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DocuSign Envelope ID:08FFF9DF-E68C-4766-AOEF-6FB69555BF48 <br /> 111111111111111 <br /> � Custom Reporting Work Order <br /> mm <br /> Date: September 30, 2016 <br /> Project: Medicaid Cost Report <br /> Contact: Felicia Williams <br /> ZOLL Orange County NC <br /> 11802 Ridge Parkway Suite 400 510 Meadowlands Dr <br /> Broomfield, CO 80021 Hillsborough, NC 27278 <br /> (303) 801-1714 Fax: (303) 379-3851 <br /> Project Objectives: <br /> The primary goal of this project is to generate the Medicaid Cost Report at the click of a button. <br /> Functional Specification <br /> The design of this project will be divided into the following modules: <br /> One Report File: <br /> DETAIL SECTION: <br /> Grouped by: <br /> • Run Number <br /> Columns for: <br /> • Run Number(Year-Run Number) <br /> • Date of Service <br /> • Primary Payor <br /> • Current Payor <br /> • Payor Category(as defined below) <br /> o Dually eligible—they have Medicare(or Medicare replacement plan)+Medicaid <br /> o Medicaid—just Medicaid <br /> o Medicare—Medicare is primary payor <br /> o Others—private pay and other commercial insurance <br /> • IncidentID <br /> SUMMARY SECTION: <br /> A Cross Tab style summary <br /> Rows for: <br /> • Payor Category(As defined above) <br /> • Grand Total for each column <br /> Summary columns for: <br /> • Subtotal by Call Type <br /> • Grand Total for each Payor Category <br /> 01 L.. I"eke 1 of 3 eolpul kli�k <br />