User Guide for the Cost Data Collection Instrument

Revenues  CMS wants to know all  sources of ground ambulance revenue. 

Total Revenue 

 You will need to provide your total revenue from all sources 

Billing 

 You will be asked if you can report revenue from the payers in the table below.  If the answer is no, you  will be asked to report the approximate share of revenue from billed transports for all payers combined.   You will be asked how “often” your agency tried to bill these payers.  Your options will be:  o Never  o Sometimes 

o Usually  o Always  

How often did  your agency bill? 

Did your agency  receive revenue? 

Is cost‐sharing  included in total? 

Payer 

Amount 

Medicare  Medicare Advantage  Medicaid  Medicaid Managed Care   TRICARE  Veterans Health Admin.  Commercial Insurance  Workers’ Compensation   Patient self‐pay 

Finally, you will be asked if your agency received any revenues from any of the sources listed in the following  table.  In this section, only revenue specifically related to ground ambulance services should be reported.

© 2020 Cornerstone Adminisystems, Inc.                                                                          

       Page | 25 

23 Old Depot Road, New Cumberland, PA 17070