Ariz. Admin. Code § R9-25-909 - Ambulance Revenue and Cost Reporting Requirements (Authorized by A.R.S. Sections 36-2232, 36-2246)
A.
A certificate holder shall submit to the Department,
no later than 180 days after the certificate holder's fiscal year end, the
appropriate Ambulance Revenue and Cost Report.
B.
According to A.R.S. §
36-2241, a certificate holder
shall maintain the following records for the Department's review and
inspection:
1. The certificate holder's
financial statements;
2. All federal and state income
tax records;
3. All employee-related expense
reports and payroll records;
4. All bank statements and
documents verifying reconciliation;
5. All documents establishing the
depreciation of assets, such as schedules or accounting records on ground
ambulance vehicles, equipment, office furniture, and other plant and equipment
assets subject to depreciation;
6. All first care forms required
in R9-25-514 and
R9-25-615 ;
7. All patient billing and
reimbursement records;
8. All dispatch records, including
the following:
a. The name of the ground
ambulance service;
b. The month of the
record;
c. The date of each
transport;
d. The number assigned to the
ground ambulance vehicle by the certificate holder;
e. Names of the ambulance
attendants;
f. The scene;
g. The actual response
time;
h. The response
code;
i. The scene
locality;
j. Whether the scene to which the
ground ambulance vehicle is dispatched is outside of the certificate holder's
service area; and
k. Whether the dispatch is a
scheduled transport;
9. All ground ambulance service
back-up agreements, contracts, grants, and financial assistance records related
to ground ambulance vehicles, EMS, and transport;
10. All written ground ambulance
service complaints; and
11. Information about destroyed or
otherwise irretrievable records in a file including:
a. A list of each record destroyed
or otherwise irretrievable;
b. A description of the
circumstances under which each record became destroyed or otherwise
irretrievable; and
c. The date each record was
destroyed or became otherwise irretrievable.
A. Except as provided in subsection (C), a
certificate holder shall ensure that an Ambulance Revenue and Cost Report for a
ground ambulance service includes, in a Department-provided format:
1. The following information to identify the
source and time period for the Ambulance Revenue and Cost Report:
a. The legal name of the ground ambulance
service and any other names by which the ground ambulance service is
known;
b. The identifying number on
the certificate holder's current certificate of necessity, if
applicable;
c. The physical address
at which financial records on which the information in the Ambulance Service
and Cost Report is based are maintained;
d. The mailing address for the ground
ambulance service, if different from the address in subsection
(A)(1)(c);
e. The name, title,
e-mail address, and telephone number of the following:
i. The individual responsible for managing
the ground ambulance service; and
ii. The individual to contact regarding the
information in the Ambulance Service and Cost Report;
f. The beginning date and ending date of the
reporting period; and
g. Whether
the method of valuing inventory is:
i.
First-in-first-out;
ii.
Last-in-first-out; or
iii. Another
method, including a description of the method;
2. The following information to provide data
in support of information in other portions of the Ambulance Revenue and Cost
Report:
a. Except as provided in subsection
(B), for each of the following, for the reporting period, under the ground
ambulance service's subscription service rate, contract rate, or general public
rate, the number of:
i. Transports billed at
the critical care rate,
ii.
Transports billed at the ALS base rate,
iii. Transports billed at the BLS base
rate,
iv. Miles billed at the
mileage rate while a patient is being transported,
v. Hours and minutes billed according to
R9-25-1108(E), and
vi. Canceled and non-billable
runs;
b. For each of
subsections (A)(2)(a)(i) through (vi), the total number for all three rates for
the reporting period; and
c. If
applicable, the number of hours different classifications of EMCT and other
ambulance attendants volunteered for the ground ambulance service and the total
number of volunteer hours for the reporting period;
3. The following information about revenue
generated for the reporting period from routine operations of the ground
ambulance service:
a. Except as provided in
subsection (B), the amount of revenue generated from the following sources of
revenue:
i. Transports billed at the critical
care rate;
ii. Transports billed at
the ALS base rate;
iii. Transports
billed at the BLS base rate;
iv.
Miles billed at the mileage rate while a patient is being
transported;
v. Hours and minutes
billed according to
R9-25-1108(E) ,
vi. Charges for disposable supplies, medical
supplies, medications, and oxygen-related items;
vii. Charges for nursing services;
viii. Charges for positioning a staffed
ground ambulance vehicle at a public or private event, such as a sporting event
or car race; and
ix. Other sources
of routine operating revenue; and
b. The total amount of revenue generated for
the reporting period from routine operations of the ground ambulance
service;
4. The costs of
goods, such as disposable supplies, medical supplies, medications, and
oxygen-related items, charged to patients for the reporting period, calculated
as:
a. Thecost of the beginning inventory of
all such goods,
b. Plus the costs
of purchased items,
c. Plus any
other costs, and
d. Minus the cost
of the ending inventory of all such goods;
5. The following information about revenue
generated for the reporting period from sources other than routine operations
of the ground ambulance service:
a. For each
entity with which the ground ambulance service has a ground ambulance service
contract:
i. The name of the entity with which
the ground ambulance service has the contract,
ii. The total number of billable runs for the
reporting period,
iii. The amount
billed for the reporting period based on the general public rate,
iv. The percent discount under the contract,
and
v. The resulting discount
amount;
b. The total
amount of the discount amount from all the entities listed according to
subsection (A)(5)(a); and
c. For a
ground ambulance service providing subscription service, subscription service
revenue and direct expenses, including:
i. The
amount billed for the reporting period at the general public rate established
according to
R9-25-1101 or
R9-25-1102;
ii. Any reductions to the amount in
subsection (A)(5)(c)(i) due to:
(1) The
discount amount the ground ambulance service receives from AHCCCS as an
allowable rate,
(2) The discount
amount the ground ambulance service receives from Medicare as an allowable
rate,
(3) The subscription service
rate established according to
R9-25-1105, and
(4) Uncollectable revenue associated with
subscription service;
iii. The total of the amounts in subsections
(A)(5)(c)(ii)(1) through (4);
iv.
The difference between the amount in subsection (A)(5)(c)(i) and the amount in
subsection (A)(5)(c)(iii);
v. The
amount of revenue from the sales of subscription service contracts;
vi. A description of other revenue associated
with subscription service and the amount of revenue;
vii. The total subscription service revenue,
calculated as the sum of the amounts in subsections (A)(5)(c)(iv) through (vi);
and
viii. Direct expenses incurred
selling subscription service contracts, by type of expense and in
total;
d. The amount of
revenue generated for the reporting period, by type of source of revenue,
including from any other sources of revenue besides routine operations of the
ground ambulance service;
e. The
total amount of revenue generated for the reporting period from sources other
than routine operations of the ground ambulance service;
6. Except as provided in subsection (B), the
following information about discounts for all applicable patients for the
reporting period, based on the difference between the general public rate a
ground ambulance service assesses a patient and the discount amount the ground
ambulance service receives for each of the following:
a. From AHCCCS reimbursement;
b. From Medicare reimbursement;
c. From a contact rate or range of rates
established according to
R9-25-1103; and
d. From the provision of subscription service
established according to
R9-25-1105;
e. From any other discount amount, including
a description of the source and the amount; and
f. The totals of subsections (A)(6)(a)
through (e);
7. The total
amount of revenue generated and allowances given by the ground ambulance
service for the reporting period;
8. The following information about personnel
of the ground ambulance service:
a. Except as
provided in subsection (B), the number of FTEs, calculated as the sum of all
hours for which employee wages were paid for the reporting period divided by
2,080, for each of the following categories of personnel, for the reporting
period:
i. Owners or officers of the ground
ambulance service;
ii. Managers of
the ground ambulance service;
iii.
Each classification of ambulance attendants who provide services on a ground
ambulance vehicle, not including personnel who were paid wages on a per run
basis; and
iv. Other types of
employees;
b. The total
number of FTEs for the reporting period;
c. Except as provided in subsection (B), the
following for each category of personnel in subsections (A)(8)(a)(i) through
(iv), including personnel who were paid wages on a per run basis:
i. Gross wages,
ii. Payroll taxes,
iii. Employee fringe benefits, and
iv. The totals of subsections (A)(8)(c)(i)
through (iii);
d. The
total amount of personnel expenses in subsection (A)(8)(c) for all
personnel;
e. Details of salaries
and wages paid to officers or owners of the ground ambulance service,
including:
i. The name, title, and percentage
ownership of each officer or owner;
ii. The salary or wages paid and FTE
equivalent for the time the officer or owner spent performing management
duties, for each officer or owner;
iii. The salary or wages paid and FTE
equivalent for the time the officer or owner spent performing duties as an
EMCT, for each officer or owner;
iv. The salary or wages paid and FTE
equivalent for the time the officer or owner spent performing office or
administerial duties, for each officer or owner;
v. The salary or wages paid and FTE
equivalent for the time the officer or owner spent performing other types of
duties, for each officer or owner; and
vi. The total salary or wages paid and FTE
equivalent for the time all officers or owners spent performing the types of
duties in subsections (A)(8)(e)(ii) through (v); and
f. Details on scheduled shifts, hourly wages,
annual salary, and amount per run or shift for each category of personnel in
subsection (A)(8)(b)(ii) through (iv);
9. Except as provided in subsection (B), the
operating expenses incurred by the ground ambulance service for the reporting
period, for each type of operating expense;
10. The total operating expenses incurred by
the ground ambulance service for the reporting period;
11. Ambulance service income, calculated as
the difference between the amount identified in subsection (A)(7) and the
amount identified in subsection (A)(10);
12. The income and expenses, other than
revenue and operating expenses, for each type of income received and expense
incurred by the ground ambulance service for the reporting period;
13. The total income and expenses, other than
revenue and operating expenses, for the reporting period;
14. The net income or loss for the reporting
period, before taxes, calculated as the sum of the amounts identified in
subsections (A)(11) and (A)(13);
15. The amounts of:
a. State income taxes,
b. Federal income taxes, and
c. The total of subsections (A)(15)(a) and
(b);
16. The net income
or loss for the reporting period, after taxes, calculated as the difference
between the amounts in subsections (A)(14) and (A)(15)(c);
17. Information pertaining to depreciation of
property or equipment;
18. The
amount of assets, for each type of asset, of the ground ambulance service for
the reporting period;
19. The total
amount of assets of the ground ambulance service for the reporting
period;
20. The amount of
liabilities, for each type of liability, of the ground ambulance service for
the reporting period;
21. The total
amount of liabilities of the ground ambulance service for the reporting
period;
22. The amount of long-term
debt, for each type of long-term debt, of the ground ambulance service for the
reporting period;
23. The total
amount of long-term debt of the ground ambulance service for the reporting
period;
24. The amount of equity,
for each type of equity, of the ground ambulance service for the reporting
period;
25. The total amount of
equity of the ground ambulance service for the reporting period;
26. The total amount of liabilities and
equity of the ground ambulance service for the reporting period;
27. The statement of cash flows for the
reporting period;
28. A list of all
business organizations or governmental entities affiliated with the certificate
holder, if applicable, including for each:
a.
The legal name;
b. The type of
business organization, if applicable; and
c. Whether the relationship to the applicant
is as a:
i. Parent organization,
ii. Subordinate organization,
iii. Subsidiary organization,
iv. Member organization, or
v. Business organization related to an
ambulance service, EMS, or transport for which a controlling person of the
applicant is also a controlling person of the business organization;
and
29. An
attestation including:
a. The signature of the
individual specified in subsection (A)(1)(e)(i), including the individual's
title and date of signature;
b. A
statement that the individual in subsection (A)(29)(a) directed the preparation
of the Ambulance Revenue and Cost Report in accordance with requirements in
this Article and using an accrual basis of accounting; and
c. A statement that the information provided
in the Ambulance Revenue and Cost Report is true and correct.
B. If a ground ambulance
service applies local resident subsidization to reimbursement under the general
public rate, a certificate holder shall ensure that the Ambulance Revenue and
Cost Report for a ground ambulance service includes, in a Department-provided
format:
1. The following, in total and broken
out for both subsidized patients and non-subsidized patients:
a. The information for subsections
(A)(2)(a)(i) through (vi) under the ground ambulance service's general public
rate;
b. The amount of revenue
generated from the sources of revenue specified in subsections (A)(3)(a)(i)
through (ix) from routine operations of the ground ambulance service;
and
c. The amount of discount for
all applicable patients for the reporting period, based on the difference
between the general public rate a ground ambulance service assesses a patient
and the discount amount the ground ambulance service receives:
i. From AHCCCS reimbursement,
ii. From Medicare reimbursement,
and
iii. Due to the local resident
subsidization;
2. The number of FTEs, calculated as the sum
of all hours for which employee wages were paid for the reporting period
divided by 2,080, for each of the following categories of personnel, for the
reporting period:
a. Managers of the ground
ambulance service;
b. Ambulance
attendants who provide services on a ground ambulance vehicle, not including
personnel who were paid wages on a per run basis; and
c. Other types of employees;
3. The following for each category
of personnel in subsection (B)(2)(a) through (c):
a. Gross wages,
b. Payroll taxes,
c. Employee fringe benefits, and
d. The totals of subsections (B)(3)(a)
through (c);
4. If
applicable, for each category of employee in subsection (B)(2)(a) through (c),
the basis of allocation of gross wages, payroll taxes, employee fringe
benefits, and the totals of the allocations; and
5. If applicable, for each category of
employee in subsection (B)(2)(a) through (c), the allocation percentage for
gross wages, payroll taxes, and employee fringe benefits;
6. The operating expenses incurred, for each
type of operating expense, by the ground ambulance service for the reporting
period in total and with the allocation percentage for each category of
operating expense, including the basis of allocation.
C. A certificate holder shall ensure that an
Ambulance Revenue and Cost Report for a ground ambulance service under A.R.S.
§
36-2246(C) includes, in a Department-provided format:
1.
The following information to identify the source and time period for the
Ambulance Revenue and Cost Report:
a. The
legal name of the ground ambulance service and any other names by which the
ground ambulance service is known; and
b. The beginning date and ending date of the
reporting period; and
2.
The following information to provide data in support of information in other
portions of the Ambulance Revenue and Cost Report:
a. For each of the following, for the
reporting period, under the ground ambulance service's subscription service
rate, contract rate, or general public rate, the number of:
i. Transports billed at the critical care
rate,
ii. Transports billed at the
ALS base rate,
iii. Transports
billed at the BLS base rate,
iv.
Miles billed at the mileage rate while a patient is being
transported,
v. Hours and minutes
billed according to
R9-25-1108(E), and
vi. Canceled and non-billable
runs;
b. For each of
subsections (C)(2)(a)(i) through (vi), the total number for all three rates for
the reporting period; and
c. If
applicable, the number of hours different classifications of EMCT and other
ambulance attendants volunteered for the ground ambulance service and the total
number of volunteer hours for the reporting period;
3. The following information about revenue
generated for the reporting period from routine operations of the ground
ambulance service:
a. The amount of revenue
generated from the following sources of revenue:
i. Transports billed at the critical care
rate;
ii. Transports billed at the
ALS base rate;
iii. Transports
billed at the BLS base rate;
iv.
Miles billed at the mileage rate while a patient is being
transported;
v. Hours and minutes
billed according to
R9-25-1108(E) ,
vi. Charges for disposable supplies, medical
supplies, medications, and oxygen-related items;
vii. Charges for nursing services;
and
viii. Charges for positioning a
staffed ground ambulance vehicle at a public or private event, such as a
sporting event or car race; and
b. The total amount of revenue generated for
the reporting period from routine operations of the ground ambulance
service;
4. The following
information about discounts for all applicable patients for the reporting
period, based on the difference between the general public rate a ground
ambulance service assesses a patient and the discount amount the ground
ambulance service receives:
a. From AHCCCS
reimbursement,
b. From Medicare
reimbursement,
c. Due to a contact
rate or range of rates established according to
R9-25-1103 ,
d. Due to a subscription service rate
established according to
R9-25-1105 ,
e. Due to any other revenue reduction,
and
f. From the totals of
subsections (C)(4)(a) through (e);
5. The total amount of revenue generated,
less allowances given, by the ground ambulance service from routine operations
for the reporting period;
6. The
following information about personnel of the ground ambulance service:
a. The total number of FTEs, calculated as
the sum of all hours for which employee wages were paid for the reporting
period divided by 2,080, for the reporting period;
b. The number of FTEs, for each of the
following categories of personnel, for the reporting period, not including
personnel who were paid wages on a per run basis:
i. Managers of the ground ambulance
service,
ii. Ambulance attendants
who provide services on a ground ambulance vehicle, and
iii. Other types of employees;
c. The gross wages for each
category of personnel in subsection (C)(6)(b)(i) through (iii);
d. Payroll taxes and employee fringe benefits
for each category of personnel; and
e. The total gross wages taxes and fringe
benefits for all category of personnel in subsections (C)(6)(b)(i) through
(iii);
7. The operating
expenses incurred by the ground ambulance service for the reporting period for
each type of operating expense;
8.
The total operating expenses incurred by the ground ambulance service for the
reporting period;
9. The total
operating income or loss, calculated as the difference between the amount
identified in subsection (C)(5) and the amount identified in subsection
(C)(8);
10. The amount of revenue
generated or income derived for the reporting period by type of source of
revenue or income, from sources other than routine operations of the ground
ambulance service, including from:
a. The sale
of subscription service contracts under
R9-25-1105;
b. Any other sources of operating revenue
besides routine operations of the ground ambulance service, including a
description of the sources and amount of revenue;
c. Local supportive funding; and
d. Any other sources of income besides
routine operations of the ground ambulance service, including a description of
the sources and amount of income;
11. Any other expenses incurred by the ground
ambulance service for the reporting period, including a description of the
sources and amount of expenses;
12.
The net income or loss for the reporting period, before taxes, from sources
other than routine operations of the ground ambulance service, calculated as
the sum of the amounts identified in subsections (C)(9) and (C)(10), minus the
amount in subsection (C)(11);
13.
The amounts of:
a. State income
taxes,
b. Federal income taxes,
and
c. The total of subsections
(C)(13)(a) and (b);
14.
The net income or loss for the reporting period, after taxes, calculated as the
difference between the amounts in subsections (C)(12) and (C)(13)(c);
15. The amount of assets, for each type of
asset, of the ground ambulance service for the reporting period;
16. The total amount of current assets of the
ground ambulance service for the reporting period;
17. Information pertaining to depreciation of
property or equipment;
18. The
amount of liabilities, for each type of liability, of the ground ambulance
service for the reporting period;
19. The total amount of liabilities of the
ground ambulance service for the reporting period;
20. The amount of long-term debt, for each
type of long-term debt, of the ground ambulance service for the reporting
period;
21. The total amount of
long-term debt of the ground ambulance service for the reporting
period;
22. The amount of equity,
for each type of equity, of the ground ambulance service for the reporting
period;
23. The total amount of
equity of the ground ambulance service for the reporting period;
24. The total amount of liabilities and
equity of the ground ambulance service for the reporting period;
25. The statement of cash flows for the
reporting period.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.