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Type; Ambulance Cost Settlement. <br />ATTACHMENT' A <br />Statement of Status For Settlement <br />Status: <br />Date: 06/1.6/14 FYE; 06/30/13 <br />Provider Name: 29 QN COUNTY EME8,2;BNCS SERVICES <br />--------------------- <br />Provider Ninnbe�rr 3`40692�g _�--------------------- Npi 1629178629 <br />DMA C.S. Accounit 11 56600032.7 <br />As Fi.led. <br />1. Cost in Excess of Reimbursement $ 670,1209,00 <br />2. State & 'Local Portion Not to be Reimbursed $ 231,585,00 <br />FIAP Used 17,6545 <br />3, ADJUSTMENTS <br />10'1';• Withholding from Tentative Settelement <br />4. Gross Amount Due The Medicaid Program <br />5, Gross Amount Due The Provider <br />(F deral Portion to be Reimbursed) <br />6, COST SETTL'EMEN'T" TRANSACTION HiS"E'47'RY <br />Number of <br />Transactions hate <br />--------- -- / <br />----------------------- ------------ <br />4- <br />(2) <br />(3) <br />(4) <br />(5) <br />(6) <br />(7') <br />t11) <br />Q1.2) <br />Q0.3) <br />(14) <br />(9.5) <br />(16) <br />231,585.00 <br />$ 4.3, 870,'00 <br />07 004 <br />$ 0.00 <br />$ 394,834'..00 <br />Item Number <br />------------------ <br />1306T55403AP <br />7, Bal'anc'e Due To / (Promo) The Medicaid Program <br />Financial DMA -4088a Operations Attention T091NS Controllers Office: Payables are <br />federal share only and must be grossed tip, <br />Receivables are whole dollar amounts and are not <br />grassed up, <br />12 <br />(Tentative Settlement) <br />Amount Division <br />(394,834.00) roa' <br />C <br />L <br />2 <br />-___ -- <br />$ (394,834,270) �edead arSa orn oeniv <br />Approved <br />Date . <br />Adjustment. <br />'tentative. <br />Settle.cment. <br />Amour¢nt. <br />$ <br />670,285.00 <br />0.00 <br />$ <br />231,585.00 <br />$ <br />07 04 <br />--------------------- <br />$ <br />231,585,00 <br />------------------ <br />$,.. <br />0.00 <br />43,8 70,00 <br />$' <br />0,00 <br />0.00 <br />0.46 <br />$ <br />0,00 <br />$ <br />0,02) <br />$ <br />394,834.00 <br />$ <br />0,0'0 <br />Amount Division <br />(394,834.00) roa' <br />C <br />L <br />2 <br />-___ -- <br />$ (394,834,270) �edead arSa orn oeniv <br />Approved <br />Date . <br />