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{"sheet":"Certification Statement","index":0,"n_rows":33,"n_cols":8,"rows_kept":33,"cut":false,"hidden":false,"merged":[[29,6,29,9],[29,0,29,5],[32,0,32,5],[22,0,24,9],[25,0,28,9],[33,0,34,5],[30,0,31,5],[30,6,31,9],[33,6,34,9],[32,6,32,9],[0,0,0,3],[0,7,0,9],[13,0,13,5],[13,6,13,9],[11,0,11,9],[4,0,4,9],[5,0,5,9],[3,0,3,9],[2,2,2,9],[12,0,12,5],[12,6,12,9],[6,0,6,9],[7,0,7,9],[8,0,10,9],[1,0,1,2],[1,6,1,9],[14,6,14,9],[14,0,14,5],[15,6,16,9],[15,0,16,5],[21,0,21,9],[20,1,20,2],[20,4,20,9],[17,5,17,9],[18,5,19,9],[17,0,17,4],[18,0,19,4]]}
["DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,"STATE OF WISCONSIN"]
["Division of Medicaid Services",null,null,null,null,null,"Wisconsin State Plan Amendment 17-0010"]
["F-11129B (01/2021)"]
[]
["WISCONSIN MEDICAID"]
["TRIBAL AND OUT-OF-STATE FEDERALLY QUALIFIED HEALTH CENTER"]
["CERTIFICATION STATEMENT"]
[]
["INSTRUCTIONS: Type or print clearly. Refer to the Tribal and Out-of-State Federally Qualified Health Center Cost Report Instructions, F-11129A, for detailed information on completing this form. For this form, \"FQHC\" refers only to tribal and out-of-state federally qualified health centers (FQHCs), not community health centers."]
[]
[]
["SECTION I – PROVIDER AND PREPARER INFORMATION"]
["Name – FQHC",null,null,null,null,null,"Provider Number"]
[]
["Name and Title – Person Preparing Cost Report",null,null,null,null,null,"Phone Number"]
[]
[]
["Reporting Period",null,null,null,null,"Fax Number"]
[]
[]
["From",null,null,"To"]
["SECTION II – CERTIFICATION AND SIGNATURE"]
["Intentional misrepresentation or falsification of any information contained in these worksheets may be punishable by fine and/or imprisonment under federal law."]
[]
[]
["I hereby certify that I have read the above statement and that I have examined the accompanying worksheets for the indicated reporting period, and that to the best of my knowledge and belief it is a true, correct, and complete statement prepared from the books and records of the FQHC in accordance with applicable instructions."]
[]
[]
[]
["Name – FQHC Officer or Administrator",null,null,null,null,null,"Title – FQHC Officer or Administrator"]
[]
[]
["SIGNATURE – FQHC Officer or Administrator",null,null,null,null,null,"Date Signed"]

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["DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,null,null,"STATE OF WISCONSIN"]
["Division of Medicaid Services",null,null,null,null,null,"Wisconsin State Plan Amendment 17-0010"]
["F-11129C (01/2021)"]
[]
["WISCONSIN MEDICAID"]
["TRIBAL AND OUT-OF-STATE FEDERALLY QUALIFIED HEALTH CENTER"]
["STATISTICAL DATA WORKSHEET"]
[]
["INSTRUCTIONS: Type or print clearly. Refer to the Tribal and Out-of-State Federally Qualified Health Center Cost Report Instructions, F-11129A, for detailed information on completing this form."]
[]
[]
["SECTION I – PROVIDER INFORMATION"]
["1.  Name – Federally Qualified Health Center (FQHC)"]
[]
["2.  Provider Number"]
[]
["3.  Address – FQHC"]
[]
[]
[]
["4.  Type of Organizational Structure"]
[]
[]
[]
["5.  Name – FQHC Owner"]
[]
[]
["6.  Reporting Period"]
[]
["From",null,null,"To"]
["SECTION II – OTHER ENTITIES OF THE FQHC OWNER"]
["7.  List all other FQHCs and providers of services including rural health clinics, hospitals, skilled nursing facilities, home health agencies, suppliers, or other entities that are owned or related through common ownership or control to the individual or entity listed in Element 5."]
["Name – Provider",null,null,"Location",null,null,"Provider Number"]
[]
[]
[]
[]
["SECTION III – PHYSICIANS DIRECTLY EMPLOYED BY THE FQHC"]
["8.  List the Medicaid-certified physicians furnishing services at the FQHC who are directly employed by the FQHC."]
[]
["Name – Physician",null,null,null,null,"Provider Number"]
[]
[]
[]
[]
[]
[]
[]
["Tribal and Out-of-State Federally Qualified Health Center Statistical Data Worksheet",null,null,null,null,null,null,null,null,"Page 2 of 2"]
["F-11129C (01/2021)"]
["SECTION IV – OTHER PROVIDERS DIRECTLY EMPLOYED BY THE FQHC"]
["9. List any other Medicaid-certified providers furnishing services at the FQHC who are not physicians but are directly employed by the FQHC."]
[]
["Name – Provider",null,null,"Medicaid Provider Type",null,null,"Provider Number"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["SECTION V – PHYSICIANS AND OTHER PROVIDERS UNDER CONTRACT WITH THE FQHC"]
["10. List the Medicaid-certified physicians and other providers furnishing services at the FQHC who are under contract with the FQHC."]
["Name – Provider",null,null,"Medicaid Provider Type",null,null,"Provider Number"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["SECTION VI – OTHER FQHC MEDICAID PROVIDER NUMBERS"]
["11. List any National Provider Identifiers or Medicaid provider numbers included in the FQHC’s expenses, excluding the provider number listed in Element 2."]
[]
["Medicaid Provider Type",null,null,null,null,"Provider Number"]

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["DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,null,null,null,null,"STATE OF WISCONSIN"]
["Division of Medcaid Services",null,null,null,null,null,null,null,"Wisconsin State Plan Amendment 17-0010"]
["F-11129D (01/2021)"]
[]
["WISCONSIN MEDICAID"]
["TRIBAL AND OUT-OF-STATE FEDERALLY QUALIFIED HEALTH CENTER"]
["RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES"]
["WORKSHEET 1"]
[]
["INSTRUCTIONS: Type or print clearly. Refer to the Tribal and Out-of-State Federally Qualified Health Center Cost Report Instructions, F-11129A, for detailed information on completing this form."]
["SECTION I – GENERAL INFORMATION"]
["Provider Number",null,"Reporting Period",null,null,null,"Trial Balance Expenses Are (Check One)"]
[{"$f":"'Statistical Data Worksheet'!A16:J16","v":0},null,"From",{"$f":"'Certification Statement'!B21","v":"00:00:00"},"To",{"$f":"'Certification Statement'!E21","v":"00:00:00"}]
[]
["SECTION II – FACILITY HEALTH CARE COSTS"]
["Cost Center","A. Compensation","B. Fringe Benefits","C. Purchased and Contract Services",null,"D. Other","E. Total (Total of Columns A Through D)","F. Reclassifi-cations","G. Reclassified Trial Balance (Total of Columns E and F)",null,"H. Adjustments Increase [Decrease]","I. Net Expenses (Total of Columns G and H)"]
[]
[]
["PRIMARY PROVIDER"]
["1.  Physician",null,null,null,null,null,{"$f":"SUM(B20:F20)","v":0},null,{"$f":"SUM(G20:H20)","v":0},null,null,{"$f":"SUM(I20:K20)","v":0}]
["2.  Physician Assistant",null,null,null,null,null,{"$f":"SUM(B21:F21)","v":0},null,{"$f":"SUM(G21:H21)","v":0},null,null,{"$f":"SUM(I21:K21)","v":0}]
["3.  Nurse Practitioner",null,null,null,null,null,0,null,0,null,null,0]
["4.  Clinical Psychologist",null,null,null,null,null,0,null,0,null,null,0]
["5.  Clinical Social Worker",null,null,null,null,null,0,null,0,null,null,0]
["6.  Dentist",null,null,null,null,null,0,null,0,null,null,0]
["7.  Nursing Care to Homebound",null,null,null,null,null,0,null,0,null,null,0]
["8.  Speech and Hearing",null,null,null,null,null,0,null,0,null,null,0]
["9.  Occupational Therapist",null,null,null,null,null,0,null,0,null,null,0]
["10. Physical Therapist",null,null,null,null,null,0,null,0,null,null,0]
["11. Vocational Therapist",null,null,null,null,null,0,null,0,null,null,0]
["12. Optometrist",null,null,null,null,null,0,null,0,null,null,0]
["13. Podiatrist",null,null,null,null,null,0,null,0,null,null,0]
["14. Psychotherapist",null,null,null,null,null,0,null,0,null,null,0]
["15. Chiropractor",null,null,null,null,null,0,null,0,null,null,0]
["16. Substance Abuse Services",null,null,null,null,null,0,null,0,null,null,0]
[]
["Tribal and Out-of-State Federally Qualified Health Center Reclassification and Adjustment of Trial Balance of Expenses",null,null,null,null,null,null,null,null,null,"Page 2 of 4"]
["F-11129D (01/2021)"]
["Cost Center","A. Compensation","B. Fringe Benefits","C. Purchased and Contract Services",null,"D. Other","E. Total (Total of Columns A Through D)","F. Reclassifi-cations","G. Reclassified Trial Balance (Total of Columns E and F)",null,"H. Adjustments Increase [Decrease]","I. Net Expenses (Total of Columns G and H)"]
[]
[]
["17. Other (Specify) _______",null,null,null,null,null,{"$f":"SUM(B42:F42)","v":0},null,{"$f":"SUM(G42:H42)","v":0},null,null,{"$f":"SUM(I42:K42)","v":0}]
["18. TOTAL – Primary Providers (Sum of Lines 1 Through 17)",{"$f":"SUM(B20:B35)+SUM(B42)","v":0},{"$f":"SUM(C20:C35)+SUM(C42)","v":0},0,null,{"$f":"SUM(F20:F35)+SUM(F42)","v":0},0,0,{"$f":"SUM(I20:J35)+SUM(I42)","v":0},null,{"$f":"SUM(K20:K35)+SUM(K42)","v":0},{"$f":"SUM(L20:L35)+SUM(L42)","v":0}]
["INDIRECT COSTS"]
["19. Laboratory-Medical",null,null,null,null,null,{"$f":"SUM(B45:F45)","v":0},null,{"$f":"SUM(G45:H45)","v":0},null,null,{"$f":"SUM(I45:K45)","v":0}]
["20. X-Ray-Medical",null,null,null,null,null,{"$f":"SUM(B46:F46)","v":0},null,{"$f":"SUM(G46:H46)","v":0},null,null,{"$f":"SUM(I46:K46)","v":0}]
["21. Pharmacy",null,null,null,null,null,0,null,0,null,null,0]
["22. Nurses",null,null,null,null,null,0,null,0,null,null,0]
["23. Patient Transportation",null,null,null,null,null,0,null,0,null,null,0]
["24. Translator",null,null,null,null,null,0,null,0,null,null,0]
["25. Health Education",null,null,null,null,null,0,null,0,null,null,0]
["26. Medical Records",null,null,null,null,null,0,null,0,null,null,0]
["27. Medical Social Worker",null,null,null,null,null,0,null,0,null,null,0]
["28. Other (Specify) ________",null,null,null,null,null,0,null,0,null,null,0]
["29. Other (Specify) ________",null,null,null,null,null,0,null,0,null,null,0]
["30. TOTAL – Indirect Costs (Sum of Lines 19 Through 29)",{"$f":"SUM(B45:B55)","v":0},{"$f":"SUM(C45:C55)","v":0},0,null,0,0,0,0,null,{"$f":"SUM(K45:K55)","v":0},0]
["31. TOTAL – Health Care\n(Sum of Lines 18 and 30)",{"$f":"B43+B56","v":0},{"$f":"C43+C56","v":0},0,null,0,0,0,0,null,0,{"$f":"L43+L56","v":0}]
["NON-REIMBURSABLE COSTS"]
["32. Education",null,null,null,null,null,{"$f":"SUM(B59:F59)","v":0},null,{"$f":"SUM(G59:H59)","v":0},null,null,{"$f":"SUM(I59:K59)","v":0}]
["33. Outreach",null,null,null,null,null,0,null,{"$f":"SUM(G60:H60)","v":0},null,null,{"$f":"SUM(I60:K60)","v":0}]
["34. Community Services ",null,null,null,null,null,0,null,0,null,null,0]
["35. Environment ",null,null,null,null,null,0,null,0,null,null,0]
["36. Research ",null,null,null,null,null,0,null,0,null,null,0]
["37. Nonmedical Social Worker",null,null,null,null,null,0,null,0,null,null,0]
["38. Other (Specify) ______",null,null,null,null,null,0,null,0,null,null,0]
["39. TOTAL – Nonreimbursable Costs (Sum of Lines 32 Through 38)",{"$f":"SUM(B59:B65)","v":0},{"$f":"SUM(C59:C65)","v":0},0,null,0,0,0,0,null,0,0]
[]
["Tribal Federally Qualified Health Center Reclassification and Adjustment of Trial Balance of Expenses",null,null,null,null,null,null,null,null,null,"Page 3 of 4"]
["F-11129D (01/2021)"]
["Cost Center","A. Compensation","B. Fringe Benefits","C. Purchased and Contract Services",null,"D. Other","E. Total (Total of Columns A Through D)","F. Reclassifi-cations","G. Reclassified Trial Balance (Total of Columns E and F)",null,"H. Adjustments Increase [Decrease]","I. Net Expenses (Total of Columns G and H)"]
[]
[]
["LOCALLY MATCHED WISCONSIN MEDICAID SERVICES CATEGORY "]
["40. Community Support Program",0,0,0,null,0,{"$f":"SUM(B74:F74)","v":0},null,{"$f":"SUM(G74:H74)","v":0},null,null,{"$f":"SUM(I74:K74)","v":0}]
["41. Targeted Case Management",null,null,null,null,null,{"$f":"SUM(B75:F75)","v":0},null,{"$f":"SUM(G75:H75)","v":0},null,null,{"$f":"SUM(I75:K75)","v":0}]
["42. TOTAL – Locally Matched Wisconsin Medicaid Services (Sum of Lines 40 and 41)",{"$f":"SUM(B74:B75)","v":0},{"$f":"SUM(C74:C75)","v":0},0,null,0,0,0,0,null,0,0]
["OVERHEAD COSTS"]
["43. Administration",null,null,null,null,null,{"$f":"SUM(B78:F78)","v":0},null,{"$f":"SUM(G78:H78)","v":0},null,null,{"$f":"SUM(I78:K78)","v":0}]
["44. Receptionist",null,null,null,null,null,0,null,0,null,null,0]
["45. Billing",null,null,null,null,null,0,null,0,null,null,0]
["46. Financial",null,null,null,null,null,0,null,0,null,null,0]
["47. Marketing",null,null,null,null,null,0,null,0,null,null,0]
["48. Legal",null,null,null,null,null,0,null,0,null,null,0]
["49. Data Processing",null,null,null,null,null,0,null,0,null,null,0]
["50. Housekeeping",null,null,null,null,null,0,null,0,null,null,0]
["51. Maintenance",null,null,null,null,null,0,null,0,null,null,0]
["52. Security",null,null,null,null,null,0,null,0,null,null,0]
["53. Supplies",null,null,null,null,null,0,null,0,null,null,0]
["54. Insurance",null,null,null,null,null,0,null,0,null,null,0]
["55. Phone",null,null,null,null,null,0,null,0,null,null,0]
["56. Utilities",null,null,null,null,null,0,null,0,null,null,0]
["57. Rent",null,null,null,null,null,0,null,0,null,null,0]
["58. Maintenance and Repair",null,null,null,null,null,0,null,0,null,null,0]
["59. Depreciation",null,null,null,null,null,0,null,0,null,null,0]
["60. Amortization",null,null,null,null,null,0,null,0,null,null,0]
["61. Contributors",null,null,null,null,null,0,null,0,null,null,0]
[]
["Tribal Federally Qualified Health Center Reclassification and Adjustment of Trial Balance of Expenses",null,null,null,null,null,null,null,null,null,"Page 4 of 4"]
["F-11129D (01/2021)"]
["Cost Center","A. Compensation","B. Fringe Benefits","C. Purchased and Contract Services",null,"D. Other","E. Total (Total of Columns A Through D)","F. Reclassifi-cations","G. Reclassified Trial Balance (Total of Columns E and F)",null,"H. Adjustments Increase [Decrease]","I. Net Expenses (Total of Columns G and H)"]
[]
[]
["62. Transportation",null,null,null,null,null,{"$f":"SUM(B103:F103)","v":0},null,{"$f":"SUM(G103:H103)","v":0},null,null,{"$f":"SUM(I103:K103)","v":0}]
["63. Mortgage Interest",null,null,null,null,null,{"$f":"SUM(B104:F104)","v":0},null,{"$f":"SUM(G104:H104)","v":0},null,null,{"$f":"SUM(I104:K104)","v":0}]
["64. Other (Specify) ________",null,null,null,null,null,{"$f":"SUM(B105:F105)","v":0},null,{"$f":"SUM(G105:H105)","v":0},null,null,{"$f":"SUM(I105:K105)","v":0}]
["65. TOTAL – Overhead (Sum of Lines 43 Through 64)",{"$f":"SUM(B78:B87)+SUM(B105)","v":0},{"$f":"SUM(C78:C87)+SUM(C105)","v":0},{"$f":"SUM(D78:D96)+SUM(D103:D105)","v":0},null,{"$f":"SUM(F78:F96)+SUM(F103:F105)","v":0},{"$f":"SUM(G78:G96)+SUM(G103:G105)","v":0},{"$f":"SUM(H78:H96)+SUM(H103:H105)","v":0},{"$f":"SUM(I78:I96)+SUM(I103:I105)","v":0},null,{"$f":"SUM(K78:K96)+SUM(K103:K105)","v":0},{"$f":"SUM(L78:L96)+SUM(L103:L105)","v":0}]
["66. TOTAL COSTS (Sum of Lines 31, 39, 42, 65)",{"$f":"B57+B66+B76+B106","v":0},{"$f":"C57+C66+C76+C106","v":0},0,null,0,0,0,0,null,0,0]

{"sheet":"Worksheet 2","index":3,"n_rows":44,"n_cols":10,"rows_kept":44,"cut":false,"hidden":false,"merged":[[39,5,39,6],[40,5,40,6],[35,5,35,6],[36,5,36,6],[37,5,37,6],[38,5,38,6],[31,5,31,6],[32,5,32,6],[33,5,33,6],[34,5,34,6],[27,5,27,6],[28,5,28,6],[29,5,29,6],[30,5,30,6],[43,0,43,2],[43,3,43,6],[43,7,43,9],[41,0,41,9],[42,3,42,6],[42,7,42,9],[42,0,42,2],[37,0,37,2],[38,0,38,2],[39,0,39,2],[40,0,40,2],[28,0,28,2],[32,0,32,2],[31,0,31,2],[29,0,29,2],[30,0,30,2],[34,0,34,2],[35,0,35,2],[36,0,36,2],[33,0,33,2],[27,0,27,2],[25,5,25,6],[21,8,22,8],[21,3,22,3],[21,9,22,9],[21,4,22,4],[23,5,23,6],[26,5,26,6],[26,0,26,2],[24,5,24,6],[21,5,22,6],[21,7,22,7],[24,0,24,2],[25,0,25,2],[19,0,19,9],[20,0,22,2],[23,0,23,2],[15,6,16,9],[17,6,18,9],[16,0,17,5],[20,3,20,6],[20,7,20,9],[14,0,15,5],[18,1,18,2],[18,4,18,5],[13,6,14,9],[0,0,0,7],[2,0,2,1],[13,0,13,5],[3,0,3,9],[2,2,2,9],[12,0,12,9],[4,0,4,9],[5,0,5,9],[6,0,6,9],[8,0,8,9],[9,0,11,9],[7,0,7,9],[1,0,1,2],[1,6,1,9]]}
["DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,null,null,"STATE OF WISCONSIN"]
["Division of Medicaid Services",null,null,null,null,null,"Wisconsin State Plan Amendment 17-0010"]
["F-11129E (01/2021)"]
[]
["WISCONSIN MEDICAID"]
["TRIBAL AND OUT-OF-STATE FEDERALLY QUALIFIED HEALTH CENTER"]
["STAFF, ENCOUNTERS, PRODUCTIVITY, AND CHARGES"]
["WORKSHEET 2"]
[]
["INSTRUCTIONS: Type or print clearly. Refer to the Tribal and Out-of-State Federally Qualified Health Center Cost Report Instructions, F-11129A, for detailed information on completing this form."]
[]
[]
["SECTION I – GENERAL INFORMATION"]
["Provider Number",null,null,null,null,null,"Figures Are (Check One)"]
[{"$f":"'Worksheet 1'!A13:B13","v":0}]
[]
["Reporting Period"]
[]
["From",{"$f":"'Worksheet 1'!D13","v":"00:00:00"},null,"To",{"$f":"'Worksheet 1'!F13","v":"00:00:00"}]
["SECTION II – STAFF AND ENCOUNTERS"]
[null,null,null,"Full-Time Equivalent (FTE) Personnel",null,null,null,"Encounters"]
[null,null,null,"A. Under Contract","B. Staff","C. Staff Total",null,"D. Non-Wisconsin Medicaid","E. Wisconsin Medicaid","F. Total"]
[]
["1.  Physician",null,null,null,null,{"$f":"SUM(D24:E24)","v":0},null,null,null,{"$f":"SUM(H24:I24)","v":0}]
["2.  Physician Assistant",null,null,null,null,{"$f":"SUM(D25:E25)","v":0},null,null,null,{"$f":"SUM(H25:I25)","v":0}]
["3.  Nurse Practitioner",null,null,null,null,0,null,null,null,0]
["4.  Clinical Psychologist",null,null,null,null,0,null,null,null,0]
["5.  Clinical Social Worker",null,null,null,null,0,null,null,null,0]
["6.  Dentist",null,null,null,null,0,null,null,null,0]
["7.  Nursing Care to Homebound",null,null,null,null,0,null,null,null,0]
["8.  Speech and Hearing",null,null,null,null,0,null,null,null,0]
["9.  Occupational Therapist",null,null,null,null,0,null,null,null,0]
["10. Physical Therapist",null,null,null,null,0,null,null,null,0]
["11. Vocational Therapist",null,null,null,null,0,null,null,null,0]
["12. Optometrist",null,null,null,null,0,null,null,null,0]
["13. Podiatrist",null,null,null,null,0,null,null,null,0]
["14. Psychotherapist",null,null,null,null,0,null,null,null,0]
["15. Chiropractor",null,null,null,null,0,null,null,null,0]
["16. Substance Abuse Services",null,null,null,null,0,null,null,null,0]
["17. Other (Specify) _____________",null,null,null,null,0,null,null,null,0]
["18. TOTAL – FTE and Encounters",null,null,{"$f":"SUM(D24:D40)","v":0},{"$f":"SUM(E24:E40)","v":0},{"$f":"SUM(F24:G40)","v":0},null,{"$f":"SUM(H24:H40)","v":0},{"$f":"SUM(I24:I40)","v":0},{"$f":"SUM(J24:J40)","v":0}]
["SECTION III – CHARGE INFORMATION"]
[null,null,null,"Medicaid-Enrolled Member Charges",null,null,null,"Total All Charges"]
["19. Charges for Reporting Period"]

{"sheet":"Worksheet 3","index":4,"n_rows":51,"n_cols":10,"rows_kept":51,"cut":false,"hidden":false,"merged":[[50,0,50,8],[51,0,51,8],[47,0,47,8],[48,0,48,8],[49,0,49,8],[33,0,33,8],[34,0,34,8],[39,0,39,8],[46,1,46,8],[42,1,42,8],[43,1,43,8],[44,1,44,8],[45,1,45,8],[41,1,41,8],[38,0,38,8],[35,0,35,9],[36,0,36,8],[37,0,37,8],[40,1,40,8],[32,0,32,8],[24,0,24,8],[25,0,25,8],[26,0,26,8],[31,0,31,9],[28,0,28,8],[29,0,29,8],[30,0,30,8],[27,0,27,8],[23,0,23,8],[15,6,16,9],[20,0,20,8],[21,0,21,8],[17,6,18,9],[19,0,19,9],[18,4,18,5],[18,0,18,1],[22,0,22,8],[16,0,17,5],[0,0,0,7],[13,0,13,5],[14,0,15,5],[3,0,3,9],[12,0,12,9],[4,0,4,9],[5,0,5,9],[6,0,6,9],[8,0,8,9],[9,0,11,9],[7,0,7,9],[13,6,14,9],[1,0,1,3],[1,8,1,9]]}
["DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,null,null,"STATE OF WISCONSIN"]
["Division of Medicaid Services ",null,null,null,null,null,null,null,"Wisconsin State Plan Amendment 17-0010"]
["F-11129F (01/2021)"]
[]
["WISCONSIN MEDICAID"]
["TRIBAL AND OUT-OF-STATE FEDERALLY QUALIFIED HEALTH CENTER"]
["DETERMINATION OF OVERHEAD, RATE, AND REIMBURSEMENT"]
["WORKSHEET 3"]
[]
["INSTRUCTIONS: Type or print clearly. Refer to the Tribal and Out-of-State Federally Qualified Health Center Cost Report Instructions, F-11129A, for detailed information on completing this form."]
[]
[]
["SECTION I – GENERAL INFORMATION"]
["Provider Number",null,null,null,null,null,"Figures Are (Check One)"]
[{"$f":"'Worksheet 1'!A13:B13","v":0}]
[]
["Reporting Period"]
[]
["From",null,{"$f":"'Worksheet 1'!D13","v":"00:00:00"},"To",{"$f":"'Worksheet 1'!F13","v":"00:00:00"}]
["SECTION II – DETERMINATION OF OVERHEAD APPLICABLE TO TRIBAL FEDERALLY QUALIFIED HEALTH CENTER (FQHC) SERVICES"]
["1. Cost of FQHC services excluding overhead (Worksheet 1; column I, sum of lines 31 and 42)",null,null,null,null,null,null,null,null,{"$f":"'Worksheet 1'!L57+'Worksheet 1'!L76","v":0}]
["2. Non-reimbursable FQHC costs excluding overhead (Worksheet 1; column I, line 39)",null,null,null,null,null,null,null,null,{"$f":"'Worksheet 1'!L66","v":0}]
["3. Cost of all services excluding overhead (Sum of lines 1 and 2)",null,null,null,null,null,null,null,null,{"$f":"SUM(J21:J22)","v":0}]
["4. Percentage of non-reimbursable FQHC costs (Line 2 divided by line 3)",null,null,null,null,null,null,null,null,{"$f":"ROUND(J22/J23,4)","v":{"$error":"#DIV/0!"}}]
["5. Total overhead (Worksheet 1; column I, line 65)",null,null,null,null,null,null,null,null,{"$f":"'Worksheet 1'!L106","v":0}]
["6. Total cost of all services and overhead (Sum of lines 3 and 5)",null,null,null,null,null,null,null,null,{"$f":"J23+J25","v":0}]
["7. Maximum allowable overhead (Primary provider and indirect costs multiplied by 50 percent)",null,null,null,null,null,null,null,null,{"$f":"'Worksheet 1'!L57*0.5","v":0}]
["8. Overhead allowed (Lesser of lines 5 or 7)",null,null,null,null,null,null,null,null,{"$f":"MIN(J25,J27)","v":0}]
["9. Overhead applicable to non-reimbursable FQHC costs (Line 4 multiplied by line 8)",null,null,null,null,null,null,null,null,{"$f":"J24*J28","v":{"$error":"#DIV/0!"}}]
["10. Overhead applicable to FQHC services (Line 8 less line 9)",null,null,null,null,null,null,null,null,{"$f":"J28-J29","v":{"$error":"#DIV/0!"}}]
["11. Total cost of FQHC services (Sum of lines 1 and 10)",null,null,null,null,null,null,null,null,{"$f":"J21+J30","v":{"$error":"#DIV/0!"}}]
["SECTION III – DETERMINATION OF FQHC RATE"]
["12.  Total cost of FQHC services (Line 11)",null,null,null,null,null,null,null,null,{"$f":"J31","v":{"$error":"#DIV/0!"}}]
["13.  Total FQHC adjusted encounters (Worksheet 2; column F, line 18)",null,null,null,null,null,null,null,null,{"$f":"'Worksheet 2'!J41","v":0}]
["14.  FQHC rate per encounter (Line 12 divided by line 13)",null,null,null,null,null,null,null,null,{"$f":"ROUND(J33/J34,2)","v":{"$error":"#DIV/0!"}}]
["SECTION IV – DETERMINATION OF TOTAL REIMBURSEMENT"]
["15. FQHC rate per encounter (Line 14)",null,null,null,null,null,null,null,null,{"$f":"J35","v":{"$error":"#DIV/0!"}}]
["16. FQHC Medicaid and Medicare / Medicaid crossover encounters during the reporting period (Worksheet 2; column E, line 18)",null,null,null,null,null,null,null,null,{"$f":"'Worksheet 2'!I41","v":0}]
["17. Medicaid reasonable costs including crossovers (Line 15 multiplied by Line 16)",null,null,null,null,null,null,null,null,{"$f":"ROUND(J37*J38,2)","v":{"$error":"#DIV/0!"}}]
["18. Less Payments received by FQHC for services during this reporting period"]
[null,"a. Payments from Medicare Part C to FQHC for crossovers during the reporting period"]
[null,"b. Payments from Medicare (excluding Part C) to FQHC for crossovers during the reporting period"]
[null,"c. Payments from Medicaid fee-for-service to FQHC during the reporting period"]
[null,"d. Payments from Medicaid for interim FQHC payments during the reporting period"]
[null,"e. Payments by or due from Medicaid managed care organizations to FQHC during the reporting period",null,null,null,null,null,null,null,{"$f":"'Worksheet 4'!H39:J39","v":0}]
[null,"f. Payments by or due from other third parties (insurance, HMOs) to FQHC for Medicaid members"]
[null,"g. Copayments from Medicaid members during this reporting period"]
["19. TOTAL – Payments received by FQHC for services during this reporting period (Sum of lines 18a–18g)",null,null,null,null,null,null,null,null,{"$f":"SUM(J41:J47)","v":0}]
["20. Balance due to or from Medicaid (Line 17 less line 19)",null,null,null,null,null,null,null,null,{"$f":"J39-J48","v":{"$error":"#DIV/0!"}}]
["21. Outstationed enrollment expenses (Worksheet 5; line 30)",null,null,null,null,null,null,null,null,{"$f":"'Worksheet 5'!J55","v":0}]
["22. Total balance due (Sum of lines 20 and 21)",null,null,null,null,null,null,null,null,{"$f":"SUM(J49:J50)","v":{"$error":"#DIV/0!"}}]

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["DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,null,null,"STATE OF WISCONSIN"]
["Division of Medicaid Services",null,null,null,"Wisconsin State Plan Amendment 17-0010"]
["F-11129G (01/2021)"]
[]
["WISCONSIN MEDICAID"]
["TRIBAL AND OUT-OF-STATE FEDERALLY QUALIFIED "]
["HEALTH CENTER MANAGED CARE INCOME REPORTING"]
["WORKSHEET 4"]
[]
["INSTRUCTIONS: Type or print clearly. Refer to the Tribal and Out-of-State Federally Qualified Health Center Cost Report Instructions, F-11129A, for detailed information on completing this form."]
[]
[]
["SECTION I – GENERAL INFORMATION"]
["Provider Number",null,null,null,"Reporting Period"]
[{"$f":"'Worksheet 1'!A13:B13","v":0}]
[null,null,null,null,"From",{"$f":"'Worksheet 1'!D13","v":"00:00:00"},null,null,"To",{"$f":"'Worksheet 1'!F13","v":"00:00:00"}]
["SECTION II – MANAGED CARE INCOME INFORMATION"]
["Managed Care Entity",null,null,"Total Medicaid Encounters",null,null,null,"Total Dollar \nAmount Received*\n(Accrual Basis)"]
[]
["EXAMPLE: Dean Health Plan",null,null,250,null,null,null,12000]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["TOTAL"]
["* The total line of this column should equal the amount reported on Worksheet 3, line 18e."]

{"sheet":"Worksheet 5","index":6,"n_rows":56,"n_cols":10,"rows_kept":56,"cut":false,"hidden":false,"merged":[[1,0,1,2],[1,6,1,9],[23,0,23,2],[37,3,46,3],[24,0,24,2],[19,0,19,9],[39,0,39,2],[40,0,40,2],[43,0,43,2],[32,5,32,6],[27,0,27,2],[28,0,28,2],[46,0,46,2],[41,0,41,2],[42,0,42,2],[37,0,37,2],[0,0,0,7],[2,0,2,9],[13,0,13,4],[15,5,16,9],[17,5,18,9],[13,5,14,9],[12,0,12,9],[4,0,4,9],[16,0,17,4],[14,0,15,4],[18,1,18,2],[5,0,5,9],[6,0,6,9],[8,0,8,9],[9,0,11,9],[7,0,7,9],[54,0,54,8],[55,0,55,8],[50,0,50,2],[51,0,51,2],[52,0,52,2],[53,0,53,2],[53,5,53,6],[20,4,21,4],[44,0,44,2],[45,0,45,2],[38,0,38,2],[33,5,33,6],[34,5,34,6],[35,5,35,6],[33,0,33,2],[34,0,34,2],[35,0,35,2],[39,5,39,6],[40,5,40,6],[38,5,38,6],[44,5,44,6],[36,0,36,9],[37,5,37,6],[43,5,43,6],[20,8,21,8],[20,7,21,7],[20,9,21,9],[23,5,23,6],[31,5,31,6],[29,5,29,6],[20,5,21,6],[30,5,30,6],[24,5,24,6],[22,0,22,9],[31,0,31,2],[29,0,29,2],[30,0,30,2],[20,0,21,2],[20,3,21,3],[32,0,32,2],[3,0,3,9],[49,0,49,2],[47,0,47,9],[48,0,48,2],[48,3,52,6],[28,5,28,6],[25,5,25,6],[26,5,26,6],[27,5,27,6],[26,0,26,2],[25,0,25,2],[45,5,45,6],[46,5,46,6],[41,5,41,6],[42,5,42,6]]}
["DEPARTMENT OF HEALTH SERVICES",null,null,null,null,null,null,null,null,"STATE OF WISCONSIN"]
["Division of Medicaid Services",null,null,null,null,null,"Wisconsin State Plan Amendment 17-0010"]
["F-11129H (01/2021)"]
[]
["WISCONSIN MEDICAID"]
["TRIBAL AND OUT-OF-STATE FEDERALLY QUALIFIED HEALTH CENTER"]
["OUTSTATIONED ENROLLMENT EXPENSES"]
["WORKSHEET 5"]
[]
["INSTRUCTIONS: Type or print clearly. Refer to the Tribal and Out-of-State Federally Qualified Health Center Cost Report Instructions, F-11129A, for detailed information on completing this form."]
[]
[]
["SECTION I — GENERAL INFORMATION"]
["Provider Number",null,null,null,null,"Figures Are (Check One)"]
[{"$f":"'[1]Worksheet 1'!A13:B13","v":0}]
[]
["Reporting Period"]
[]
["From",{"$f":"'[1]Worksheet 1'!D13","v":"00:00:00"},null,"To",{"$f":"'[1]Worksheet 1'!F13","v":"00:00:00"}]
["SECTION II — OUTSTATIONED ENROLLMENT EXPENSES"]
[null,null,null,"Worksheet 1 Line Number","Compensation","Fringe Benefits",null,"Purchased and Contract Services","Other","TOTAL"]
[]
["PERSONNEL LISTED ON WORKSHEET 1"]
["1.    Clinical Social Worker",null,null,5,null,null,null,null,null,{"$f":"SUM(E24:I24)","v":0}]
["2.    Other (Specify) __________",null,null,17,null,null,null,null,null,0]
["3.    Nurses",null,null,22,null,null,null,null,null,0]
["4.    Translator",null,null,24,null,null,null,null,null,0]
["5.    Health Education",null,null,25,null,null,null,null,null,0]
["6.    Medical Social Worker",null,null,27,null,null,null,null,null,0]
["7.    Other (Specify) __________",null,null,28,null,null,null,null,null,0]
["8.    Other (Specify) __________",null,null,29,null,null,null,null,null,0]
["9.    Outreach",null,null,33,null,null,null,null,null,0]
["10.  Community Services",null,null,34,null,null,null,null,null,0]
["11.  Nonmedical Social Worker",null,null,37,null,null,null,null,null,0]
["12.  Other (Specify) __________",null,null,38,null,null,null,null,null,0]
["13. Administration",null,null,43,null,null,null,null,null,0]
["PERSONNEL NOT LISTED ON WORKSHEET 1"]
["14.  Clinical Social Worker",null,null,null,null,null,null,null,null,{"$f":"SUM(E38:I38)","v":0}]
["15.  Nurses",null,null,null,null,null,null,null,null,0]
["16.  Translator",null,null,null,null,null,null,null,null,0]
["17.  Health Education",null,null,null,null,null,null,null,null,0]
["18.  Medical Social Worker",null,null,null,null,null,null,null,null,0]
["19.  Outreach",null,null,null,null,null,null,null,null,0]
["20.  Community Services",null,null,null,null,null,null,null,null,0]
["21.  Nonmedical Social Worker",null,null,null,null,null,null,null,null,0]
["22.  Other (Specify) __________",null,null,null,null,null,null,null,null,0]
["23.  Other (Specify) __________",null,null,null,null,null,null,null,null,0]
["MATERIALS AND SUPPLIES"]
["24. Pamphlets and Materials",null,null,null,null,null,null,null,null,{"$f":"SUM(H49:I49)","v":0}]
["25. Supplies",null,null,null,null,null,null,null,null,{"$f":"SUM(H50:I50)","v":0}]
["26. Phone",null,null,null,null,null,null,null,null,{"$f":"SUM(H51:I51)","v":0}]
["27. Other (Specify) __________",null,null,null,null,null,null,null,null,{"$f":"SUM(H52:I52)","v":0}]
["28. Other (Specify) __________",null,null,null,null,null,null,null,null,{"$f":"SUM(H53:I53)","v":0}]
["29.  TOTAL (Sum of Lines 1-28)",null,null,null,{"$f":"SUM(E24:E36)+SUM(E38:E47)","v":0},{"$f":"SUM(F24:G36)+SUM(F38:G47)","v":0},null,{"$f":"SUM(H24:H36)+SUM(H38:H47)+SUM(H49:H53)","v":0},{"$f":"SUM(I24:I36)+SUM(I38:I47)+SUM(I49:I53)","v":0},{"$f":"SUM(E54:I54)","v":0}]
["30. REIMBURSABLE AMOUNT",null,null,null,null,null,null,null,null,{"$f":"SUM(J24:J36)+SUM(J38:J47)+SUM(J49:J53)","v":0}]
["31. TOTAL APPLICATIONS PROCESSED DURING REPORTING PERIOD"]