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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 (05/2016) Available as fill in PDF Document

DHCS 3076 (04/2017) Available as Excel Workbook

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 3076 (05/2016) or DHCS 3076 (04/2017). Submission of outdated Medi-Cal cost report schedules will be rejected. Click here to download the instructions for completing the ICF-DDH/N Cost Report.

DHCS 3076-Supp A (06/2012)

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.

DHCS 3076-Supp B (06/2012) 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.

DHCS 3099 (05/2016) Available as fill in PDF Document

DHCS 3099 (04/2017) Available as Excel Workbook

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. Click here to download the instructions for completing the ICF-DDH/N Home Office Cost Report.

 


 

 

FQHC/RHC Forms Form Title Description
​N/A (04/16) available as PDF ​Medi-Cal Electronic Submission Protocol for FQHC/RHC/IHS/MOA Electronic submission protocol for FQHC, RHC, IHS, and MOA programs.​
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 (12/15) available as Excel Spreadsheet Medi-Cal Home Office Cost Report - PPS Rate Setting
 
THIS HOME OFFICE COST REPORT IS ONLY FOR PROVIDERS THAT HAVE 6 OR LESS FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) OR RURAL HEALTH CLINIC (RHC).  Filing of a home office cost report is required for freestanding FQHCs/RHCs which are part of a chain organization or multiple clinic organization that operate at least two or more health care facilities or one FQHC/RHC and a non-healthcare entity/business for Prospective Payment System (PPS) Initial Rate Setting (projected or actual), Rate Setting and Change in Scope-of-Service Request. DHCS 3089 (12/15) Instructions.

DHCS 3089.1 (12/15) available as Excel Spreadsheet

Medi-Cal Home Office Cost Report - PPS Rate Setting
 
THIS HOME OFFICE COST REPORT IS ONLY FOR PROVIDERS THAT HAVE 7 OR MORE FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) OR RURAL HEALTH CLINIC (RHC).  Filing of a home office cost report is required for freestanding FQHCs/RHCs which are part of a chain organization or multiple clinic organization that operate at least two or more health care facilities or one FQHC/RHC and a non-healthcare entity/business for Prospective Payment System (PPS) Initial Rate Setting (projected or actual), Rate Setting and Change in Scope-of-Service Request. DHCS 3089.1i (12/15) Instructions.
DHCS 3090 (01/16) 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 their facility PPS rate . Instructions:  DHCS 3090i (01/16) available as Word document.

DHCS 3096 (12/15) 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 3096i (12/15) Instructions.

DHCS 3097 (1/2016) available as 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. Instructions:  DHCS 3097i (01/2016) available as Word document.

DHCS 3100 (rls. 10/2013) 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 3106 (05/13) available as Word document

FQHC and RHC Initial Rate Setting Application Package

This package includes (a) FQHC/RHC Initial Rate Setting Application Instructions (pages 1-4) (b) Prospective Payment Election Form (pages 5-6) (c) Summary of Current Services Provided by Clinic (page 7) and (d) Summary of Healthcare Practitioners (page 8).  These forms will be used to establish initial PPS rate for newly approved FQHC and RHC. The current median PPS Rates by County. If you have any questions regarding this package, please send email to clinics@dhcs.ca.gov or contact the Audit Review and Analysis Section at (916) 650-6696.

 


 

 

Acute Care Forms Form Title Description
DHCS 3092 (12-05)
Available as PDF
Print only
Medi-Cal Supplemental Worksheets

The Medi-Cal Supplemental Worksheets are currently being revised for compliance with the CMS 2552-10 cost report and the new DRG payment methodology. For up to date information and guidance for reporting your Medi-Cal costs please send an email to acute question mail box at Acute.Questions@dhcs.ca.gov

DHCS 3092 (12-05) 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.


 

 

 

FAB Documents Document Title Description
Administrator Compensation Ranges Available as PDF
Print only
 Rls. 01/29/2015
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.

 


 

Last modified on: 11/13/2017 11:49 AM