2],[16,0,16,2],[48,0,48,2],[49,0,49,2],[41,0,41,4],[43,0,43,4],[17,0,17,2],[18,0,18,2],[36,0,36,6],[28,0,28,6],[22,0,22,2],[23,0,23,2],[33,0,33,6],[14,0,14,2],[54,0,54,2],[63,0,63,4],[0,0,0,6],[8,0,8,6],[11,0,11,2],[10,0,10,6],[2,2,2,6],[3,2,3,6],[4,5,4,6],[5,5,5,6],[1,0,1,6],[7,0,7,6],[9,0,9,6],[6,2,6,6],[59,0,59,2],[12,0,12,2],[76,0,76,4],[51,0,51,2],[15,0,15,2],[71,0,71,4],[65,0,65,4],[30,0,30,6],[67,0,67,4],[29,1,29,2],[38,0,38,6],[37,1,37,2],[66,0,66,2],[32,0,32,6],[31,0,31,2],[52,0,52,2],[39,0,39,2],[40,0,40,2]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",null,{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",null,{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:",null,"From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:",null,"From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:",null,"Services Provided"]
["Part 1 is for single site or consolidated information for services provided.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1 - SERVICES PROVIDED (Consolidated)"]
["Part 1A is for consolidated information for services provided by CCBHC staff.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1A - CCBHC STAFF SERVICES"]
["Description",null,null,"Number of Full-Time Equivalent (FTE) Staff\n\n1","Total Number of Services Provided for CCBHC Services\n\n2","\nDirect Cost \n(from Trial Balance, Col. 9)\n\n3","Average Cost per Service by Position (Col. 3 divided by Col. 2)\n\n4"]
["1.         Psychiatrist",null,null," ",null,{"$f":"'Trial Balance'!L13","v":0},{"$f":"IF(SUM(E13)=0,0,F13/E13)","v":0}]
["2.         Psychiatric nurse",null,null," ",null,{"$f":"'Trial Balance'!L14","v":0},0]
["3.         Child psychiatrist",null,null,null,null,{"$f":"'Trial Balance'!L15","v":0},0]
["4.         Adolescent psychiatrist",null,null,null,null,{"$f":"'Trial Balance'!L16","v":0},0]
["5.         Substance abuse specialist",null,null,null,null,{"$f":"'Trial Balance'!L17","v":0},0]
["6.         Case manager",null,null,null,null,{"$f":"'Trial Balance'!L18","v":0},0]
["7.         Recovery coach",null,null,null,null,{"$f":"'Trial Balance'!L19","v":0},0]
["8.         Peer specialist",null,null,null,null,{"$f":"'Trial Balance'!L20","v":0},0,null,"`"]
["9.         Family support specialist",null,null,null,null,{"$f":"'Trial Balance'!L21","v":0},0]
["10.       Licensed clinical social worker",null,null,null,null,{"$f":"'Trial Balance'!L22","v":0},0]
["11.       Licensed mental health counselor",null,null,null,null,{"$f":"'Trial Balance'!L23","v":0},0]
["12.       Mental health professional (trained \n             and credentialed for psychological \n             testing)",null,null,null,null,{"$f":"'Trial Balance'!L24","v":0},0]
["13.       Licensed marriage and family \n             therapist",null,null,null,null,{"$f":"'Trial Balance'!L25","v":0},0]
["14.       Occupational therapist",null,null,null,null,{"$f":"'Trial Balance'!L26","v":0},0]
["15.       Interpreters or linguistic counselor",null,null,null,null,{"$f":"'Trial Balance'!L27","v":0},0]
["16.       General practice \n             (performing CCBHC services)",null,null,"  ",null,{"$f":"'Trial Balance'!L28","v":0},0]
["17.       Other staff services (specify details below)"]
["17a",{"$f":"IF('Trial Balance'!B30=\"\",\"\",'Trial Balance'!B30)","v":""},null,null,null,{"$f":"'Trial Balance'!L30","v":0},{"$f":"IF(SUM(E30)=0,0,F30/E30)","v":0}]
["Additional lines inserted via Trial Balance tab"]
["18.       Subtotal staff services \n             (sum of lines 1-17)",null,null,{"$f":"SUM(D13:D31)","v":0},{"$f":"SUM(E13:E31)","v":0},{"$f":"'Trial Balance'!L32","v":0},{"$f":"IF(SUM(E32)=0,0,F32/E32)","v":0}]
["Part 1B is for consolidated information for services provided under agreement.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1B - CCBHC SERVICES UNDER AGREEMENT"]
["Description",null,null,"Number of Full-Time Equivalent (FTE) Staff\n\n1","Total Number of Services Provided for CCBHC Services\n\n2","\nDirect Cost \n(from Trial Balance, Col. 9)\n\n3","Average Cost per Service by Position (Col. 3 divided by Col. 2)\n\n4"]
["19.       CCBHC services from DCO",null,null,"This cell is left intentionally blank.",null,{"$f":"'Trial Balance'!L36","v":0},{"$f":"IF(SUM(E36)=0,0,F36/E36)","v":0}]
["20.       Other CCBHC services (specify details below)",null,null,"This cell is left intentionally blank.",null,{"$f":"'Trial Balance'!L37","v":0},0]
["20a",{"$f":"IF('Trial Balance'!B38=\"\",\"\",'Trial Balance'!B38)","v":""},null,"This cell is left intentionally blank.",null,{"$f":"'Trial Balance'!L38","v":0},{"$f":"IF(SUM(E38)=0,0,F38/E38)","v":0}]
["Additional lines inserted via Trial Balance tab"]
["21.       Subtotal services under agreement \n             (sum of lines 19-20)",null,null,"This cell is left intentionally blank.",{"$f":"SUM(E36:E39)","v":0},{"$f":"'Trial Balance'!L40","v":0},{"$f":"IF(SUM(E40)=0,0,F40/E40)","v":0}]
["22.       Total services \n             (sum of lines 18 and 21)",null,null,{"$f":"SUM(D40,D32)","v":0},{"$f":"E32+E40","v":0},{"$f":"F32+F40","v":0},{"$f":"IF(SUM(E41)=0,0,F41/E41)","v":0}]
["Part 2 is for reporting specific information for each site.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2 - SERVICES PROVIDED BY SITE (For additional satellite sites, create new tab and copy and paste Part 2 for each additional site included)"]
["Part 2A is for site-specific information for services provided by CCBHC staff.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2A - CCBHC STAFF SERVICES"]
["Description",null,null,"Number of Full-Time Equivalent (FTE) Staff\n\n1","Total Number of Services Provided for CCBHC Services\n\n2"]
["1.         Psychiatrist"]
["2.         Psychiatric nurse"]
["3.         Child psychiatrist"]
["4.         Adolescent psychiatrist"]
["4.         Adolescent psychiatrisu"]
["5.         Substance abuse specialist"]
["6.         Case manager"]
["7.         Recovery coach"]
["8.         Peer specialist"]
["9.         Family support specialist"]
["10.       Licensed clinical social worker"]
["11.       Licensed mental health counselor"]
["12.       Mental health professional (trained \n             and credentialed for psychological \n             testing)"]
["13.       Licensed marriage and family \n             therapist"]
["14.       Occupational therapist"]
["15.       Interpreters or linguistic counselor"]
["16.       General practice \n             (performing CCBHC services)"]
["17.       Other staff services (specify details below)"]
["17a",{"$f":"IF('Trial Balance'!B30=\"\",\"\",'Trial Balance'!B30)","v":""}]
["Additional lines inserted via Trial Balance tab"]
["18.       Subtotal staff services \n             (sum of lines 1-17)",null,null,{"$f":"SUM(D47:D66)","v":0},{"$f":"SUM(E47:E66)","v":0}]
["Part 2B is for site-specific information for services provided under agreement.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2B - CCBHC SERVICES UNDER AGREEMENT"]
["Description",null,null,"Number of Full-Time Equivalent (FTE) Staff\n\n1","Total Number of Services Provided for CCBHC Services\n\n2"]
["19.       CCBHC services from DCO",null,null,"This cell is left intentionally blank."]
["20.       Other CCBHC services (specify details below)",null,null,"This cell is left intentionally blank."]
["20a",{"$f":"IF('Trial Balance'!B38=\"\",\"\",'Trial Balance'!B38)","v":""},null,"This cell is left intentionally blank."]
["Additional lines inserted via Trial Balance tab"]
["21.       Subtotal services under agreement \n             (sum of lines 19-20)",null,null,"This cell is left intentionally blank.",{"$f":"SUM(E71:E74)","v":0}]
["22.       Total services \n             (sum of lines 18 and 21)",null,null,{"$f":"SUM(D75,D67)","v":0},{"$f":"E67+E75","v":0}]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Comments","index":10,"n_rows":273,"n_cols":11,"rows_kept":273,"cut":false,"hidden":false,"merged":[[0,0,0,10],[5,0,5,1],[1,0,1,10],[7,0,7,10],[2,0,2,1],[2,2,2,10],[3,0,3,1],[3,2,3,10],[4,0,4,1],[4,5,4,10],[271,0,271,10],[272,0,272,10],[8,0,8,10],[5,5,5,10],[6,0,6,1],[6,2,6,10]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",null,{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",null,{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:",null,"From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:",null,"From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:",null,"Comments"]
["The bottom section is used to identify the worksheet, line and comments.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["Please explain or comment on any additional considerations that should be taken into account in determining the appropriate payment rate"]
["Worksheet","Line","Comment 1","Comment 2","Comment 3","Comment 4","Comment 5","Comment 6","Comment 7","Comment 8","Comment 9"]
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["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"CC PPS-1 Rate","index":11,"n_rows":24,"n_cols":6,"rows_kept":24,"cut":false,"hidden":false,"merged":[[23,0,23,5],[9,0,9,4],[15,0,15,4],[8,0,8,5],[0,0,0,5],[21,0,21,5],[14,0,14,5],[19,0,19,4],[18,0,18,4],[17,0,17,4],[16,0,16,4],[12,0,12,4],[11,0,11,4],[20,0,20,4],[10,0,10,4],[22,0,22,5],[7,0,7,5],[13,0,13,5],[1,0,1,5],[2,1,2,5],[3,1,3,5],[6,1,6,5],[4,4,4,5],[5,4,5,5]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:","From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:","From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:","CC PPS-1 Rate"]
["Part 1 is automatically populated with the direct and indirect costs for CCBHC services.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1 - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO THE CCBHC "]
["Description",null,null,null,null,"Amount\n1"]
["1.         Total direct cost of CCBHC services (Trial Balance, column 9, line 29)",null,null,null,null,{"$f":"'Trial Balance'!L53","v":0}]
["2.         Indirect cost applicable to CCBHC services (Indirect Cost Allocation, line 16)",null,null,null,null,{"$f":"+'Indirect Cost Allocation'!H25","v":0}]
["3.         Total allowable CCBHC costs (sum of lines 1-2)",null,null,null,null,{"$f":"F12+F11","v":0}]
["Part 2 calculates the CC PPS 1 rate after the MEI is entered in line 7.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2 - DETERMINATION OF CC PPS-1 RATE"]
["Description",null,null,null,null,"Amount\n1"]
["4.         Total allowable CCBHC costs (line 3)",null,null,null,null,{"$f":"+F13","v":0}]
["5.         Total CCBHC visits* (Daily Visits, column 1, line 4)",null,null,null,null,{"$f":"'Daily Visits'!H14","v":0}]
["6.         Unadjusted PPS rate (line 4 divided by line 5)",null,null,null,null,{"$f":"IF(F18=0,0,F17/F18)","v":0}]
["7.         Medicare Economic Index (MEI) adjustment from midpoint of the cost period to the midpoint of \n             the rate period",null,null,null,null,0]
["8.         CC PPS-1 rate (line 6 adjusted by factor from line 7)",null,null,null,null,{"$f":"F19*(1+F20)","v":0}]
["* Total should reflect the total count of CCBHC visits provided and not be restricted to Medicaid visits"]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"CC PPS-2 Rate","index":12,"n_rows":31,"n_cols":10,"rows_kept":31,"cut":false,"hidden":false,"merged":[[18,0,18,7],[17,0,17,1],[10,0,10,1],[13,0,13,1],[15,0,15,1],[16,0,16,1],[14,0,14,1],[11,0,11,1],[12,0,12,1],[22,0,22,1],[23,0,23,1],[24,0,24,1],[19,0,19,9],[30,0,30,9],[28,0,28,9],[21,0,21,1],[20,0,20,9],[25,0,25,1],[26,0,26,1],[27,0,27,1],[21,8,27,8],[29,0,29,9],[1,0,1,9],[7,0,7,9],[0,0,0,9],[8,0,8,9],[9,8,17,8],[9,0,9,1],[2,1,2,9],[3,1,3,9],[4,4,4,9],[5,4,5,9],[6,1,6,9]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:","From:",{"$f":"IF('Provider Information'!E5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:","From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:","CC PPS-2 Rate"]
["Part 1 is used to determine the cost-to-charge ratio allocation by population group. Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 1 - COST-TO-CHARGE RATIO ALLOCATION"]
["Description",null,"Standard Population\nCharges and Costs for CCBHC Services:\nAt or Below the Outlier Threshold\n1a","Standard Population\nCharges and Costs for CCBHC Services:\nAbove the Outlier Threshold\n1b","Certain Conditions 1\nCharges and Costs for CCBHC Services:\nAt or Below the Outlier Threshold\n2a","Certain Conditions 1\nCharges and Costs for CCBHC Services:\nAbove the Outlier Threshold\n2b","Certain Conditions 2\nCharges and Costs for CCBHC Services:\nAt or Below the Outlier Threshold\n3a","Certain Conditions 2\nCharges and Costs for CCBHC Services:\nAbove the Outlier Threshold\n3b","\nAdditional columns inserted via Monthly Visits tab","Total Population Charges and Costs\n(Sum of all Columns) \n\n\nTotal"]
["1.         Actual charges",null,null,null,null,null,null,null,null,{"$f":"SUM(C11:I11)","v":0}]
["2.         Anticipated additional charges (DY1 \n            only)",null,null,null,null,null,null,null,null,{"$f":"SUM(C12:I12)","v":0}]
["3.         Total charges (sum of lines 1-2)",null,{"$f":"SUM(C11:C12)","v":0},0,0,0,{"$f":"SUM(G11:G12)","v":0},0,null,{"$f":"SUM(J11:J12)","v":0}]
["4.         Total direct costs (Trial Balance, \n            column 9, line 29)",null,"This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.",null,{"$f":"'Trial Balance'!L53","v":0}]
["5.         Indirect cost applicable to CCBHC \n             services (Indirect Cost Allocation,\n             line 16)",null,"This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.",null,{"$f":"+'Indirect Cost Allocation'!H25","v":0}]
["6.         Total allowable costs for CCBHC \n             services (sum of lines 4-5)",null,"This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.",null,{"$f":"J14+J15","v":0}]
["7.         Cost-to-charge ratio \n            services (line 6 divided by line 3)",null,"This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.",null,{"$f":"IF(J13=0,0,+J16/J13)","v":0}]
["8.         Total cost of CCBHC services \n             (line 3 times line 7)",null,{"$f":"+C13*$J$17","v":0},0,0,0,0,0,null,{"$f":"+J13*$J$17","v":0}]
["Cross Check:  Total costs should tie to the total direct and indirect costs applicable to CCBHC services (line 6)",null,null,null,null,null,null,null,"Difference",{"$f":"+J18-J16","v":0}]
["Part 2 is used to calculate preliminary CC PPS-2 rates after MEI is entered in line 12.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["PART 2 - DETERMINATION OF CC PPS-2 RATE"]
["Description",null,"Standard Population\nCosts for CCBHC Services:\nAt or Below the Outlier Threshold\n1a","Standard Population\nCosts for CCBHC Services:\nAbove the Outlier Threshold\n1b","Certain Conditions 1\nCosts for CCBHC Services:\nAt or Below the Outlier Threshold\n2a","Certain Conditions 1\nCosts for CCBHC Services:\nAbove the Outlier Threshold\n2b","Certain Conditions 2\nCosts for CCBHC Services:\nAt or Below the Outlier Threshold\n3a","Certain Conditions 2\nCosts for CCBHC Services:\nAbove the Outlier Threshold\n3b","\nAdditional columns inserted via Monthly Visits tab","Total Population Costs\n(Sum of all Columns) \n\n\nTotal"]
["9.         Total allowable CCBHC costs \n             (line 8)",null,{"$f":"+C18","v":0},{"$f":"+D18","v":0},0,0,{"$f":"+G18","v":0},0,null,{"$f":"+J18","v":0}]
["10.       Total months patients \n             received CCBHC services\n             (Monthly Visits, line 5)*","Total CCBHC visits (Monthly Visits, line 4)*",{"$f":"'Monthly Visits'!C16","v":0},"This cell is left intentionally blank.",{"$f":"'Monthly Visits'!E16","v":0},"This cell is left intentionally blank.",{"$f":"'Monthly Visits'!G16","v":0},"This cell is left intentionally blank.",null,{"$f":"'Monthly Visits'!J16","v":0}]
["11.       Total allowable cost per visit  \n             (line 9 divided by line 10)","Total allowable cost per visit  (line 35 divided by line 36)",{"$f":"IF(C24=0,0,C23/C24)","v":0},"This cell is left intentionally blank.",{"$f":"IF(E24=0,0,E23/E24)","v":0},"This cell is left intentionally blank.",{"$f":"IF(G24=0,0,G23/G24)","v":0},"This cell is left intentionally blank.",null,{"$f":"IF(J24=0,0,J23/J24)","v":0}]
["12.       Medicare Economic Index (MEI) \n             adjustment from midpoint of the cost \n             period to the midpoint of the rate\n             period","Medicare Economic Index (MEI) adjustment from midpoint of the cost period to the midpoint of the rate period","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.","This cell is left intentionally blank.",null,0]
["13.       CC PPS-2 rate (line 11 adjusted by \n             factor from column Total, line 12)","CC PPS-2 rate (line 37 adjusted by factor from column Total, line 38)",{"$f":"C25*(1+$J$26)","v":0},"This cell is left intentionally blank.",{"$f":"E25*(1+$J$26)","v":0},"This cell is left intentionally blank.",{"$f":"G25*(1+$J$26)","v":0},"This cell is left intentionally blank.",null,{"$f":"J25*(1+J26)","v":0}]
["14.       Outlier pool (line 9)","Outlier pool (line 35)","This cell is left intentionally blank.",{"$f":"D23","v":0},"This cell is left intentionally blank.",{"$f":"F23","v":0},"This cell is left intentionally blank.",{"$f":"H23","v":0},null,{"$f":"SUM(C28:I28)","v":0}]
["* Column \"a\" reflects the count for All visits. The total reflects the sum of \"a\" columns."]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]

{"sheet":"Certification","index":13,"n_rows":21,"n_cols":6,"rows_kept":21,"cut":false,"hidden":false,"merged":[[0,0,0,11],[2,0,2,1],[3,0,3,1],[4,0,4,1],[5,0,5,1],[2,2,2,11],[3,2,3,11],[4,5,4,11],[5,5,5,11],[1,0,1,11],[13,3,13,11],[14,0,14,2],[14,3,14,11],[8,0,8,11],[9,0,9,11],[10,0,10,11],[11,0,11,11],[6,0,6,1],[6,2,6,11],[20,0,20,11],[15,0,15,2],[15,3,15,11],[16,0,16,2],[16,3,16,11],[17,0,17,2],[17,3,17,11],[19,0,19,11],[7,0,7,11],[18,0,18,2],[18,3,18,11],[12,0,12,2],[12,3,12,11],[13,0,13,2]]}
["CCBHC Cost Report"]
["This is the top section.  It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID ID:",null,{"$f":"IF('Provider Information'!$D$3=\"\",\"\",'Provider Information'!$D$3)","v":""}]
["NPI:",null,{"$f":"IF('Provider Information'!$D$4=\"\",\"\",'Provider Information'!$D$4)","v":""}]
["REPORTING PERIOD:",null,"From:",{"$f":"IF('Provider Information'!$E$5=\"\",\"\",'Provider Information'!$E$5)","v":""},"To:",{"$f":"IF('Provider Information'!$G$5=\"\",\"\",'Provider Information'!$G$5)","v":""}]
["RATE PERIOD:",null,"From:",{"$f":"IF('Provider Information'!$E$6=\"\",\"\",'Provider Information'!$E$6)","v":""},"To:",{"$f":"IF('Provider Information'!$G$6=\"\",\"\",'Provider Information'!$G$6)","v":""}]
["WORKSHEET:",null,"Certification"]
["The bottom section is used to certify the completeness and accuracy of the data in this workbook.  Use tab to move to input areas. Use the arrow keys to read through the document."]
["MEDICAID COST REPORT"]
["for Certified Community Behavioral Health Clinics"]
["MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE\nPUNISHABLE BY CRIMINAL, CIVIL, AND ADMINISTRATIVE ACTION; FINE; AND/OR IMPRISONMENT UNDER \nFEDERAL LAW.  FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED \nDIRECTLY OR INDIRECTLY THROUGH THE PAYMENT OF A KICKBACK OR WERE OTHERWISE ILLEGAL, \nCRIMINAL, CIVIL, AND ADMINISTRATIVE ACTION; FINES; AND/OR IMPRISONMENT MAY RESULT. CERTIFICATION\nBY OFFICER OR ADMINISTRATOR IS REQUIRED."]
["I HEREBY CERTIFY that I have read the above certification statement and that I have examined the \naccompanying electronically filed or manually submitted cost report and that to the best of my \nknowledge and belief, this report and statement are true, correct, complete, and prepared from the \nbooks and records of the Provider in accordance with applicable instructions, except as noted. I \nfurther certify that I am familiar with the laws and regulations regarding the provision of health care \nservices, and that the services identified in the cost report were provided in compliance with such \nlaws and regulations.\n\n"]
["Signature of Officer: "]
["Title: "]
["Clinic: "]
["Medicaid ID: "]
["From Period: "]
["To Period: "]
["Preparer (If other than Officer): "]
["OMB #0398-1148   CMS-10398 (#43)"]
["End of Worksheet"]