Department of Health Care Services (DHCS) facility Cost Report forms are available for download. The Cost Report Tracking Section (CRTS) receives filed Cost Report forms. CRTS will update the forms and documents as they become available.
The forms are Adobe Acrobat PDF files and Microsoft Excel files. If you are unable to access a form and would like to request a copy, please send an email to FRDaudits.Questions@dhcs.ca.gov or contact CRTS at (916) 650-6696.
Caution – All forms are subject to revision. When preparing a new Cost Report, access the forms from this website to ensure the most current version is used. Submission of outdated forms is subject to rejection by CRTS and will require a resubmission with updated forms.
Note – You must submit the corresponding DocuSign Certification Statement with each Cost Report to avoid rejection.
Inpatient Program
Long-Term Care Forms and Documents
Individual Intermediate Care Facility - Provider
Individual Intermediate Care Facility for the Developmentally Disabled Habilitative/Nursing (ICF-DDH/N) providers must complete and submit DHCS 3076 Cost Report on an annual basis. The Cost Report requires certain disclosure information and financial operating cost to the facility and the Medi-Cal program.
Individual Intermediate Care Facility - Home Office
ICF-DDH/N Home Offices must complete and submit DHCS 3099 Home Office Cost Report on an annual basis. The Cost Report is for chain organizations operating or controlling two (2) or more ICF-DDH/N facilities. The Cost Report requires certain disclosure information of the Home Office and the distribution of Home Office costs to the various ICF-DDH/N facilities.
Outpatient Program
Federally Qualified Health Center/Rural Health Clinic (FQHC/RHC) Forms and Documents
FQHC/RHC/Indian Health Services Memorandum of Agreement (IHS-MOA) providers and FQHC/RHC Home Offices must complete and submit DHCS 3088 Medi-Cal Worksheets Electronic Submission Protocol.
Home Office - Six (6) or Less
Freestanding FQHC/RHC providers that have six (6) or less FQHC/RHC clinics must complete and submit DHCS 3089 Home Office Cost Report for Prospective Payment System (PPS) Rate Setting (projected or actual) and Change in Scope-of-Service Request (CSOSR). These providers are part of a chain organization or multiple clinic organization that operates at least two (2) or more health care clinics or one (1) FQHC/RHC and a non-healthcare entity/business.
Home Office - Seven (7) or More
Freestanding FQHC/RHC providers that have seven (7) or more FQHC/RHC clinics must complete and submit DHCS 3089.1 Home Office Cost Report for PPS Rate Setting (projected or actual) and CSOSR. These providers are part of a chain organization or multiple clinic organization that operates at least two (2) or more health care clinics or one (1) FQHC/RHC and a non-healthcare entity/business.
Rate Setting before January 1, 2021
FQHC and RHC providers with Fiscal Period End (FPE) dates before January 1, 2021 must complete and submit DHCS 3090 Cost Report to determine its PPS rate.
Rate Setting after January 1, 2021
FQHC and RHC providers with FPE dates after January 1, 2021 must complete and submit DHCS 3090 (Post FPE January 1, 2021) Cost Report to determine its PPS rate.
Change in Scope-of-Service Request before January 1, 2021
FQHC and RHC providers with FPE dates before January 1, 2021 must complete and submit DHCS 3096 CSOSR Form to request a PPS rate adjustment if specific criteria are met.
Change in Scope-of-Service Request after January 1, 2021
FQHC and RHC providers with FPE dates after January 1, 2021 must complete and submit DHCS 3096 (Post FPE January 1, 2021) CSOSR Form to request a PPS rate adjustment if specific criteria are met.
Reconciliation Request (updated October 31, 2024)
FQHC and RHC providers must complete and submit DHCS 3097 Reconciliation Request annually for DHCS to perform reconciliations for Managed Care Plans (MCPs) and Medicare crossover visits to ensure clinics are paid an amount equal to its PPS rate.
Pursuant to Welfare & Institutions (W&I) Code section 14105.201, DHCS developed targeted rate increases (TRI) for providers in Medi-Cal effective for dates of service on or after January 1, 2024. More information about TRI can be found at Medi-Cal Targeted Provider Rate Increases and Investments.
W&I Code section 14087.325(d) requires MCPs to reimburse contracted FQHC and RHC providers in a manner that is not less than the level and amount of payment that the MCP would make for the same scope of services if the services were furnished by a provider that is not an FQHC or RHC. While the TRI rates do not directly affect FQHC or RHC providers, DHCS acknowledges that in some instances, an increase in the MCP rates paid to non-FQHC and RHC providers may result in MCPs increasing contracted rates paid to FQHC and RHC providers. FQHC and RHC providers must include all MCP payments in the reconciliation requests, including any increased payments resulting from TRI.
Based on the TRI implementation timeline, DHCS is extending the Fiscal Year Ending (FYE) 2024 DHCS 3097 Reconciliation Request due date for FQHC and RHC providers with a Fiscal Year End (FYE) between January 31st and September 30th. The extension is designed to allow sufficient time for FQHC and RHC providers to receive and record all MCP payments, including any resulting from TRI. FYE 2024 DHCS 3097 Reconciliation Request for FQHC and RHC providers with a FYE between January 31st and September 30th will be due by March 31, 2025.
- DHCS 3097 Reconciliation Request can only be accessed through the new web-based portal Enterprise Cost Reporting Settlement System (ECRS).
- Each clinic must have an administrator added to the system. If you do not have an administrator assigned, email CRTS at Reconciliation.clinics@dhcs.ca.gov and provide the following: National Provider Identifier (NPI) number, Legal Name (clinic), Service Address, Administrator’s First and Last Name, and email (please use a company email).
- If you have any technical issues, please email ECRS@dhcs.ca.gov.
Indian Health Services Memorandum of Agreement Reconciliation
All IHS-MOA, 638 Clinics and Tribal Federally Qualified Health Centers (TRIBAL-FQHC) clinics must complete and submit DHCS 3098 Reconciliation Request annually for DHCS to perform reconciliations for Managed Care Plans and Medicare crossover visits to ensure that clinics are paid an amount equal to the federal All-Inclusive Rate.
- DHCS 3098 IHS Reconciliation Request can only be accessed through the new web-based portal ECRS.
- Each clinic must have an administrator added to the system. If you do not have an administrator assigned, email CRTS at Reconciliation.clinics@dhcs.ca.gov and provide the following: NPI number, Legal Name (clinic), Service Address, Administrator’s First and Last Name, and email (please use a company email).
- If you have any technical issues, please email ECRS@dhcs.ca.gov.
Differential Rate Request
FQHC and RHC providers must complete and submit DHCS 3100 Differential Rate Request Form to establish or change the Managed Care Plan differential rate, code 521 T1015 SE (formerly code 18). 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.
Medicare Advantage Plan Code 529
FQHC and RHC providers must complete and submit DHCS 3104 Request Form to establish or change the Managed Care Plan differential rate, code 529 G0466-G0470 (formerly code 20). 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.
Initial Rate Setting Application Package
The FQHC/RHC Initial Rate Setting Application package, DHCS 3106, includes:
- Application Instructions (pages 1-4),
- Prospective Payment Election Form (pages 5-6),
- Election (pages 7-8),
- Summary of Current Services Provided by Clinic (page 9), and
- Summary of Healthcare Practitioners (page 10).
These forms will be used to establish the initial PPS rate for newly approved FQHC and RHC. If you have any questions regarding this package, please send an email to clinics@dhcs.ca.gov or contact CRTS at (916) 650-6696.
