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 Virginia Administrative Code (Last Updated: January 10, 2017)
 Title 12. Health
 Agency 30. Department of Medical Assistance Services
 Chapter 90. Methods and Standards for Establishing Payment Rates for Long-Term Care

  Appendix 9998. FORMS (12VAC30-90)  

Latest version.

  • Certificate of Medical Necessity -- Durable Medical Equipment and Supplies, DMAS-352 (rev. 8/95).

    Cost Reporting Forms for Nursing Facility with Multiple Level of Care or Hospital-Based Nursing Facilities (RUGS 1090 Series).

    Facility Description, Schedule A-1 (eff. 7/93).

    Computation of Base Operating Costs, Schedule A-3 (eff. 7/93).

    Computation of Direct Patient Care Nursing Service Costs, Schedule A-4 (rev. 7/00).

    Computation of Title XIX Direct Patient Care Ancillary Service Costs, Schedule C (eff. 7/93).

    Statement of Compensation of Owners, Schedule E (eff. 10/90).

    Statement of Compensation of Administrators and/or Assistant Administrators, Schedule F (eff. 10/90).

    Computation of Title XIX (Medicaid) Base Costs and Prospective Rate/ RUGS, Schedule H (rev. 7/00).

    Calculation of Medical Service Reimbursement Settlement, Schedule J (rev. 7/00).

    Calculation of NATCEPs Reimbursement Settlement, Schedule J-1 (eff. 7/92).

    Calculation of Criminal Record Check Costs Reimbursement, Schedule J-2 (eff. 7/93).

    Debt and Interest Expense, Schedule K (eff. 7/93).

    Nurse Aide Training and Competency Evaluation Program Costs and Competency Evaluation Programs (NATCEPs), Schedule N (eff. 10/90).

    Compilation of Nursing Salaries, Benefits and Hours, Schedule S-1 (eff. 7/00).

    Cost Reporting Forms for Nursing Facility (Single Level of Care) (RUGS 1090 Series).

    Facility Description and Statistical Data, Schedule A (eff. 10/90).

    Certification by Officer or Administrator of Provider, Schedule A-2 (eff. 10/90).

    Reclassification and Adjustment of Trial Balance of Expenses, Schedule B (not dated).

    Reclassifications, Schedule B-1 (not dated).

    Analysis of Administrative and General -- Other, Schedule B-2 (eff. 10/90).

    Adjustment to Expenses, Schedule B-4 (eff. 10/90).

    Cost Allocation -- Employee Benefits, Schedule B-5, Part I (eff. 7/93).

    Cost Allocation -- Employee Benefits Statistical Basis, Schedule B-5, Part II (eff. 7/93).

    Computation of Title XIX Direct Patient Care Ancillary Service Costs, Schedule C (eff. 7/93).

    Statement of Cost of Services from Related Organizations, Schedule D (eff. 10/90).

    Statement of Compensation of Owners, Schedule E (eff. 10/90).

    Statement of Compensation of Administrators and/or Assistant Administrators, Schedule F (eff. 10/90).

    Balance Sheet, Schedule G (not dated).

    Statement of Patient Revenues, Schedule G-1 (eff. 10/90).

    Statement of Operations, Schedule G-2 (eff. 10/90).

    Computation of Title XIX (Medicaid) Base Costs and Prospective Rate (RUGs), Schedule H (rev. 7/00).

    Calculation of Medical Service Reimbursement Settlement, Schedule J (rev. 7/00).

    Calculation of NATCEPs Reimbursement Settlement, Schedule J-1 (eff. 7/92).

    Calculation of Criminal Record Check Costs Reimbursement, Schedule J-2 (eff. 7/93).

    Debt and Interest Expense, Schedule K (eff. 7/93).

    Limitation on Federal Participation for Capital Expenditures Questionnaire, Schedule L (eff. 10/90).

    Nurse Aide Training and Competency Evaluation Program Costs and Competency Evaluation Programs (NATCEPs), Schedule N (eff. 10/90).

    Compilation of Nursing Salaries, Benefits and Hours, Schedule S-1 (eff. 7/00).

    Computation of Specialized Care Base Operating Costs, Pediatric, Schedule SC-3 (rev. 7/98).

    Computation of Specialized Care Direct Patient Care Nursing Service Costs, Pediatric, Schedule SC-4 (rev. 7/98).

    Computation of Specialized Care Kinetic Therapy Ancillary Service Costs, Pediatric, Schedule SC-5 (rev. 7/98).

    Computation of Specialized Care Direct Patient Care Ancillary Service Costs, Pediatric, Schedule SC-6 (rev. 7/98).

    Computation of Specialized Care Base Costs and Prospective Rate, Pediatric, Schedule SC-7P (rev. 7/00).

    Computation of Prospective Specialized Care Operating Efficiency Incentive Rates, Pediatric, Schedule SC-8P (rev. 7/98).

    Part I Computation of Nursing Facility Specialized Care Settlement, Part II Analysis of Nursing Facility Specialized Care Interim Payments for Title XIX Services, Part III Analysis of Quarterly Title XIX (Medicaid) Specialized Care Patient Days, Pediatric, Schedule SC-9 (rev. 7/00).

    Computation of Specialized Care Base Operating Costs, Adult, Schedule SC-3 (rev. 7/98).

    Computation of Specialized Care Direct Patient Care Nursing Service Costs, Adult, Schedule SC-4 (rev. 7/98).

    Computation of Specialized Care Kinetic Therapy Ancillary Service Costs, Adult, Schedule SC-5 (rev. 7/98).

    Computation of Specialized Care Direct Patient Care Ancillary Service Costs, Adult, Schedule SC-6 (rev. 7/98).

    Computation of Specialized Care Base Costs and Prospective Rate, Adult, Schedule SC-7 (rev. 7/98).

    Computation of Prospective Specialized Care Operating Efficiency Incentive Rates, Adult, Schedule SC-8 (rev. 7/98).

    Part I Computation of Nursing Facility Specialized Care Settlement, Part II Analysis of Nursing Facility Specialized Care Interim Payments for Title XIX Services, Part III Analysis of Quarterly Title XIX (Medicaid) Specialized Care Patient Days, Adult, Schedule SC-9 (rev. 1/00).

    Cost Reporting Forms for Nursing Facilities with Other Long-Term Care Services, HCPA-2540-96 Worksheets (eff. 7/96).