Common use of Indian Health Service Clause in Contracts

Indian Health Service. (IHS) Hospitals and tribally-operated 638 hospitals who do not file a full Form CMS 2552-10 Medicare Cost Report but rather file an abbreviated Medicare cost report in accordance with Medicare Provider Reimbursement Manual, Part I, Section 2208.1.E (Method E cost report). Such IHS Hospitals and tribally-operated 638 hospitals can submit a Private Facility Information Sheet (PFIS) to AHCCCS using data from the IHS Method E report that is filed with CMS as well as supporting hospital financial reports, as necessary. The method of extracting and compiling the data from the hospital’s financial records shall conform to the instructions for the Form CMS 2552-10. All other non-Medicare Cost Report data and documentation as described on the PFIS cover sheet will be required by such hospitals. EXHIBIT 1 to ATTACHMENT C AHCCCS Disproportionate Share Hospital Payment Methodology Calculation of OBRA Limits for Governmentally-Operated Hospitals for the Purpose of Certified Public Expenditures Each governmentally-operated hospital certifying its expenditures for Disproportionate Share Hospital (DSH) payments shall compute and report its OBRA limit as prescribed by this Exhibit. The governmentally-operated hospital’s OBRA limit is comprised of two components:

Indian Health Service. (IHS) Hospitals and tribally-operated 638 hospitals who do not file a full Form CMS 2552-10 Medicare Cost Report but rather file an abbreviated Medicare cost report in accordance with Medicare Provider Reimbursement Manual, Part I, Section 2208.1.E (Method E cost report). Such IHS Hospitals and tribally-operated 638 hospitals can submit a Private Facility Information Sheet (PFIS) to AHCCCS using data from the IHS Method E report that is filed with CMS as well as supporting hospital financial reports, as necessary. The method of extracting and compiling the data from the hospital’s financial records shall conform to the instructions for the Form CMS 2552-10. All other non-Medicare Cost Report data and documentation as described on the PFIS cover sheet will be required by such hospitals. EXHIBIT 1 to ATTACHMENT C AHCCCS Disproportionate Share Hospital Payment Methodology Calculation of OBRA Limits for Governmentally-Operated Hospitals for the Purpose of Certified Public Expenditures Each governmentally-operated hospital certifying its expenditures for Disproportionate Share Hospital (DSH) payments shall compute and report its OBRA limit as prescribed by this Exhibit. The governmentally-governmentally- operated hospital’s OBRA limit is comprised of two components:

Indian Health Service. (IHS) Hospitals and tribally-operated 638 hospitals who do not file a full Form CMS 2552-10 96 Medicare Cost Report but rather file an abbreviated Medicare cost report in accordance with Medicare Provider Reimbursement Manual, Part I, Section 2208.1.E (Method E cost report). Such IHS Hospitals and tribally-operated 638 hospitals can submit a Private Facility Information Sheet (PFIS) to AHCCCS using data from the IHS Method E report that is filed with CMS as well as supporting hospital financial reports, as necessary. The method of extracting and compiling the data from the hospital’s financial records shall conform to the instructions for the Form CMS 2552-1096. All other non-Medicare Cost Report data and documentation as described on the PFIS cover sheet will be required by such hospitals. EXHIBIT 1 to ATTACHMENT C AHCCCS Disproportionate Share Hospital Payment Methodology Calculation of OBRA Limits for Governmentally-Operated Hospitals for the Purpose of Certified Public Expenditures Each governmentally-operated hospital certifying its expenditures for Disproportionate Share Hospital (DSH) payments shall compute and report its OBRA limit as prescribed by this Exhibit. The governmentally-operated hospital’s OBRA limit is comprised of two components: