SCHEDULE 5 PROGRAM: NON CONTRACT SCHEDULE OF MEDICAL ANCILLARY COSTS_part7 potx

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
JULY 1, 2006 THROUGH JUNE 30, 2007 29
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
ALHAMBRA HOSPITAL MEDICAL CENTER
Adjustments
Explanation of Audit Adjustments
HSC 30281H
Cost Report
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
16 4A Not Reported Medi-Cal Administrative Days (September 1, 2006 - March 31, 2007) 0 14 14
4A Not Reported Medi-Cal Administrative Day Rate (September 1, 2006 - March 31, 2007) $0 $310.68 $310.68
17 6 Not Reported Medi-Cal Ancillary Charges - Radiology - Diagnostic $0 $230 $230
6 Not Reported Medi-Cal Ancillary Charges - Laboratory 0 2,798 2,798
6 Not Reported Medi-Cal Ancillary Charges - Physical Therapy 0 129 129
6 Not Reported Medi-Cal Ancillary Charges - Drugs Charged to Patients 0 9,616 9,616
6 Not Reported Medi-Cal Ancillary Charges - Total 0 12,773 12,773
18 2 Not Reported Medi-Cal Routine Charges $0 $20,050 $20,050
2 Not Reported Medi-Cal Ancillary Charges 0 12,773 12,773
19 3 Not Reported Medi-Cal Deductibles $0 $106 $106
20 1 Not Reported Medi-Cal Interim Payments $0 $8,331 $8,331
To adjust Medi-Cal Settlement Data to agree with the following
EDS Paid Claims Summary:
Report Date: June 9, 2008
Payment Period: July 1, 2006 through June 9, 2008
Service Period: July 1, 2006 through June 30, 2007
42 CFR 413.20, 413.24, 413.50, 413.53, 413.60,
413.64, and 433.139
CMS Pub. 15-1, Sections 2304, 2404, and 2408

CCR, Title 22, Section 51541
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www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
JULY 1, 2006 THROUGH JUNE 30, 2007 29
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
ALHAMBRA HOSPITAL MEDICAL CENTER
Adjustments
Explanation of Audit Adjustments
HSC 30281H
Cost Report
ADJUSTMENT TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBPROVIDER (REHABILITATION)
21 4-1 D-1 I XIX 9.00 3 Medi-Cal Days - Rehabilitation 194 (194) 0
To eliminate the reported Subprovider I (Rehabilitation) Medi-Cal
settlement data since the unit did not meet the criteria to be
reported as a separate level of care.
42CFR 413.50 and 413.53(b)(c) / CMS Pub. 15-1, Section 2336.1
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
JULY 1, 2006 THROUGH JUNE 30, 2007 29
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References

ALHAMBRA HOSPITAL MEDICAL CENTER
Adjustments
Explanation of Audit Adjustments
HSC 30281H
Cost Report
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - CONTRACT
22 Contract 4 D-1 I XIX 9.00 1 Medi-Cal Days - Adults & Pediatrics 3,913 427 4,340
Contract 4A D-1 II XIX 43.00 4 Medi-Cal Days - Intensive Care Unit 611 98 709
23 Contract 6 D-4 XIX 37.00 2 Medi-Cal Ancillary Charges - Operating Room $736,018 ($310,492) $425,526
Contract 6 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 1,145,081 213,163 1,358,244
Contract 6 D-4 XIX 43.00 2 Medi-Cal Ancillary Charges - Radioisotope 303,623 (45,903) 257,720
Contract 6 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 2,374,752 684,975 3,059,727
Contract 6 D-4 XIX 46.00 2 Medi-Cal Ancillary Charges - Whole Blood and Packed Red Blood Cells 146,399 (499) 145,900
Contract 6 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 3,594,122 (418,312) 3,175,810
Contract 6 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 70,457 144,347 214,804
Contract 6 D-4 XIX 52.00 2 Medi-Cal Ancillary Charges - Speech Pathology 24,160 40,356 64,516
Contract 6 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 692,442 89,993 782,435
Contract 6 D-4 XIX 54.00 2 Medi-Cal Ancillary Charges - Electroencephalography 0 17,798 17,798
Contract 6 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1,030,893 632,202 1,663,095
Contract 6 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4,499,013 470,561 4,969,574
Contract 6 D-4 XIX 57.00 2 Medi-Cal Ancillary Charges - Renal Dialysis 354,888 (2,922) 351,966
Contract 6 D-4 XIX 61.00 2 Medi-Cal Ancillary Charges - Emergency 499,261 (80,872) 418,389
Contract 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 15,471,109 1,434,395 16,905,504
24 Contract 2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges $11,257,102 ($2,657,878) $8,599,224
Contract 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 15,471,109 1,434,395 16,905,504
25 Contract 3 E-3 III XIX 33.00 1 Medi-Cal Deductibles $0 $3,809 $3,809
Contract 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance 0 272,303 272,303
To adjust Medi-Cal Settlement Data to agree with the following
EDS Paid Claims Summary:
Report Date: June 9, 2008

Payment Period: July 1, 2006 through June 9, 2008
Service Period: July 1, 2006 through June 30, 2007
42 CFR 413.20, 413.24, 413.50, 413.53, 413.60,
413.64, and 433.139
CMS Pub. 15-1, Sections 2304, 2404, and 2408
CCR, Title 22, Section 51541
Page 10
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
JULY 1, 2006 THROUGH JUNE 30, 2007 29
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
ALHAMBRA HOSPITAL MEDICAL CENTER
Adjustments
Explanation of Audit Adjustments
HSC 30281H
Cost Report
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - ADULT SUBACUTE
26 AS 1 Not Reported Medi-Cal Adult Subacute Days - Ventilator 0 4,212 4,212
AS 1 D-1 I XIX 9.00 1 Medi-Cal Adult Subacute Days - Total 8,937 (85) 8,852
To adjust Medi-Cal Settlement Data to agree with the following
EDS Paid Claims Summary:
Report Date: June 9, 2008
Payment Period: July 1, 2006 through June 9, 2008
Service Period: July 1, 2006 through June 30, 2007
42 CFR 413.20, 413.24, 413.50, 413.53, 413.60,
413.64, and 433.139

CMS Pub. 15-1, Sections 2304, 2404, and 2408
CCR, Title 22, Section 51541
27 AS 1 Not Reported Total Adult Subacute Days - Ventilator 0 4,325 4,325
AS 1 Not Reported Total Adult Subacute Days - Nonventilator 0 4,764 4,764
To reflect total Adult Subacute ventilator and nonventilator days
in the audit report.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
28 AS 1 Not Reported Subacute - Ventilator Equipment Cost $0 $32,438 $32,438
To reflect total ventilator equipment expense in the audit report.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
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This is trial version
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
JULY 1, 2006 THROUGH JUNE 30, 2007 29
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
ALHAMBRA HOSPITAL MEDICAL CENTER
Adjustments
Explanation of Audit Adjustments
HSC 30281H
Cost Report
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - ADULT SUBACUTE
29 AS 4 D-4 XIX 41.00 2 Adult Subacute Ancillary Charges - Radiology - Diagnostic $32,687 $19,495 $52,182
AS 4 D-4 XIX 44.00 2 Adult Subacute Ancillary Charges - Laboratory 272,618 22,522 295,140
AS 4 D-4 XIX 49.00 2 Adult Subacute Ancillary Charges - Respiratory Therapy 5,177,220 142,539 5,319,759

AS 4 D-4 XIX 50.00 2 Adult Subacute Ancillary Charges - Physical Therapy 35,044 9,983 45,027
AS 4 D-4 XIX 52.00 2 Adult Subacute Ancillary Charges - Speech Therapy 0 15,960 15,960
AS 4 D-4 XIX 55.00 2 Adult Subacute Ancillary Charges - Medical Supplies Charged To Patients 1,355,230 16,665 1,371,895
AS 4 D-4 XIX 56.00 2 Adult Subacute Ancillary Charges - Drugs Charged To Patients 3,607,747 98,259 3,706,006
AS 5 D-4 XIX 101.00 2 Adult Subacute Ancillary Charges - Total 10,480,546 325,423 10,805,969
To adjust allowable Subacute ancillary charges to agree with the provider's
general ledger.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Section 2300 and 2304
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