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[null,"DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,"STATE OF WISCONSIN"]
[null,"Division of Medicaid Services",null,null,null,null,null,null,"Administrative Code: WI SPA 17-0010"]
[null,"F-02656 (01/2021)"]
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[null,"Federally Qualified Health Center Cost Report"]
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[null,"Basic FQHC Information"]
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[null,"FQHC Address Information"]
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[null,"FQHC Cost Information"]
[null,"Worksheet ","Description",null,"Information Required from FQHCs"]
[null,null,"Trial Balance",null,"All cost information including direct cost, indirect cost, non-reimbursable cost, depreciation and overhead. Cost within each category can be allocated to outstationed enrollment. "]
[null,null,"Clinician Time and Encounters",null,"Hours worked and encounters provided. "]
[null,null,"Individual Contractor Clinician Time ",null,"All contractor hours at FQHC sites and within the network."]
[null,null,"Revenue",null,"All charges, payments and encounters and dollars received by managed care entities."]
[null,null,"Final Review and Edits",null,"Responses to preliminary desk review checks highlighting all data entered which falls outside of the expected range. "]
[null,null,"Reimbursement Calculation",null,"Review and Certification of all reported cost information. "]
[]
[null,"Optional Comment Section for Informational Purposes Only (for upcoming projects or special circumstances that DHS should be aware of)"]

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[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},null,"Hours rendered at FQHC",null,null,"Hours rendered outside of FQHC "]
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[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"Payments from Medicare Part C to FQHC for crossovers during the reporting period",null,null,null,{"$f":"'Worksheet C'!H19:I19","v":{"$error":"#VALUE!"}}]
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[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"Payments from Medicaid fee-for-service to FQHC during the reporting period",null,null,null,{"$f":"'Worksheet C'!H21:I21","v":{"$error":"#VALUE!"}}]
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[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"Payments by or due from other third parties (insurance, HMOs) to FQHC for Medicaid members",null,null,null,{"$f":"'Worksheet C'!H24:I24","v":{"$error":"#VALUE!"}}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"Copayments from Medicaid members during this reporting period",null,null,null,{"$f":"'Worksheet C'!H25:I25","v":{"$error":"#VALUE!"}}]
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[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},null,"Total Medicaid Encounters","Total Dollar Amount Received "]
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[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"Cost Category"]
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[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"2. Non-reimbursable FQHC costs excluding overhead (Worksheet A, Total Non-Reimbursable)",{"$f":"'Summary & Certification'!C15","v":"WS A Overhead Grand Total "}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"3. Cost of all services excluding overhead (sum of Line 1 and Line 2)",{"$f":"'Summary & Certification'!C16","v":0}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"4. Percentage of non-reimbursable FQHC costs (Line 2 divided by Line 3)",{"$f":"'Summary & Certification'!C17","v":"WS A (Total Non-Reimbursable Costs)"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"5. Total overhead (Worksheet A, Total Overhead)",{"$f":"'Summary & Certification'!C18","v":"WS A (Find Under Non-Reimbursable Costs)"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"6. Total cost of all services and overhead (sum of Line 3 and Line 5)",{"$f":"'Summary & Certification'!C19","v":"Line 3 - Line 4"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"7. Maximum allowable overhead (Line 6 multiplied by 30%)",{"$f":"'Summary & Certification'!C20","v":"Line 5 / (Line 1 + Line 5)"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"8. Overhead allowed (lesser of Line 5 or Line 7)",{"$f":"'Summary & Certification'!C21","v":"Line 2 * Line 6"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"9. Overhead applicable to non-reimbursable FQHC costs (Line 4 multiplied by Line 8)",{"$f":"'Summary & Certification'!C22","v":"Line 2 - Line 7"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"10. Overhead applicable to FQHC services (Line 8 less Line 9)",{"$f":"'Summary & Certification'!C23","v":"Line 1 * 50%"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"11. Total cost of FQHC services (sum of Line 1 and Line 10)",{"$f":"'Summary & Certification'!C24","v":"Minimum of Line 8 and Line 9"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"12.  Total cost of FQHC services (Line 11)",{"$f":"'Summary & Certification'!C26","v":"Line 1 + Line 10"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"13.  Total FQHC adjusted encounters (Worksheet B, Total Encounters)",{"$f":"'Summary & Certification'!C27","v":0}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"14.  FQHC rate per encounter (Line 12 divided by Line 13)",{"$f":"'Summary & Certification'!C28","v":"Line 12"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"15.  FQHC rate per encounter (Line 14)",{"$f":"'Summary & Certification'!C30","v":"Line 13 / Line 14"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"16. Total Medicaid Encounters (Worksheet B, Contract and FTE Total Medicaid)",{"$f":"'Summary & Certification'!C31","v":0}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"17. Medicaid reasonable costs including crossovers (Line 15 multiplied by Line 16)",{"$f":"'Summary & Certification'!C32","v":"Line 15"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"18. Outstationed enrollment expenses (Worksheet 5; Line 30)",{"$f":"'Summary & Certification'!C33","v":"WS B C86 + WS B G86"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"19. Total Costs",{"$f":"'Summary & Certification'!C34","v":"Line 16 * Line 17"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"20. Total Encounter Rate (Line 19 divided by Line 16)",{"$f":"'Summary & Certification'!C35","v":"Line 18 / Line 17"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"21. Behavioral Encounter Rate ",{"$f":"'Summary & Certification'!C36","v":"Medicare Economic Index"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"22. Dental Encounter Rate",{"$f":"'Summary & Certification'!C37","v":"Line 19 * (1+ Line 20)"}]
[{"$f":"'FQHC Cost Report Overview'!$B$15","v":"Please Select"},"23. Medical Encounter Rate ",{"$f":"'Summary & Certification'!C38","v":0}]

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[null,"DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,null,null,"STATE OF WISCONSIN"]
[null,"Division of Medicaid Services",null,null,null,null,null,null,null,null,"Administrative Code: WI SPA 17-0010"]
[null,"F-02656 (01/2021)"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DR2"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DR3"]
[null,"Federally Qualified Health Center Cost Report",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DR4"]
[null,{"$f":"'FQHC Cost Report Overview'!B8","v":"Annual FY 1900 Medicaid Cost Report "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DR5"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DR 8 and 9"]
[null,"Direct Medical Costs"]
[null,"Primary Provider ","Compensation","Fringe Benefits","Purchased & Contract Services","Direct Service Non-Personnel","Total (Columns C+D+E+F)","Reclassifications","Adjustments","Adjusted Expenses (Columns G+H+I)","Notes (Required if Other is selected)",null,null,null,null,null,null,"Selected Type",null,null,"Missing Salary or Purchased","Comp Fringe","Bene >75","Missing Fringe","Other Costs Notes",null,null,null,"Cost/FTE","BLS RangeLower","BLS Higher","Low","High"]
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[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B29,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G29/'Worksheet B'!K33, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B29,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B29,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B30,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G30/'Worksheet B'!K34, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B30,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B30,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B31,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G31/'Worksheet B'!K35, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B31,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B31,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B32,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G32/'Worksheet B'!K36, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B32,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B32,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B33,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G33/'Worksheet B'!K37, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B33,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B33,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C34:F34)","v":0},null,null,{"$f":"SUM(G34:I34)","v":0},null,null,null,null,{"$f":"VLOOKUP(B34,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G34/'Worksheet B'!K38, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B34,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B34,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B35,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G35/'Worksheet B'!K39, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B35,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B35,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B36,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G36/'Worksheet B'!K40, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B36,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B36,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B37,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G37/'Worksheet B'!K41, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B37,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B37,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B38,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G38/'Worksheet B'!K42, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B38,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B38,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B39,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G39/'Worksheet B'!K43, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B39,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B39,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B40,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G40/'Worksheet B'!K44, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B40,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B40,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B41,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G41/'Worksheet B'!K45, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B41,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B41,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B42,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,null,null,null,{"$f":"IFERROR(G42/'Worksheet B'!K46, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B42,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B42,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,{"$f":"VLOOKUP(B43,'Dropdown Menus - Hidden'!$E$1:$F$25,2,FALSE)","v":"Type of Service"},1,null,0,0,0,"","","",0,0,"Missing ",null,null,{"$f":"IFERROR(G43/'Worksheet B'!K47, \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B43,'Dropdown Menus - Hidden'!$J$2:$K$23, 2, FALSE), \"N/A\")","v":"N/A"},{"$f":"IFERROR(VLOOKUP(B43,'Dropdown Menus - Hidden'!$J$2:$L$23, 3, FALSE), \"N/A\")","v":"N/A"},0,0]
[null,"Behavioral Health Total",{"$f":"SUMIF($O14:$O43,\"Behavioral Health\",C14:C43)","v":0},0,0,0,0,0,0,0,0,null,null,null,null,{"$f":"SUBTOTAL(109,P14:P43)","v":30},null,{"$f":"SUM(R14:R43)","v":0},{"$f":"SUM(S14:S43)","v":0},{"$f":"SUM(T14:T43)","v":0},{"$f":"SUM(U14:U43)","v":0},null,{"$f":"SUM(W14:W43)","v":0},{"$f":"SUM(X14:X43)","v":0},{"$f":"SUM(Y15:Y43)","v":0},{"$f":"IFERROR(SUM(U44+X44),0)","v":0},null,null,null,null,null,{"$f":"SUM(AF14:AF43)","v":0},{"$f":"SUM(AG14:AG43)","v":0}]
[null,"Dental Total",{"$f":"SUMIF($O14:$O43,\"Dental\",C14:C43)","v":0},0,0,0,0,0,0,0,0]
[null,"Medical Total",{"$f":"SUMIF($O14:$O43,\"Medical\",C14:C43)","v":0},0,0,0,0,0,0,0,0,null,null,null,null,"Reclassification net 0"]
[null,"Total",{"$f":"SUM(C14:C43)","v":0},0,0,0,0,0,0,0,null,null,null,null,null,{"$f":"IF(ROUND(H47+H129+H102+H83,1)<>0, 1,0)","v":0}]
[]
[]
[]
[null,"Indirect Costs"]
[null,"Indirect Cost Category","Compensation","Fringe Benefits","Purchased & Contract Services","Indirect Service Non-Personnel","Total (Columns C+D+E+F)","Reclassifications","Adjustments","Adjusted Expenses (Columns G+H+I)","Notes (Required if Other is selected)",null,null,null,null,null,null,"Selected Type",null,null,"Missing Salary or Purchased","Comp Fringe","Bene >75","Missing Fringe","Other Costs Notes"]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C53:F53)","v":0},null,null,{"$f":"SUM(G53:I53)","v":0},null,null,null,null,{"$f":"IF(OR(B53=\"Other (Dental Expenses)\",B53=\"Other (Medical Expenses)\",B53=\"Other (Behavioral Health Expenses)\"),1,0)","v":0},1,null,{"$f":"IF(B53= \"Please Select\", 0,1)","v":0},{"$f":"IF(R53=1,IF(C53<>0, 1, 0),0)","v":0},{"$f":"IF(R53=1,IF(E53<>0, 1, 0),0)","v":0},{"$f":"IF(AND( SUM(S53:T53)<0.99, R53=1), 1,\"\")","v":""},{"$f":"IF(C53>0.01,IFERROR(D53/C53,0), \"\")","v":""},{"$f":"IF(AND(V53>0.75, V53<>\"\"),1, \"\")","v":""},{"$f":"IF(V53=0, 1, 0)","v":0},{"$f":"IF(AND(B53=\"Other\",K53=\"\"), 1,0)","v":0}]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C54:F54)","v":0},null,null,{"$f":"SUM(G54:I54)","v":0},null,null,null,null,0,1,null,0,0,0,{"$f":"IF(AND( SUM(S54:T54)<0.99, R54=1), 1,\"\")","v":""},"",{"$f":"IF(AND(V54>0.75, V54<>\"\"),1, \"\")","v":""},{"$f":"IF(V54=0, 1, 0)","v":0},0]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C55:F55)","v":0},null,null,{"$f":"SUM(G55:I55)","v":0},null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,{"$f":"IF(AND( SUM(S62:T62)<0.99, R62=1), 1,\"\")","v":""},"",{"$f":"IF(AND(V62>0.75, V62<>\"\"),1, \"\")","v":""},0,0]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C63:F63)","v":0},null,null,{"$f":"SUM(G63:I63)","v":0},null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C64:F64)","v":0},null,null,{"$f":"SUM(G64:I64)","v":0},null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C73:F73)","v":0},null,null,{"$f":"SUM(G73:I73)","v":0},null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C74:F74)","v":0},null,null,{"$f":"SUM(G74:I74)","v":0},null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,0,1,null,0,0,0,"","","",0,0,"Missing"]
[null,"Total",{"$f":"SUM(C53:C82)","v":0},0,0,0,0,0,0,0]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUBTOTAL(109,P53:P82)","v":30},null,{"$f":"SUM(R53:R82)","v":0},{"$f":"SUM(S53:S82)","v":0},{"$f":"SUM(T53:T82)","v":0},{"$f":"SUM(U53:U83)","v":0},null,{"$f":"SUM(W53:W83)","v":0},{"$f":"SUM(X53:X82)","v":0},{"$f":"SUM(Y53:Y82)","v":0},{"$f":"IFERROR(SUM(U84+X84),0)","v":0}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Reclassification net 0"]
[null,"Non-Reimbursable Costs",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ROUND(H47+H129+H102+H83,1)<>0, 1,0)","v":0}]
[null,"Cost Category","Compensation","Fringe Benefits","Purchased & Contract Services","Non Reimbursable Non-Personnel","Total (Columns C+D+E+F)","Reclassifications","Adjustments","Adjusted Expenses (Columns G+H+I)","Notes (Required if Other is selected)",null,null,null,null,null,null,"Selected Type",null,null,"Missing Salary or Purchased","Comp Fringe","Bene >75","Missing Fringe",null,"Select cost category","Other Costs Notes"]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C89:F89)","v":0},null,null,{"$f":"SUM(G89:I89)","v":0},null,null,null,null,null,1,null,{"$f":"IF(B89= \"Please Select\", 0,1)","v":0},{"$f":"IF(R89=1,IF(C89<>0, 1, 0),0)","v":0},{"$f":"IF(R89=1,IF(E89<>0, 1, 0),0)","v":0},{"$f":"IF(AND( SUM(S89:T89)<0.99, R89=1), 1,\"\")","v":""},{"$f":"IF(C89>0.01,IFERROR(D89/C89,0), \"\")","v":""},{"$f":"IF(AND(V89>0.75, V89<>\"\"),1, \"\")","v":""},{"$f":"IF(V89=0, 1, 0)","v":0},{"$f":"SUM(U89:X89)","v":0},{"$f":"IF(AND(Y89>0.99,B89=\"Please Select\"), 1,\"\")","v":""},{"$f":"IF(AND(B89=\"Other Non-Reimbursable\",K89=\"\"), 1,0)","v":0}]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C90:F90)","v":0},null,null,{"$f":"SUM(G90:I90)","v":0},null,null,null,null,null,1,null,0,0,0,{"$f":"IF(AND( SUM(S90:T90)<0.99, R90=1), 1,\"\")","v":""},"",{"$f":"IF(AND(V90>0.75, V90<>\"\"),1, \"\")","v":""},{"$f":"IF(V90=0, 1, 0)","v":0},{"$f":"SUM(U90:X90)","v":0},"",0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,null,1,null,0,0,0,"","","",0,0,"",0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,null,1,null,0,0,0,"","","",0,0,"",0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,null,1,null,0,0,0,"","","",0,0,"",0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,null,1,null,0,0,0,"","","",0,0,"",0]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C95:F95)","v":0},null,null,{"$f":"SUM(G95:I95)","v":0},null,null,null,null,null,1,null,0,0,0,"","","",0,0,"",0]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C96:F96)","v":0},null,null,{"$f":"SUM(G96:I96)","v":0},null,null,null,null,null,1,null,0,0,0,{"$f":"IF(AND( SUM(S96:T96)<0.99, R96=1), 1,\"\")","v":""},"","",0,0,"",0]
[null,"Please Select",null,null,null,null,0,null,null,{"$f":"SUM(G97:I97)","v":0},null,null,null,null,null,1,null,0,0,0,"","","",0,0,"",0]
[null,"Please Select",null,null,null,null,{"$f":"SUM(C98:F98)","v":0},null,null,{"$f":"SUM(G98:I98)","v":0},null,null,null,null,null,1,null,0,0,0,{"$f":"IF(AND( SUM(S98:T98)<0.99, R98=1), 1,\"\")","v":""},"",{"$f":"IF(AND(V98>0.75, V98<>\"\"),1, \"\")","v":""},{"$f":"IF(V98=0, 1, 0)","v":0},{"$f":"SUM(U98:X98)","v":0},"",0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,null,1,null,0,0,0,"","","",0,0,"",0]
[null,"Please Select",null,null,null,null,0,null,null,{"$f":"SUM(G100:I100)","v":0},null,null,null,null,null,1,null,0,0,0,"","","",0,0,"",0]
[null,"Please Select",null,null,null,null,0,null,null,0,null,null,null,null,null,1,null,0,0,0,{"$f":"IF(AND( SUM(S101:T101)<0.99, R101=1), 1,\"\")","v":""},"","",0,0,"",0,"Missing"]
[null,"Total",{"$f":"SUM(C89:C101)","v":0},0,0,0,0,0,0,0]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Reclassification net 0",{"$f":"SUBTOTAL(109,P89:P101)","v":13},null,{"$f":"SUM(R89:R101)","v":0},{"$f":"SUM(S89:S101)","v":0},{"$f":"SUM(T89:T101)","v":0},{"$f":"SUM(U89:U102)","v":0},null,{"$f":"SUM(W89:W102)","v":0},{"$f":"SUM(X89:X101)","v":0},null,{"$f":"SUM(Z89:Z101)","v":0},{"$f":"SUM(AA89:AA101)","v":0},{"$f":"IFERROR(SUM(U103+Z103),0)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ROUND(H47+H129+H102+H83,1)<>0, 1,0)","v":0}]
[]
[null,"Overhead Costs"]
[null,"Cost Category","Compensation","Fringe Benefits","Purchased & Contract Services","Overhead \nNon-Personnel","Total (Columns C+D+E+F)","Reclassifications","Adjustments","Adjusted Expenses (Columns G+H+I)","Notes (Required if Other is selected)",null,null,null,null,null,null,"Selected Type",null,null,"Missing Salary or Purchased","Comp Fringe","Bene >75","Missing Fringe","Other Costs Notes"]
[null,"Accounting",null,null,null,null,{"$f":"SUM(C108:F108)","v":0},null,null,{"$f":"SUM(G108:I108)","v":0},null,null,null,null,null,null,null,{"$f":"IF(B108=\"Please Select\", 0,1)","v":1},{"$f":"IF(R108=1,IF(C108<>0, 1, 0),0)","v":0},{"$f":"IF(R108=1,IF(E108<>0, 1, 0),0)","v":0},{"$f":"IF(AND(J108<>0,SUM(S108:T108)<0.99), 1, \"\")","v":""},{"$f":"IF(C108>0.01,IFERROR(D108/C108,0), \"\")","v":""},{"$f":"IF(AND(V108>0.75, V108<>\"\"),1, \"\")","v":""},{"$f":"IF(V108=0, 1, 0)","v":0},{"$f":"IF(AND(B108=\"Other\",K108=\"\"), 1,0)","v":0}]
[null,"Administration",null,null,null,null,{"$f":"SUM(C109:F109)","v":0},null,null,{"$f":"SUM(G109:I109)","v":0},null,null,null,null,null,null,null,{"$f":"IF(B109=\"Please Select\", 0,1)","v":1},0,0,{"$f":"IF(AND(J109<>0,SUM(S109:T109)<0.99), 1, \"\")","v":""},"",{"$f":"IF(AND(V109>0.75, V109<>\"\"),1, \"\")","v":""},{"$f":"IF(V109=0, 1, 0)","v":0},0]
[null,"Billing",null,null,null,null,{"$f":"SUM(C110:F110)","v":0},null,null,{"$f":"SUM(G110:I110)","v":0},null,null,null,null,null,null,null,1,0,0,"","","",0,0]
[null,"Clerical",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,1,0,0,"","","",0,0]
[null,"Communications",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,1,0,0,"","","",0,0]
[null,"Emergency Services",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,1,0,0,"","","",0,0]
[null,"Financial",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,1,0,0,"","","",0,0]
[null,"Houskeeping",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,1,0,0,"","","",0,0]
[null,"Human Resouces",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,1,0,0,"","","",0,0]
[null,"Information Technology (IT)",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,1,0,0,"","","",0,0]
[null,"Legal",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,1,0,0,"","","",0,0]
[null,"Maintenance and Repairs",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,1,0,0,"","","",0,0]
[null,"Security",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,{"$f":"IF(B120=\"Please Select\", 0,1)","v":1},0,0,"","","",0,0]
[null,"Office Supplies",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"Insurance",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"Telephone",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"Utilities",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"Lease and Rental",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"Transportation",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"Mortgage Interest",null,null,null,null,0,null,null,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"Depreciation","Enter Depreciable Assets in Rows 131 - 141 Below",null,null,{"$f":"I145","v":0},0,null,null,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Missing"]
[null,"Total",{"$f":"SUM(C108:C128)","v":0},0,0,0,0,0,0,0]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Reclassification net 0",null,null,{"$f":"SUM(R108:R120)","v":13},{"$f":"SUM(S108:S120)","v":0},{"$f":"SUM(T108:T120)","v":0},{"$f":"SUM(U108:U127)","v":0},null,{"$f":"SUM(W108:W127)","v":0},{"$f":"SUM(X108:X127)","v":0},{"$f":"SUM(Y108:Y128)","v":0},{"$f":"IFERROR(SUM(U130+X130),0)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ROUND(H47+H129+H102+H83,1)<>0, 1,0)","v":0}]
[null,"Depreciation"]
[null,"Asset Description",null,null,"Beginning Balance","Purchases and Donations","Disposals and Retirements","Ending Balance","Depreciation expense during reporting period","Fully Depreciated Assets","Notes",null,null,null,null,null,null,null,"Depcriation in period too high","Missing Beg. Balance",null,"Other Costs Notes"]
[null,"Land",null,null,null,null,null,{"$f":"(E134+F134)-G134","v":0},null,null,null,null,null,null,null,1,null,{"$f":"IF(AND(E134<>0, I134<>0), I134/H134, 0)","v":0},{"$f":"IF(R134>0.2, 1,0)","v":0},{"$f":"IF(AND(H134<>0, E134=\"\"), 1, 0)","v":0}]
[null,"Land Improvements",null,null,null,null,null,{"$f":"(E135+F135)-G135","v":0},null,null,null,null,null,null,null,1,null,{"$f":"IF(AND(E135<>0, I135<>0), I135/H135, 0)","v":0},{"$f":"IF(R135>0.2, 1,0)","v":0},0]
[null,"Buildings and Fixtures",null,null,null,null,null,{"$f":"(E136+F136)-G136","v":0},null,null,null,null,null,null,null,1,null,0,0,0]
[null,"Building Improvements",null,null,null,null,null,{"$f":"(E137+F137)-G137","v":0},null,null,null,null,null,null,null,1,null,0,0,0]
[null,"Fixed Equipment",null,null,null,null,null,0,null,null,null,null,null,null,null,1,null,0,0,0]
[null,"Movable Equipment",null,null,null,null,null,0,null,null,null,null,null,null,null,1,null,0,0,0]
[null,"HIT-designated Assets",null,null,null,null,null,0,null,null,null,null,null,null,null,1,null,{"$f":"IF(AND(E140<>0, I140<>0), I140/H140, 0)","v":0},{"$f":"IF(R140>0.2, 1,0)","v":0},0,null,null,null,null,null,"Missing"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,null,0,null,null,null,{"$f":"IF(AND(B141=\"\", K141=\"\"), 0,1)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,null,0,null,null,null,{"$f":"IF(AND(B142=\"\", K142=\"\"), 0,1)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,null,0,null,null,null,{"$f":"IF(AND(B143=\"\", K143=\"\"), 0,1)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,null,0,null,null,null,{"$f":"IF(AND(B144=\"\", K144=\"\"), 0,1)","v":0}]
[null,"Total",null,null,{"$f":"SUM(E134:E144)","v":0},0,0,{"$f":"SUM(H134:H144)","v":0},{"$f":"SUM(I134:I144)","v":0},{"$f":"SUM(J134:J144)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUBTOTAL(109,P134:P144)","v":7},null,{"$f":"IF(AND(E145<>0, I145<>0), I145/H145, 0)","v":0},{"$f":"IF(R146>0.2, 1,0)","v":0},{"$f":"SUM(T134:T140)","v":0},null,{"$f":"SUM(V134:V144)","v":0},null,null,null,{"$f":"SUM(S146:V146)","v":0}]
[null,"FQHC Cost Summary",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(R146>0.2,1,0)","v":0}]
[null,"Cost Category",null,null,null,null,null,"Total Non - FQHC","Total Outstationed Enrollment","Total FQHC Cost","Grand Total"]
[null,"Direct Medical Costs",null,null,null,null,null,null,null,{"$f":"J47","v":0},{"$f":"J149","v":0},null,null,null,null,"Indirect to Total",null,"Overhead to FQHC Cost",null,"Outstationed to Total Cost",null,"Oustation per app"]
[null,"Indirect Costs",null,null,null,null,null,null,null,{"$f":"J83","v":0},{"$f":"J150","v":0},null,null,null,null,{"$f":"IFERROR(J150/J153, \"\")","v":""},{"$f":"IF(P150>0.3, 1,0)","v":1},{"$f":"IFERROR(J152/J153, \"\")","v":""},{"$f":"IF(R150>0.3, 1,0)","v":1},{"$f":"IFERROR(I153/J153, \"\")","v":""},{"$f":"IF(T150>0.05, 1,0)","v":1},{"$f":"IFERROR(IF(I155>200, 1,0), 1)","v":0}]
[null,"Non-Reimbursable Costs",null,null,null,null,null,{"$f":"J102","v":0},null,null,{"$f":"H151","v":0}]
[null,"Overhead Costs",null,null,null,null,null,{"$f":"IFERROR(J129*H151/(SUM(J149:J150)+H151), 0)","v":0},null,{"$f":"IFERROR(J129*SUM(J149:J150)/(SUM(J149:J150)+H151),0)","v":0},{"$f":"SUM(H152:J152)","v":0}]
[null,"Total",null,null,null,null,null,{"$f":"SUM(H151:H152)","v":0},null,{"$f":"SUM(J149:J152)","v":0},{"$f":"SUM(K149:K152)","v":0}]
[null,"Total Applications Processed (Outstationed Enrollment)"]
[null,"Cost per Application"]

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[null,"DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,null,null,"STATE OF WISCONSIN"]
[null,"Division of Medicaid Services",null,null,null,null,null,null,null,null,"Administrative Code: WI SPA 17-0010"]
[null,"F-02656 (01/2021)"]
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[null,"Federally Qualified Health Center Cost Report",null,null,null,null,null,null,null,null,null,null,{"$f":"IF(B7=\"Please Select\",\"Hide\",\"\")","v":""}]
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[null,"Please note: Provider Types are prepopulated to mirror Primary Providers certified by Wisconsin Medicaid reported under the \"Direct Medical Costs\" section of Worksheet A \n(rows 11-40)",null,null,null,null,null,null,null,null,null,null,""]
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[null,null,null,null,null,null,null,null,null,null,null,null,""]
[null,"Clinician Time",null,null,null,null,null,null,null,null,null,null,""]
[null,"Provider Type","FQHC Staff",null,null,null,"Contractors",null,null,null,"Total FTEs",null,""]
[null,null,"Direct Hours","Other Paid Hours","Staff FTEs","Productivity Percentage","Direct Hours","Other Paid Hours","Contracted FTEs","Productivity Percentage",null,null,{"$f":"IF(B17=\"Please Select\",\"Hide\",\"\")","v":""},null,null,null,"Missing Direct Hours","Productivity % high","Productivity % low",null,"Cost per FTE Unutually Low","Cost per FTE Unutually High"]
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[null,"N/A",{"$f":"IF(SUM('Worksheet A'!C41:D41)=0,0,IF(AND(B121<>\"\",E45<>0,E83<>0),E83/E45,\"Missing required field\"))","v":0},{"$f":"IF(SUM('Worksheet A'!C41:D41)=0,0,IF(AND(B121<>\"\",E45<>0,SUM('Worksheet A'!C41:D41)<>0),SUM('Worksheet A'!C41:D41)/E45,\"Missing required field\"))","v":0},{"$f":"IF(SUM('Worksheet A'!C41:D41)=0,0,IF(AND(B121<>\"\",E83<>0,SUM('Worksheet A'!C41:D41)<>0),SUM('Worksheet A'!C41:D41)/E83,\"Missing required field\"))","v":0},{"$f":"IF(SUM('Worksheet A'!C41:D41)=0,0,IF(AND(B121<>\"\", C45<>0,E83<>0),C45/E83,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E41=0,0,IF(AND(B121<>\"\",I45<>0,I83<>0),I83/I45,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E41=0,0,IF(AND(B121<>\"\",I45<>0,'Worksheet A'!E41<>0),'Worksheet A'!E41/I45,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E41=0,0,IF(AND(B121<>\"\", I83<>0,'Worksheet A'!E41<>0),'Worksheet A'!E41/I83,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E41=0,0,IF(AND(B121<>\"\", G45<>0,I83<>0),G45/I83,\"Missing required field\"))","v":0},"",null,"Hide",null,{"$f":"VLOOKUP(B121,'Dropdown Menus - Hidden'!$E$1:$F$24, 2, FALSE)","v":{"$error":"#N/A"}},null,0,1,0,null,0,0,0]
[null,"N/A",{"$f":"IF(SUM('Worksheet A'!C42:D42)=0,0,IF(AND(B122<>\"\",E46<>0,E84<>0),E84/E46,\"Missing required field\"))","v":0},{"$f":"IF(SUM('Worksheet A'!C42:D42)=0,0,IF(AND(B122<>\"\",E46<>0,SUM('Worksheet A'!C42:D42)<>0),SUM('Worksheet A'!C42:D42)/E46,\"Missing required field\"))","v":0},{"$f":"IF(SUM('Worksheet A'!C42:D42)=0,0,IF(AND(B122<>\"\",E84<>0,SUM('Worksheet A'!C42:D42)<>0),SUM('Worksheet A'!C42:D42)/E84,\"Missing required field\"))","v":0},{"$f":"IF(SUM('Worksheet A'!C42:D42)=0,0,IF(AND(B122<>\"\", C46<>0,E84<>0),C46/E84,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E42=0,0,IF(AND(B122<>\"\",I46<>0,I84<>0),I84/I46,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E42=0,0,IF(AND(B122<>\"\",I46<>0,'Worksheet A'!E42<>0),'Worksheet A'!E42/I46,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E42=0,0,IF(AND(B122<>\"\", I84<>0,'Worksheet A'!E42<>0),'Worksheet A'!E42/I84,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E42=0,0,IF(AND(B122<>\"\", G46<>0,I84<>0),G46/I84,\"Missing required field\"))","v":0},"",null,"Hide",null,{"$f":"VLOOKUP(B122,'Dropdown Menus - Hidden'!$E$1:$F$24, 2, FALSE)","v":{"$error":"#N/A"}},null,0,1,0,null,0,0,0]
[null,"N/A",{"$f":"IF(SUM('Worksheet A'!C43:D43)=0,0,IF(AND(B123<>\"\",E47<>0,E85<>0),E85/E47,\"Missing required field\"))","v":0},{"$f":"IF(SUM('Worksheet A'!C43:D43)=0,0,IF(AND(B123<>\"\",E47<>0,SUM('Worksheet A'!C43:D43)<>0),SUM('Worksheet A'!C43:D43)/E47,\"Missing required field\"))","v":0},{"$f":"IF(SUM('Worksheet A'!C43:D43)=0,0,IF(AND(B123<>\"\",E85<>0,SUM('Worksheet A'!C43:D43)<>0),SUM('Worksheet A'!C43:D43)/E85,\"Missing required field\"))","v":0},{"$f":"IF(SUM('Worksheet A'!C43:D43)=0,0,IF(AND(B123<>\"\", C47<>0,E85<>0),C47/E85,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E43=0,0,IF(AND(B123<>\"\",I47<>0,I85<>0),I85/I47,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E43=0,0,IF(AND(B123<>\"\",I47<>0,'Worksheet A'!E43<>0),'Worksheet A'!E43/I47,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E43=0,0,IF(AND(B123<>\"\", I85<>0,'Worksheet A'!E43<>0),'Worksheet A'!E43/I85,\"Missing required field\"))","v":0},{"$f":"IF('Worksheet A'!E43=0,0,IF(AND(B123<>\"\", G47<>0,I85<>0),G47/I85,\"Missing required field\"))","v":0},"",null,"Hide",null,{"$f":"VLOOKUP(B123,'Dropdown Menus - Hidden'!$E$1:$F$24, 2, FALSE)","v":{"$error":"#N/A"}},null,0,1,0,null,{"$f":"IF(AND(B123<>\"N/A\", OR(E123<25, I123<25, E123=\"Missing required field\", I123=\"Missing required field\")), 1,0)","v":0},0,0]
[null,"Total Number of Edits",{"$f":"SUM(C94:C123)","v":0},{"$f":"SUM(D94:D123)","v":0},{"$f":"SUM(E94:E123)","v":0},{"$f":"SUM(F94:F123)","v":0},{"$f":"SUM(G94:G123)","v":0},{"$f":"SUM(H94:H123)","v":0},{"$f":"SUM(I94:I123)","v":0},{"$f":"SUM(J94:J123)","v":0},{"$f":"SUM(K94:K123)","v":0},null,"",null,null,null,{"$f":"SUBTOTAL(109,Q94:Q123)","v":0},{"$f":"SUBTOTAL(109,R94:R123)","v":0},0,null,0,{"$f":"SUBTOTAL(109,V94:V123)","v":0},{"$f":"SUBTOTAL(109,W94:W123)","v":0}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUMIF($O94:$O125,\"Behavioral Health\",M96:M125)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUMIF($O94:$O125,\"Dental\",M96:M125)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUMIF($O94:$O125,\"Medical\",M96:M125)","v":0}]

{"sheet":"Worksheet B-1","index":4,"n_rows":84,"n_cols":20,"rows_kept":84,"cut":false,"hidden":true,"merged":[[7,1,7,10],[6,1,6,10],[5,1,5,10],[55,1,55,3],[55,4,55,6],[55,7,55,9],[54,1,54,3],[53,1,53,3],[47,1,47,4],[11,1,12,10],[52,1,52,10],[15,3,16,3],[15,4,16,4],[14,1,14,10],[15,1,16,1],[15,2,16,2],[77,4,77,6],[77,7,77,9],[58,1,58,3],[57,1,57,3],[75,1,75,3],[76,1,76,3],[58,4,58,6],[59,4,59,6],[60,4,60,6],[66,4,66,6],[67,4,67,6],[67,7,67,9],[69,7,69,9],[65,4,65,6],[65,7,65,9],[68,4,68,6],[61,4,61,6],[54,7,54,9],[57,7,57,9],[58,7,58,9],[59,7,59,9],[60,7,60,9],[57,4,57,6],[61,7,61,9],[77,1,77,3],[71,1,71,3],[66,1,66,3],[64,1,64,3],[63,1,63,3],[67,1,67,3],[65,1,65,3],[74,1,74,3],[61,1,61,3],[69,1,69,3],[72,1,72,3],[62,1,62,3],[73,1,73,3],[70,1,70,3],[68,1,68,3],[62,4,62,6],[64,4,64,6],[63,4,63,6],[66,7,66,9],[69,4,69,6],[68,7,68,9],[62,7,62,9],[63,7,63,9],[64,7,64,9],[15,5,15,7],[15,8,15,10],[60,1,60,3],[56,4,56,6],[56,7,56,9],[56,1,56,3],[53,4,53,6],[53,7,53,9],[54,4,54,6],[59,1,59,3],[76,4,76,6],[76,7,76,9],[73,4,73,6],[73,7,73,9],[74,4,74,6],[74,7,74,9],[75,4,75,6],[75,7,75,9],[71,7,71,9],[72,7,72,9],[70,4,70,6],[71,4,71,6],[72,4,72,6],[70,7,70,9]]}
[null,"DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,null,null,"STATE OF WISCONSIN"]
[null,"Division of Medicaid Services",null,null,null,null,null,null,null,null,"Administrative Code: WI SPA 17-0010"]
[null,"F-02656 (01/2021)"]
[]
[]
[]
[null,"Federally Qualified Health Center Cost Report"]
[null,{"$f":"'FQHC Cost Report Overview'!B8","v":"Annual FY 1900 Medicaid Cost Report "}]
[]
[null,null,null,null,null,null,null,null,null,null,{"$f":"IF('FQHC Cost Report Overview'!B15=\"Please Select\",\"\",'FQHC Cost Report Overview'!B15)","v":""}]
[]
[null,"Please note: This worksheet is intended to capture the number of hours worked by contracted providers within the FQHC and outside of the FQHC. Contracted hours by provider type from Worksheet B must match the hours listed on Worksheet B-1. "]
[]
[]
[null,"Contracted Clinician Time "]
[null,"Provider Type","Location of Service(s)","Contracted Clinician Name ","Contracted Agency Name","Hours rendered at FQHC",null,null,"Hours rendered outside of FQHC "]
[null,null,null,null,null,"Direct Hours","Other Paid Hours","FQHC FTEs","Direct Hours","Other Paid Hours","External FTEs",null,null,null,null,null,"Total Rows","Missing Data","Sum"]
[null,"Please Select",null,null,null,null,null,{"$f":"ROUND((F18+G18)/2080,2)","v":0},null,null,{"$f":"ROUND((I18+J18)/2080,2)","v":0},null,null,{"$f":"IF('Worksheet B'!E18<>0, 'Worksheet B'!B18, \"--\")","v":"--"},{"$f":"IF(N18<>\"Please Select\",N18,\"\")","v":"--"},null,1,{"$f":"IF(AND(B18<>\"Please Select\", OR(C18=\"\",D18=\"\",E18=\"\")), 1,0)","v":0},{"$f":"SUBTOTAL(109,R18:R47)","v":0}]
[null,"Please Select",null,null,null,null,null,{"$f":"ROUND((F19+G19)/2080,2)","v":0},null,null,{"$f":"ROUND((I19+J19)/2080,2)","v":0},null,null,{"$f":"IF('Worksheet B'!E19<>0, 'Worksheet B'!B19, \"--\")","v":"--"},{"$f":"IF(N19<>\"Please Select\",N19,\"\")","v":"--"},null,1,{"$f":"IF(AND(B19<>\"Please Select\", OR(C19=\"\",D19=\"\",E19=\"\")), 1,0)","v":0}]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E20<>0, 'Worksheet B'!B20, \"--\")","v":"--"},"--"," ",1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E21<>0, 'Worksheet B'!B21, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E22<>0, 'Worksheet B'!B22, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E23<>0, 'Worksheet B'!B23, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E24<>0, 'Worksheet B'!B24, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E25<>0, 'Worksheet B'!B25, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E26<>0, 'Worksheet B'!B26, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E27<>0, 'Worksheet B'!B27, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E28<>0, 'Worksheet B'!B28, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E29<>0, 'Worksheet B'!B29, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E30<>0, 'Worksheet B'!B30, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E31<>0, 'Worksheet B'!B31, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E32<>0, 'Worksheet B'!B32, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E33<>0, 'Worksheet B'!B33, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E34<>0, 'Worksheet B'!B34, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E35<>0, 'Worksheet B'!B35, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E36<>0, 'Worksheet B'!B36, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E37<>0, 'Worksheet B'!B37, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E38<>0, 'Worksheet B'!B38, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E39<>0, 'Worksheet B'!B39, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E40<>0, 'Worksheet B'!B40, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E41<>0, 'Worksheet B'!B41, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E42<>0, 'Worksheet B'!B42, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E43<>0, 'Worksheet B'!B43, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E44<>0, 'Worksheet B'!B44, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E45<>0, 'Worksheet B'!B45, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E46<>0, 'Worksheet B'!B46, \"--\")","v":"--"},"--",null,1,0]
[null,"Please Select",null,null,null,null,null,0,null,null,0,null,null,{"$f":"IF('Worksheet B'!E47<>0, 'Worksheet B'!B47, \"--\")","v":"--"},null,null,1,0]
[null,"Total FTEs",null,null,null,null,null,{"$f":"SUBTOTAL(109,H18:H47)","v":0},null,null,{"$f":"SUBTOTAL(109,K18:K47)","v":0},null,null,null,null,null,{"$f":"SUBTOTAL(109,Q18:Q47)","v":30}]
[]
[]
[]
[]
[null,"Total Contracted FQHC FTEs Desk Review and Edit Check"]
[null,"Provider Type",null,null,"Total Contracted FTEs (Worksheet B)",null,null,"Total Contracted FTEs (Worksheet B-1)",null,null,"FTEs Do Not Match",null,null,null,"Please Select",null,null,"Do not Match","Ratio at FQHC/outside"]
[null,"Alcohol and Other Drug Abuse Counselor",null,null,{"$f":"IFERROR(VLOOKUP(B55,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,{"$f":"(SUMIF($B$18:$B$47,B55,$H$18:$H$47)+ SUMIF($B$18:$B$47, B55, $K$18:$K$47))","v":0},null,null,{"$f":"IF(M55= 0, \"\", \"Please Review\")","v":""},null,{"$f":"IF(AND(H55<>E55,E55<>0), 1,0)","v":0},{"$f":"IF('Worksheet B'!I18<>0, 'Worksheet B'!B18, \"--\")","v":"--"},{"$f":"IF(N55<>\"Please Select\",N55,\"\")","v":"--"},null,null,{"$f":"IF(K55= \"Please Review\",1,\"\")","v":""},{"$f":"IFERROR(IF((H48/K48)<0.5, 1,0), 1)","v":1}]
[null,"Anesthesiologists",null,null,{"$f":"IFERROR(VLOOKUP(B56,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,{"$f":"(SUMIF($B$18:$B$47,B56,$H$18:$H$47)+ SUMIF($B$18:$B$47, B56, $K$18:$K$47))","v":0},null,null,{"$f":"IF(M56= 0, \"\", \"Please Review\")","v":""},null,{"$f":"IF(AND(H56<>E56,E56<>0), 1,0)","v":0},{"$f":"IF('Worksheet B'!I19<>0, 'Worksheet B'!B19, \"--\")","v":"--"},{"$f":"IF(N56<>\"Please Select\",N56,\"\")","v":"--"}]
[null,"APNP (Behavioral)",null,null,{"$f":"IFERROR(VLOOKUP(B57,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,{"$f":"IF(M57= 0, \"\", \"Please Review\")","v":""},null,0,{"$f":"IF('Worksheet B'!I20<>0, 'Worksheet B'!B20, \"--\")","v":"--"},"--",null,null,{"$f":"IF(K57= \"Please Review\",1,\"\")","v":""}]
[null,"APNP (Medical)",null,null,{"$f":"IFERROR(VLOOKUP(B58,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,{"$f":"IF(M58= 0, \"\", \"Please Review\")","v":""},null,0,{"$f":"IF('Worksheet B'!I21<>0, 'Worksheet B'!B21, \"--\")","v":"--"},"--",null,null,""]
[null,"Audiologists",null,null,{"$f":"IFERROR(VLOOKUP(B59,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I22<>0, 'Worksheet B'!B22, \"--\")","v":"--"},"--",null,null,""]
[null,"Certified Nurse-Midwife",null,null,{"$f":"IFERROR(VLOOKUP(B60,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I23<>0, 'Worksheet B'!B23, \"--\")","v":"--"},"--",null,null,""]
[null,"Chiropractor",null,null,{"$f":"IFERROR(VLOOKUP(B61,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I24<>0, 'Worksheet B'!B24, \"--\")","v":"--"},"--",null,null,""]
[null,"Dentist",null,null,{"$f":"IFERROR(VLOOKUP(B62,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I25<>0, 'Worksheet B'!B25, \"--\")","v":"--"},"--",null,null,""]
[null,"Dental Hygienist",null,null,{"$f":"IFERROR(VLOOKUP(B63,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I26<>0, 'Worksheet B'!B26, \"--\")","v":"--"},"--",null,null,""]
[null,"Nurse practitioner",null,null,{"$f":"IFERROR(VLOOKUP(B64,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I27<>0, 'Worksheet B'!B27, \"--\")","v":"--"},"--",null,null,""]
[null,"Obstetrics/Gynecologist",null,null,{"$f":"IFERROR(VLOOKUP(B65,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I28<>0, 'Worksheet B'!B28, \"--\")","v":"--"},"--",null,null,""]
[null,"Occupational Therapy Assistant",null,null,{"$f":"IFERROR(VLOOKUP(B66,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I29<>0, 'Worksheet B'!B29, \"--\")","v":"--"},"--",null,null,""]
[null,"Occupational Therapist",null,null,{"$f":"IFERROR(VLOOKUP(B67,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I30<>0, 'Worksheet B'!B30, \"--\")","v":"--"},"--",null,null,""]
[null,"Optometrist",null,null,{"$f":"IFERROR(VLOOKUP(B68,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I31<>0, 'Worksheet B'!B31, \"--\")","v":"--"},"--",null,null,""]
[null,"Physical Therapy Assistant",null,null,{"$f":"IFERROR(VLOOKUP(B69,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I32<>0, 'Worksheet B'!B32, \"--\")","v":"--"},"--",null,null,""]
[null,"Physical Therapist",null,null,{"$f":"IFERROR(VLOOKUP(B70,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I33<>0, 'Worksheet B'!B33, \"--\")","v":"--"},"--",null,null,""]
[null,"Physician Assistant",null,null,{"$f":"IFERROR(VLOOKUP(B71,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I34<>0, 'Worksheet B'!B34, \"--\")","v":"--"},"--",null,null,""]
[null,"Physician",null,null,{"$f":"IFERROR(VLOOKUP(B72,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I35<>0, 'Worksheet B'!B35, \"--\")","v":"--"},"--",null,null,""]
[null,"Podiatrist",null,null,{"$f":"IFERROR(VLOOKUP(B73,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I36<>0, 'Worksheet B'!B36, \"--\")","v":"--"},"--",null,null,""]
[null,"Psychiatrist",null,null,{"$f":"IFERROR(VLOOKUP(B74,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,{"$f":"IF(M74= 0, \"\", \"Please Review\")","v":""},null,0,{"$f":"IF('Worksheet B'!I37<>0, 'Worksheet B'!B37, \"--\")","v":"--"},"--",null,null,""]
[null,"Psychologist",null,null,{"$f":"IFERROR(VLOOKUP(B75,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I38<>0, 'Worksheet B'!B38, \"--\")","v":"--"},"--",null,null,"",null,{"$f":"SUM(R55:R77)","v":0}]
[null,"Psychotherapist (APSW,LCSW, LPC, ISW, MFT)",null,null,{"$f":"IFERROR(VLOOKUP(B76,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I39<>0, 'Worksheet B'!B39, \"--\")","v":"--"},"--",null,null,""]
[null,"Speech-Language Pathologist",null,null,{"$f":"IFERROR(VLOOKUP(B77,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,"",null,0,{"$f":"IF('Worksheet B'!I40<>0, 'Worksheet B'!B40, \"--\")","v":"--"},"--",null,null,""]
[null,"Qualified Treatment Trainee",null,null,{"$f":"IFERROR(VLOOKUP(B78,'Worksheet B'!$B$18:$K$47, 8, FALSE), 0)","v":0},null,null,0,null,null,{"$f":"IF(M78= 0, \"\", \"Please Review\")","v":""},null,0,{"$f":"IF('Worksheet B'!I41<>0, 'Worksheet B'!B41, \"--\")","v":"--"},"--",null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,0,{"$f":"IF('Worksheet B'!I42<>0, 'Worksheet B'!B42, \"--\")","v":"--"},"--",null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,0,{"$f":"IF('Worksheet B'!I43<>0, 'Worksheet B'!B43, \"--\")","v":"--"},"--",null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,0,{"$f":"IF('Worksheet B'!I44<>0, 'Worksheet B'!B44, \"--\")","v":"--"},"--",null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,0,{"$f":"IF('Worksheet B'!I45<>0, 'Worksheet B'!B45, \"--\")","v":"--"},"--",null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,0,{"$f":"IF('Worksheet B'!I46<>0, 'Worksheet B'!B46, \"--\")","v":"--"},"--",null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,0,{"$f":"IF('Worksheet B'!I47<>0, 'Worksheet B'!B47, \"--\")","v":"--"},"--"]

{"sheet":"Worksheet C","index":5,"n_rows":77,"n_cols":16,"rows_kept":77,"cut":false,"hidden":true,"merged":[[7,1,7,8],[6,1,6,8],[5,1,5,8],[67,5,67,6],[67,7,67,8],[59,5,59,6],[62,3,62,4],[63,3,63,4],[61,7,61,8],[62,7,62,8],[63,7,63,8],[64,7,64,8],[65,7,65,8],[67,1,67,4],[64,1,64,2],[65,3,65,4],[62,5,62,6],[63,5,63,6],[61,5,61,6],[12,1,12,8],[23,7,23,8],[24,7,24,8],[19,1,19,6],[20,1,20,6],[21,1,21,6],[22,1,22,6],[23,1,23,6],[24,1,24,6],[19,7,19,8],[20,7,20,8],[21,7,21,8],[22,7,22,8],[16,1,16,8],[17,1,17,6],[14,7,14,8],[17,7,17,8],[18,1,18,6],[18,7,18,8],[13,7,13,8],[13,1,14,2],[13,3,13,4],[13,5,13,6],[14,3,14,4],[14,5,14,6],[66,1,66,2],[66,3,66,4],[66,5,66,6],[66,7,66,8],[58,7,58,8],[65,1,65,2],[58,1,58,2],[59,1,59,2],[60,1,60,2],[61,1,61,2],[62,1,62,2],[63,1,63,2],[59,7,59,8],[60,7,60,8],[58,3,58,4],[59,3,59,4],[64,5,64,6],[65,5,65,6],[64,3,64,4],[61,3,61,4],[29,1,29,2],[40,1,40,2],[41,1,41,2],[42,1,42,2],[43,1,43,2],[29,3,29,4],[30,3,30,4],[31,3,31,4],[32,3,32,4],[33,3,33,4],[34,3,34,4],[35,3,35,4],[36,3,36,4],[37,3,37,4],[25,7,25,8],[57,3,57,4],[60,3,60,4],[58,5,58,6],[60,5,60,6],[35,1,35,2],[36,1,36,2],[37,1,37,2],[38,1,38,2],[39,1,39,2],[30,1,30,2],[31,1,31,2],[32,1,32,2],[33,1,33,2],[34,1,34,2],[25,1,25,6],[27,1,27,8],[28,1,28,2],[28,3,28,4],[28,5,28,6],[28,7,28,8],[41,3,41,4],[42,3,42,4],[43,3,43,4],[29,5,29,6],[30,5,30,6],[31,5,31,6],[32,5,32,6],[33,5,33,6],[34,5,34,6],[35,5,35,6],[36,5,36,6],[37,5,37,6],[38,5,38,6],[39,5,39,6],[40,5,40,6],[41,5,41,6],[38,3,38,4],[39,3,39,4],[40,3,40,4],[43,7,43,8],[42,5,42,6],[43,5,43,6],[38,7,38,8],[39,7,39,8],[40,7,40,8],[41,7,41,8],[42,7,42,8],[29,7,29,8],[30,7,30,8],[31,7,31,8],[32,7,32,8],[33,7,33,8],[34,7,34,8],[35,7,35,8],[36,7,36,8],[37,7,37,8]]}
[null,"DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,"STATE OF WISCONSIN"]
[null,"Division of Medicaid Services",null,null,null,null,null,null,"Administrative Code: WI SPA 17-0010"]
[null,"F-02656 (01/2021)"]
[]
[]
[]
[null,"Federally Qualified Health Center Cost Report"]
[null,{"$f":"'FQHC Cost Report Overview'!B8","v":"Annual FY 1900 Medicaid Cost Report "}]
[]
[null,null,null,null,null,null,null,null,{"$f":"IF('FQHC Cost Report Overview'!B15=\"Please Select\",\"\",'FQHC Cost Report Overview'!B15)","v":""}]
[]
[]
[null,"Charges for the Reporting Period",null,null,null,null,null,null,null,null,null,{"$f":"SUM(L15+L19+L68)","v":2}]
[null,"Total Charges",null,"Medicaid Charges",null,"Non-Medicaid Charges",null,"Total Charges",null,null,null,"Missing data"]
[null,null,null,null,null,null,null,{"$f":"D15+F15","v":0},null,null,null,{"$f":"IF(OR(D15=\"\",F15=\"\"), 1,0)","v":1},"cost to charge"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IFERROR(IF(O16>2, 1,0), 0)","v":0},{"$f":"'Summary & Certification'!D26","v":{"$error":"#DIV/0!"}},{"$f":"N16/H15","v":{"$error":"#DIV/0!"}}]
[null,"Payments Received by the FQHC for Services to Medicaid members During Reporting Period",null,null,null,null,null,null,null,null,null,null,{"$f":"IFERROR(IF(O16<0.75, 1,0), 0)","v":0}]
[null,"Payment Type",null,null,null,null,null,"Payment Amount",null,null,null,"Missing Data"]
[null,"Payments from Medicare Part C to FQHC for crossovers during the reporting period",null,null,null,null,null,null,null,null,null,{"$f":"IF(OR(H19=\"\",H20=\"\",H21=\"\",H22=\"\",H23=0,H24=\"\",H25=\"\"), 1,0)","v":1},"Ratio vs. Ratio"]
[null,"Payments from Medicare (excluding Part C) to FQHC for crossovers during the reporting period",null,null,null,null,null,null,null,null,null,null,{"$f":"IFERROR(D15/F15, 1)","v":1},{"$f":"IFERROR(('Worksheet B'!C89+'Worksheet B'!G89)/('Worksheet B'!D89+'Worksheet B'!H89), 1)","v":1},{"$f":"IFERROR(IF((M20/N20)>0.3, 1,0), 1)","v":1},{"$f":"M20/N20","v":1}]
[null,"Payments from Medicaid fee-for-service to FQHC during the reporting period"]
[null,"Payments from Medicaid for interim FQHC payments during the reporting period"]
[null,"Payments by or due from Medicaid managed care organizations to FQHC during the reporting period",null,null,null,null,null,{"$f":"H68","v":0}]
[null,"Payments by or due from other third parties (insurance, HMOs) to FQHC for Medicaid members"]
[null,"Copayments from Medicaid members during this reporting period"]
[null,"Total Payment Amount",null,null,null,null,null,{"$f":"SUM(H19:I25)","v":0}]
[]
[null,"Managed Care Revenue (including any incentive payments received)"]
[null,"Managed Care Entity",null,"Notes ",null,"Total Medicaid Encounters",null,"Total Dollar Amount Received ",null,null,null,"Missing Data"]
[null,"Please Select",null,null,null,null,null,null,null,null,1,{"$f":"IF(AND(B30<>\"Please Select\",OR(F30=\"\",H30=\"\")), 1,0)+IF(AND(B30=\"Please Select\",OR(F30<>0,H30<>0)),1,0)","v":0}]
[null,"Please Select",null,null,null,null,null,null,null,null,1,{"$f":"IF(AND(B31<>\"Please Select\",OR(F31=\"\",H31=\"\")), 1,0)+IF(AND(B31=\"Please Select\",OR(F31<>0,H31<>0)),1,0)","v":0}]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Please Select",null,null,null,null,null,null,null,null,1,0]
[null,"Total ",null,null,null,{"$f":"SUM(F30:G67)","v":0},null,{"$f":"SUM(H30:I67)","v":0},null,null,{"$f":"SUBTOTAL(109, K30:K67)","v":15},{"$f":"SUBTOTAL(109,L30:L67)","v":0}]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null," "]

{"sheet":"Desk Review","index":6,"n_rows":59,"n_cols":13,"rows_kept":59,"cut":false,"hidden":true,"merged":[[6,1,6,9],[5,1,5,9],[27,6,27,9],[28,4,28,5],[28,6,28,9],[23,6,23,9],[25,6,25,9],[19,6,19,9],[13,6,13,9],[16,6,16,9],[17,6,17,9],[15,6,15,9],[18,6,18,9],[11,1,11,9],[17,4,17,5],[14,6,14,9],[40,6,40,9],[7,1,7,9],[49,4,49,5],[30,6,30,9],[31,4,31,5],[31,6,31,9],[39,4,39,5],[39,6,39,9],[45,6,45,9],[48,6,48,9],[49,6,49,9],[48,4,48,5],[46,6,46,9],[47,6,47,9],[45,4,45,5],[42,1,42,9],[22,6,22,9],[37,6,37,9],[24,6,24,9],[25,4,25,5],[33,4,33,5],[33,6,33,9],[36,4,36,5],[24,4,24,5],[34,6,34,9],[34,4,34,5],[35,6,35,9],[36,6,36,9],[26,6,26,9],[27,4,27,5],[32,6,32,9],[26,4,26,5],[37,4,37,5],[47,4,47,5],[41,6,41,9],[44,1,44,9],[20,4,20,5],[20,6,20,9],[21,4,21,5],[21,6,21,9],[35,4,35,5],[38,6,38,9],[40,4,40,5],[38,4,38,5],[22,4,22,5],[32,4,32,5],[41,4,41,5],[29,6,29,9],[30,4,30,5],[12,4,12,5],[13,4,13,5],[18,4,18,5],[19,4,19,5],[14,4,14,5],[16,4,16,5],[15,4,15,5],[29,4,29,5],[23,4,23,5],[12,6,12,9],[57,4,57,5],[58,4,58,5],[55,4,55,5],[54,6,54,9],[46,4,46,5],[50,6,50,9],[51,6,51,9],[52,6,52,9],[50,4,50,5],[53,4,53,5],[51,4,51,5],[52,4,52,5],[54,4,54,5],[53,6,53,9],[56,4,56,5]]}
[null,"DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,null,"STATE OF WISCONSIN"]
[null,"Division of Medicaid Services",null,null,null,null,null,null,null,"Administrative Code: WI SPA 17-0010"]
[null,"F-02656 (01/2021)"]
[]
[]
[]
[null,"Federally Qualified Health Center Cost Report"]
[null,{"$f":"'FQHC Cost Report Overview'!B8","v":"Annual FY 1900 Medicaid Cost Report "}]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"IF('FQHC Cost Report Overview'!B15=\"Please Select\",\"\",'FQHC Cost Report Overview'!B15)","v":""}]
[]
[null,"Automatic Desk Review Edits"]
[null,"Edit Number","Page","Range","Edit",null,"Provider Explanation"]
[null,1,"Overview",{"$f":"IF(L14>0.99,\"B12:F20\", \"\")","v":"B12:F20"},"Data Incomplete - one or more required fields omitted",null,null,null,null,null,null,{"$f":"'FQHC Cost Report Overview'!W15","v":2}]
[null,{"$f":"1+B14","v":2},"Worksheet A",null,"Data Incomplete - one or more required fields omitted",null,null,null,null,null,null,{"$f":"'Worksheet A'!Z44+'Worksheet A'!Z84+'Worksheet A'!AB103+'Worksheet A'!Z130+'Worksheet A'!Z146","v":0}]
[null,{"$f":"1+B15","v":3},"Worksheet A",null,"Compensation reported without fringe benefits",null,null,null,null,null,null,{"$f":"'Worksheet A'!X44+'Worksheet A'!X84+'Worksheet A'!X103+'Worksheet A'!X130","v":0}]
[null,4,"Worksheet A",null,"Fringe benefits exceed 75% of compensation",null,null,null,null,null,null,{"$f":"'Worksheet A'!W44+'Worksheet A'!W84+'Worksheet A'!W103+'Worksheet A'!W130","v":0}]
[null,5,"Worksheet A",{"$f":"IF(L18>0.99,\"B128:M138\", \"\")","v":""},"Ratio of depreciation expense to ending asset value is unusually high",null,null,null,null,null,null,{"$f":"'Worksheet A'!R147","v":0},0.2]
[null,6,"Worksheet A",null,"Reclassifications costs do not net to 0",null,null,null,null,null,null,{"$f":"'Worksheet A'!P47+'Worksheet A'!P87+'Worksheet A'!O104+'Worksheet A'!O131","v":0}]
[null,7,"Worksheet A",null,"Other cost selected without entering an explanation in the Notes section",null,null,null,null,null,null,{"$f":"'Worksheet A'!Y44+'Worksheet A'!Y84+'Worksheet A'!AA103+'Worksheet A'!Y130","v":0}]
[null,8,"Worksheet A",{"$f":"IF(L21>0.99,\"J152:J155\", \"\")","v":"J152:J155"},"Ratio of indirect costs to total  FQHC costs are above the expected range ",null,null,null,null,null,null,{"$f":"'Worksheet A'!Q150","v":1},0.3]
[null,9,"Worksheet A",{"$f":"IF(L22>0.99,\"J154:J155\", \"\")","v":"J154:J155"},"Ratio of overhead to total FQHC cost is above the expect range",null,null,null,null,null,null,{"$f":"'Worksheet A'!S150","v":1},0.3]
[null,{"$f":"1+B22","v":10},"Worksheet B",null,"Data Incomplete - one or more required fields omitted",null,null,null,null,null,null,{"$f":"'Worksheet B'!Q48+'Worksheet B'!Q86","v":0}]
[null,{"$f":"1+B23","v":11},"Worksheet B",{"$f":"IF(L24>0.99,\"C91:C120\", \"\")","v":""},"Encounters per contracted or staff FTE is above the expected range for one of more provider types",null,null,null,null,null,null,{"$f":"'Worksheet B'!Q124","v":0},5000]
[null,12,"Worksheet B",{"$f":"IF(L25>0.99,\"C91:C120\", \"\")","v":""},"Encounters per contracted or staff FTE is below the expected range for one of more provider types",null,null,null,null,null,null,{"$f":"'Worksheet B'!R124","v":0},2100]
[null,13,"Worksheet B",null,"Direct cost per FTE is above the expected range for one or more provider types",null,null,null,null,null,null,{"$f":"'Worksheet A'!AG44","v":0},"BLS Data"]
[null,14,"Worksheet B",null,"Direct cost per FTE is below the expected range for one or more provider types",null,null,null,null,null,null,{"$f":"'Worksheet A'!AF44","v":0},"BLS Data"]
[null,15,"Worksheet B",{"$f":"IF(L28>0.99,\"E91:E120\", \"\")","v":""},"Direct cost per contracted or staff encounter is above the expected range for one or more provider types",null,null,null,null,null,null,{"$f":"'Worksheet B'!S124","v":0},200]
[null,16,"Worksheet B",{"$f":"IF(L29>0.99,\"E91:E120\", \"\")","v":""},"Direct cost per contracted or staff encounter is below the expected range for one or more provider types",null,null,null,null,null,null,{"$f":"'Worksheet B'!U124","v":0},25]
[null,17,"Worksheet B",{"$f":"IF(L30>0.99,\"F91:F120\", \"\")","v":""},"Direct hours per contracted or staff encounter is above the expected range for one or more provider types",null,null,null,null,null,null,{"$f":"'Worksheet B'!V124","v":0},"1.5 hours"]
[null,18,"Worksheet B",{"$f":"IF(L31>0.99,\"F91:F120\", \"\")","v":""},"Direct hours per contracted or staff encounter is below the expected range for one or more provider types",null,null,null,null,null,null,{"$f":"'Worksheet B'!W124","v":0},"15 min"]
[null,19,"Worksheet B",{"$f":"IF(L32>0.99, \"C14:K44\", \"\")","v":""},"Hours not reported for one or more providers who have costs or encounters reported",null,null,null,null,null,null,{"$f":"'Worksheet B'!Q48","v":0},"N/A"]
[null,20,"Worksheet B",{"$f":"IF(L33>0.99, \"C53:K82\", \"\")","v":""},"Encounters not reported for one or more providers who have costs or hours reported ",null,null,null,null,null,null,{"$f":"'Worksheet B'!Q86","v":0},"N/A"]
[null,21,"Worksheet B",{"$f":"IF(L34>0.99,\"F15:F44\", \"\")","v":""},"Productivity Percentage for one or FQHC staff (not applicable to contractors) is above the expected range ",null,null,null,null,null,null,{"$f":"'Worksheet B'!R48","v":0},0.9]
[null,22,"Worksheet B",{"$f":"IF(L35>0.99,\"F15:F44\", \"\")","v":""},"Productivity Percentage for one or more FQHC staff (not applicable to contractors) is below the expected range ",null,null,null,null,null,null,{"$f":"'Worksheet B'!S48","v":0},0.25]
[null,23,"Worksheet \nB-1",null,"Data Incomplete - one or more required fields omitted",null,null,null,null,null,null,{"$f":"'Worksheet B-1'!S18","v":0},"N/A"]
[" ",24,"Worksheet \nB-1",{"$f":"IF(L37>0.99,\"B1022:K1043\", \"\")","v":""},"Contracted FTEs on Worksheet B do not match Contracted FTEs on Worksheet B-1",null,null,null,null,null,null,{"$f":"'Worksheet B-1'!T75","v":0},"N/A"]
[" ",25,"Worksheet \nB-1",{"$f":"IFERROR(IF(L38>0.99,\"B1022:K1043\", \"\"),\"\")","v":"B1022:K1043"},"Ratio of Contracted FTEs provided at the FQHC  to Contracted FTEs provided outside the FQHC is above the expected range",null,null,null,null,null,null,{"$f":"'Worksheet B-1'!S55","v":1},0.5]
[null,26,"Worksheet C",null,"Data Incomplete - one or more required fields omitted",null,null,null,null,null,null,{"$f":"'Worksheet C'!L13","v":2},"N/A"]
[null,27,"Worksheet C",{"$f":"IF(L40>0.99,\"D12:I12\", \"\")","v":""},"Cost to charge ratio for the reporting period is above the expected range",null,null,null,null,null,null,{"$f":"'Worksheet C'!M16","v":0},2]
[null,28,"Worksheet C",{"$f":"IF(L41>0.99,\"D12:I12\", \"\")","v":""},"Cost to charge ratio for the reporting period is below the expected range",null,null,null,null,null,null,{"$f":"'Worksheet C'!M17","v":0},0.75]
[null,29,"Worksheet C",{"$f":"IF(L42>0.99,\"D12:I12\", \"\")","v":"D12:I12"},"Ratio of Medicaid-enrolled member charges to non-enrolled charges is significantly higher than the ratio of Medicaid encounters to non-Medicaid encounters",null,null,null,null,null,null,{"$f":"'Worksheet C'!O20","v":1},0.3]
[]
[]
[null,"FQHC Specific Desk Review Edits (Will populate after submission of cost report)"]
[null,"Edit Number","Page","Range","Edit",null,"Provider Explanation (Highlighted if Required)"]
[null,34,"Worksheet A",null,"Paid claims without supporting cost data for one or more service types"]
[null,{"$f":"1+B47","v":35},"Summary",null,"Ratio of Medicaid paid claims to total Medicaid cost is outside the expected range "]
[null,36,"Summary ",null,"The variance between the year to year total encounters reported are outside of the expected range "]
[null,37,"Summary ",null,"The variance between the year to year total direct medical costs reported are outside of the expected range "]
[null,38,"Summary ",null,"The variance between the year to year indirect costs are outside of the expected range"]
[null,39,"Summary ",null,"The variance between the year to year overhead costs reported are outside of the expect range "]
[null,40,"Summary ",null,"The variance between the year to year total FTEs reported are outside of the expected range "]
[null,41,"Summary ",null,"The variance between the year to year reported cost center (specify) are outside the expected range "]
[null,42,"Summary ",null,"The variance between the year to year reported revenue (specify) are outside of the expected range "]
[null,43,"Summary",null,"Rates vary significantly from FQHC reasonableness threshold calculated using adjusted 2001 rates (see reasonableness threshold tab)"]
[null,44,"Cost Report",null,"We have not receive your single audit, plesae submit it to WIFQHC@PCGUS.com"]
[null,45,"Cost Report",null," FQHC cost report guidance has been continuously updated to accommodate FQHC questions and feedback. Please update your report for any of the following items or reply to this edit confirming that no updates are needed:\n- The direct service now includes the following additions:\n Anesthesiologist, APNP (Behavioral), Certified Nurse-Midwife, Occupational Therapy Assistant, Physical Therapy Assistant, Podiatrist, Psychotherpaist (APSW, LCSW,         LPC, ISW, MFT),Qualified Treatment Trainee                                                                                                                                                                                                                                                             - Drug costs associated with pharmacy services should be broken out under the indirect cost category as “Pharmacy-Staff and Dispensing Fee Costs” and under the non-reimbursable cost category as “Pharmacy-Drug Costs”\n-  Medical records and transcriptionist sections have been moved from Overhead to the indirect cost section. In addition, any costs that are associated with medical records/EMRs that are non-FQHC should be reported in the non-reimbursable section"]
[null,46,"Cost Report",null,"Formulas have been updated to fix glitches within the report. Please review updated values and recertify report on Summary and Certification page with the current  date. "]

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[null,"DEPARTMENT OF HEALTH SERVICES",null,"STATE OF WISCONSIN"]
[null,"Division of Medicaid Services                             ",null,"Administrative Code: WI SPA 17-0010"]
[null,"F-02656 (01/2021)"]
[]
[]
[]
[null,"Federally Qualified Health Center Cost Report"]
[null,{"$f":"'FQHC Cost Report Overview'!B8","v":"Annual FY 1900 Medicaid Cost Report "}]
[]
[null,null,null,{"$f":"IF('FQHC Cost Report Overview'!B15=\"Please Select\",\"\",'FQHC Cost Report Overview'!B15)","v":""}]
[]
[null,"Updated Overhead Applicable to FQHC Services",null,null,null,"Cost Information"]
[null,"Cost Category","Formula","Amount",null,"Cost ",null,"Amount"]
[null,"1.  Direct and Indirect Costs ","WS A (Total Cost of Direct and Indirect)",{"$f":"'Worksheet A'!J47+'Worksheet A'!J83","v":0},null,"1. Total Behavioral Cost",null,{"$f":"'Worksheet A'!J44","v":0},null,null,null,null,"Date Range:"]
[null,"2. Total Reported Overhead","WS A Overhead Grand Total ",{"$f":"'Worksheet A'!K152","v":0},null,"2. Total Dental Cost",null,{"$f":"'Worksheet A'!J45","v":0},null,null,null,null,"Year Ended:"]
[null,"Reimbursable FQHC Overhead Costs",null,null,null,"3. Total Medical Cost",null,{"$f":"'Worksheet A'!J46","v":0},null,null,null,null,"Signer:"]
[null,"3.  FQHC Non-Reimbursable Costs (Prior to Adjustments to Bad Debt and Pharmacy)","WS A (Total Non-Reimbursable Costs)",{"$f":"'Worksheet A'!K151","v":0},null,"4. Total Indirect Cost",null,{"$f":"'Worksheet A'!J83","v":0},null,null,null,null,"Title:"]
[null,"4. Bad Debt and Pharmacy Drug Costs (Adjusted out)","WS A (Find Under Non-Reimbursable Costs)",0,null,"5. Total Non-Reimbursable Cost",null,{"$f":"'Worksheet A'!J102","v":0},null,null,null,null,"Date Signed:"]
[null,"5.  FQHC Non-Reimbursable Cost (After Adjustments to Bad Debt and Pharmacy)","Line 3 - Line 4",{"$f":"D17-D18","v":0},null,"6. Percentage of Non-Reimbursable Cost",null,{"$f":"H18/(H16+H14+H15+H17+H18)","v":{"$error":"#DIV/0!"}},null,null,null,null,"Phone Number:"]
[null,"6.  Percentage of FQHC Non-Reimbursable Costs","Line 5 / (Line 1 + Line 5)",{"$f":"D19/(D14+D19)","v":{"$error":"#DIV/0!"}},null,"7. Total Overhead",null,{"$f":"'Worksheet A'!J129","v":0}]
[null,"7.  FQHC Non-Reimbursable Overhead","Line 2 * Line 6",{"$f":"D15*D20","v":{"$error":"#DIV/0!"}},null,"8. Total Cost of Services and Overhead",null,{"$f":"H16+H14+H15+H17+H20+H18","v":0}]
[null,"8.  FQHC Reimbursable Overhead","Line 2 - Line 7",{"$f":"D15-D21","v":{"$error":"#DIV/0!"}},null,"9. Maximum Allowable Overhead",null,{"$f":"H21*0.3","v":0}]
[null,"9.  Maximum Allowable Overhead  (50% of Direct and Indirect Costs)","Line 1 * 50%",{"$f":"D14*0.5","v":0},null,"10. Overhead Allowed",null,{"$f":"MIN(H20,H22)","v":0}]
[null,"10. Lessor of FQHC Reimbursable Overhead and Maximum Allowable Overhead","Minimum of Line 8 and Line 9",{"$f":"MIN(D22,D23)","v":{"$error":"#DIV/0!"}},null,"11. Overhead Applicable to Non-Reimbursable",null,{"$f":"H19*H23","v":{"$error":"#DIV/0!"}}]
[null,"11. Overhead Over the Cap ","Line 8 - Line 10",{"$f":"IF(D22>D23,D22-D23,\"$0\")","v":{"$error":"#DIV/0!"}},null,"12. Overhead Applicable to FQHC Services",null,{"$f":"H23-H24","v":{"$error":"#DIV/0!"}}]
[null,"12.  Total Cost of FQHC Services","Line 1 + Line 10",{"$f":"D14+D24","v":{"$error":"#DIV/0!"}},null,"13. Total Cost of FQHC Services",null,{"$f":"H16+H14+H15+H17+H25","v":{"$error":"#DIV/0!"}}]
[null,"Determination of FQHC Rate",null,null,null,"14. Outstationed enrollment expenses",null,{"$f":"'Worksheet A'!I153","v":0}]
[null,"13.  Total Cost of FQHC Services ","Line 12",{"$f":"D26","v":{"$error":"#DIV/0!"}}]
[null,"14.  Total FQHC Adjusted Encounters ","WS B K86",{"$f":"'Worksheet B'!K89","v":0},null,"Encounter Information"]
[null,"15.  FQHC Rate per Encounter (not including Outstationed Enrollment Cost and MEI)","Line 13 / Line 14",{"$f":"IF(D29<>0,D28/D29,0)","v":0},null,"Encounters",null,"Amount"]
[null,"Determination of Total Reimbursement",null,null,null,"15. Total Behavioral Encounters",null,{"$f":"'Worksheet B'!K86","v":0}]
[null,"16.  FQHC Rate per Encounter","Line 15",{"$f":"D30","v":0},null,"16. Total Dental Encounters",null,{"$f":"'Worksheet B'!K87","v":0}]
[null,"17. Total Medicaid Encounters","WS B C86 + WS B G86",{"$f":"'Worksheet B'!C89+'Worksheet B'!G89","v":0},null,"17. Total Medical Encounters",null,{"$f":"'Worksheet B'!K88","v":0}]
[null,"18. Medicaid Reasonable Total Costs including crossovers ","Line 16 * Line 17",{"$f":"D32*D33","v":0},null,"18. Total FQHC Encounters",null,{"$f":"H31+H32+H33","v":0}]
[null,"19. Total Encounter Rate ","Line 18 / Line 17",{"$f":"IF(D33<>0,D34/D33,0)","v":0},null,"19. Total Medicaid Encounters",null,{"$f":"'Worksheet B'!C89+'Worksheet B'!G89","v":0}]
[null,"20. MEI (if applicable)","Medicare Economic Index",1.9E-2]
[null,"21. MEI Adjusted Total Encounter Rate","Line 19 * (1+ Line 20)",{"$f":"IFERROR(D35*(1+D36), D35)","v":0}]
[null,"Determination of Reconciliation",null,null,null,"Cost ",null,"Direct Cost Per Encounter","Indirect Cost per Encounter","Overhead Cost per Encounter","Outstationed Enrollment per Encounter","Total Cost per Encounter"]
[null,"22. Medicaid Reimbursement Due from Encounter Rate ","Line 17 * Line 21",{"$f":"D33*D37","v":0}]
[null,"23. Settlement (Recoupment) Due to FQHC","Line 22 - WS C H23",{"$f":"D39-'Worksheet C'!H26","v":0},null,"Behavioral Health",null,{"$f":"H14/H31","v":{"$error":"#DIV/0!"}},{"$f":"$H$17/$H$34","v":{"$error":"#DIV/0!"}},{"$f":"$H$25/$H$34","v":{"$error":"#DIV/0!"}},{"$f":"$H$27/$H$35","v":{"$error":"#DIV/0!"}},{"$f":"SUM(H40:K40)","v":{"$error":"#DIV/0!"}}]
[null,"Determination of Outstationed Enrollment Costs",null,null,null,"Dental",null,{"$f":"H15/H32","v":{"$error":"#DIV/0!"}},{"$f":"$H$17/$H$34","v":{"$error":"#DIV/0!"}},{"$f":"$H$25/$H$34","v":{"$error":"#DIV/0!"}},{"$f":"$H$27/$H$35","v":{"$error":"#DIV/0!"}},{"$f":"SUM(H41:K41)","v":{"$error":"#DIV/0!"}}]
[null,"24.  Outstationed Enrollment Costs","Outstationed Enrollment Survey",null,null,"Medical",null,{"$f":"H16/H33","v":{"$error":"#DIV/0!"}},{"$f":"$H$17/$H$34","v":{"$error":"#DIV/0!"}},{"$f":"$H$25/$H$34","v":{"$error":"#DIV/0!"}},{"$f":"$H$27/$H$35","v":{"$error":"#DIV/0!"}},{"$error":"#DIV/0!"}]
[null,null,null,null,null,"Total",null,{"$f":"SUM(H14:H16)/H34","v":{"$error":"#DIV/0!"}},{"$f":"$H$17/$H$34","v":{"$error":"#DIV/0!"}},{"$f":"$H$25/$H$34","v":{"$error":"#DIV/0!"}},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"}]

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["Please Select","Please Select","Please Select","Please Select","Please Select","Type of Service","Please Select","Please Select","Please Select","Please Select","BLS Data Low w/Benefits","BLS Data High w/Benefits","BLS Data Ranges Low","BLS Data Ranges High",null,"Professional Level","Lower","Upper"]
["Dental","Access","Agency Employee","Abri Health Plan","Alcohol and Other Drug Abuse Counselor","Behavioral Health","Case Management","Community Services ","Behavioral Health Only","Alcohol and Other Drug Abuse Counselor",{"$f":"M2*$I$23","v":36472.759496600003},{"$f":"N2*$I$23","v":109418.2784898},23260,69780,null,"Alcohol and Other Drug Abuse Counselor",36472.759485732204,109418.2784571966]
["Medical","Beloit","Contractor","Americhoice","Anesthesiologists","Medical","Dental Assistant","County Run Community Based Programs","Behavioral Health and Dental","Advanced Practice Nurse Prescriber",{"$f":"M3*$I$23","v":74215.636585300002},222646.90975590001,47330,141990,null,"Advanced Practice Nurse Prescriber",74215.636563185995,222646.90968955786]
["Behavioral Health","Bridge",null,"Anthem BCBS Medicaid","APNP (Behavioral)","Behavioral Health","Dental Hygienist - Not WI Medicaid Certified","Education","Behavioral Health and Medical","Audiologists",62306.324101350001,186918.97230405,39735,119205,null,"Audiologists",62306.324082784602,186918.9722483537]
[null,"Kenosha",null,"Atrium Health Plan","APNP (Medical)","Medical","Genetic Counselor","Environment ","Behavioral Health, Dental and Medical","Certified Nurse-Midwife",57515.9423188,172547.82695640001,36680,110040,null,"Certified Nurse-Midwife",57515.942301661962,172547.82690498588]
[null,"La Clinica",null,"Badger Care ","Audiologists","Medical","Health Education - Enabling Services","Fundraising","Dental Only","Chiropractor",{"$f":"M6*$I$23","v":59766.088917150002},179298.26675144999,38115,114345,null,"Chiropractor",59766.088899341485,179298.26669802447]
[null,"Lake Superior",null,"Beacon Health Strategies","Certified Nurse-Midwife","Medical","Health Educator","Grant Funded - WIC (Women Infant Children)","Dental and Medical","Dentist",159603.60384185001,478810.81152554997,101785,305355,null,"Dentist",159603.6037942929,478810.81138287863]
[null,"Lakeshore",null,"Care Wisconsin ","Chiropractor","Medical","Laboratory - Medical Support","Medical Records/Electronic Medical Records- non-FQHC reimbursable programs and services","Medical Only","Dental Hygienist",50020.680479000002,150062.04143700001,31900,95700,null,"Dental Assistant",28891.255095641267,86673.765286923794]
[null,"Marshfield",null,"Cenpatico ","Dentist","Dental","Medical Assistant","Other Non-Reimbursable",null,"Nurse practitioner",52090.501740200001,156271.5052206,33220,99660,null,"Dental Hygienist",50020.680464095327,150062.04139228599]
[null,"Milwaukee Health System",null,"Children's Community Health  Plan","Dental Hygienist","Dental","Medical Director","Outreach",null,"Obstetrics/Gynecologist",{"$f":"M10*$I$23","v":177024.59945695},{"$f":"N10*$I$23","v":531073.79837085004},112895,338685,null,"Nurse practitioner",52090.501724678586,156271.50517403573]
[null,"N.E.W.",null,"Community Care Connections ","Nurse practitioner","Medical","Medical Records/Electronic Medical Records-FQHC services","Pharmacy- Drug Costs",null,"Occupational Therapy Assistant",53211.654923349997,159634.96477004999,33935,338685,null,"Obstetrics/Gynecologist",177024.59940420196,531073.79821260576]
[null,"Northern",null,"CompCare ","Obstetrics/Gynecologist","Medical","Medical Social Worker","Research ",null,"Occupational Therapist",53211.654923349997,159634.96477004999,33935,101805,null,"Occupational Therapist",53211.654907494507,159634.96472248354]
[null,"Northlakes",null,"Dean Health Plan","Occupational Therapy Assistant","Medical","Nurses (RN, LPN) - Not WI Medicaid Certified",null,null,"Optometrist",81993.146778900002,245979.4403367,52290,156870,null,"Optometrist",81993.1467544685,245979.44026340544]
[null,"Outreach",null,"Dental Providers of Wisconsin","Occupational Therapist","Medical","Nutritionist",null,null,"Physical Therapy Assistant",60487.39026575,181462.17079725,38575,115725,null,"Physical Therapist",60487.390247726558,181462.17074317968]
[null,"Partnership",null,"Dentaquest ","Optometrist","Medical","Outreach for Outstationed Enrollment",null,null,"Physical Therapist",60487.39026575,181462.17079725,38575,115725,null,"Physician Assistant",72843.595954844772,218530.78786453433]
[null,"Progressive",null,"Family Care ","Physical Therapy Assistant","Medical","Patient Transportation - Enabling Services",null,null,"Physician Assistant",72843.595976550001,218530.78792964999,46455,139365,null,"Physician",177024.59940420196,531073.79821260576]
[null,"Scenic Bluffs",null,"Family Planning ","Physical Therapist","Medical","Pharmacy - Staff and Dispensing Fee Cost",null,null,"Physician",177024.59945695,531073.79837085004,112895,338685,null,"Podiatrist",149309.37911571024,447928.13734713075]
[null,"Sixteenth Street",null,"Group Health Cooperative","Physician Assistant","Medical","Radiology - Medical Support",null,null,"Podiatrist",149309.37916020001,447928.13748059998,95220,285660,null,"Psychiatrist",163508.03935402949,490524.11806208838]
[null,null,null,"Group Health Cooperative of Eau Claire","Physician","Medical","Registered Dietician",null,null,"Psychiatrist",163508.03940275,490524.11820824997,104275,312825,null,"Psychologist",69088.124804013802,207264.37441204139]
[null,null,null,"Group Health Cooperative of South Central Wisconsin","Podiatrist","Medical","SBIRT Services",null,null,"Psychologist",69088.124824600003,207264.37447380001,44060,132180,null,"Psychotherapist (APSW,LCSW, LPC, ISW, MFT)",163508.03935402949,490524.11806208838]
[null,null,null,"Gundersen","Psychiatrist","Behavioral Health","Telemedicine - Medical Support",null,null,"Psychotherapist (APSW,LCSW, LPC, ISW, MFT)",163508.03940275,490524.11820824997,104275,312825,null,"Speech-Language Pathologist",51957.217779868297,155871.65333960488]
[null,null,null,"Health Tradition Health Plan","Psychologist","Behavioral Health","Translation Services - Enabling Services",null,null,"Speech-Language Pathologist",51957.21779535,155871.65338604999,33135,99405]
[null,null,null,"HSM","Psychotherapist (APSW,LCSW, LPC, ISW, MFT)","Behavioral Health","Transcriptionist",null,1.56804641,"Qualified Treatment Trainee",67880.7290889,135761.4581778,43290,86580]
[null,null,null,"Independent Care Health Plan","Speech-Language Pathologist","Medical","Vocational Therapy - Enabling Services"]
[null,null,null,"Lakeland Care District","Qualified Treatment Trainee","Behavioral Health","X-Ray - Medical Support"]
[null,null,null,"Managed Health Services"]
[null,null,null,"Medicaid – MI / Dept of Social Service "]
[null,null,null,"MercyCare Insurance Company"]
[null,null,null,"Milwaukee Department of Family Care"]
[null,null,null,"Molina Dental (Scion)"]
[null,null,null,"Molina Healthcare "]
[null,null,null,"Network Health Plan"]
[null,null,null,"Physicians Plus"]
[null,null,null,"Security Health Plan"]
[null,null,null,"Southeast Dental Associates "]
[null,null,null,"Trilogy Health Insurance"]
[null,null,null,"United Healthcare  (Behavioral Health) "]
[null,null,null,"United Healthcare (Dental) "]
[null,null,null,"United Healthcare (Medicaid) "]
[null,null,null,"Unity Health Plans"]
[null,null,null,"Valley Health Plan"]
[null,null,null,"Well Woman"]
[null,null,null,"Western Wisconsin Cares"]
[null,null,null,"Other (Please Specify in Notes)"]
[]
[]
[]
[]
[]
[]
[]
[]
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