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{"sheet":"Survey Set-Up","index":0,"n_rows":218,"n_cols":21,"rows_kept":218,"cut":false,"hidden":true,"merged":[[5,3,6,8],[217,0,217,13],[9,7,9,8]]}
["State:","Georgia",null,"Year:",2017,null,"Including Section L (provider tax form) in Part II?",null,null,null,"Yes",null,null,null,null,null,null,null,null,null,"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, K and L of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital.  All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim.  I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions.  Detailed support exists for all amounts reported in the survey.  These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested.  "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, and K of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital.  All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim.  I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions.  Detailed support exists for all amounts reported in the survey.  These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested.  "]
[null,"Submission Information  (Flows to Checklist Sheet)",null,"Are you using the Myers and Stauffer DSH Web Portal?",null,null,null,null,"Yes"]
[null,"Myers and Stauffer LC"]
[null,"ATTN:  DSH Examinations"]
[null,"700 W. 47th Street, Suite 1100",null,"After entering state, click on \"Run page setup\" below to set-up the headers and footers with the state name and year (in all sheets).  This is a slow process so be patient!"]
[null,"Kansas City, Missouri 64112"]
[null,"Fax:  (816) 945-5301"]
[null,"Phone:  (800) 374-6858"]
[null,"E-Mail: ",null,null,null,null,null,"Output Directory:",null,"G:\\Data\\State Data\\Georgia\\Georgia DSH Project\\2019 DSH Project\\Survey Part I\\"]
[]
[null,1,2,3,4,5,6,7,8,9,10,11]
[null,"Hospital Name","Medicaid Provider ID","Medicaid SubProvider1 ID","Medicaid SubProvider2 ID","Medicare Provider ID","Report Period From","Reporting Period To","Report Period From","Reporting Period To","Report Period From","Reporting Period To"]
[null,"SELECT HOSPITAL NAME","M'Caid #","M'caid Sub 1 #","M'caid Sub 2 #","M'care #"]
[1,"HAMILTON MEDICAL CENTER             ","000000899A",null,null,110001,"2016-10-01","2017-09-30"]
[{"$f":"A15+1","v":2},"UPSON REGIONAL MEDICAL CENTER       ","000001988A",null,null,110002,"2017-01-01","2017-12-31"]
[{"$f":"A16+1","v":3},"MEMORIAL SATILLA HEALTH             ","000001229A",null,null,110003,"2017-01-01","2017-04-30","2017-05-01","2017-12-31"]
[4,"NORTHSIDE HOSPITAL-FORSYTH          ","000000767A",null,null,110005,"2016-10-01","2017-09-30"]
[5,"SAINT MARY'S HOSPITAL               ","000001823A",null,null,110006,"2016-07-01","2017-06-30"]
[6,"PHOEBE PUTNEY MEMORIAL HOSPITAL     ","000001482A","000001416A",null,110007,"2016-08-01","2017-07-31"]
[7,"NORTHSIDE HOSPITAL-CHEROKEE         ","000001108A",null,null,110008,"2016-10-01","2017-09-30"]
[8,"EMORY UNIVERSITY HOSPITAL           ","000000712A","000000712B",null,110010,"2016-09-01","2017-08-31"]
[9,"TANNER MEDICAL CENTER-CARROLLTON    ","000001867A",null,null,110011,"2016-07-01","2017-06-30"]
[10,"TANNER MEDICAL CENTER-VILLA RICA    ","000002032A",null,null,110015,"2016-07-01","2017-06-30"]
[11,"WELLSTAR WEST GEORGIA HOSPITAL      ","000002065A",null,null,110016,"2016-07-01","2017-06-30"]
[12,"PIEDMONT NEWTON HOSPITAL            ","000001394A",null,null,110018,"2016-07-01","2017-06-30"]
[13,"GORDON HOSPITAL                     ","000000833A",null,null,110023,"2017-01-01","2017-12-31"]
[14,"CANDLER HOSPITAL                    ","000000327A",null,null,110024,"2016-07-01","2017-06-30"]
[15,"SOUTHEAST GEORGIA MEDICAL CENTER    ","000000822A",null,null,110025,"2016-05-01","2017-04-30"]
[16,"ELBERT MEMORIAL HOSPITAL            ","000000668A",null,null,110026,"2016-07-01","2017-06-30"]
[17,"ST. MARYS SACRED HEART HOSPITAL     ","000000437A",null,null,110027,"2016-07-01","2017-06-30"]
[18,"UNIVERSITY HOSPITAL                 ","000001977A",null,null,110028,"2017-01-01","2017-12-31"]
[19,"NORTHEAST GEORGIA MEDICAL CENTER    ","000000888A","000000888S",null,110029,"2016-10-01","2017-09-30"]
[20,"CARTERSVILLE MEDICAL CENTER         ","000001625A",null,null,110030,"2016-10-01","2017-09-30"]
[21,"WELLSTAR SPALDING REGIONAL HOSPITAL ","000000866A",null,null,110031,"2016-07-01","2017-06-30"]
[22,"STEPHENS COUNTY HOSPITAL            ","000001834A",null,null,110032,"2016-10-01","2017-09-30"]
[23,"MEDICAL COLLEGE OF GA HOSP & CLINICS","000000723A",null,null,110034,"2016-07-01","2017-06-30"]
[24,"WELLSTAR KENNESTONE HOSPITAL        ","000001119A",null,null,110035,"2016-07-01","2017-06-30"]
[25,"MEMORIAL HEALTH UNIV MEDICAL CENTER ","000001273A",null,null,110036,"2017-01-01","2018-01-31"]
[26,"JOHN D. ARCHBOLD MEMORIAL HOSPITAL","000000063A",null,null,110038,"2016-10-01","2017-09-30"]
[27,"TRINITY HOSPITAL OF AUGUSTA         ","000001779A",null,null,110039,"2016-10-01","2017-06-30"]
[28,"NORTHRIDGE MEDICAL CENTER           ","000000151A",null,null,110040,"2017-01-01","2017-12-31"]
[29,"HABERSHAM COUNTY MEDICAL CENTER     ","000000877A",null,null,110041,"2016-07-01","2017-06-30"]
[30,"WELLSTAR PAULDING HOSPITAL          ","000001438A",null,null,110042,"2016-07-01","2017-06-30"]
[31,"ST. JOSEPH HOSPITAL SAVANNAH","000001801A",null,null,110043,"2016-07-01","2017-06-30"]
[32,"PHOEBE SUMTER MEDICAL CENTER        ","000000019A",null,null,110044,"2016-08-01","2017-07-31"]
[33,"BARROW REGIONAL MEDICAL CENTER      ","000002098A",null,null,110045,"2017-01-01","2017-09-30"]
[34,"PIEDMONT WALTON","000020677A",null,null,110046,"2016-10-01","2017-09-30"]
[35,"MURRAY MEDICAL CENTER               ","000001383A",null,null,110050,"2017-01-01","2017-12-31"]
[36,"UNION GENERAL HOSPITAL              ","000001966A",null,null,110051,"2016-05-01","2017-04-30"]
[37,"FLOYD MEDICAL CENTER                ","000000756A",null,null,110054,"2016-07-01","2017-06-30"]
[38,"MIDTOWN MEDICAL CENTER              ","000001196A","000148233A",null,110064,"2016-07-01","2017-06-30"]
[39,"HOUSTON MEDICAL CENTER              ","000000976A",null,null,110069,"2017-01-01","2017-12-31"]
[40,"APPLING HOSPITAL                    ","000000052A",null,null,110071,"2016-09-01","2017-08-31"]
[41,"DORMINY MEDICAL CENTER              ","000000613A",null,null,110073,"2016-08-01","2017-07-31"]
[42,"PIEDMONT ATHENS REGIONAL MED CTR    ","000000074A",null,null,110074,"2016-10-01","2017-06-30"]
[43,"EAST GEORGIA MEDICAL CENTER         ","000000272A",null,null,110075,"2016-10-01","2017-09-30"]
[44,"DEKALB MEDICAL CENTER               ","000000536A",null,null,110076,"2016-07-01","2017-06-30"]
[45,"EMORY UNIVERSITY HOSPITAL MIDTOWN   ","000000503A",null,null,110078,"2016-09-01","2017-08-31"]
[46,"CHILDREN'S HLTHCRE-HUGHES SPALDING  ","000679808A",null,null,110079,"2017-01-01","2017-12-31"]
[47,"GRADY MEMORIAL HOSPITAL             ","000000855A",null,null,110079,"2017-01-01","2017-12-31"]
[48,"ST. JOSEPH HOSPITAL-ATLANTA","000001812A",null,null,110082,"2016-09-01","2017-08-31"]
[49,"PIEDMONT HOSPITAL                   ","000001504A",null,null,110083,"2016-07-01","2017-06-30"]
[50,"WASHINGTON COUNTY REGIONAL MED CTR  ","000001218A",null,null,110086,"2016-09-01","2017-08-31"]
[51,"GWINNETT MEDICAL CENTER-DULUTH      ","000001064A",null,null,110087,"2016-07-01","2017-06-30"]
[52,"GWINNETT MEDICAL CTR LAWRENCEVILLE  ","000000294A",null,null,110087,"2016-07-01","2017-06-30"]
[53,"COFFEE REGIONAL MEDICAL CENTER      ","000000448A",null,null,110089,"2017-01-01","2017-12-31"]
[54,"ROCKDALE MEDICAL CENTER             ","000001603A",null,null,110091,"2016-10-01","2017-09-30"]
[55,"DODGE COUNTY HOSPITAL               ","000000591A",null,null,110092,"2016-10-01","2017-09-30"]
[56,"TIFT REGIONAL MEDICAL CENTER        ","000001922A",null,null,110095,"2016-10-01","2017-09-30"]
[57,"JEFFERSON HOSPITAL                  ","000001031A",null,null,110100,"2017-01-01","2017-12-31"]
[58,"COOK MEDICAL CENTER                 ","000001251A",null,null,110101,"2016-07-01","2017-06-30"]
[59,"CRISP REGIONAL HOSPITAL             ","000000514A",null,null,110104,"2016-07-01","2017-06-30"]
[60,"COLQUITT REGIONAL MEDICAL CENTER    ","000002021A",null,null,110105,"2016-10-01","2017-09-30"]
[61,"MEDICAL CENTER OF CENTRAL GEORGIA   ","000001207A",null,null,110107,"2016-10-01","2017-09-30"]
[62,"EMANUEL MEDICAL CENTER              ","000000701A",null,null,110109,"2016-07-01","2017-06-30"]
[63,"UNIVERSITY HOSPITAL MCDUFFIE        ","000001185A",null,null,110111,"2017-01-01","2017-12-31"]
[64,"BURKE MEDICAL CENTER                ","000000283A",null,null,110113,"2016-06-01","2017-05-31"]
[65,"WELLSTAR ATLANTA MEDICAL CENTER     ","000000789A","000001713A",null,110115,"2016-07-01","2017-06-30"]
[66,"GRADY GENERAL HOSPITAL              ","000000844A",null,null,110121,"2016-10-01","2017-09-30"]
[{"$f":"A80+1","v":67},"SOUTH GEORGIA MEDICAL CENTER        ","000001724A","000001724G",null,110122,"2016-10-01","2017-09-30"]
[68,"WAYNE MEMORIAL HOSPITAL             ","000002054A",null,null,110124,"2016-07-01","2017-06-30"]
[69,"FAIRVIEW PARK HOSPITAL              ","000001141A",null,null,110125,"2016-05-01","2017-04-30"]
[70,"MEADOWS REGIONAL MEDICAL CENTER     ","000001086A",null,null,110128,"2016-07-01","2017-06-30"]
[71,"SAINT FRANCIS HOSPITAL              ","000001768A",null,null,110129,"2017-01-01","2017-12-31"]
[72,"IRWIN COUNTY HOSPITAL               ","000000987A",null,null,110130,"2016-12-01","2017-11-30"]
[73,"MEMORIAL HOSPITAL & MANOR-BAINBRIDGE","000001262A",null,null,110132,"2016-04-01","2017-03-31"]
[74,"TAYLOR REGIONAL HOSPITAL            ","000001548A",null,null,110135,"2016-04-01","2017-03-31"]
[75,"EVANS MEMORIAL HOSPITAL             ","000000734A",null,null,110142,"2016-10-01","2017-09-30"]
[76,"WELLSTAR COBB HOSPITAL              ","000000426A",null,null,110143,"2016-07-01","2017-06-30"]
[77,"SOUTHEAST GA HLTH SYS-CAMDEN CAMPUS ","000000811A",null,null,110146,"2016-05-01","2017-04-30"]
[78,"OCONEE REGIONAL MEDICAL CENTER      ","000000129A",null,null,110150,"2016-10-01","2017-09-30"]
[79,"PERRY HOSPITAL","000001471A",null,null,110153,"2017-01-01","2017-12-31"]
[80,"NORTHSIDE HOSPITAL                  ","000001405A",null,null,110161,"2016-10-01","2017-09-30"]
[81,"COLISEUM MEDICAL CENTER             ","000000459A",null,null,110164,"2016-07-01","2017-06-30"]
[82,"SOUTHERN REGIONAL MEDICAL CENTER    ","000000404A",null,null,110165,"2017-01-01","2017-12-31"]
[83,"REDMOND REGIONAL MEDICAL CENTER     ","000001581A",null,null,110168,"2016-07-01","2017-06-30"]
[84,"DOCTORS HOSPITAL-AUGUSTA            ","000000558A",null,null,110177,"2016-04-01","2017-03-31"]
[85,"WELLSTAR DOUGLAS HOSPITAL           ","000000624A",null,null,110184,"2016-07-01","2017-06-30"]
[86,"FANNIN REGIONAL HOSPITAL            ","000134406A",null,null,110189,"2017-01-01","2017-12-31"]
[87,"FLINT RIVER HOSPITAL                ","000149487A",null,null,110190,"2017-01-01","2017-12-31"]
[88,"PIEDMONT HENRY HOSPITAL             ","000182388A",null,null,110191,"2016-07-01","2017-06-30"]
[89,"EMORY EASTSIDE MEDICAL CENTER       ","000190088A",null,null,110192,"2016-09-01","2017-08-31"]
[90,"DONALSONVILLE HOSPITAL              ","000206181A",null,null,110194,"2016-07-01","2017-06-30"]
[91,"WELLSTAR NORTH FULTON REGIONAL HOSP ","000275976A",null,null,110198,"2016-07-01","2017-06-30"]
[92,"NORTHSIDE MEDICAL CENTER            ","000315642A",null,null,110200,"2016-07-01","2017-06-30"]
[93,"COLISEUM NORTHSIDE                  ","000295358A",null,null,110201,"2016-07-01","2017-06-30"]
[94,"PIEDMONT FAYETTE HOSPITAL           ","000755323A",null,null,110215,"2016-07-01","2017-06-30"]
[95,"PIEDMONT MOUNTAINSIDE HOSPITAL      ","000001493A",null,null,110225,"2016-07-01","2017-06-30"]
[96,"DEKALB MEDICAL CENTER-HILLENDALE    ","000000536U",null,null,110226,"2016-07-01","2017-06-30"]
[97,"PIEDMONT NEWNAN HOSPITAL            ","000000492A",null,null,110229,"2016-07-01","2017-06-30"]
[98,"EMORY JOHNS CREEK                   ","344886600A",null,null,110230,"2016-09-01","2017-08-31"]
[99,"SOUTH GEORGIA MED CTR - BERRIEN","000000173A",null,null,110234,"2016-10-01","2017-09-30"]
[100,"CORNERSTONE MEDICAL CENTER          ","003180661A",null,null,110236,"2017-01-01","2017-12-29"]
[101,"SOUTHWEST GEORGIA REGIONAL MEDICAL C","000001427A",null,null,111300,"2016-08-01","2017-07-31"]
[102,"BLECKLEY MEMORIAL HOSPITAL          ","000000195A",null,null,111302,"2016-04-01","2017-03-31"]
[103,"JASPER MEMORIAL HOSPITAL            ","000000998A",null,null,111303,"2016-10-01","2017-09-30"]
[104,"MORGAN MEMORIAL HOSPITAL            ","000694229A",null,null,111304,"2016-07-01","2017-06-30"]
[105,"MILLER COUNTY HOSPITAL              ","000001317A",null,null,111305,"2016-07-01","2017-06-30"]
[106,"EFFINGHAM HOSPITAL                  ","000000657A",null,null,111306,"2016-07-01","2016-10-31","2016-11-01","2017-06-30"]
[107,"CLINCH MEMORIAL HOSPITAL            ","000000415A",null,null,111308,"2016-07-01","2017-06-30"]
[108,"MEDICAL CENTER OF PEACH COUNTY      ","000001449A",null,null,111310,"2016-10-01","2017-09-30"]
[109,"OPTIM MEDICAL CENTER - JENKINS      ","000001042A",null,null,111311,"2017-01-01","2017-06-15"]
[110,"OPTIM MEDICAL CENTER - SCREVEN      ","000001647A",null,null,111312,"2017-01-01","2017-12-31"]
[111,"PUTNAM GENERAL HOSPITAL             ","000001537A",null,null,111313,"2016-10-01","2017-09-30"]
[112,"PIONEER HLTH SERV OF EARLY COUNTY   ","000000635A",null,null,111314,"2016-10-01","2017-10-31"]
[113,"WARM SPRINGS MEDICAL CENTER         ","000001284A",null,null,111316,"2017-01-01","2017-12-31"]
[114,"MONROE COUNTY HOSPITAL              ","000001361A",null,null,111318,"2016-10-01","2017-09-30"]
[115,"WELLSTAR SYLVAN GROVE HOSPITAL      ","000001856A",null,null,111319,"2016-07-01","2017-06-30"]
[116,"HIGGINS GENERAL HOSPITAL            ","000000954A",null,null,111320,"2016-07-01","2017-06-30"]
[117,"OPTIM MEDICAL CENTER - TATTNALL     ","000001878A",null,null,111323,"2017-01-01","2017-12-31"]
[118,"CHATUGE REGIONAL HOSPITAL           ","000001933A",null,null,111324,"2016-05-01","2017-04-30"]
[119,"WILLS MEMORIAL HOSPITAL             ","000002087A",null,null,111325,"2016-05-01","2017-04-30"]
[120,"SOUTH GEORGIA MED CTR - LANIER      ","000001163A",null,null,111326,"2016-10-01","2017-09-30"]
[121,"BACON COUNTY HOSPITAL               ","000000118A",null,null,111327,"2016-07-01","2017-06-30"]
[122,"PHOEBE WORTH MEDICAL CENTER         ","000002109A",null,null,111328,"2016-08-01","2017-07-31"]
[123,"ST. MARYS GOOD SAMARITAN            ","000001328A",null,null,111329,"2016-07-01","2017-06-30"]
[124,"POLK MEDICAL CENTER                 ","000001526A",null,null,111330,"2016-07-01","2017-06-30"]
[125,"MITCHELL COUNTY HOSPITAL            ","000001339A",null,null,111331,"2016-10-01","2017-09-30"]
[126,"BROOKS COUNTY HOSPITAL              ","000000239A",null,null,111332,"2016-10-01","2017-09-30"]
[127,"JEFF DAVIS HOSPITAL                 ","000001009A",null,null,111333,"2016-10-01","2017-09-30"]
[128,"CANDLER COUNTY HOSPITAL             ","000000316A",null,null,111334,"2017-01-01","2017-12-31"]
[129,"LIBERTY REGIONAL MEDICAL CENTER     ","000001152A",null,null,111335,"2016-12-01","2017-11-30"]
[130,"MOUNTAIN LAKES MEDICAL CENTER       ","000001559A",null,null,111336,"2017-01-01","2017-12-31"]
[{"$f":"A144+1","v":131},"SHEPHERD CENTER                     ","000248069A",null,null,112003,"2016-04-01","2017-03-31"]
[132,"DEKALB MEDICAL CENTER AT DECATUR","000000525A",null,null,112006,"2016-07-01","2017-06-30"]
[133,"WELLSTAR WINDY HILL HOSPITAL        ","000001999A",null,null,112007,"2016-07-01","2017-06-30"]
[134,"KINDRED HOSPITAL ROME               ","000886179A",null,null,112010,"2016-09-01","2017-08-31"]
[135,"HEALTHSOUTH WALTON REHAB HOSPITAL","000368387A",null,null,113030,"2016-04-01","2017-03-31"]
[136,"ROOSEVELT WARM SPRGS LTAC HOSPITAL  ","000000778A",null,null,113028,"2016-07-01","2017-06-30"]
[137,"CHILDREN'S HOSPITAL ATL AT EGLESTON ","000000943A",null,null,113300,"2017-01-01","2017-12-31"]
[138,"CHILDREN'S HEALTHCARE-SCOTTISH RITE ","000001636A",null,null,113301,"2017-01-01","2017-12-31"]
[139]
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[{"$f":"A208+1","v":195}]
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["If more providers are needed, insert rows above this line. DO NOT delete this line and continue the list."]

{"sheet":"Instructions","index":1,"n_rows":24,"n_cols":3,"rows_kept":24,"cut":false,"hidden":false,"merged":[[24,0,24,2],[23,0,23,2]]}
["A. General Instructions and Identification of Cost Reports that Cover the DSH Year:"]
[]
["1.",null,"Select the \"Sec. A-C DSH Year Data\" tab in Excel workbook.  In row 1, select your facility from the drop-down menu provided (if not already populated).  When your facility is selected, the following fields will be populated: in-state Medicaid provider number and Medicare provider number.  Review information and indicate whether it is correct or incorrect.  If incorrect, provide correct information."]
[]
["2.",null,"Provide your cost reporting periods that are needed to completely cover the DSH year.  If the end date for cost report period 1 is before the end date of the DSH year, report your next cost reporting period (cost report 2).  If this cost report ends prior to the end of the DSH year, report your next cost reporting period (cost report 3).  The cost reporting periods must cover the entire DSH year. "]
[null,null,"NOTE:  For the 2015 DSH Survey, if your hospital completed the DSH survey for 2014, the first cost report year should follow the last cost report year reported on the 2014 DSH survey.  The last cost report year on the 2015 survey must end on or after the end of the 2015 DSH year.  If your hospital did not complete the 2014 survey, your cost reports for 2015 must cover the entire 2015 DSH year."]
[]
["3.",null,"Supporting documentation for all data elements provided within the DSH survey must be maintained for a minimum of five years from the date of survey submission."]
["B. DSH OB Qualifying Information:"]
[]
["1.",null,"Answer \"B. DSH OB Qualifying Information\" questions 1, 2 and 3 to determine if your hospital is eligible to receive DSH payments."]
[]
["C. Disclosure of Other Medicaid Payments Received:"]
[]
["1.",null,"Medicaid supplemental payments should include UPL and Non-Claim Specific payments paid based on the state fiscal year. However, DSH payments should NOT be included."]
[]
[]
["Certification:"]
[]
["1.",null,"The hospital CEO or CFO must certify the accuracy of the survey responses.  Provide hospital and outside preparer contacts who can respond to requests for additional information and answer questions related to the hospital's responses. "]
[]
[]
[]
[{"$f":"IF(TaxForm=\"No\", \"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-K included in the separate DSH survey Part II file.\", \"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-L included in the separate DSH Survey Part II file.\")","v":"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-L included in the separate DSH Survey Part II file."}]

{"sheet":"Instructions ","index":2,"n_rows":28,"n_cols":3,"rows_kept":28,"cut":false,"hidden":true,"merged":[[27,0,27,2],[28,0,28,2]]}
["DSH Waiver & MIUR Data"]
[]
[{"$f":"IF(State=\"Missouri\",1,\"\")","v":""},null,"A DSH Waiver & MIUR Data form is included in DSH Survey Part I. A hospital that did not receive an interim DSH payment for the year under examination and elects not to receive a Missouri Medicaid interim DSH payment for the upcoming interim DSH payment year must complete the DSH Waiver & MIUR Data form and indicate it elects not to receive an interim DSH payment.  The hospital must also complete the “Days” section on the DSH Waiver & MIUR Data form so the hospital’s MIUR may be calculated. However, the remainder of DSH Year Survey Part I and all of DSH Year Survey Part II do not need to be completed.  CMS requires the state of Missouri to submit the MIUR for each hospital in the state that receives a Medicaid payment.  It is important that the “Days” section is completed so the MIUR can be accurately reported to CMS as the MIUR data may affect future federal funding.    "]
[]
["A. General Instructions and Identification of Cost Reports that Cover the DSH Year:"]
[]
["1.",null,"Select the \"Sec. A-C DSH Year Data\" tab in Excel workbook.  In row 1, select your facility from the drop-down menu provided (if not already populated).  When your facility is selected, the following fields will be populated: in-state Medicaid provider number and Medicare provider number.  Review information and indicate whether it is correct or incorrect.  If incorrect, provide correct information."]
[]
["2.",null,"Provide your cost reporting periods that are needed to completely cover the DSH year.  If the end date for cost report period 1 is before the end date of the DSH year, report your next cost reporting period (cost report 2).  If this cost report ends prior to the end of the DSH year, report your next cost reporting period (cost report 3).  The cost reporting periods must cover the entire DSH year. "]
[null,null,"NOTE:  For the 2015 DSH Survey, if your hospital completed the DSH survey for 2014, the first cost report year should follow the last cost report year reported on the 2014 DSH survey.  The last cost report year on the 2015 survey must end on or after the end of the 2015 DSH year.  If your hospital did not complete the 2014 survey, your cost reports for 2015 must cover the entire 2015 DSH year."]
[]
["3.",null,"Supporting documentation for all data elements provided within the DSH survey must be maintained for a minimum of five years from the date of survey submission."]
["B. DSH OB Qualifying Information:"]
[]
["1.",null,"The “Sec. A-C DSH Year Data” tab of DSH Year Survey Part I, Section B. DSH OB Qualifying Information, has two sets of OB questions. The first set of OB questions relates to the interim DSH payments which are the subject of the federal DSH examination. The second set of OB questions relates to the interim DSH payments for the upcoming SFY interim DSH payment calculation. You must complete the first set of OB questions if you are required to participate in the DSH examination. You must complete the second set of OB questions if you are electing to participate in the upcoming SFY interim DSH payment calculation."]
[]
["C. Disclosure of Other Medicaid Payments Received:"]
[]
["1.",null,{"$f":"'Sec. A-C DSH Year Data'!B67","v":"(Should include UPL and Non-Claim Specific payments paid based on the state fiscal year.  However, DSH payments should NOT be included.)"}]
[]
[]
["Certification:"]
[]
["1.",null,"The hospital CEO or CFO must certify the accuracy of the survey responses.  Provide hospital and outside preparer contacts who can respond to requests for additional information and answer questions related to the hospital's responses. "]
[]
[]
[]
[{"$f":"IF(TaxForm=\"No\", \"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-K included in the separate DSH survey Part II file.\", \"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-L included in the separate DSH Survey Part II file.\")","v":"Please submit your completed survey Sections A through C and the certification electronically to Myers and Stauffer LC.  Also include Sections D-L included in the separate DSH Survey Part II file."}]

{"sheet":"DSH Waiver & MIUR Data","index":3,"n_rows":83,"n_cols":10,"rows_kept":83,"cut":false,"hidden":true,"merged":[[14,1,14,6],[38,2,38,3],[5,4,5,6],[66,1,66,6],[28,1,28,8],[29,1,29,8],[30,1,30,8],[21,1,21,7],[50,1,50,6],[51,1,51,6]]}
[]
["DSH Waiver & MIUR Data Form"]
[]
["General Information & DSH Waiver"]
[]
[1,"Hospital Name",null,null,{"$f":"HOSPITALNAME_ADJ","v":"WELLSTAR WEST GEORGIA HOSPITAL      "}]
[]
[2,"Missouri Medicaid Provider Number:",null,null,{"$f":"McaidNum_ADJ","v":"000002065A"}]
[]
[]
[3,"Medicare Provider Number:",null,null,{"$f":"McareNum_ADJ","v":110016}]
[]
[4,"DSH Payment Year:",null,"From:","2018-07-01","To:","2019-06-30"]
[]
[null,{"$f":"CONCATENATE(\"Based on the hospital's projections, the above named hospital does not anticipate it will have uncompensated cost of care for Medicaid and the uninsured that would be eligible for an interim DSH payment for SFY \",YEAR($G$13),\".  Therefore, this hospital elects not to receive an interim DSH payment for SFY \",YEAR($G$13),\".\")","v":"Based on the hospital's projections, the above named hospital does not anticipate it will have uncompensated cost of care for Medicaid and the uninsured that would be eligible for an interim DSH payment for SFY 2019.  Therefore, this hospital elects not to receive an interim DSH payment for SFY 2019."}]
[]
[5,{"$f":"CONCATENATE(\"Waive interim DSH payment for SFY \",YEAR(DSH_Payment_Year_End),\":\")","v":"Waive interim DSH payment for SFY 2019:"},null,null,null,null,"No"]
[]
[]
["Required Federal Reporting of MIUR Data - Hospital Patient Days"]
["Note:","If you selected \"No\" above, you do not need to fill out the days or certification block below.",null,null,null,null,null,null,null,{"$f":"CONCATENATE(\"Cost Report Year (\", TEXT(MAX(FYB_1_ADJ,FYB_2_ADJ,FYB_3_ADJ),\"mm/dd/yy\"), \" - \", TEXT(MAX(FYE_1_ADJ,FYE_2_ADJ,FYE_3_ADJ),\"mm/dd/yy\"),\")\")","v":"Cost Report Year (07/01/16 - 06/30/17)"}]
[null,"If you selected \"Yes\" above, you must fill out the days below.  CMS requires that the State of Missouri submit the MIUR for each hospital in the state that receives a Medicaid payment.  This information is necessary for the accurate reporting of the MIUR and may affect future federal funding."]
[]
[6,"Missouri Total Paid Medicaid FFS Days "]
[7,"Missouri Total Paid Medicaid Managed Care Days "]
[8,"Missouri Total Paid Medicaid FFS Crossover Days "]
[9,"Missouri Other Medicaid Eligible Days (No Medicaid Payment)"]
[10,"Out-of-State Paid Medicaid Days  (Include FFS, Medicaid Managed Care, FFS Crossover, and Other Eligible)"]
[11,"Total Hospital Days Per Cost Report Excluding Swing-Bed (C/R, W/S S-3, Pt. I, Col. 8, Sum of Lns. 14, 16, 17, 18.xx less lines 5 & 6)"]
[12,"Total Medicaid Hospital Days Per Cost Report Excluding Swing Bed (W/S S-3, Pt. I, Col. 7, Sum of Lns. 2-4, 14, 16, 17, 18.xx less lines 5 & 6)"]
[13,"Unreconciled Medicaid Hospital Days (Primary Medicaid Days including Out-of-State less Cost Report Total) (please include explanation on Variance tab)",null,null,null,null,null,null,null,{"$f":"J24+J25+J28-J30","v":0}]
[]
[]
["Missouri Medicaid Inpatient Utilization Rate (MIUR) Calculation"]
[]
[14,"Total Medicaid Eligible Days",null,null,"Sum of Line 6 thru Line 10",null,null,null,null,{"$f":"J24+J25+J26+J27+J28","v":0}]
[15,"Total Hospital Days (excludes swing-bed)",null,null,"Line 11",null,null,null,null,{"$f":"J29","v":0}]
[16,"MIUR",null,null,"Line 14 divided by Line 15",null,null,null,null,{"$f":"IF(J37>0,ROUND(J36/J37,4),0)","v":0}]
[]
["Missouri DSH OB Qualifying Information"]
[]
["Note:","If you selected \"No\" above, you do not need to fill out the OB responses or certification block below. Please complete the OB responses on \"Sec. A-C DSH Year Data\"."]
[null,"Questions 17-19, below, should be answered in the accordance with Sec. 1923(d) of the Social Security Act."]
[null,"During the Interim DSH Payment Year:",null,null,null,null,null,null,null,{"$f":"CONCATENATE(\"*Interim DSH Payment Year (\", TEXT(DSH_Payment_Year_Begin,\"mm/dd/yy\"), \" - \", TEXT(DSH_Payment_Year_End,\"mm/dd/yy\"),\")\")","v":"*Interim DSH Payment Year (07/01/18 - 06/30/19)"}]
[17,"Does the hospital have at least two obstetricians who have staff privileges at the hospital who have agreed to"]
[null,"provide obstetric services to Medicaid-eligible individuals during the DSH year?  (In the case of a hospital"]
[null,"located in a rural area, the term \"obstetrician\" includes any physician with staff privileges at the "]
[null,"hospital to perform nonemergency obstetric procedures.)  "]
[]
[null,"List the Names of the two Obstetricians (or case of rural hospital, Physicians) who have agreed to perform OB services:"]
[]
[]
[]
[18,"Is the hospital exempt from the requirement listed under #1 above because the hospital's "]
["","inpatients are predominantly under 18 years of age? "]
[19,"Is the hospital exempt from the requirement listed under #1 above because it did not offer non-"]
[null,"emergency obstetric services to the general population when federal Medicaid DSH regulations"]
[null,"were enacted on December 22, 1987?  "]
[]
["19a.","Was the hospital open as of December 22, 1987?"]
[]
["19b.","What date did the hospital open?"]
[]
[]
["Certification"]
[]
[null,"The information provided above is true and accurate to the best of our ability, and supported by the financial and other records of the hospital.  I understand that a hospital that does not receive an interim DSH payment for a SFY will not be included in the independent DSH examination related to that SFY and will not be eligible for final DSH examination payment adjustments related to that SFY unless it submits a request to the MO HealthNet Division to be included in the independent DSH examination."]
[]
[]
[]
[]
[]
[]
[]
[null,"Signature of CEO or Other Authorized Person",null,null,null,null,"Date"]
[]
[]
[]
[null,"Print Name"]
[]
[]
[]
[null,"Title"]

{"sheet":"Variance","index":4,"n_rows":4,"n_cols":1,"rows_kept":4,"cut":false,"hidden":true,"merged":[[3,1,16,12]]}
[]
["Please explain variances below."]
[]
[13]

{"sheet":"Sec. A-C DSH Year Data","index":5,"n_rows":103,"n_cols":29,"rows_kept":103,"cut":false,"hidden":false,"merged":[[102,2,102,5],[16,2,16,4],[100,9,100,12],[65,1,65,4],[101,9,101,12],[99,2,99,5],[97,9,97,12],[101,2,101,5],[100,2,100,5],[99,9,99,12],[88,4,88,6],[5,2,5,6],[64,1,64,4],[11,6,11,13],[12,6,12,13],[98,9,98,12],[97,2,97,5],[98,2,98,5],[83,1,83,13],[81,2,81,13],[82,1,82,13],[53,1,53,4],[54,1,54,4],[13,6,13,13],[91,4,91,6],[91,8,91,10],[86,1,86,10]]}
[null,null,null,null,null,null,null,null,"DSH Version",null,5.2,null,"2017-11-01",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"State","v":"Georgia"}]
["A.  General DSH Year Information",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Waiver_Response","v":"No"}]
[null,null,"Begin",null,"End"]
["1.","DSH Year:","2016-07-01",null,"2017-06-30"]
[]
["2.","Select Your Facility from the Drop-Down Menu Provided:","WELLSTAR WEST GEORGIA HOSPITAL      "]
[]
[]
[null,"Identification of cost reports needed to cover the DSH Year:"]
[null,null,"Cost Report",null,"Cost Report"]
[null,null,"Begin Date(s)",null,"End Date(s)"]
["3.","Cost Report Year 1",{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,6,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,6,FALSE))","v":"2016-07-01"},null,{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,7,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,7,FALSE))","v":"2017-06-30"},null,{"$f":"IF(ISNUMBER(FYE_1),\"Must also complete a separate survey file for each cost report period listed - SEE DSH SURVEY PART II FILES\", \"\")","v":"Must also complete a separate survey file for each cost report period listed - SEE DSH SURVEY PART II FILES"}]
["4.","Cost Report Year 2 (if applicable)",{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,8,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,8,FALSE))","v":""},null,{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,9,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,9,FALSE))","v":""},null,{"$f":"IF(ISNUMBER(FYE_2),\"Must also complete a separate survey file for each cost report period listed - SEE DSH SURVEY PART II FILES\", \"\")","v":""}]
["5.","Cost Report Year 3 (if applicable)",{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,10,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,10,FALSE))","v":""},null,{"$f":"IF(VLOOKUP(HOSPITALNAME,DATATABLE,11,FALSE)=0,\"\",VLOOKUP(HOSPITALNAME,DATATABLE,11,FALSE))","v":""},null,{"$f":"IF(ISNUMBER(FYE_3),\"Must also complete a separate survey file for each cost report period listed - SEE DSH SURVEY PART II FILES\", \"\")","v":""}]
[]
[]
[null,null,"Data"]
["6.","Medicaid Provider Number:",null,null,{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,2,FALSE)","v":"000002065A"}]
["7.","   Medicaid Subprovider Number 1 (Psychiatric or Rehab):",null,null,{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,3,FALSE)","v":0}]
["8.","   Medicaid Subprovider Number 2 (Psychiatric or Rehab):",null,null,{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,4,FALSE)","v":0}]
["9.","Medicare Provider Number:",null,null,{"$f":"VLOOKUP(HOSPITALNAME,DATATABLE,5,FALSE)","v":110016}]
[]
[]
[]
[]
[]
[]
[]
["B.  DSH OB Qualifying Information"]
[null,"Questions 1-3, below, should be answered in the accordance with Sec. 1923(d) of the Social Security Act."]
[null,"During the DSH Examination Year:",null,null,null,null,null,null,{"$f":"CONCATENATE(\"DSH Examination Year (\", TEXT(DSH_Year_Begin,\"mm/dd/yy\"), \" - \", TEXT(DSH_Year_End,\"mm/dd/yy\"),\")\")","v":"DSH Examination Year (07/01/16 - 06/30/17)"}]
[1,"Did the hospital have at least two obstetricians who had staff privileges at the hospital that agreed to",null,null,null,null,null,null,"Yes"]
[null,"provide obstetric services to Medicaid-eligible individuals during the DSH year?  (In the case of a hospital"]
[null,"located in a rural area, the term \"obstetrician\" includes any physician with staff privileges at the "]
[null,"hospital to perform nonemergency obstetric procedures.)  "]
[2,"Was the hospital exempt from the requirement listed under #1 above because the hospital's ",null,null,null,null,null,null,"No"]
["","inpatients are predominantly under 18 years of age? "]
[3,"Was the hospital exempt from the requirement listed under #1 above because it did not offer non-",null,null,null,null,null,null,"No"]
[null,"emergency obstetric services to the general population when federal Medicaid DSH regulations"]
[null,"were enacted on December 22, 1987?  "]
[]
["3a.","Was the hospital open as of December 22, 1987?",null,null,null,null,null,null,"Yes"]
[]
["3b.","What date did the hospital open?",null,null,null,null,null,null,"1966-07-01"]
[]
[null,"Questions 4-6, below, should be answered in the accordance with Sec. 1923(d) of the Social Security Act."]
[null,"During the Interim DSH Payment Year:",null,null,null,null,null,null,{"$f":"CONCATENATE(\"DSH Payment Year (\", TEXT(DSH_Payment_Year_Begin,\"mm/dd/yy\"), \" - \", TEXT(DSH_Payment_Year_End,\"mm/dd/yy\"),\")\")","v":"DSH Payment Year (07/01/18 - 06/30/19)"}]
[4,"Does the hospital have at least two obstetricians who have staff privileges at the hospital who have agreed to",null,null,null,null,null,null,"Yes"]
[null,"provide obstetric services to Medicaid-eligible individuals during the DSH year?  (In the case of a hospital"]
[null,"located in a rural area, the term \"obstetrician\" includes any physician with staff privileges at the "]
[null,"hospital to perform nonemergency obstetric procedures.)  "]
[]
[null,"List the Names of the two Obstetricians (or case of rural hospital, Physicians) who have agreed to perform OB services:"]
[null,"Bakarich, Michael A., DO"]
[null,"Brendell, James J., MD"]
[]
[5,"Is the hospital exempt from the requirement listed under #1 above because the hospital's ",null,null,null,null,null,null,"No"]
["","inpatients are predominantly under 18 years of age? "]
[6,"Is the hospital exempt from the requirement listed under #1 above because it did not offer non-",null,null,null,null,null,null,"No"]
[null,"emergency obstetric services to the general population when federal Medicaid DSH regulations"]
[null,"were enacted on December 22, 1987?  "]
[]
[]
["C.  Disclosure of Other Medicaid Payments Received:"]
[]
["1.",{"$f":"CONCATENATE(IF(State=\"Missouri\",\"Other Medicaid Payments for DSH Year \",\"Medicaid Supplemental Payments for DSH Year \"), TEXT(DSH_Year_Begin,\"mm/dd/yyy\"), \" - \", TEXT(DSH_Year_End,\"mm/dd/yyyy\"))","v":"Medicaid Supplemental Payments for DSH Year 07/01/2016 - 06/30/2017"},null,null,null,null,null,null,1437277]
[null,{"$f":"IF(State=\"Missouri\",\"Should include all Non-Claim Specific payments paid based on the state fiscal year including Direct Medicaid, GME, UPL, Children's Outliers, etc.  However, DSH payments should NOT be included.\",\"(Should include UPL and Non-Claim Specific payments paid based on the state fiscal year.  However, DSH payments should NOT be included.)\")","v":"(Should include UPL and Non-Claim Specific payments paid based on the state fiscal year.  However, DSH payments should NOT be included.)"}]
[]
[]
[]
[]
[]
[]
[]
["Certification:"]
[null,null,null,null,null,null,null,null,"Answer"]
["1.","Was your hospital allowed to retain 100% of the DSH payment it received for this DSH year?",null,null,null,null,null,null,"Yes"]
[null,"Matching the federal share with an IGT/CPE is not a basis for answering this question \"no\".  If your"]
[null,"hospital was not allowed to retain 100% of its DSH payments, please explain what circumstances were"]
[null,"present that prevented the hospital from retaining its payments."]
[]
[null,"Explanation for \"No\" answers:"]
[]
[]
[]
[null,"The following certification is to be completed by the hospital's CEO or CFO:"]
[null,{"$f":"IF(TaxForm=\"No\", NoTax, WithTax)","v":"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, K and L of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital.  All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim.  I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions.  Detailed support exists for all amounts reported in the survey.  These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested.  "}]
[]
[null,null,null,null,"Chief Financial Officer"]
[null,"Hospital CEO or CFO Signature",null,null,"Title",null,null,null,null,null,"Date"]
[]
[null,"Paul Perrotti",null,null,"706-302-5492",null,null,null,"perrottip@wghealth.org"]
[null,"Hospital CEO or CFO Printed Name",null,null,"Hospital CEO or CFO Telephone Number",null,null,null,"Hospital CEO or CFO E-Mail"]
[]
[null,"Contact Information for individuals authorized to respond to inquiries related to this survey:"]
[]
[null,"Hospital Contact:",null,null,null,null,null,null,"Outside Preparer:"]
[null,"Name","Esther Bailes",null,null,null,null,null,"Name","Hal Guthrie"]
[null,"Title","Reimbursement Department MHM",null,null,null,null,null,"Title:","Partner"]
[null,"Telephone Number","(470) 956-4993",null,null,null,null,null,"Firm Name:","Dixon Hughes Goodman LLP"]
[null,"E-Mail Address","esther.bailed@wellstar.org",null,null,null,null,null,"Telephone Number","(404) 575-8947"]
[null,"Mailing Street Address","1514 Vernon Road",null,null,null,null,null,"E-Mail Address","hal.guthrie@dhgllp.com"]
[null,"Mailing City, State, Zip","LaGrange, GA 30240"]

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["DSH Survey Submission Checklist"]
[null,"Please indicate with an \"X\" each item included or a \"N/A\" if not included.  Consider a separate cover letter to explain any \"N/A\" answers to avoid additional documentation requests."]
[null,"X",null,"1.",{"$f":"CONCATENATE(\"Electronic copy of the DSH Survey Part I - DSH Year Data -  \", TEXT(DSH_Year_Begin,\"mm/dd/yyyy\"), \" - \", TEXT(DSH_Year_End,\"mm/dd/yyyy\"))","v":"Electronic copy of the DSH Survey Part I - DSH Year Data -  07/01/2016 - 06/30/2017"}]
[null,"X",null,"2.",{"$f":" CONCATENATE(\"Electronic copy of the DSH Survey Part II - Cost Report Data - Cost Report Year \", TEXT(FYB_1,\"mm/dd/yyyy\"), \" - \", TEXT(FYE_1,\"mm/dd/yyyy\"))","v":"Electronic copy of the DSH Survey Part II - Cost Report Data - Cost Report Year 07/01/2016 - 06/30/2017"}]
[null,"N/A",null,"3.",{"$f":"IF(ISNUMBER('Sec. A-C DSH Year Data'!E13),CONCATENATE(\"Electronic copy of the DSH Survey Part II - Cost Report Data - Cost Report Year \", TEXT(FYB_2,\"mm/dd/yyyy\"), \" - \", TEXT(FYE_2,\"mm/dd/yyyy\")),\"N/A\")","v":"N/A"}]
[null,"N/A",null,"4.",{"$f":"IF(ISNUMBER('Sec. A-C DSH Year Data'!E14),CONCATENATE(\"Electronic copy of the DSH Survey Part II - Cost Report Data - Cost Report Year \", TEXT(FYB_3,\"mm/dd/yyyy\"), \" - \", TEXT(FYE_3,\"mm/dd/yyyy\")),\"N/A\")","v":"N/A"}]
[null,"X",null,"5 (a).","Electronic copy of Exhibit A - Uninsured Charges / Days"]
[null,null,null,null,null,"- Must be in Excel (.xls or .xlsx) or CSV (.csv) using either a TAB or | (pipe symbol above the ENTER key)"]
[null,null,null,"5 (b).","Description of logic used to compile Exhibit A.  Include a copy of all financial classes and payor plan codes utilized during the cost report period and a description of which codes were included or excluded if applicable."]
[null,"X",null,"6 (a).","Electronic copy of Exhibit B - Self-Pay Payments"]
[null,null,null,null,null,"- Must be in Excel (.xls or .xlsx) or CSV (.csv) using either a TAB or | (pipe symbol above the ENTER key)."]
[null,null,null,"6 (b).","Description of logic used to compile Exhibit B. Include a copy of all transaction codes utilized to post payments during the cost reporting period and a description of which codes were included or excluded if applicable."]
[null,"X",null,"7 (a).","Electronic copy of Exhibit C for hospital-generated data (includes Medicaid eligibles, Medicare crossover, Medicaid MCO, or Out-Of-State Medicaid data that isn't supported by a state-provided or MCO-provided report)"]
[null,null,null,null,null,"- Must be in Excel (.xls or .xlsx) or CSV (.csv) using either a TAB or | (pipe symbol above the ENTER key)."]
[null,null,null,"7 (b).","Description of logic used to compile each Exhibit C. Include a copy of all financial classes and payor plan codes utilized during the cost report period and a description of which codes were included or excluded if applicable."]
[null,"N/A",null,"8.","Copies of all out-of-state Medicaid fee-for-service PS&Rs (Remittance Advice Summary or Paid Claims Summary including crossovers)"]
[null,"N/A",null,"9.","Copies of all out-of-state Medicaid managed care PS&Rs (Remittance Advice Summary or Paid Claims Summary including crossovers)"]
[null,"N/A",null,"10.","Copies of in-state Medicaid managed care PS&Rs (Remittance Advice Summary or Paid Claims Summary including crossovers)"]
[null,"N/A",null,"11.","Support for Section 1011 (Undocumented Alien) payments if not applied at patient level in Exhibit B"]
[null,"N/A",null,"12.","Documentation supporting out-of-state DSH payments received"]
[null,null,null,null,null,"- Examples may include remittances, detailed general ledgers, or add-on rates."]
[null,"X",null,"13.","Financial statements or other documentation to support total charity care charges and subsidies reported on Section F of DSH Survey Part II"]
[null,"X",null,"14.","Revenue code cross-walk used to prepare cost report, or supporting grouping schedules"]
[null,"X",null,"15a.","A detailed working trial balance used to prepare each cost report (including revenues)"]
[null,"X",null,"15b.","A detailed revenue working trial balance by payor/contract.  The schedule should show charges, contractual adjustments, and revenues by payor plan and contract (e.g., Medicare, each Medicaid agency payor, each Medicaid Managed care contract)"]
[null,"X",null,"16.","Electronic copy of all cost reports used to prepare each DSH Survey Part II"]
[null,"X",null,"17.","Documentation supporting cost report payments calculated for Medicaid/Medicare cross-overs (dual eligible cost report payments)"]
[null,"N/A",null,"18.","Documentation supporting Medicaid Managed Care Quality Incentive Payments, or any other Medicaid Managed Care lump sum payments"]
[]
[]
[null,null,null,null,"Please upload all checklist items above to the Myers and Stauffer Web Portal. If you are unable to access the Web Portal, please call or email. Web Portal Address:"]
[null,null,null,null,"https://dsh.mslc.com"]
[null,null,null,null,"All electronic (CD or DVD - CDs or DVDs must be encryped and/or password protected) and paper documentation can be mailed (using certified or other traceable delivery) to:"]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B4","v":"Myers and Stauffer LC"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B5","v":"ATTN:  DSH Examinations"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B6","v":"700 W. 47th Street, Suite 1100"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B7","v":"Kansas City, Missouri 64112"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B8","v":"Fax:  (816) 945-5301"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B9","v":"Phone:  (800) 374-6858"}]
[null,null,null,null,null,null,null,{"$f":"'Survey Set-Up'!B10","v":"E-Mail: "}]
[null,null,null,null,"Please Call Myers and Stauffer if you have any questions on completing the DSH survey."]

{"sheet":"Sec. A-C DSH Year Data ADJ","index":7,"n_rows":103,"n_cols":31,"rows_kept":103,"cut":false,"hidden":true,"merged":[[102,2,102,5],[99,2,99,5],[99,9,99,12],[100,2,100,5],[100,9,100,12],[101,2,101,5],[101,9,101,12],[97,2,97,5],[97,9,97,12],[98,2,98,5],[98,9,98,12],[88,4,88,6],[91,4,91,6],[91,8,91,10],[82,1,82,13],[53,1,53,4],[54,1,54,4],[83,1,83,13],[86,1,86,10],[5,2,5,6],[16,2,16,4],[64,1,64,4],[65,1,65,4],[81,2,81,13]]}
[null,null,null,null,null,null,null,null,"DSH Version",null,{"$f":"Version","v":5.2},null,{"$f":"'Sec. A-C DSH Year Data'!M1","v":"2017-11-01"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"State","v":"Georgia"}]
["A.  General DSH Year Information",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"IOWA",null,{"$f":"Waiver_Response","v":"No"}]
[null,null,"Begin",null,"End",null,null,null,"Workpaper #:",null,null,null,"Reviewer:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ARIZONA "]
["1.","DSH Year:",{"$f":"DSH_Year_Begin","v":"2016-07-01"},null,{"$f":"DSH_Year_End","v":"2017-06-30"},null,null,null,"Examiner:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ARKANSAS"]
[null,null,null,null,null,null,null,null,"Date:"]
["2.","Select Your Facility from the Drop-Down Menu Provided:",{"$f":"HOSPITALNAME","v":"WELLSTAR WEST GEORGIA HOSPITAL      "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALABAMA"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALASKA"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"COLORADO "]
[null,"Identification of cost reports needed to cover the DSH Year:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CONNECTICUT"]
[null,null,"Cost Report",null,"Cost Report"]
[null,null,"Begin Date(s)",null,"End Date(s)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DELAWARE"]
["3.","Cost Report Year 1",{"$f":"FYB_1","v":"2016-07-01"},null,{"$f":"FYE_1","v":"2017-06-30"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DISTRICT OF COLUMBIA"]
["4.","Cost Report Year 2 (if applicable)",{"$f":"FYB_2","v":""},null,{"$f":"FYE_2","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FLORIDA"]
["5.","Cost Report Year 3 (if applicable)",{"$f":"FYB_3","v":""},null,{"$f":"FYE_3","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"GEORGIA"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"HAWAII"]
[null,null,"Data",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MAINE"]
["6.","Medicaid Provider Number:",null,null,{"$f":"McaidNum","v":"000002065A"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MASSACHUSETTS"]
["7.","   Medicaid Subprovider Number 1 (Psychiatric or Rehab):",null,null,{"$f":"SubNum1","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MICHIGAN"]
["8.","   Medicaid Subprovider Number 2 (Psychiatric or Rehab):",null,null,{"$f":"SubNum2","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MINNESOTA"]
["9.","Medicare Provider Number:",null,null,{"$f":"McareNum","v":110016},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MISSISSIPPI"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MISSOURI"]
[]
[]
["B.  DSH OB Qualifying Information"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B30","v":"Questions 1-3, below, should be answered in the accordance with Sec. 1923(d) of the Social Security Act."}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B31","v":"During the DSH Examination Year:"},null,null,null,null,null,null,{"$f":"'Sec. A-C DSH Year Data'!I31","v":"DSH Examination Year (07/01/16 - 06/30/17)"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MONTANA"]
[{"$f":"'Sec. A-C DSH Year Data'!A32","v":1},"Did the hospital have at least two obstetricians who had staff privileges at the hospital that agreed to",null,null,null,null,null,null,{"$f":"OBYes","v":"Yes"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEBRASKA"]
[null,"provide obstetric services to Medicaid-eligible individuals during the DSH year?  (In the case of a hospital",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEVADA"]
[null,"located in a rural area, the term \"obstetrician\" includes any physician with staff privileges at the ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW HAMPSHIRE"]
[null,"hospital to perform nonemergency obstetric procedures.)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW JERSEY"]
[{"$f":"'Sec. A-C DSH Year Data'!A36","v":2},"Was the hospital exempt from the requirement listed under #1 above because the hospital's ",null,null,null,null,null,null,{"$f":"OBExempt1Yes","v":"No"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW MEXICO"]
["","inpatients are predominantly under 18 years of age?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW YORK"]
[{"$f":"'Sec. A-C DSH Year Data'!A38","v":3},"Was the hospital exempt from the requirement listed under #1 above because it did not offer non-",null,null,null,null,null,null,{"$f":"OBExempt2Yes","v":"No"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NORTH CAROLINA"]
[null,"emergency obstetric services to the general population when federal Medicaid DSH regulations",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NORTH DAKOTA"]
[null,"were enacted on December 22, 1987?  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OHIO"]
[]
[{"$f":"'Sec. A-C DSH Year Data'!A42","v":"3a."},"Was the hospital open as of December 22, 1987?",null,null,null,null,null,null,{"$f":"OpenAsOf_Exam","v":"Yes"}]
[]
[{"$f":"'Sec. A-C DSH Year Data'!A44","v":"3b."},"What date did the hospital open?",null,null,null,null,null,null,{"$f":"IF(OR(OpenDate_Exam=\"\",OpenDate_Exam=0),\"\",OpenDate_Exam)","v":"1966-07-01"}]
[]
[null,{"$f":"'Sec. A-C DSH Year Data'!B46","v":"Questions 4-6, below, should be answered in the accordance with Sec. 1923(d) of the Social Security Act."}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B47","v":"During the Interim DSH Payment Year:"},null,null,null,null,null,null,{"$f":"'Sec. A-C DSH Year Data'!I47","v":"DSH Payment Year (07/01/18 - 06/30/19)"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MONTANA"]
[{"$f":"'Sec. A-C DSH Year Data'!A48","v":4},{"$f":"'Sec. A-C DSH Year Data'!B48","v":"Does the hospital have at least two obstetricians who have staff privileges at the hospital who have agreed to"},null,null,null,null,null,null,{"$f":"OBYes_Payment","v":"Yes"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEBRASKA"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B49","v":"provide obstetric services to Medicaid-eligible individuals during the DSH year?  (In the case of a hospital"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEVADA"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B50","v":"located in a rural area, the term \"obstetrician\" includes any physician with staff privileges at the "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW HAMPSHIRE"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B51","v":"hospital to perform nonemergency obstetric procedures.)  "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW JERSEY"]
[]
[null,{"$f":"'Sec. A-C DSH Year Data'!B53","v":"List the Names of the two Obstetricians (or case of rural hospital, Physicians) who have agreed to perform OB services:"}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B54","v":"Bakarich, Michael A., DO"}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B55","v":"Brendell, James J., MD"}]
[]
[{"$f":"'Sec. A-C DSH Year Data'!A57","v":5},{"$f":"'Sec. A-C DSH Year Data'!B57","v":"Is the hospital exempt from the requirement listed under #1 above because the hospital's "},null,null,null,null,null,null,{"$f":"OBExempt1Yes_Payment","v":"No"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW MEXICO"]
["",{"$f":"'Sec. A-C DSH Year Data'!B58","v":"inpatients are predominantly under 18 years of age? "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW YORK"]
[{"$f":"'Sec. A-C DSH Year Data'!A59","v":6},{"$f":"'Sec. A-C DSH Year Data'!B59","v":"Is the hospital exempt from the requirement listed under #1 above because it did not offer non-"},null,null,null,null,null,null,{"$f":"OBExempt2Yes_Payment","v":"No"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NORTH CAROLINA"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B60","v":"emergency obstetric services to the general population when federal Medicaid DSH regulations"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NORTH DAKOTA"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B61","v":"were enacted on December 22, 1987?  "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OHIO"]
[]
[]
["C.  Disclosure of Supplemental Medicaid Payments Received:"]
[]
["1.",{"$f":"CONCATENATE(IF(State=\"Missouri\",\"Other Medicaid Payments for DSH Year \",\"Medicaid Supplemental Payments for DSH Year \"), TEXT(DSH_Year_Begin,\"mm/dd/yyy\"), \" - \", TEXT(DSH_Year_End,\"mm/dd/yyyy\"))","v":"Medicaid Supplemental Payments for DSH Year 07/01/2016 - 06/30/2017"},null,null,null,null,null,null,{"$f":"UPL_Payments","v":1437277}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B67","v":"(Should include UPL and Non-Claim Specific payments paid based on the state fiscal year.  However, DSH payments should NOT be included.)"}]
[]
[]
[]
[]
[]
[]
[]
["Certification:"]
[null,null,null,null,null,null,null,null,"Answer"]
["1.","Was your hospital allowed to retain 100% of the DSH payment it received for this DSH year?",null,null,null,null,null,null,{"$f":"RetainDSHYes","v":"Yes"}]
[null,"Matching the federal share with an IGT/CPE is not a basis for answering this question \"no\".  If your"]
[null,"hospital was not allowed to retain 100% of its DSH payments, please explain what circumstances were"]
[null,"present that prevented the hospital from retaining its payments."]
[]
[null,"Explanation for \"No\" answers:",{"$f":"'Sec. A-C DSH Year Data'!C82","v":0}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B83","v":0}]
[null,{"$f":"'Sec. A-C DSH Year Data'!B84","v":0}]
[]
[null,"The following certification is to be completed by the hospital's CEO or CFO:"]
[null,{"$f":"'Sec. A-C DSH Year Data'!B87","v":"I hereby certify that the information in Sections A, B, C, D, E, F, G, H, I, J, K and L of the DSH Survey files are true and accurate to the best of our ability, and supported by the financial and other records of the hospital.  All Medicaid eligible patients, including those who have private insurance coverage, have been reported on the DSH survey regardless of whether the hospital received payment on the claim.  I understand that this information will be used to determine the Medicaid program's compliance with federal Disproportionate Share Hospital (DSH) eligibility and payments provisions.  Detailed support exists for all amounts reported in the survey.  These records will be retained for a period of not less than 5 years following the due date of the survey, and will be made available for inspection when requested.  "}]
[]
[null,{"$f":"Signature","v":0},null,null,{"$f":"Signature_Title","v":"Chief Financial Officer"},null,null,null,null,null,{"$f":"IF(OR(Signature_Date=\"\",Signature_Date=0),\"\",Signature_Date)","v":""}]
[null,"Hospital CEO or CFO",null,null,"Title",null,null,null,null,null,"Date"]
[]
[null,{"$f":"Signature_Printed_Name","v":"Paul Perrotti"},null,null,{"$f":"Signature_Telephone","v":"706-302-5492"},null,null,null,{"$f":"Signature_EMail","v":"perrottip@wghealth.org"}]
[null,"Hospital CEO or CFO Printed Name",null,null,"Hospital CEO or CFO Telephone Number",null,null,null,"Hospital CEO or CFO E-Mail"]
[]
[null,"Contact Information for individuals authorized to respond to inquiries related to this survey:"]
[]
[null,"Hospital Contact:",null,null,null,null,null,null,"Outside Preparer:"]
[null,"Name",{"$f":"'Sec. A-C DSH Year Data'!C98","v":"Esther Bailes"},null,null,null,null,null,"Name",{"$f":"'Sec. A-C DSH Year Data'!J98","v":"Hal Guthrie"}]
[null,"Title",{"$f":"'Sec. A-C DSH Year Data'!C99","v":"Reimbursement Department MHM"},null,null,null,null,null,"Title:",{"$f":"'Sec. A-C DSH Year Data'!J99","v":"Partner"}]
[null,"Telephone Number",{"$f":"'Sec. A-C DSH Year Data'!C100","v":"(470) 956-4993"},null,null,null,null,null,"Firm Name:",{"$f":"'Sec. A-C DSH Year Data'!J100","v":"Dixon Hughes Goodman LLP"}]
[null,"E-Mail Address",{"$f":"'Sec. A-C DSH Year Data'!C101","v":"esther.bailed@wellstar.org"},null,null,null,null,null,"Telephone Number",{"$f":"'Sec. A-C DSH Year Data'!J101","v":"(404) 575-8947"}]
[null,"Mailing Street Address",{"$f":"'Sec. A-C DSH Year Data'!C102","v":"1514 Vernon Road"},null,null,null,null,null,"E-Mail Address",{"$f":"'Sec. A-C DSH Year Data'!J102","v":"hal.guthrie@dhgllp.com"}]
[null,"Mailing City, State, Zip",{"$f":"'Sec. A-C DSH Year Data'!C103","v":"LaGrange, GA 30240"}]

{"sheet":"Exam Adjustments","index":8,"n_rows":18,"n_cols":11,"rows_kept":18,"cut":false,"hidden":true,"merged":[[6,0,6,9],[2,2,2,7],[0,0,0,9],[5,0,5,10]]}
["Medicaid DSH Survey Adjustments"]
[]
["PROVIDER:",null,{"$f":"'Sec. A-C DSH Year Data ADJ'!C6:G6","v":"WELLSTAR WEST GEORGIA HOSPITAL      "},null,null,null,null,null,"Mcaid Number:",{"$f":"McaidNum_ADJ","v":"000002065A"}]
["FROM:",null,{"$f":"DSH_Year_Begin","v":"2016-07-01"},null,"TO:",{"$f":"DSH_Year_End","v":"2017-06-30"},null,null,"Mcare Number:",{"$f":"McareNum_ADJ","v":110016}]
[]
["Myers and Stauffer DSH Survey Adjustments"]
[]
["Adj. #","Schedule","Line #","Line Description","Column","Column Description","Year","Explanation for Adjustment","Original Amount","Adjustment","Adjusted Total"]
[null,"Certification",1,"Retain 100% of DSH Payment?","1.00","Answer",{"$f":"DSH_Year_End","v":"2017-06-30"},"Adjust answer based on examination results.",{"$f":"RetainDSHYes","v":"Yes"},{"$f":"IF(K9<>I9,K9,0)","v":0},{"$f":"RetainDSHYes_ADJ","v":"Yes"}]
[null,"B - DSH OB Qualifying Information",1,"Have two OBs?","1.00","Answer","2017-06-30","Adjust answer based on examination results.",{"$f":"OBYes","v":"Yes"},0,{"$f":"OBYes_ADJ","v":"Yes"}]
[null,"B - DSH OB Qualifying Information",2,"Exempt to OB due to inpatients under age 18?","1.00","Answer","2017-06-30","Adjust answer based on examination results.",{"$f":"OBExempt1Yes","v":"No"},0,{"$f":"OBExempt1Yes_ADJ","v":"No"}]
[null,"B - DSH OB Qualifying Information",3,"Exempt to OB due to not offering OB on 12/22/87?","1.00","Answer","2017-06-30","Adjust answer based on examination results.",{"$f":"OBExempt2Yes","v":"No"},0,{"$f":"OBExempt2Yes_ADJ","v":"No"}]
[null,"B - DSH OB Qualifying Information","3a","Was the hospital open as of 12/22/87?","1.00","Answer","2017-06-30","Adjust answer based on review results.",{"$f":"OpenAsOf_Exam","v":"Yes"},{"$f":"IF(K13<>I13,K13,0)","v":0},{"$f":"OpenAsOf_Exam_ADJ","v":"Yes"}]
[null,"B - DSH OB Qualifying Information","3b","Year Hospital opened?","1.00","Answer","2017-06-30","Adjust answer based on review results.",{"$f":"IF(OR(OpenDate_Exam=\"\",OpenDate_Exam=0),\"\",OpenDate_Exam)","v":"1966-07-01"},{"$f":"IF(K14<>I14,K14,0)","v":"00:00:00"},{"$f":"IF(OpenDate_Exam_ADJ=\"\",\"\",OpenDate_Exam_ADJ)","v":"1966-07-01"}]
[null,"B - DSH OB Qualifying Information",4,"Have two OBs?","1.00","Answer",{"$f":"DSH_Payment_Year_End","v":"2019-06-30"},"Adjust answer based on review results.",{"$f":"OBYes_Payment","v":"Yes"},0,{"$f":"OBYes_Payment_ADJ","v":"Yes"}]
[null,"B - DSH OB Qualifying Information",5,"Exempt to OB due to inpatients under age 18?","1.00","Answer",{"$f":"DSH_Payment_Year_End","v":"2019-06-30"},"Adjust answer based on review results.",{"$f":"OBExempt1Yes_Payment","v":"No"},0,{"$f":"OBExempt1Yes_Payment_ADJ","v":"No"}]
[null,"B - DSH OB Qualifying Information",6,"Exempt to OB due to not offering OB on 12/22/87?","1.00","Answer",{"$f":"DSH_Payment_Year_End","v":"2019-06-30"},"Adjust answer based on review results.",{"$f":"OBExempt2Yes_Payment","v":"No"},0,{"$f":"OBExempt2Yes_Payment_ADJ","v":"No"}]
[null,"C - Disclosure of Other M'Caid Payments",1,"Medicaid Supplemental Payments for DSH Year","1.00","Answer",{"$f":"DSH_Year_End","v":"2017-06-30"},"Adjust to state's report.",{"$f":"UPL_Payments","v":1437277},{"$f":"K18-I18","v":0},{"$f":"UPL_Payments_ADJ","v":1437277}]