STANDARD RATE APPLICATION CHECKLIST

Updated: April 2010

A. General Information Requirements

Please refer to the Standard Application Instructions for more

detailed information on completing the application.

►►► NOTE: All application pages MUST be numbered.

In the space provided by each numbered item, one of the following MUST
be used:

A- Specific page number in the application where the

explanation can be found (not just “see Exhibit H”);
B- Yes/No and page number in the application if further
explanation is required; and,
C- NA if not applicable to the hospital.

►►► NOTE: checkmarks, “done”, etc. will NOT be accepted.

_____ 1. Copy of the published legal advertisement (See Exhibit A) and

proof of publication. (Note: Provide proof of publication within
ten (10) days of filing the rate application. Failure to provide
the proof of publication timely will result in a delay in the
issuance of the hospital’s rate decision.) Requested limits and
percent of change over projected actual is required for both acute
inpatient and outpatient. Home Health and Hospice statistics are
to be reported with Acute.

_____ 2. Copy of the Hospital’s Board approved budget.

_____ 3. Provide detailed budget assumptions including but not limited to

anticipated changes in the following: utilization, revenues,
expenses, case mix, service mix, reimbursement, organizational
structure, capital assets, supply costs, pharmaceutical costs, new
technology, etc.

_____ 4. Original certification by the Chairman of the Board and Hospital

Administrator. (See Exhibit B)

_____ 5. Copy of the hospital’s current license.

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_____ 6. Report on the hospital’s cost containment efforts (“Section 21”

report).

_____ 7. Summary of the hospital’s rate increase request. Include with the
summary, an explanation for the hospital’s need for the requested
rate increase.

_____ 8. For the projected actual year’s data, provide the following
information:
a. _____Number of months actual data was used (8 or 9)
b. _____Number of months projected data was used (4 or 3)

►►► NOTE: Application must be filed with either 8 months actual

and 4 months projected or 9 months actual and 3 months
projected data

_____ 9. Verify that the projected data takes into account any facility
changes including but not limited to service mix, utilization,
expenses, etc.

_____ 10. Provide the year-to-date (based on the number of months reported
in 8a above) revenue and utilization by payor and the calculations
used to determine the projected actual revenue and utilization by
payor reported in the application.

_____ 11. Is the hospital in compliance with all financial disclosure

requirements including Uniform Billing submissions? A rate
decision will not be issued if the hospital is not in compliance with
financial disclosure. The hospital’s current status with regard to
financial disclosure requirements can be found in the Health Care
Authority’s newsletter which is located on the Authority’s website at
www.hcawv.org. (Hospitals should contact Donna Crane or Mary
Fitzgerald of the Authority’s Financial Disclosure Division to
determine whether their financial disclosure file is complete and
Sheila Chapman of the Data and Public Disclosure Division to
determine if the UB data file is complete.)

_____ 12. Are the hospital’s Related Organizations in compliance with all
financial disclosure requirements? (Hospitals should contact
Donna Crane or Mary Fitzgerald of the Authority’s Analysis Division
to determine whether the Related Organization’s financial
disclosure file is complete.) Note: Compliance is required for
deeming complete.

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_____ 13. Has a copy of the complete FY 20___ rate application been
provided to the Consumer Advocate by mailing the application
to PO Box 11685 Charleston, WV 25339-1685 or delivering to
One Players Club Drive, Third Floor Charleston, WV 25311?

_____ 14. Does the hospital have any CON applications pending for services
that will be starting this fiscal year? (Yes) (No). If YES, does the
application contain any expenses, utilization or revenues for this
CON? (Yes) (No). If YES, revise application to remove all
expenses, utilization and revenues for the pending CON.

_____ 15. Does the hospital provide services to patients covered by the Small
Business Insurance Plan? If so, all utilization, revenue and
expenses for these patients are reported under the “Other
Governmental” category. (See Policy Statement 2004-2)

_____ 16. Verify that any discounts provided to self-pay or uninsured patients
that do not qualify under the hospital’s charity care policy are
reported according to Policy Statement 2000-4.

_____ 17. ADDITIONAL INFORMATION REQUIRED – (1) Exhibit G is

completed and includes the required data (malpractice expense,
provider tax, and other taxes) for the most current year for which a
full year of actual data is available. (2) Exhibit C is completed for
the budget year (a current listing of all Distinct Part Units (DPUs)).

►►► NOTE: The Authority no longer sets Distinct Part Unit rates.
The data for these units are NOT to be included with acute
care data at any time. If the hospital acquires a CON for a new
DPU, then that data is to be filed with DPU data. If there is a
question about whether it should be a DPU or not, please
contact the Authority for determination before filing the rate
application.

For the purposes of the rate application the following are the Authority’s
definitions:

1. Significant – Of significant importance to warrant disclosure or likely to

influence judgments or decisions. (A Dictionary for Accountants, Fourth
Addition)

2. Extraordinary Items – Events and transactions that are distinguished by

their unusual nature and by the infrequency of their occurrence. Both of
the following criteria shall be met to classify an event or transaction as an
extraordinary item:

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a. Unusual nature – the underlying event or transaction

possesses a high degree of abnormality and is of the type
clearly unrelated to, or only incidentally related to, the
ordinary and typical activities or the enterprise.

b. Infrequency of occurrence – the underlying event or

transaction is of a type that would not reasonably be
expected to recur in the foreseeable future, taking into
account the environment in which the enterprise operates.
(APB 30, paragraph 20 or FASB Accounting Standards,
Current Text 117.401)

3. Outpatient visit – all services provided to an outpatient in the course of

a single appearance in an outpatient or inpatient unit. (HFMA –
“Fundamentals of Healthcare Financial Management”)

4. Distinct Part Unit – See Exhibit C for further instructions as to the

Authority’s definition of Distinct Part Units.

5. Related Organization – See 65 C.S.R.§13.2.6.(a-h) for the definition of

a related organization as defined by the Financial Disclosure Rule.

B. CBM-1 Discharges, Days, Visits and CBM-2 Gross Inpatient and

Outpatient Revenues – Include Home Health and Hospice with Acute
statistics.

_____ 1. Provide an explanation only if the hospital is reporting a significant

increase or decrease from the prior year’s budget to projected
actual OR from the projected actual to the new budget for
discharges/days/visits and revenues.

_____ 2. Verify that nursery discharges are NOT included with the
discharges and days reported on the CBM-1. Nursery discharges
to be EXCLUDED are MS-DRG 794 and 795 with revenue code
170 and 171.

_____ 3. Verify that nursery revenue is INCLUDED with the inpatient

revenue reported on the CBM-2.

_____ 4. Are series account revenue and observation revenue included as

outpatient revenue and consistent with utilization? (YES) (NO) If
NO, provide a detailed explanation.

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C. CBM-3 Salary and Wage Summary – Submit one form for Acute care
(which includes Home Health and Hospice) and a TOTAL CBM-3
form.

►►► NOTE: All physicians employed by the hospital should be

reported as “supervisory atypical”.

_____ 1. Lines 1a, 1b, and 1c are the same as the prior year’s rate
application – lines 3a, 3b and 3c.

_____ 2. Does the hospital give a discount to ALL of its employees (such as
waiving co-pays or discount on the co-pays)? (YES) (NO) If YES,
these discounts are considered additional fringe benefits and
should be reported as an operating expense (i.e. not bad debts or
charity care) and NOT a contractual allowance. If the hospital
granted discounts to only certain employees, then these discounts
must be reported on the CBM-DC forms as discounts. (See Policy
Statement 2000-4 for further details)

_____ 3. Compare projected actual salaries and benefits (line 2) to prior

year’s budgeted salaries and benefits (line 1). Provide an
explanation only if the hospital experienced significant variances
that are either over or under budget. (i.e. FTEs were replaced by
contract labor) Note: Any variance in projected actual non-
supervisory salaries and benefits that are below the prior
year’s budget (line 1) may result in a reduction of the
requested rate.

_____ 4. Provide an explanation only if the hospital experienced a significant

increase or decrease of FTEs from prior year’s budget to projected
actual to current budget. If the hospital utilized contract labor in lieu
of the budgeted FTEs please provide thorough documentations –
such as FTE reduction, reductions in benefits, etc.

_____ 5. Do the total supervisory and non-supervisory wages and fringe

benefits equal the total wages and benefits on the Board-approved
budget? (YES) (NO) If NO, provide a narrative reconciliation of
any differences.

_____ 6. Have there been any additions or reductions in fringe benefits that
have caused the percentage to increase/decrease? (YES) (NO) If
YES, provide a detailed explanation, including the estimated dollar
amounts of the benefits.

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D. CBM-4 (Operating Expenses) – Submit a separate form for acute care

(which includes Home Health and Hospice), a separate form which
includes ALL Distinct Part Unit(s), as well as a TOTAL CBM-4 form.

_____ 1. For total atypical operating expenses (lines 4 through 12), provide
an explanation only if the hospital experiences a significant
increase or decrease from last year’s budget to projected actual.

_____ 2. Do the total expenses on line 3 equal the total operating expenses
on the Board-approved budget and line 6 – operating expenses on
CBM-5? If NOT, provide a reconciliation of any differences (e.g.
bad debt expense listed as an operating expense on the Board-
approved budget, but not on CBM-4; etc.).

_____ 3. Do CBM-4 line items reported in the hospital’s Board-approved

budget agree with the CBM form? (YES) (NO) If NO, provide a
detailed explanation.

_____ 4. Are capital related costs allocated to the Distinct Part Units? (YES)
(NO) If NO, please provide a brief explanation as to why they are
not allocated.

_____ 5. ADDITIONAL INFORMATION REQUIRED – Exhibit G is to be

completed and include the required data (malpractice expense,
provider tax, and other taxes) for the most current year for
which actual data is available.

E. CBM-5 (Income Statement) – Submit a separate form for acute care

services (which include Home Health and Hospice), a separate form
which includes ALL Distinct Part Unit(s) as well as a TOTAL CBM-5
form.

_____ 1. Provide an explanation only if the hospital experienced a significant

variance for any line item when comparing the current year’s
budget to projected actual and projected actual to the new budget.

_____ 2. Indicate on the TOTAL CBM-5 form for both the projected actual
and budget years the amount of Medicaid disproportionate share
funds received that have been netted against Medicaid inpatient
contractual allowances.

_____ 3. Has there been any change in the method of allocating expenses to
Distinct Part Units from prior years? (YES) (NO) If YES, provide a
detailed explanation of the reason for the change.

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_____ 4. Any amount on a CBM-5 line item that is also stated as a separate
item on the Hospital’s Board-approved budget must agree. If NOT,
provide a detailed explanation.

_____ 5. Are unrealized gains and/or losses reflected in the EROE? (YES)
(NO). If YES, revise the CBM-5 (projected actual and budget) to
exclude unrealized gains and/or losses.

F. CBM-6 (Balance Sheet)

►►► NOTE: The reporting time periods must be the same for both
prior and current year. Also, please indicate the period ending
date on the form.

_____ 1. Explain significant variances from prior year to current year.

_____ 2. Have there been significant changes in any line items from prior to
current year? (YES) (NO) If YES, provide a detailed explanation.

G. CBM-DC and CBM-DCL (Discount Contracts) – Both forms must be

submitted with the rate application. Submit a TOTAL CBM-DC form
and a CBM-DCL form for both projected actual and budget years. All
contracts should be listed on the CBM-DCL form including separate
Distinct Part Unit Contracts. Please read the forms and instructions
carefully before completing. See Policy Statement 2002-1 for further
explanation.

_____ 1. All new contracts or contract amendments have been included in

the application and all are complete (fully executed and dated) and
consistent with the CBM-DC and CBM-DCL forms.

______ 2. The Verification of the CBM-DC Form (Exhibit D) has been signed
by the CEO and notarized.

_____ 3. All discount contracts and their respective discounts, and all other
discounts (i.e. unallowed administrative write-offs) provided during
the projected actual year are listed on the projected actual CBM-
DCL form.

_____ 4. All discount contracts and their respective discounts, and all other
discounts (i.e. unallowed administrative write-offs) budgeted for the
rate year, are listed on the budget CBM-DCL form. Note: Any

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contract not listed on the budget CBM-DCL form, will not be

approved for the upcoming year.

_____ 5. The expiration date of each contract listed on the DCL form is noted
beside the contract name. If the contract is an automatic renewal,
then enter Auto.

_____ 6. All contracts for which the CBM-DCL form indicates as a “Must
Separate” for either the inpatient or outpatient discounts, must be
reported on the CBM-DC form in a separate column. Conversely,
only those contracts in which the CBM-DCL form indicates as a
“Combine” for both the inpatient and outpatient discounts can be
reported in a combined column on the CBM-DC form.

_____ 7. All new contracts or contracts without a current approval are

reported separately on both the projected actual (if utilized in the
current year) and budget CBM-DC forms.

_____ 8. All discounts that are considered non-third party contracts by the
Authority are listed in the lower section of the CBM-DCL form and
are reported separately on the CBM-DC forms.

_____ 9. All contracts that have utilization equal to or greater than five (5)
percent of the total nongovernmental utilization are listed in the
lower section of the CBM-DCL form and are reported separately
on the CBM-DC form. (See CBM-DCL template form for calculation
of five percent volume threshold.) Note: DO NOT put a contract
in both the top and the bottom section of the B-DCL form. Any
“Must Separate” contract must be removed from the top
section and moved to the bottom section of the B-DCL form.

_____ 10. All contracts that are for an HMO or include risk-based
reimbursements are listed in the lower section of the CBM-DCL
form and are reported separately on the CBM-DC form.

_____ 11. Costs on line 9 and line 18 for all columns must be allocated on the
total cost to charge ratio that is used on the CBM-5 form and
entered on line 12 and line 21.

_____ 12. Contracts with separate discount percentages contained

within one contract are to be listed as one contract in one
column on the CBM-DC form (e.g.: Basic, PPO/HMO rates are
to be converted to a combined percentage for the over-all
contract).

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_____ 13. The total inpatient contractual allowance amount (line 7) must equal
the total nongovernmental contractual allowance on CBM-5, (line 2,
column F).

_____ 14. The total outpatient contractual allowance amount (line 16) must
equal the total nongovernmental contractual allowance on CBM-5,
(line 2, column G).

_____ 15. Confirm that items not considered a contractual allowance per
Policy Statement 2000-4 are NOT listed on the CBM-DC form as a
contractual allowance.

_____ 16. Separate columns are required for any contract that was used prior
to obtaining approval by the Authority. (i.e. contract was used Jan.,
Feb., and March without obtaining the Authority’s approval.
Approval was given April 2, then, there should be a column for the
discounts granted Jan., Feb., and March and a column for the
discounts granted from April 2 to the fiscal year end.) Note: If
otherwise qualified to be combined, the approved portion of
the provided discounts may be included in the combined
column.

H. CBM-RO (Related Organizations)

_____ 1. Complete a column for each related organization. Note: Each

related organization must be in compliance with financial
disclosure to be eligible for deeming complete.

_____ 2. Does the hospital receive management fees? (YES) (NO) If YES,
provide a detailed summary of the services received for these fees.

_____ 3. Does the hospital pay management fees? (YES) (NO) If YES,
please provide a detailed summary of the services covered by the
fees.

_____ 4. Please provide the following hospital data with respect to

Management fees paid by the hospital.

Prior year actual management fees ______________

Current year projected actual management fees ______________
Budgeted management fees ______________

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_____ 5. Please provide an explanation of how management fees are

calculated.

_____ 6. Has the calculation of management fees changed since the prior
fiscal year?

_____ 7. If the hospital receives or pays other monies, provide a detailed

summary of the source of the funds received or paid.

I. CBM-9 (Rate Compliance) - COMPLETE ENTIRE FORM, EVEN IF NO

OVERAGE (Use only the CBM-9 form entitled: “Application CBM-9”)

_____ 1. Case Mix – (Excluding outliers per Policy Statement 2006-1

and nursery discharges with an MS-DRG of 794 or 795 with
revenue codes of 170 or 171) Provide details and back-up for the
projected actual year (regardless of whether or not the hospital has
an overage). The reporting time periods are the same for both
projected actual year and the prior year data. Also, please indicate
the reporting time periods (e.g. July 1 through March 31). The
reporting time period should be the same as the reporting period
indicated in Section A number 8a of this checklist.

_____ 2. The case mix backup data (excluding outliers and nursery
discharges with an MS-DRG of 794 or 795 with revenue codes of
170 or 171) includes the following required information for each
discharge:

Account Number, Date of Discharge, DRG, Weight,

Length of Stay, Total Charges, Financial Class Code,
and Insurance Plan Code.

►►► NOTE: Case mix backup should include NONGOVERNMENTAL

PAYORS ONLY.

Also, provide a key or crosswalk from the hospital’s financial

class codes and insurance plan codes to the class and code
full description.

_____ 3. Outliers - Provide details and back-up for the projected actual year
(regardless of whether or not the hospital has an overage). The
reporting time periods are the same for both projected actual year
and the prior year data. Also, please indicate the reporting time

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periods (e.g. July 1 through March 31). The reporting time period
should be the same as the reporting period indicated in Section A
number 8a of this checklist.

►►► NOTE: If no outliers occurred, please indicate.

►►► NOTE: Outliers are defined as cases, which have a charge

exceeding $44,000 and/or stays in excess of 30 days. If the
outliers in last year’s application were under a different
definition (such as benchmarking) then for compliance
purposes, the outlier back-up must also be submitted using
last year’s definition.

The “prior year” and “current year” outliers reported on the B-

9 must be stated using the same outlier threshold. Therefore,
the “prior year” outliers may need to be restated using the
outlier threshold the hospital was under for the “current year”.
This threshold was stated in your most current rate order.

_____ 4. The outlier backup data includes the following required information
for each outlier:

Account Number, Date of Discharge, DRG, Weight,

Length of Stay, Total Charges, Financial Class Code,
and Insurance Plan Code.

►►► NOTE: Outlier backup should include NONGOVERNMENTAL

PAYORS ONLY.

_____ 5. The revenues and discharges or visits projected for the current year
on the CBM-9 should match the projected actual on the CBM-1 and
CBM-2 forms.

_____ 6. Amounts on Lines 6, 7, and 8 have been revised to reflect the

projected actual data reported in the prior year’s rate application on
Lines 1, 2, and 3 of the prior year’s CBM-9.

_____ 7. The amount on Line 9 should equal the prior year’s unjustified
overage per discharge (either assessed or placed in abeyance)
from the most recent order (NOT the amount of the penalty levied).

_____ 8. For any new services not included in the prior year’s budget and is
being used as justification for an overage, Exhibit H must be
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completed. If applicable, provide information as to when the new

service began and the date of CON approval, or notification to the
Authority. Further, provide the date of the HCA Rate Review
Division order establishing a rate for the new service.

►►► NOTE: In order to utilize new service(s) as justification for an

overage it must first have been approved by the Rate Review
Division. Approval or non-reviewability by CON does NOT
constitute approval by the Rate Review Division.

_____ 9. If more than one rate order was in effect for the current year,
complete Exhibit E for the weighted allowed calculation. Utilization
used in this calculation must match the CBM-1 form for projected
actual.

_____ 10. Provide detailed back-up justification for each overage.

Justification for any overage must be: (a) described narratively; (b)
quantified; and, (c) verifiable. Use Exhibit F attached to this
checklist for outpatient overage justification. Note: See Policy
Statement 2009-2, which revised the method for calculating the
outpatient overage justification.

►►► NOTE: All high cost/low cost procedures provided in the

budget will be utilized (those with increased utilization as well
as decreased utilization) when calculating outpatient overage
justification in the next rate application. (See Policy Statement
2009-2)

_____ 11. Provide revenues and visits included in the budget for any high
cost/low cost outpatient procedures that the hospital may wish the
Authority to consider as potential justification for any potential
overages in the next year. (e.g.: Ambulatory Surgeries, MRI, etc.)
REMEMBER: If this data is NOT provided, the hospital cannot
use these items as justification for an overage in the next rate
application.

J. MISCELLANEOUS – Your signature at the end of this document verifies

the application has been completed according to the following guidelines
unless a detailed explanation regarding any variances from required
guidelines is provided. Failure to follow the guidelines and/or supply a
detailed explanation may result in the application not being deemed
complete or completeness may be rescinded at a later date.

1. CBM-1
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a. Excluded from the patient days and patient discharges

are the days and discharges the hospital recorded as
normal newborn nursery days and discharges. These
are newborns billed on the UB forms that are indicated
with MS-DRG 794 and 795 with Revenue Codes of 170
or 171.

b. Outpatient visits must include outpatient series visits with

a brief explanation of how the visits are counted. Series
visits represent recurring visits on separate days, over
the course of a treatment period. (e.g. outpatient
physical therapy) A visit should be recorded for each day
treatment is provided.

c. Nongovernmental payors observation statistics must be

included as outpatient statistics with lengths of stay less
than 24 hours. NOTE: Observation stays included in
outpatient statistics and outpatient revenue are not
to exceed a 24-hour length of stay. (e.g.: 23 hours 59
minutes)

d. All CBM forms are completed for both the projected

actual year and budget year.

e. Home Health visits – only count a visit where a charge

(billable visit) is made.

2. CBM-2

Ancillary revenues are included with Distinct Part Units even though each
Distinct Part Unit is not reported separately in the application.

NOTE: If ancillary revenues are NOT included with Distinct Part

Units, please provide an explanation as to why they are not and
where they are accounted for in the application.

3. CBM-4

All costs are allocated between inpatient and outpatient and allocated
proportional to the gross revenues on CBM-2 for each Distinct Part Unit
even though separate forms for Distinct Part Units are no longer required.

NOTE: If all costs are NOT allocated between inpatient and

outpatient and allocated proportional to the gross revenues on the

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CBM-2, what other method of allocation is used? Provide the

documentation for the basis of the allocation and provide detail and
verifiable back-up data.

4. CBM-5

Total operating expenses are allocated by payor for each Distinct Part Unit
based on the gross revenues by payor on line 1 even though separate
forms for Distinct Part Units are no longer required.

5. CBM-DC

a. Exhibit D has been signed by the hospital CEO and notarized.

b. The application only includes a total form. No separate forms are

required for acute and Distinct Part Units. (NOTE: The Total form
must include all contracts, including contracts negotiated
specifically for Distinct Part Units. Further, the total form
contractuals must match the total form CBM-5 contractual
allowances. The total CBM-DC form is for the entire hospital
operation.)

6. CBM-9

a. The prior year case mix used on the form matches what was
accepted in the prior year order. If this is not quoted in the rate
order, then the case mix index must match what was submitted on
the prior year’s CBM-9 Line 12. However, this must now be re-
stated removing the outliers at the threshold stated in the order that
set the revenue limits on Line 4. (See Policy Statement 2006-1 for
additional information)

b. Outlier information should be projected actual for both prior and

current years and for revenue and utilization data. (See
instructions for CBM-9 and Outlier Policy for greater detail.)

c. Lines 6, 7, and 8 must provide the prior year’s projected actual data
if an increase in case mix is being used as justification for an
overage, otherwise, these lines may be left blank.

d. The CBM-9 form is completed for both inpatient and outpatient

regardless of whether or not there is an overage.

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K. MATHEMATICAL CROSS-CHECKS & EDIT – Your signature at the

end of this document verifies that all the following math checks and
edits have been completed for both projected actual and current
budget. Failure to complete edit checks may result in the application
not being deemed complete and/or completeness may be rescinded
at a later date.

1. CBM-1-A, B & C

a. On CBM-1 and CBM-1A, the sum of lines 1 and 2 for each payor
equals line 3. The total column equals the sum of all payors.

b. On CBM-1B, the sum of lines 1 through 6 equals the total acute on

line 7. The total of lines 7 and 8 equals the total on line 9 for each
payor. The total column equals the sum of all payors.

c. On CBM-1C, the total licensed and set-up beds for each unit should
equal the “total” at the bottom of the form. Compare the licensed
beds on this form to the copy of the hospital license submitted with
the application and provide an explanation of any differences.
(NOTE: Respite and swing beds are counted in the medical
surgical bed complement by Licensure.)

2. CBM-2 and 2A

a. CBM-2 – Gross Inpatient Revenue (including any Hospice revenue)

– Total acute gross inpatient revenue equals the sum of acute
gross inpatient revenue for each payor for both projected actual
and budget years.

b. CBM-2 – Hospital Distinct Part Unit(s) Inpatient Revenue – Total

hospital distinct part unit(s) inpatient revenue equals the sum of
hospital distinct part unit(s) inpatient revenue for each payor for
both projected actual and budget years.

c. CBM-2 – Total Inpatient Revenue – Total inpatient revenue equals

the sum of acute gross inpatient revenue and hospital distinct part
unit(s) inpatient revenue for all payor classes and total.

NOTE: CBM-2 Total Gross Inpatient Revenue must match the

Total CBM-5 Inpatient Revenue.

d. CBM-2A – Acute Gross Outpatient Revenue (including Home

Health and Hospice) – Acute gross outpatient revenue equals the

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sum of acute gross outpatient revenue for each payor for both
projected actual and budget years.

e. CBM-2A – Hospital Distinct Part Unit(s) Outpatient Revenue – Total

hospital distinct part unit(s) outpatient revenue equals the sum of
hospital distinct part unit(s) outpatient revenue for each payor for
both projected actual and budget year.

f. CBM-2A – Total Outpatient Revenue – Total outpatient revenue

equals the sum of acute gross outpatient revenue and hospital
distinct part unit(s) outpatient revenue.

NOTE: CBM-2A Total Gross Outpatient Revenue must match

the Total CBM-5 Outpatient Revenue.

3. CBM-3

Line a + Line b = Line c for Lines 1, 2 and 3, except for the last two
columns. For those two columns, Line c is calculated the same as
Lines a and b.

4. CBM-4

a. The sum of line 1 + line 2 equals line 3; the sum of lines 5 through
13 equals line 14; line 3 less line 14 equals line 15; line 16 + line 17
equals line 18; line 15 equals line 18.

b. For projected actual and budget, the atypical costs on lines 2a and
3a on the CBM-3 should equal the sum of the respective
supervisory and non-supervisory salaries/benefits on line 9 through
11 and line 13 on the CBM-4 for current and budget years
respectively.

c. The sum of atypical FTEs listed on the CBM-4 form (lines 9 through
11 and 13) for projected actual and budget years should equal
atypical FTEs listed on line 2a and 3a on the CBM-3 form for each
unit and in total.

5. CBM-5

a. Line 1 (less) the sum of lines 2 through 4 equals line 5; line 5 less
line 6 equals line 7; the sum of lines 7 through 12 equals line 13.

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b. Totals on each line in column A equals the sum of columns B

through G.

c. The sum of the corresponding figures on each line and column for
both acute and hospital distinct part units equals the grand total
CBM-5 form.

d. Line 6, column A must equal line 3 of the CBM-4 form for both
projected actual and budget years.

e. Line 2, column F must equal line 7 of the total column of the CBM-
DC form and line 2, column G must equal line 16 of the total
column of the CBM-DC form.

6. CBM-6

a. For assets, the sum of lines 1 though 6 equals line 7; the sum of
lines 7 through 9 plus line 12 equals line 13.

b. For liabilities and fund balance, the sum of lines 1 through 5 equals
line 6; the sum of lines 6 through 12 equals line 13; the sum of lines
13 through 15 equals line 16.

NOTE: There cannot be numbers in both lines 14 and 15.

7. CBM-DC

a. The total column equals the “Combined Contracts” column

and all the individually reported discount contract columns for Lines
4, 5, 7-9, 13, 14, 16-18.

b. For all contract columns, Line 5 less Line 7 equals Line 8 and Line
14 less Line 16 equals Line 17.

c. For the individual contract columns, Line 10 equals Line 5 divided

by Line 4; Line 11 equals Line 9 divided by Line 4; Line 19 equals
Line 14 divided by Line 13; and, Line 20 equals Line 18 divided by
Line 13.

d. Lines 12 and 21 equal the cost-to-charge ratio that matches the

CBM-5 form.

NOTE: The total column on page one (1) includes all

subsequent pages. There is NOT a total column for each page.

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I hereby verify that the application has been completed in accordance with
the checklist directives and guidelines unless specifically noted. I further
acknowledge that failure to follow these directives and guidelines may result in
this application not being deemed complete or that completeness may be
rescinded at a later date.

________________________________________
Preparer of Rate Application

________________________________________
Contact Person***

________________________________________
Contact Person’s fax number

________________________________________
Contact Person’s telephone number

________________________________________
Contact Person’s email address

________________________________________
CFO

________________________________________
CEO

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***NOTE: Please indicate a contact person either from the hospital or

within the consultant’s firm to which questions are to be directed.

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EXHIBIT A

LEGAL NOTICE

In accordance with the Procedural Rules of the West Virginia Health Care
Authority (Authority), _________________________ Hospital, on __________
applied for a change to its current schedule of rates. The application and
proposed budget for Fiscal Year ___________ includes an increase of _____%
from the hospital’s nongovernmental acute projected actual average charge per
patient stay, from $_______ to $_________. The application and proposed
budget for Fiscal Year __________ includes an increase of ______% from the
hospital’s nongovernmental acute projected actual average charge per
outpatient visit, from $___________ to $__________.

The application and proposed budget are available for public inspection at
the hospital or the offices of the West Virginia Health Care Authority at 100 Dee
Drive, Charleston, WV 25311 during regular business hours. Any person who
claims to be an interested person in the proceedings for the setting of the
hospital’s rate schedule must file with the Authority, a written notice setting forth
the interested person’s name, address and facts relied upon to establish his or
her interest. This notice must be filed within thirty days from the date of the
hospital’s filing of its application with the Authority.

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EXHIBIT B

CERTIFICATION OF STANDARD RATE APPLICATION

I hereby certify that I have examined the accompanying standard rate

application for ____________ Hospital located at ____________, West Virginia,
and to the best of my knowledge and belief, it is a true, correct and is a complete
statement prepared from the books and records of the Hospital in accordance
with the applicable instructions.

Further, I hereby certify that I have examined the accompanying proposed

20___ budget for _____________________ Hospital and that said budget was
approved by the Board of Directors of _________________ Hospital on
___________.

________________________________________ _______________
Administrator Date

________________________________________ _______________
Chairman of the Board of Trustees Date

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EXHIBIT C

Although separate forms are not required, the hospital is to provide the
Authority a listing of all Distinct Part Units (DPUs) for the budget year only.
However, if there is a change from current year to budget year please note any
change. Remember DPU data is NOT to be included with acute care data
EXCEPT for home health and hospice which IS included with acute care.

For rate review purposes the following are considered rate review approved
DPUs:

Skilled Nursing Facility, Long Term Care Unit, Rehabilitation Unit, Respite
Care, Physicians’ Office Practice (owned by the hospital), Clinics (could include
Ambulatory Care, Rural Health, Primary Care and others), Swing beds and
Psychiatric/Behavioral Medicine/Substance Abuse.

For budget year FY 20___, the hospital has the following rate review approved
DPUs (Note: if more than 1 clinic please list each separately):

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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EXHIBIT D

WEST VIRGINIA
HEALTH CARE AUTHORITY

________________________________________
Hospital Name

VERIFICATION OF CBM-DC AND CBM-DCL

I certify that the information pertaining to discount contracts for

the projected actual year of 20____, and budget year of 20____
contained in the CBM-DC and CBM-DCL forms are accurate and true
to the best of my knowledge and belief.

________________________________________
Hospital Administrator (CEO)

Taken, sworn and subscribed to me by ___________________

this _________ day or ________________, 20____.

________________________________________ (SEAL)
Notary Public

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EXHIBIT E
Form CBM-9

Weighted Allowed Calculation per Discharge

(Complete only if more than one rate was in effect during the projected actual year)

Time Period Utilization for Revenue Allowe

Rate was in the Time X Limit in = d Revenue
Effect Period Effect
X
X
X
Total Total
Utilization* = Revenue =

Total Allowed Revenue _________ ÷ Total Utilization for the time period_______ =
Weighted Allowed per Discharge

*NOTE: The total utilization must match the projected actual total
nongovernmental acute discharges reported on the CBM-1 form.

Weighted Allowed Calculation per O/P Visit

Time Period Utilization for Revenue Allowe

Rate was in the Time X Limit in = d Revenue
Effect Period Effect
X
X
X
Total Total
Utilization** = Revenue =

Total Allowed Revenue _________ ÷ Total Utilization for the time period_______ =
Weighted Allowed per Outpatient Visit

**NOTE: The total utilization must match the projected actual total
nongovernmental acute visits reported on the CBM-1 form.

EXHIBIT F

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Outpatient Overage Justification

TABLE A
FY 20___ Projected Actual

1 Nongovernmental Acute Outpatient Revenue

2 Divide by: Nongovernmental Acute Visits

3 Average Projected Actual Rate per Visit

4 Less: FY 20__ Allowed or Wtd. Allowed*

5 FY 20__ Overage**
*Must match CBM/B-9 – Line 4 of the rate application **Must match CBM/B-9 – Line 5 of the rate application

TABLE B

High Cost/Low Cost Procedure Calculation

NOTE: The hospital must include ALL (those with increased utilization as well as decreased
utilization) high cost and/or low cost procedures included with the budget when calculating the
outpatient overage justification.
FY 20__ - FY 20__ - Difference (FY 20__
Current Year Current Year current projected actual
Budget Projected Actual less FY 20__ budget)
Column 3 minus Column 2
(1) (2) (3)
1 CT Scans* Revenues^^
2 Visits
3 Avg/Visit^
4 MRI* Revenues^^
5 Visits
6 Avg/Visit^
7 Amb. Surgery* Revenues^^
8 Visits
9 Avg/Visit^

10 Totals Revenue
11 Visits
*High cost/Low cost categories may be changed as needed to include those high cost/low cost
categories provided with the budget.
^The current year projected actual average charge per visit (column 2) must equal the current year
budgeted average charge per visit (column 1).
^^The current year projected actual revenue is calculated by multiplying the current year projected
actual utilization by the average charge per visit.

TABLE C
“Calculated” Per Visit Table

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Less: Sums of FY 20__ Current

FY 20__ Projected
Projected Actual less FY 20__ “Calculated”
Actual Average
Budget (From Table B Column Revenue per Visit
(From Table A)
#3 – Totals)
1 Revenue

2 Visits

3 Avg. per visit

TABLE D
Dollar Value of High Cost/Low Cost Procedures

1 Projected Actual Revenue per visit (from Table A, line 3)

2 Less: “Calculated” Revenue per Visit (from Table C, line 3)

3 Increase Due to Change in High/Low Cost Procedures

TABLE E
Calculation for remaining overages

1 FY 20__ Overage (from Table A, line 5)

Less: Justification due to change in high/low cost
2
procedures (from Table D, line 3)
3 Remaining Outpatient Overage – (unjustified overage)

EXHIBIT G

Additional Information Required

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Please provide the following data for the most current year for which actual data
would be available.

FY 20___ Malpractice Expense $_____________

FY 20___ Provider Tax $_____________

FY 20___ Other taxes (sales tax, $_____________

personal property tax, etc.)

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EXHIBIT H
New Service Justification

In order to use a New Service as justification for an overage it must have been
submitted previously to the Rate Review Division and received approval (§ 65-5-
13).

If the New Service is for both inpatient and outpatient, complete the entire form.
However, if the New Service is only inpatient or outpatient then only complete the
applicable portion of the form.

TABLE A

FY 20___ Projected Actual

Date of Order from the Rate Division that approved the new service: __________

INPATIENT

1 Nongovernmental Acute Inpatient Revenue

2 Divided by: Nongovernmental Acute Discharges
3 Average Projected Actual Charge per Discharge

*Must4match
Less: FY- Line
CBM/B9 20____
4 of the Allowed or
rate application Wtd.
**Must Allowed*
match CBM/B9 – Line 5 of the rate application

5 FY 20___ Inpatient Overage**

OUTPATIENT

1 Nongovernmental Acute Outpatient Revenue

2 Divided by: Nongovernmental Acute Visits

3 Average Projected Actual Charge per Visit

*Must4match
Less: FY– Line
CBM/B9 20____
4 of theAllowed or Wtd.
rate application **MustAllowed*
match CBM/B9 – Line 5 of the rate application

5 FY 20___ Outpatient Overage**

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TABLE B

New Service Calculation

INPATIENT OUTPATI

FY 20__
Current
Year
Projected
Actual
1 New Service* Nongov't Revenues 1 New Service* Nongov't R
2 Nongov't Discharges 2 Nongov't V
3 Nongov't Avg/Disch. 3 Nongov't A
4 New Service* Nongov't Revenues 4 New Service* Nongov't R
5 Nongov't Discharges 5 Nongov't V
*The actual name of the new service should be submitted in place of “New Service”.
6 Nongov't Avg/Disch. 6 Nongov't A
7 Totals TABLE C
Nongov't Revenues 7 Totals Nongov't R
8 Nongov't Discharges 8 Nongov't V
“Calculated” Per Discharge and/or Visit Tables
9 Nongov't Avg/Disch. 9 Nongov't A
INPATIENT

Less: Total FY 20___

FY 20__ Nongov't Prj. Actual New “Calcu
Projected Actual Services (From Table B Revenu
(From Table A) – lines 7 and 8) Disch

1 Revenue

2 Discharges

3 Avg. per Disch.

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OUTPATIENT

Less: Total FY 20___

FY 20__ Nongov't Prj. Actual New
Projected Actual Services (From Table B “Calcu
(From Table A) – lines 7 and 8) Revenue

1 Revenue
2 Visits
3 Avg. per Visit TABLE D

Dollar Value of New Services

INPATIENT

1 Projected Actual Revenue per Discharge (from Table A - Inpatient, line3)

2 Less: "Calculated" Revenue per Discharge (from Table C - Inpatient, line3)

3 Increase in Average Charge per Discharge due to New Service

OUTPATIENT

1 Projected Actual Revenue per Visit (from Table A - Outpatient, line3)

2 Less: "Calculated" Revenue per Visit (from Table C - Outpatient, line3)

3 Increase in Average Charge per Visit due to New Service

HCA – April – 2010