CHECKLIST FOR FILING WYOMING MEDICAID FINANCIAL REPORT FOR NURSING HOMES

(Please use a separate checklist for each cost report)

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Provider NameProvider #

Contact Person______Phone #______

Period of Report: From______to ______

Check One

Electronic versions of the following items are requested, if available.
Required Items (Must be submitted with your filing) / Prev.
(Included)Sub-
YesNoN/A*mitted
1.CompletedWyoming Medicaid Financial Report for Nursing Homes (Excel format preferred) / ___
2.Copy of the ECR file as submitted to Medicare (electronic cost report, SN or EC format) / ______
3.Signed copy of page one of both the Wyoming Medicaid Financial Report for Nursing Homes and of the Medicare cost report (PDF accepted)
4.Working Trial Balance (WTB) used to prepare the cost report and any supporting schedules used to prepare cost report (Excel format preferred) / ___
5. If the source WTB in #4 was not generated directly from your accounting software, a system generated WTB is also required in support of the information in #4 above / ___
6.Completed Cost Report Checklist
Additional Items (Should be submitted with your filing)
1.Annual audit, review, or compilation statement prepared by an independent accountant
2.Straight-line depreciation schedule
3.Lease/Loan agreements and Amortization Schedules (if not previously submitted)
4.Home Office Cost Statement
5.Management company contract and if a related party, the allocation basis and schedule of management company costs
6.Copy of the Nursing Home Medicare PS&R report for the reporting period.

Please provide an explanation for the items indicated to be No or N/A (Not Applicable) on the attached sheet.

* N/A means this information does not exist for this facility.

EXPLANATION OF CHECKLIST FOR FILING

WYOMING MEDICAIDFINANCIAL REPORT FOR NURSING HOMES

In order to facilitate the desk review process, the checklist information and materials are requested at the time of cost report filing. Please provide a brief explanation below of the items checked No or N/A:

Item Marked

No or N/AExplanation

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Checklist 0114.doc