NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT BASIS OF ALLOCATION SCHEDULE Schedule A-5 Center Name: DHS License Number: DO NOT change any preprinted Molina Number: wording on this schedule. Cost Report F.Y.E.: A B C D E Percent Percent Code Basis Applicable Applicable to Total Applicable Applicable to to PMDC Non-PMDC to PMDC Non-PMDC 1 DEFAULT (100% Day Care) 2 Recipient Days 3 Accumulated Costs 4 Number of Meals Served Square Feet 5 Other: 6 Other: 7 Other: 8 9 Other: 10 Other: 11 Other: 12 Other: Other: 13 Other: 14 Other: 15 16 Other: 17 Other: 18 Other: 19 Other: Other: 20 Other: 21 Other: 22 Other: 23 24 Other: 25 Other: 26 Other: The following allocation bases are acceptable. Only one allocation base may be used per line. This form MUST BE completed for ALL applicable lines. Use of any other basis MUST BE accompanied by the letter approving the use of the Department’s other basis. The letter is valid for a one-year period only. Use the default (0) for all 100% Pediatric Medical Day Department’s Care Center lines. Cost Center Allocation Basis 1. General Fringe Benefits, Administration and Other Recipient Days or Accumulated Costs Administrative 2. Dietary, Food Recipient Days or Number of Meals Served 3. Housekeeping, Other General Services, ALL Property Square Feet Operating and Fixed Properly Cost Centers 4. Nursing, All Special Care Cost Centers Recipient Days or Actual Cost
NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT BASIS OF ALLOCATION SCHEDULE Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: Schedule A-5 DO NOT change any preprinted wording on this schedule. Code Basis A B C D E Applicable to PMDC Applicable to Non-PMDC Total Percent Applicable to PMDC Percent Applicable to Non-PMDC 1 DEFAULT (100% Day Care) 2 Recipient Days 3 Accumulated Costs 4 Number of Meals Served 5 Square Feet 6 Other: 7 Other: 8 Other: 9 Other: 10 Other: 11 Other: 12 Other: 13 Other: 14 Other: 15 Other: 16 Other: 17 Other: 18 Other: 19 Other: 20 Other: 21 Other: 22 Other: 23 Other: 24 Other: 25 Other: 26 Other: The following allocation bases are acceptable. Only one allocation base may be used per line. This form MUST BE completed for ALL applicable lines. Use of any other basis MUST BE accompanied by the Department’s letter approving the use of the other basis. The Department’s letter is valid for a one-year period only. Use the default (0) for all 100% Pediatric Medical Day Care Center lines. Cost Center Allocation Basis 1. General Fringe Benefits, Administration and Other Administrative Recipient Days or Accumulated Costs 2. Dietary, Food Recipient Days or Number of Meals Served 3. Housekeeping, Other General Services, ALL Property Operating and Fixed Properly Cost Centers Square Feet 4. Nursing, All Special Care Cost Centers Recipient Days or Actual Cost
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