Audits & Investigations Forms

Audits and Investigations - Financial Audits Branch Cost Report Forms and Documents

The following is a listing of the various forms used by Financial Audits Branch (FAB). The form numbers listed provide a direct link to the form. The list is not all-inclusive as some forms are not yet available on-line. The list will be updated as forms become available.

The forms are Adobe Acrobat PDF files. The forms can be filled in and printed, or printed as a blank form for manual completion. The forms may also be saved as a blank version for completion later. Please note that Adobe Acrobat Reader does not allow forms with entered data to be saved. If you are unable to access a particular form and would like to request a hard copy, please contact Financial Audits Branch, Audit Review and Analysis Section at (916) 650-6696. Forms and instructions will be sent upon request.

Caution - These forms are subject to revision. Please access the forms from this website to ensure the most current version is used.

Long Term Care Forms	Form Title	Description
DHCS 3076 (03/2011) Available as fill in PDF Document	Intermediate Care Facility for the Developmentally Disabled Habilitative/Nursing (ICF-DDH/N) Cost Report	Cost Report is to be completed by individual ICF-DDH/N providers on an annual basis. The cost report requires certain disclosure information and financial operating cost to the facility and the Medi-Cal Program. Do not use an old version of the Medi-Cal cost report schedule. Use only the current version DHCS (03/2011). Submission of outdated Medi-Cal cost report schedules will be rejected.
DHCS 3076-Supp A (05/2011)	Adult Day Services Retroactive Payments - Supplemental Schedule A General Information and Certification Form	This is the supplemental cost reporting form to be used by an Intermediate Care Facility for the Developmentally Disabled, Habilitative or Nursing that claimed/received retroactive reimbursement beginning July 2007 for Adult Day Services and Related Transportation costs from the Department of Developmental Services (DDS). Complete form DHCS 3076-Supp A for each fiscal period that DDS was billed in arrears. Click here to download the instructions for completing supplemental form A, available as a PDF document. Either the old version (03/2011) or the current version (05/2011) may be used. The current version is more user friendly.
DHCS 3076-Supp B (05/2011)	Adult Day Services Retroactive Payments - Supplemental Schedule B Cost Reporting Form	This is the supplemental cost reporting form to be used by an Intermediate Care Facility for the Developmentally Disabled, Habilitative or Nursing that claimed/received retroactive reimbursement beginning July 2007 for Adult Day Services and Related Transportation costs from the Department of Developmental Services (DDS). Complete DHCS 3076-Supp B for each fiscal period that DDS was billed in arrears. Click here to download the instructions for completing supplemental form B, available as a PDF document. Either the old version (03/2011) or the current version (05/2011) may be used. The current version is more user friendly.
DHCS 3099 (12-04) Available as PDF Print and Fill	Intermediate Care Facility for the Developmentally Disabled Habilitative/Nursing (ICF-DDH/N) Home Office Cost Report	Cost Report is for chain organizations operating or controlling two or more ICF-DDH/N facilities. The cost report requires certain disclosure information of the home office and the distribution of home office cost to the various ICF-DDH/N facilities. The home office cost report is to be completed on an annual basis.

FQHC/RHC Forms	Form Title	Description
DHCS 3078 (02/11) available as Excel Spreadsheet	FQHC/RHC Dental Hygienist Services Prospective Payment System Alternate Payment Methodology Worksheet	Under California State Plan Amendment (SPA) No. 08-003, clinics that provided the services of dental hygienists or dental hygienists in an alternative practice as of 1/1/08 can elect to be reimbursed under the Prospective Payment System (PPS) Alternate Payment Methodology (APM). This worksheet was designed for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) that included dental hygienist services in their PPS rate as of 12/31/07. Any clinic that does not fit this description but instead added dental hygienist services after 12/31/07 should submit a Change in Scope-of-Services Request (CSOSR) form (DHCS 3096). DHCS 3078i (02/11) Instructions
DHCS 3089 (03-07) available as Excel Spreadsheet	Medi-Cal Home Office Cost Report - PPS Rate Setting	THIS FORM IS ONLY FOR FQHC AND RHC FACILITIES THAT HAVE 6 OR LESS FACILITIES. Federally Qualified Health Centers or Rural Health Clinics, which are part of a chain organization (multiple clinic organization), submitting a requests to set their new facility PPS rate based on a projected cost report must also submit a Home Office Cost Report specifically designed for New Facility PPS Rate. A Home Office cost report must be submitted if the organization operates two or more health facilities, or one FQHC/RHC and a non-healthcare entity/business. DHCS 3089 (02/07) Instructions.
DHCS 3089.1 (03-07) available as Excel Spreadsheet	Medi-Cal Home Office Cost Report - PPS Rate Setting	THIS FORM IS ONLY FOR FQHC AND RHC FACILITIES THAT HAVE 7 OR MORE FACILITIES. Federally Qualified Health Centers or Rural Health Clinics, which are part of a chain organization (multiple clinic organization), submitting a requests to set their new facility PPS rate based on a projected cost report must also submit a Home Office Cost Report specifically designed for New Facility PPS Rate. A Home Office cost report must be submitted if the organization operates two or more health facilities, or one FQHC/RHC and a non-healthcare entity/business. DHCS 3089 (02/07) Instructions.
DHCS 3090 (12/11) available as Excel Spreadsheet	Medi-Cal Freestanding – PPS Rate Setting Cost Report	Federally Qualified Health Centers and Rural Health Clinics complete and submit this Cost Report to determine what their facility PPS rate will be. DHCS 3090i (12/11) Instructions.
DHCS 3096 (7-04) Available as an Excel Spreadsheet	Federally Qualified Health Center/Rural Health Clinic Change in Scope-of-Services Request	Federally Qualified Health Centers and Rural Health Clinics must complete and submit the Change in Scope-of-Service Request Forms to apply for an adjustment to their Prospective Payment System rates. DHCS 3096 (7-04) Instructions
DHCS 3097 (2-11) Available as an Excel Spreadsheet	Federally Qualified Health Center/Rural Health Clinic Reconciliation Request	The Reconciliation Request Form is to be filed annually by clinics in order for DHCS to perform reconciliations for Managed Care and Medicare crossover visits to ensure that clinics are paid an amount equal to their prospective payment rate. DHCS 3097 (2-11) Instructions
DHCS 3098 (7-04) Available as an Excel Spreadsheet	Federally Qualified Health Center/Rural Health Clinic - Home Office Cost Report for Change in Scope-of-Service Request	Federally Qualified Health Centers or Rural Health Clinics, which are part of a chain organization (multiple clinic organization), submitting Requests for Changes in Scope of Service must also submit a Home Office Cost Report specifically designed for use with request for a Change in Scope of Services forms. A Home Office cost report must be submitted if the organization operates two or more health facilities, or one FQHC/RHC and a non-healthcare entity/business. DHCS 3098 (7-04) Instructions
DHCS 3100 (rls. 04/2011) Available as an Excel Spreadsheet	Medi-Cal Code 18 Rate Request for Managed Care Differential	Federally Qualified Health Centers or Rural Health Clinics submit this form to establish or change a Code 18 rate. This form is designed to determine an interim rate to reimburse providers for the difference between their PPS rate and their Medi-Cal Managed Care Plan payments. Download DHCS 3100i Instructions. (PDF download)
DHCS 3104 (rls. 10/2009). Available as an Excel Spreadsheet	Medi-Cal Code 20 Rate Request for Capitated Medicare Advantage Plans	Federally Qualified Health Centers or Rural Health Clinics submit this form to establish or change a Code 20 rate. This form is designed to determine an interim rate to reimburse providers for the difference between their PPS rate and their Capitated Medicare Advantage Plan payments. Download DHCS 3104i Instructions. (available as an word document)
DHCS 3105 (rls. 10/2010). Children's Health Insurance Program. Available as an Excel Spreadsheet	Medi-Cal Code 19 Rate Request for Healthy Families Plan - Children’s Health Insurance Program (HFP-CHIP)	Federally Qualified Health Centers or Rural Health Clinics submit this form to establish or change a Code 19 rate. This form is designed to determine an interim rate to reimburse providers for the difference between their PPS rate and their Healthy Families Plan aka CHIP payments. Download form DHCS 3105i Instructions. Available as a word document.

Acute Care Forms	Form Title	Description
DHCS 3092 (12-05) Available as PDF Print only	Medi-Cal Supplemental Worksheets	Schedule is to be completed by acute care providers on an annual basis. The schedules requires additional disclosure and financial information related to the filing of the Medi-Cal cost report. DHCS 3092 (12-05) Instructions
DHCS 3094 (8-05) Available as PDF Print and Fill	Rate Development Branch (RDB) Schedules	Worksheet is to be completed by individual acute care providers on an annual basis. The worksheets requires certain disclosure information to be forwarded to DHCS Rate Development Branch (RDB). RDB utilizes the reported information to establish the acute provider's all-inclusive rate per discharge limitation. DHCS 3094 (8-05) Instructions
DHCS 3095 (6-05) Available as PDF Print and Fill	Medi-Cal Home Office Cost Report *Note same form as Adult Day Health Care Home Office Cost Report	Cost Report is for chain organizations operating or controlling two or more healthcare facilities - generally acute care or long term care facilities. The cost report requires certain disclosure information of the home and the distribution of home office cost to the various acute or long term care facilities that the home office operates. (Note: In most cases, the Medicare Home Office Cost Report, Form CMS-287-92 may be substituted in lieu of filing the Medi-Cal Home Office Cost Report (DHCS 3095). The home office cost report is to be completed on an annual basis. DHCS 3095 (6-05) Instructions.

Adult Day Health Care Forms	Document Title	Description
Adult Day Health Care (ADHC) Cost Report (Form DHCS 9089) Available as a Spreadsheet Release Date: 05/05/2008 Updated Version: 11/01/2010	Adult Day Health Care Cost Report	Adult Day Health Care (ADHC) Centers must complete and submit this form on an annual basis for fiscal periods ending December 31, 2007 and later. An example of a completed ADHC cost report is available on-line. Instructions for completing the ADHC Cost Report (DHCS 9089 INSTRUCTIONS) form is available as a Microsoft Word document. * Please check this website for periodic updates to the Cost Report format and instructions.
DHCS 9090 (Rev. 12/2008) Available as an Excel file. Release Date: 12/01/2008 Updated Version: 05/14/2009	Medi-Cal Home Office Cost Report for ADHC Providers	Cost Report is for chain organizations operating or controlling two or more healthcare facilities. An example of a completed ADHC home office cost report is available on-line.The cost report requires certain disclosure information of the home and the distribution of home office cost to the various Adult Day Health Care (ADHC) facilities that the home office operates. Note: The Medicare Home Office Cost Report, Form CMS-287-92 may be substituted in lieu of filing the Medi-Cal Home Office Cost Report for ADHC Providers (DHCS 9090). The home office cost report is to be completed on an annual basis. DHCS 9090 (Rev. 05/14/2009) Instructions.

Adult Day Health Care Forms

Document Title

Description

Adult Day Health Care (ADHC) Cost Report (Form DHCS 9089) Available as a Spreadsheet

Release Date: 05/05/2008

Updated Version: 11/01/2010

Adult Day Health Care Cost Report

Adult Day Health Care (ADHC) Centers must complete and submit this form on an annual basis for fiscal periods ending December 31, 2007 and later. An example of a completed ADHC cost report is available on-line. Instructions for completing the ADHC Cost Report (DHCS 9089 INSTRUCTIONS) form is available as a Microsoft Word document.

* Please check this website for periodic updates to the Cost Report format and instructions.

DHCS 9090 (Rev. 12/2008) Available as an Excel file.

Release Date: 12/01/2008

Updated Version: 05/14/2009

Medi-Cal Home Office Cost Report for ADHC Providers

Cost Report is for chain organizations operating or controlling two or more healthcare facilities. An example of a completed ADHC home office cost report is available on-line.The cost report requires certain disclosure information of the home and the distribution of home office cost to the various Adult Day Health Care (ADHC) facilities that the home office operates. Note: The Medicare Home Office Cost Report, Form CMS-287-92 may be substituted in lieu of filing the Medi-Cal Home Office Cost Report for ADHC Providers (DHCS 9090). The home office cost report is to be completed on an annual basis. DHCS 9090 (Rev. 05/14/2009) Instructions.

FAB Documents	Document Title	Description
Administrator Compensation Ranges Available as PDF Print only Rls. 08/06/2009	Administrator Compensation for California Long Term Care Facilities	This document reflects the administrator compensation ranges for freestanding skilled nursing facilities level -- B (FS/NF-B) in California. The administrator compensation ranges are divided into 3 tables according to bed sizes (1-59 beds, 60-99 beds, over 100+ beds).