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Version 5.02","","2019年，北卡罗来纳州医疗补助体系下的护理设施（包含院内型护理设施）年度成本申报需依循的提交要求与操作指引，重点覆盖DH B Medicaid Cost Report及Supplemental Schedules Version 5.02。文件说明适用的CMS 2540-10/CMS 2552-10电子成本报表、Print Image MCR以及电子补充表格与签章认证材料，并明确第5个月截止的申报时点。内容还给出工作底稿、试算平衡“crosswalk”、午夜人口统计、相关组织费用凭证、加密传送方式，以及补充表按顺序录入的Excel模板命名规则与单元录入注意事项。",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":46,"@type":70,"position":76},"https://docshare.wps.com/template/paper-templates/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/snf-2019-medicaid-cost-report-instructions-version-502/200247/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/snf-2019-medicaid-cost-report-instructions-version-502/200247.png","ImageObject",442,249,{"name":88,"@type":89},"Rizky","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-08","2026-09-04",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"SNF 2019 Medicaid Cost Report需要包含哪些核心组成部分？","Question",{"text":108,"@type":109},"需提交CMS 2540-10或CMS 2552-10电子成本报表（清除Level 1 Edit错误后）、Print Image MCR、电子North Carolina Medicaid补充成本申报表，以及经原始签名的NC Medicaid Certification Statement纸质/手写或PDF版本。","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"成本申报的截止时间与必须提交的补充信息有哪些？",{"text":113,"@type":109},"申报到服务期结束后的第5个月月底为止。除最新Medicare护理设施成本报表与Medicaid Supplemental Schedules Version 5.02外，还需提交工作底稿试算平衡Excel“crosswalk”、午夜人口统计的电子PDF，以及如存在相关组织/总部费用时的相关成本报表硬拷贝或PDF。",{"name":115,"@type":106,"acceptedAnswer":116},"Medicaid补充表的填写顺序和Excel模板文件命名规则是什么？",{"text":117,"@type":109},"Medicaid补充表需在完成Medicare成本报表（FORM CMS 2540-10/CMS 2552-10）后按文件给出的顺序填写，后续表依赖前面数据录入。开始填写前需从DHB网站复制Excel工作簿并保存为345xxx_2019_A1.xls或345xxx_2019_A1.xlsx；第二套短期成本报表则用B1替换A1。","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},200247,1791043075,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":45,"category_name":46,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":15,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":79},962085564807,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","NURSING FACILITIES &  \nHOSPITAL BASED NURSING FACILITIES  \nDIVISION OF HEALTH BENEFITS MEDICAID COST REPORT AND SUPPLEMENTAL SCHEDULES  \n2019  \nINSTRUCTIONS  \n(Version 5.02)  \nProvider Check List  \nLevel 1 Edits Cleared ………..…………………………..   Working Trial Balance & Supporting Workpapers ……...   ECR Electronic File for DHB……………………………  Print Image Medicare Cost Report ……………………….   Original Hardcopy of Certification ………………………   \nPer the North Carolina Administrative Code, 10A NCAC 22G.0104, Nursing facility providers are required to file an annual year ending cost report with the Division of Health Benefits. Providers can access the cost reporting forms and instructions on-line at [https://medicaid.ncdhhs.gov/providers/programs-services/long-term-care/nursing-facilities](https://medicaid.ncdhhs.gov/providers/programs-services/long-term-care/nursing-facilities) and select the appropriate cost report.  \nThe NC Medicaid Nursing Facility cost report consists of:  \n• CMS 2540-10 Electronic Cost Report (ECR) file for free-standing nursing facilities / CMS 2552-10 Electronic Cost Report (ECR) file for hospital-based nursing facilities (ensure that all Level 1 Edit Errors are removed before filing)  \n• Print Image MCR  \n• Electronic North Carolina Medicaid Supplemental Cost Reporting Schedules completed as described herein  \n•  Hardcopy of NC Medicaid Certification Statement, signed with original signature.  \nYour cost report is due by the end of the fifth month of the year ending service period. The following information must be submitted along with your most recent Medicare Nursing Facility cost report and Medicaid Supplemental Schedules Version 5.02:  \n• An Excel electronic copy of your facility working trial balance, with a “crosswalk” of the provider’s accounts to the CMS Medicare Cost reporting lines. (Do not submit in PDF format)  \n• An electronic ‘pdf’ copy of your facility’s midnight census. A Census Summary is acceptable at the time of filing the Cost Report. DHB Provider Audit will request an entire census if needed.  \n• If the provider has related organization / home office costs in the CMS cost reporting schedules, the provider must submit ahardcopy or pdf version of the provider’s related organization / home office cost report.  \n• Note – no Capital Data Survey for Fair Rental Value is to be submitted with this Version of the cost report. The Capital Data Survey has been delinked from the submission of the cost report and will be a separate filing with the Division by 12/31 each year.  \nPlease submit the above-referenced cost report and information on a CD and/or Flashdrive to the following address; please encrypt any electronic file with Protected Health Information (PHI) and furnish individual contact information for encryption password:  \n US Mail   \nAudit Section  \nAttn: Mike D’Alessio Division of Health Benefits 2501 Mail Service Center Raleigh, NC 27699-2501  \nExpress Mail/Overnight Shipping  \nAudit Section  \nAttn: Mike D’Alessio Division of Health Benefits  \n820 S. Boylan Avenue Raleigh, NC 27603  \nIf a settlement is due the Medicaid program, make check payable to Division of Health Benefits for the amount due andremit it under separate cover to:  \nDHHS Controller’s Office  \nAccounts Receivable Health Benefits  \n2022 Mail Service Center  \nRaleigh, NC 27699–2022  \nIf you have questions, you may search the DHHS/DHB website for Supplemental Cost Report FAQs otherwise, please contact Mike D’Alessio at (919) 527-7160 or [e-mail](e-mail Mike.Dalessio@dhhs.nc.gov)[ ](e-mail Mike.Dalessio@dhhs.nc.gov)[Mike.Dalessio@dhhs.nc.gov](e-mail Mike.Dalessio@dhhs.nc.gov).  \nSincerely,  \nMichael J. D’Alessio Audit Manager  \nRECOMMENDED SEQUENCE FOR COMPLETING MEDICAID SCHEDULES  \nThe Medicaid Supplemental Schedules must be completed after the Medicare Cost Reporting Worksheets (FORM CMS 2540-10 / CMS 2552-10) are completed. Providers must use Medicare cost reporting principles in 42 CFR § 413 to complete the CMS 2540 / CMS 2552 cost repo","cbCaijCEJhRqphoX","https://ap.wps.com/l/cbCaijCEJhRqphoX","pdf",501382,"English","# Provider Check List\n## Submission requirements\n## Recommended sequence for completing Medicaid schedules\n# DHB-SUPPLEMENTAL SCHEDULES\n## Schedule A - General Information","[{\"question\":\"SNF 2019 Medicaid Cost Report需要包含哪些核心组成部分？\",\"answer\":\"需提交CMS 2540-10或CMS 2552-10电子成本报表（清除Level 1 Edit错误后）、Print Image MCR、电子North Carolina Medicaid补充成本申报表，以及经原始签名的NC Medicaid Certification Statement纸质/手写或PDF版本。\"},{\"question\":\"成本申报的截止时间与必须提交的补充信息有哪些？\",\"answer\":\"申报到服务期结束后的第5个月月底为止。除最新Medicare护理设施成本报表与Medicaid Supplemental Schedules Version 5.02外，还需提交工作底稿试算平衡Excel“crosswalk”、午夜人口统计的电子PDF，以及如存在相关组织/总部费用时的相关成本报表硬拷贝或PDF。\"},{\"question\":\"Medicaid补充表的填写顺序和Excel模板文件命名规则是什么？\",\"answer\":\"Medicaid补充表需在完成Medicare成本报表（FORM CMS 2540-10/CMS 2552-10）后按文件给出的顺序填写，后续表依赖前面数据录入。开始填写前需从DHB网站复制Excel工作簿并保存为345xxx_2019_A1.xls或345xxx_2019_A1.xlsx；第二套短期成本报表则用B1替换A1。\"}]","SNF 2019 Medicaid Cost Report Instructions - Version 5.02 | PDF",1788508369]