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{"sheet":"e-216","index":0,"n_rows":5010,"n_cols":105,"rows_kept":562,"cut":true,"hidden":false,"merged":[[1,20,1,21],[2,6,2,11],[0,20,0,21],[2,20,2,21],[3,20,3,21],[4,20,4,21],[4,6,4,12],[3,6,3,12],[5,20,5,21],[5,2,5,4],[5,0,5,1],[8,6,8,14],[8,20,8,21],[7,5,7,6],[7,7,7,13],[6,20,6,21],[7,20,7,21],[8,3,8,5],[6,6,6,12],[5,6,5,12]],"bounds":{"rows_first":250,"rows_last":62,"rows_between":250,"halvings":3}}
[null,null,null,null,null,null,null,"2025 REMITTANCE ADVICE (FORM e-216)",null,null,null,null,null,null,null,"Insurer Code",{"$f":"IF(AL9=\"rer\",\" \",AL9)","v":" "},"Receipt Date","Receipt Date",null,null,null,null,"V1.0.6",null,null,0.28999999999999998,null,null,null,null,null,null,null,"Current Value","Opening Value",null,null,null,"Static NOW","PreOpening Date",null,null,"Ending Credit Balance Calaulations",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
["216 Date:","Submission Date",null,null,null,null,null,{"$f":"\"For remitting coverage that incepted or renewed in \"&LEFT(H1,4)&\" only\"","v":"For remitting coverage that incepted or renewed in 2025 only"},null,null,null,null,null,null,null,"Check/EFT #",null,"Count","Transaction Count",{"$f":"COUNT(O11:O8953)","v":0},{"$f":"COUNTA(M11:M5010)","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,0,{"$f":"SUM(C:W)","v":0},0,null,null,"2020-01-21T10:08:00","Completion Date",null,{"$f":"IF(U2>0,IF(B2=\"Enter Today's Date\",NOW(),B2),\"\")","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,"Please Select Primary Insurer",null,null,null,null,null,null,null,null,"Check / EFT Amount",null,"Policy Exam.","Coverage Specialist",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,null,null,null,null,null,null,null,{"$f":"SUM(Q6+Q7)","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
["Related #:",null,null,null,null,null,"Contact Person's Name",null,null,null,null,null,null,null,null,null,null,"Contact Code","Contact Code",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(Q5+Q6)","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,2,3,4,5,6,7]
["Entity Name:",null,null,null,null,null,"Contact Person's Address",null,null,null,null,null,null,null," ","Assessment Total",{"$f":"SUM(S11:S5010)","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,4455,2424,2838,3490,3751,2980,3490]
["Basic Insurance Coverage Limit:",null,"$500,000/$2,500,000 Hospital",null,null,null,"Contact Person's Telephone #",null,null,null,null,null,null,null,null,"Beginning Crdt Bal",0,"From e216 dated:","From e-216 dated:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8725,4304,5204,6624,7193,5511,6532]
[null,null,"$500,000/$1,500,000 All Others",null,null,null,"Contact Person's Email",null,null,null,null,null,null,null," ","Crdt Bal Used",0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(P2=\"Select Payment Type\",AK9,P2)","v":"Check/EFT #"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,15552,7308,8985,11636,12696,9560,11636]
[null,null,null,null,null,"Email completed e-216 to:",null,"ra-in-remittance@pa.gov",null,null,null,null,null,null,null,"Ending Crdt Bal",{"$f":"IF(Q5>0,AR3,AR4)","v":0},"To e216 dated:","To e-216 dated:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DocuShare","DocuShare",null,"Insurer Cde","Official e-216","Run Date","Check # Text","Check",null,"DocuShare Email Agent Collection"]
[null,null,null,"Email subject line should be",null,null,{"$f":"Q1&AK9&AM9&AK9&TEXT(AN9,\"mm/dd/yy\")&AK9&AO9&AK9&Q2&AK9","v":"         "},null,null,null,null,null,null,null,null,"Amount Due",{"$f":"SUM(Q5-Q7)","v":0},null,"Email date:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(B2=\"Completion Date\",\" \",\"<To:Mcare216>\")","v":"<To:Mcare216>"},">"," ",{"$f":"RIGHT(G3,3)","v":"rer"},{"$f":"IF(B2=\"Submission Date\",\" \",\"Official e-216\")","v":" "},{"$f":"IF(B2=\"Submission Date\",\" \",B2)","v":" "},{"$f":"IF(Q2>0,\"Check/EFT No.\",AK9)","v":" "},{"$f":"IF(Q2>0,Q2,\"N/A \")","v":"N/A "}," √316",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"*"]
["License or Assigned Number","Name\nLast, First, M.I.","From\nDate","To\nDate","Cancel\nDate","Retro\nDate","Insurer's Policy #","Policy Type","F.T.E. Factor","Part-Time","Resident/Fellow/ New Doctor","Policy Modifier","County Code","Specialty Code","Primary Insurer's Premium","Prevailing Primary Premium","Full Assessment","2009 Abatement %","Remitted Assessment",null,"Comment","Related License or Assigned Number","FOR MCARE'S OFFICIAL USE ONLY","Additional Identification","Slot Identification #","Work Address Street 1","Work Address Street 2","Work Address City","Work Address Zip","Zip +4",null,null,"Return Surcharge","Surcharge Payment","# of Days","# of Cncl Days","Daily rate","Adjusted PPP","Adjusted F.T.E.","Adjusted P/T","Adjusted New/Res",null,null,null,"P08","P16","P24","PT        Total",null,"Res/New R","Res/New 1","Res/New 2","Res/New 3","Res/New Total",null,"DX Terr 1","DX Terr 2","DX Terr 3","DX Terr 4","DX Terr 5","DX Terr 6","DX Total",null,null,11216,5400,6583,8453,9201,6988,8453,"Class Code","Territory 1","Territory 2","Territory 3","Territory 4","Territory 5","Territory 6","Territory 7","Territory ",null,null,null,"100% Abatement","50% Abatement","0% Abatement","Abated Assessment","Class Code","Unabated Assessment","Assessment","No Rating of Tail","New Retro Coverage","Add \"-\" to Policy #","New Retro Policy #",null,null,"Slot Specialty ","Slot Position","Is Slot Rating OK",null,"$$$\nMoney Auditor",null,null,null,"USER NOTES"]
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["017",22580,6548.2,10400,3016,12880,3735.2,16794,4870.2599999999993,18361,5324.69,13727,3980.83,16645,4827.0499999999993,"017"]
["020",26161,7586.69,11975,3472.7499999999995,14863,4310.2699999999995,19422,5632.3799999999992,21247,6161.6299999999992,15851,4596.79,18114,5253.0599999999995,"020"]
["022",36257,10514.529999999999,16418,4761.2199999999993,20456,5932.24,26834,7781.86,29384,8521.3599999999988,21838,6333.0199999999995,24654,7149.66,"022"]
["025",39393,11423.97,17798,5161.42,22194,6436.2599999999993,29135,8449.15,30336,8797.4399999999987,23697,6872.1299999999992,25690,7450.0999999999995,"025"]
["030",35813,10385.769999999999,16222,4704.38,20211,5861.19,26507,7687.03,29026,8417.5399999999991,21574,6256.4599999999991,25134,7288.86,"030"]
["035",54049,15674.21,24247,7031.6299999999992,30313,8790.7699999999986,39893,11568.97,43326,12564.539999999999,32389,9392.81,35957,10427.529999999999,"035"]
["050",46910,13603.9,21105,6120.45,26358,7643.82,34653,10049.369999999999,37970,11011.3,28156,8165.24,34148,9902.92,"050"]
["060",54694,15861.259999999998,24530,7113.7,30670,8894.2999999999993,40366,11706.14,44244,12830.759999999998,32771,9503.59,40179,11651.91,"060"]
["070",86631,25122.989999999998,38582,11188.779999999999,48363,14025.269999999999,63808,18504.32,69985,20295.649999999998,51709,14995.609999999999,61347,17790.629999999997,"070"]
["080",107646,31217.339999999997,47830,13870.699999999999,60006,17401.739999999998,79234,22977.859999999997,86925,25208.25,64172,18609.879999999997,73484,21310.359999999997,"080"]
["090",57874,16783.46,25930,7519.7,32432,9405.2799999999988,42701,12383.289999999999,46808,13574.32,34657,10050.529999999999,42701,12383.289999999999,"090"]
["100",166382,48250.78,73673,21365.17,92546,26838.339999999997,122345,35480.049999999996,134265,38936.85,99002,28710.579999999998,117491,34072.39,"100"]
["120",5233,1517.57,2767,802.43,3270,948.3,4061,1177.6899999999998,4378,1269.6199999999999,3441,997.89,4061,1177.6899999999998,"120"]
["130",37859,10979.109999999999,17123,4965.67,21343,6189.4699999999993,28009,8122.61,29066,8429.14,22788,6608.5199999999995,24174,7010.4599999999991,"130"]
["900",34723,10069.67,15743,4565.4699999999993,19607,5686.03,25707,7455.03,27754,8048.66,20929,6069.41,23092,6696.6799999999994,"900"]
[null,null,null,null,null,null,null,null,null,"Certified Nurse Midwife = 900",null,null,80116]
[null,null,null,null,null,null,null,null,null,"Podiatrist Non-surgical = 120",null,null,80993]
[null,null,null,null,null,null,null,null,null,"Podiatrist Surgical = 130",null,null,80994]
["Territory 1 = Philadelphia (51)"]
["Territory 2 = Remainder of State (01, 05, 06, 08, 10-12, 14, 16, 18, 21, 24, 27-32, 34, 36, 38, 41, 42, 44, 47, 49, 50, 52, 53, 55-62, 64, 66, 67)"]
["Territory 3 = Allegheny (02), Armstrong (03), Beaver (04), Carbon (13), Clearfield (17), Dauphin (22), Jefferson (33), Washington (63)"]
["Territory 4 = Delaware (23), Fayette (26), Luzerne (40), Mercer (43)"]
["Territory 5 = Lackawanna (35)"]
["Territory 6 = Bucks (09), Chester (15), Columbia (19), Crawford (20), Erie (25), Lawrence (37), Lehigh (39), Monroe (45), Montgomery (46), Northampton (48),"]
[null,"Schuylkill (54), westmoreland (65)"]
["Territory 7 = Blair (07)"]

{"sheet":"HS WS","index":2,"n_rows":49,"n_cols":41,"rows_kept":49,"cut":false,"hidden":false,"merged":[[7,2,7,7],[8,6,8,7],[0,1,1,7],[2,2,2,7],[3,2,3,7],[4,2,4,7],[5,2,5,7],[6,2,6,7],[48,1,48,6],[41,1,41,7],[13,1,14,7],[25,1,26,7],[10,1,10,7],[42,1,43,7],[44,1,44,6],[46,1,46,6],[47,1,47,6]]}
[null,"2025 EXHIBIT 6 - HOSPITAL WORKSHEET (SPECIALTY CODE 80612)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(C:W)","v":24359.750000000007},null,null,null,"2018-07-09T13:16:00","2018 EXHIBIT 6 - HOSPITAL WORKSHEET (SPECIALTY CODE 80612)"]
[null,"Primary Insurer",{"$f":"IF('e-216'!G3=\"Please Select Primary Insurer\",\"\",'e-216'!G3)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,229756.04738561649]
[null,"Insurer Code",{"$f":"'e-216'!Q1","v":" "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(C:W)","v":24359.750000000007},null,null,null,"2017-12-21T10:21:00","Insurer's #:"]
[null,"Date",{"$f":"IF('e-216'!B2=\"Submission Date\",\"\",'e-216'!B2)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,23200.67]
[null,"Hospital's Name"]
[null,"Hospital's Address"]
[null,"Hospital's Assigned #"]
[null,"Basic Insurance Coverage Limits:",null,"$   500,000.00 Per Occ."]
[null,null,null,"$2,500,000.00 Per Agg."]
[null,"Entry Worksheets must be transferred to the e-216 by clicking the \"Transfer to e-216\" button."]
[null,"From Date","To  Date","Retro Date","Policy #","Policy Type","County","Territory",null,null,"Terr 1","Terr 2","Terr 3","Terr 4"]
[null,null,null,null,null,null,null,{"$f":"O13","v":0},null,null,{"$f":"IF(OR(G13=23,G13=51),1,\"0\")","v":"0"},{"$f":"IF(OR(G13=23,G13=51,G13=2,G13=20,G13=25,G13=35,G13=37,G13=40,G13=43,G13=9,G13=15,G13=46,G13=0,G13=\"\"),0,\"2\")","v":0},{"$f":"IF(OR(G13=2,G13=20,G13=25,G13=35,G13=37,G13=40,G13=43),3,\"0\")","v":"0"},{"$f":"IF(OR(G13=9,G13=15,G13=46),4,\"0\")","v":"0"},{"$f":"SUM(K13+L13+M13+N13)","v":0}]
[" ","List of Annual Occupied Bed Counts"]
[]
[null,"Exposure Type:","Bed Count","Terr. 1 Rates","Terr. 2 Rates","Terr. 3 Rates","Terr. 4 Rates","Subtotal",null,null,null,null,null,null,"Daily Rate","# of Days",null,"Rounded Count",null,null,null,null,"Terr 1 PPP","Terr 2 PPP","Terr 3 PPP","Terr 4 PPP"]
[null,"Hospital (acute care)",null,{"$f":"IF(OR(H13=1), W17,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X17,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y17,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z17,\"0\")","v":"0"},{"$f":" S17*P17","v":0},null,null,{"$f":"VALUE(D17)","v":0},{"$f":"VALUE(E17)","v":0},{"$f":"VALUE(F17)","v":0},{"$f":"VALUE(G17)","v":0},{"$f":"(K17+L17+M17+N17)*C17/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C17,0)","v":0},{"$f":"(K17+L17+M17+N17)*R17/365","v":0},null,null,"Hospital (acute care)",7980.46,3543.31,4437.12,7094.64]
[]
[null,"Mental Health/Mental Rehab.",null,{"$f":"IF(OR(H13=1),W19,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X19,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y19,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z19,\"0\")","v":"0"},{"$f":" S19*P19","v":0},null,null,{"$f":"VALUE(D19)","v":0},0,0,0,{"$f":"(K19+L19+M19+N19)*C19/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C19,0)","v":0},{"$f":"(K19+L19+M19+N19)*R19/365","v":0},null,null,"Mental Health/Mental Rehab.",3993.65,1773.19,2220.4699999999998,3550.34]
[]
[null,"Extended Care",null,{"$f":"IF(OR(H13=1),W21,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X21,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y21,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z21,\"0\")","v":"0"},{"$f":" S21*P21","v":0},null,null,0,0,0,0,{"$f":"(K21+L21+M21+N21)*C21/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C21,0)","v":0},{"$f":"(K21+L21+M21+N21)*R21/365","v":0},null,null,"Extended Care",355.29,157.74,197.54,315.83999999999997]
[]
[null,"Out-Patient Surgical",null,{"$f":"IF(OR(H13=1),W23,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X23,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y23,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z23,\"0\")","v":"0"},{"$f":" S23*P23","v":0},null,null,0,0,0,0,{"$f":"(K23+L23+M23+N23)*C23/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C23,0)","v":0},{"$f":"(K23+L23+M23+N23)*R23/365","v":0},null,null,"Out-Patient Surgical",7980.46,3543.31,4437.12,7094.64]
[]
[null,"Health Institution",null,{"$f":"IF(OR(H13=1),W25,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X25,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y25,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z25,\"0\")","v":"0"},{"$f":" S25*P25","v":0},null,null,0,0,0,0,{"$f":"(K25+L25+M25+N25)*C25/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C25,0)","v":0},{"$f":"(K25+L25+M25+N25)*R25/365","v":0},null,null,"Health Institution",1598.84,709.87,888.95,1421.34]
[null,"List of Annual Visit Counts"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"(K27+L27+M27+N27)*R27/365","v":0}]
[null,"Exposure Type:","Total Visit Count*","Terr. 1 Rates","Terr. 2 Rates","Terr. 3 Rates","Terr. 4 Rates","Subtotal"]
[null,"Emergency",null,{"$f":"IF(OR(H13=1),W29,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X29,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y29,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z29,\"0\")","v":"0"},{"$f":" S29*P29","v":0},null,null,{"$f":"VALUE(D29)","v":0},{"$f":"VALUE(E29)","v":0},{"$f":"VALUE(F29)","v":0},{"$f":"VALUE(G29)","v":0},{"$f":"(K29+L29+M29+N29)*(C29/100)/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C29,0)","v":0},{"$f":"(K29+L29+M29+N29)*(R29/100)/365","v":0},null,null,"Emergency",797.72,354.2,443.53,709.17]
[]
[null,"Other",null,{"$f":"IF(OR(H13=1),W31,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X31,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y31,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z31,\"0\")","v":"0"},{"$f":" S31*P31","v":0},null,null,{"$f":"VALUE(D31)","v":0},0,0,0,{"$f":"(K31+L31+M31+N31)*(C31/100)/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C31,0)","v":0},{"$f":"(K31+L31+M31+N31)*(R31/100)/365","v":0},null,null,"Other",319.08,141.68,177.42,283.67]
[]
[null,"Mental Health/Mental Rehab.",null,{"$f":"IF(OR(H13=1),W33,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X33,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y33,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z33,\"0\")","v":"0"},{"$f":" S33*P33","v":0},null,null,0,0,0,0,{"$f":"(K33+L33+M33+N33)*(C33/100)/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C33,0)","v":0},{"$f":"(K33+L33+M33+N33)*(R33/100)/365","v":0},null,null,"Mental Health/Mental Rehab.",199.45,88.54,110.86,177.28]
[]
[null,"Extended Care",null,{"$f":"IF(OR(H13=1),W35,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X35,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y35,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z35,\"0\")","v":"0"},{"$f":" S35*P35","v":0},null,null,0,0,0,0,{"$f":"(K35+L35+M35+N35)*(C35/100)/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C35,0)","v":0},{"$f":"(K35+L35+M35+N35)*(R35/100)/365","v":0},null,null,"Extended Care",17.7,7.88,9.83,15.76]
[]
[null,"Out-Patient Surgical",null,{"$f":"IF(OR(H13=1),W37,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X37,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y37,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z37,\"0\")","v":"0"},{"$f":" S37*P37","v":0},null,null,0,0,0,0,{"$f":"(K37+L37+M37+N37)*(C37/100)/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C37,0)","v":0},{"$f":"(K37+L37+M37+N37)*(R37/100)/365","v":0},null,null,"Out-Patient Surgical",797.72,354.2,443.53,709.17]
[]
[null,"Health Institution",null,{"$f":"IF(OR(H13=1),W39,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X39,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y39,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z39,\"0\")","v":"0"},{"$f":" S39*P39","v":0},null,null,0,0,0,0,{"$f":"(K39+L39+M39+N39)*(C39/100)/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C39,0)","v":0},{"$f":"(K39+L39+M39+N39)*(R39/100)/365","v":0},null,null,"Health Institution",119.64,53.13,66.53,106.37]
[]
[null,"Home Health Care",null,{"$f":"IF(OR(H13=1),W41,\"0\")","v":"0"},{"$f":"IF(OR(H13=2),X41,\"0\")","v":"0"},{"$f":"IF(OR(H13=3),Y41,\"0\")","v":"0"},{"$f":"IF(OR(H13=4),Z41,\"0\")","v":"0"},{"$f":" S41*P41","v":0},null,null,0,0,0,0,{"$f":"(K41+L41+M41+N41)*(C41/100)/365","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},null,{"$f":"ROUND(C41,0)","v":0},{"$f":"(K41+L41+M41+N41)*(R41/100)/365","v":0},null,null,"Home Health Care",199.45,88.54,110.86,177.28]
[null,"* Enter the actual \"Visit Count.\"  The spreadsheet will divide the \"Visit Count\" entered by 100."]
[null,"Hospital's Assessment"]
[]
[null,"Prevailing Primary Premium",null,null,null,null,null,{"$f":" H17+H19+H21+H23+H25+H29+H31+H33+H35+H37+H39+H41","v":0}]
[]
[null,"Experience Modification Factor (as provided by Mcare)"]
[null,"2025 Mcare Assessment %",null,null,null,null,null,0.28999999999999998]
[null,"Mcare Assessment",null,null,null,null,null,{"$f":"ROUND(K49,0)","v":0},null,null,{"$f":"(H45*H47)*H48","v":0}]

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[null,"2025 EXHIBIT 5 - CORPORATION, ASSOCIATION & COMPANY, & PARTNERSHIP WORKSHEET\n(SPECIALTY CODE 80999)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"=SUM(C[-33]:C[-13])",null,null,null,"2018-01-16T09:22:00","2018 EXHIBIT 5 - CORPORATION, ASSOCIATION & PARTNERSHIP WORKSHEET\n(SPECIALTY CODE 80999)"]
[null,"Primary Insurer",{"$f":"IF('e-216'!G3=\"Please Select Primary Insurer\",\"\",'e-216'!G3)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"=SUM(C[-33]:C[-13])"]
[null,"Insurer Code",{"$f":"'e-216'!Q1","v":" "}]
[null,"Date",{"$f":"IF('e-216'!B2=\"Submission Date\",\"\",'e-216'!B2)","v":""}]
[null,"Entity's Name"]
[null,"Entity's Address"]
[null,"Entity's Assigned #"]
[null,"Basic Insurance Coverage Limits:",null,"$   500,000.00 Per Occ."]
[null,null,null,"$1,500,000.00 Per Agg."]
[null,"Entry Worksheets must be transferred to the e-216 by clicking the \"Transfer to e-216\" button."]
[null,"From Date","To Date","Retro Date","Policy #","Policy Type","County Code","Mcare Assessment"]
[null,null,null,null,null,null,null,{"$f":"P17","v":0}]
[null,"List all shareholders, owners, partners and employed health care providers"]
[" ",null,null,null,null,null,null,null," "]
[" ","License #","Name",null,"Specialty Code","County Code","HCP's Annual Assessment","Other Rating Factors",null,null,null,"Total Assessment","# of Days","Daily Rate","Entity Assessment","Rounded Assesment "]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(G17:G215)","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},{"$f":"L17/365","v":0},{"$f":"(N17*M17)*15%","v":0},{"$f":"ROUND(O17,0)","v":0}]
[]
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[null,"This worksheet will NOT include health care providers listed below this point in the calculation."]

{"sheet":"PC WS","index":4,"n_rows":30,"n_cols":41,"rows_kept":30,"cut":false,"hidden":false,"merged":[[29,0,29,5],[6,1,6,6],[7,1,7,6],[10,0,10,6],[13,0,14,6],[25,0,26,6],[27,0,27,5],[0,0,1,6],[2,1,2,6],[3,1,3,6],[4,1,4,6],[5,1,5,6]]}
["2025 EXHIBIT 8 - PRIMARY HEALTH CENTER WORKSHEET (SPECIALTY CODE 80614)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(C:W)","v":4552.93},null,null,null,"2017-12-27T11:01:00","2025 EXHIBIT 8 - PRIMARY HEALTH CENTER WORKSHEET (SPECIALTY CODE 80614)"]
["Primary Insurer",{"$f":"IF('e-216'!G3=\"Please Select Primary Insurer\",\"\",'e-216'!G3)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,97202.381004410869]
["Insurer Code",{"$f":"'e-216'!Q1","v":" "}]
["Date",{"$f":"IF('e-216'!B2=\"Submission Date\",\"\",'e-216'!B2)","v":""}]
["PHC's Name"]
["PHC's Address"]
["PHC's Assigned #"]
["Basic Insurance Coverage Limits:",null,"$   500,000.00 Per Occ."]
[null,null,"$1,500,000.00 Per Agg."]
["Entry Worksheets must be transferred to the e-216 by clicking the \"Transfer to e-216\" button."]
["From Date","To Date","Retro Date","Policy #","Policy Type","County Code","Territory",null,null,null,null,"Terr. 1 ","Terr. 2","Terr. 3","Terr. 4","County"]
[null,null,null,null,null,null,{"$f":"P13","v":0},null,null,null,null,{"$f":"IF(OR(F13=23, F13=51),1,\"0\")","v":"0"},{"$f":"IF(OR(F13=23, F13=51, F13=2, F13=20,F13=25, F13=35,F13=37,F13=40,F13=43,F13=9,F13=15,F13=46,F13=0,F13=\" \"),0,\"2\")","v":0},{"$f":"IF(OR(F13=2, F13=20, F13=25, F13=35, F13=37, F13=40, F13=43),3,\"0\")","v":"0"},{"$f":"IF(OR(F13=9, F13=15, F13=46),4,\"0\")","v":"0"},{"$f":"SUM(L13+M13+N13+O13)","v":0}]
["List Annual Visit Counts"]
[]
["Exposure Type","Total Visit Count","Terr. 1 Rates","Terr. 2 Rates","Terr. 3 Rates","Terr. 4 Rates","Subtotal",null,null,null,null,null,null,"Daily Rate","# of Days",null,"Rounded Visits",null,null,null,"Terr. 1 PPP","Terr. 2 PPP","Terr. 3 PPP","Terr. 4 PPP"]
["Emergency",null,{"$f":"IF(OR(G13=1),U17,\"0\")","v":"0"},{"$f":"IF(OR(G13=2),V17,\"0\")","v":"0"},{"$f":"IF(OR(G13=3),W17,\"0\")","v":"0"},{"$f":"IF(OR(G13=4),X17,\"0\")","v":"0"},{"$f":"(N17*O17)*(Q17/100)","v":0},null,null,null,null,{"$f":"SUM(C17+D17+E17+F17)","v":0},{"$f":"B17/100","v":0},{"$f":"(C17+D17+E17+F17)/365","v":0},{"$f":"IF(AND(A13<45351,B13>45351),(B13-A13)-1,B13-A13)","v":0},{"$f":"(O17*N17)*M17","v":0},{"$f":"ROUND(B17,0)","v":0},null,null,"Emergency",784.97,348.51,436.45,697.83]
[]
["Other",null,{"$f":"IF(OR(G13=1),U19,\"0\")","v":"0"},{"$f":"IF(OR(G13=2),V19,\"0\")","v":"0"},{"$f":"IF(OR(G13=3),W19,\"0\")","v":"0"},{"$f":"IF(OR(G13=4),X19,\"0\")","v":"0"},{"$f":"(N19*O19)*(Q19/100)","v":0},null,null,null,null,{"$f":"SUM(C19+D19+E19+F19)","v":0},{"$f":"B19/100","v":0},{"$f":"(C19+D19+E19+F19)/365","v":0},{"$f":"IF(AND(A13<45351,B13>45351),(B13-A13)-1,B13-A13)","v":0},{"$f":"(O19*N19)*M19","v":0},{"$f":"ROUND(B19,0)","v":0},null,null,"Other",313.99,139.4,174.58,279.14]
[]
["Mental Health/Mental Rehab.",null,{"$f":"IF(OR(G13=1),U21,\"0\")","v":"0"},{"$f":"IF(OR(G13=2),V21,\"0\")","v":"0"},{"$f":"IF(OR(G13=3),W21,\"0\")","v":"0"},{"$f":"IF(OR(G13=4),X21,\"0\")","v":"0"},{"$f":"(N21*O21)*(Q21/100)","v":0},null,null,null,null,0,0,0,{"$f":"IF(AND(A13<45351,B13>45351),(B13-A13)-1,B13-A13)","v":0},0,0,null,null,"Mental Health/Mental Rehab.",196.27,87.15,109.13,174.49]
[]
["Out-Patient Surgical",null,{"$f":"IF(OR(G13=1),U23,\"0\")","v":"0"},{"$f":"IF(OR(G13=2),V23,\"0\")","v":"0"},{"$f":"IF(OR(G13=3),W23,\"0\")","v":"0"},{"$f":"IF(OR(G13=4),X23,\"0\")","v":"0"},{"$f":"(N23*O23)*(Q23/100)","v":0},null,null,null,null,0,0,0,{"$f":"IF(AND(A13<45351,B13>45351),(B13-A13)-1,B13-A13)","v":0},0,0,null,null,"Out-Patient Surgical",784.97,348.51,436.45,697.83]
[]
["Home Health Care",null,{"$f":"IF(OR(G13=1),U25,\"0\")","v":"0"},{"$f":"IF(OR(G13=2),V25,\"0\")","v":"0"},{"$f":"IF(OR(G13=3),W25,\"0\")","v":"0"},{"$f":"IF(OR(G13=4),X25,\"0\")","v":"0"},{"$f":"(N25*O25)*(Q25/100)","v":0},null,null,null,null,0,0,0,{"$f":"IF(AND(A13<45351,B13>45351),(B13-A13)-1,B13-A13)","v":0},0,0,null,null,"Home Health Care",196.27,87.15,109.13,174.49]
["Primary Health Center's Assessment"]
[]
["Prevailing Primary Premium",null,null,null,null,null,{"$f":"SUM(G17,G19,G21,G23,G25)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"G28*29%","v":0}]
["Mcare Assessment",null,null,null,null,null,{"$f":"ROUND(L29,0)","v":0}]

{"sheet":"NC WS","index":5,"n_rows":29,"n_cols":26,"rows_kept":29,"cut":false,"hidden":false,"merged":[[6,2,6,7],[0,1,1,7],[2,2,2,7],[3,2,3,7],[4,2,4,7],[5,2,5,7],[27,4,27,6],[28,1,28,6],[7,2,7,7],[8,1,8,2],[10,1,10,7],[14,1,18,7],[24,1,25,7],[26,1,26,6]]}
[null,"2025 EXHIBIT 7 - NURSING HOME WORKSHEET (SPECIALTY CODE 80924)"]
[]
[null,"Primary Insurer",{"$f":"IF('e-216'!G3=\"Please Select Primary Insurer\",\"\",'e-216'!G3)","v":""}]
[null,"Insurer Code",{"$f":"'e-216'!Q1","v":" "}]
[null,"Date",{"$f":"IF('e-216'!B2=\"Submission Date\",\"\",'e-216'!B2)","v":""}]
[null,"Nursing Home Name"]
[null,"Nurs. Home's Address"]
[null,"Nurs. Home's Assigned #"]
[null,"Basic Insurance Coverage Limits:",null,"$   500,000.00 Per Occ."]
[null,null,null,"$1,500,000.00 Per Agg."]
[null,"Entry Worksheets must be transferred to the e-216 by clicking the \"Transfer to e-216\" button."]
[]
[null,"From Date","To Date","Retro Date","Policy #","Policy Type","County Code","Territory",null,null,null,"Terr 1","Terr 2","Terr 3","Terr 4"]
[null,null,null,null,null,null,null,{"$f":"P14","v":0},null,null,null,{"$f":"IF(OR(G14=23,G14=51),1,\"0\")","v":"0"},{"$f":"IF(OR(G14=23,G14=51,G14=2,G14=20,G14=25,G14=35,G14=37,G14=40,G14=43,G14=9,G14=15,G14=46,G14=0,G14=\"\"),0,\"2\")","v":0},{"$f":"IF(OR(G14=2,G14=20,G14=25,G14=35,G14=37,G14=40,G14=43),3,\"0\")","v":"0"},{"$f":"IF(OR(G14=9,G14=15,G14=46),4,\"0\")","v":"0"},{"$f":"SUM(L14+M14+N14+O14)","v":0}]
[null,"List Annual Occupied Bed Counts"]
[]
[]
[]
[]
[null,"Exposure Type","Bed Count","Terr. 1 Rates","Terr. 2 Rates","Terr. 3 Rates","Terr. 4 Rates","Prevailing Primary Premium",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Terr. 1 PPP","Terr. 2 PPP","Terr. 3 PPP","Terr. 4 PPP"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Daily Rate","# of Days"]
[null,"Convalescent",null,{"$f":"IF(OR(H14=1),W22,\"0\")","v":"0"},{"$f":"IF(OR(H14=2),X22,\"0\")","v":"0"},{"$f":"IF(OR(H14=3),Y22,\"0\")","v":"0"},{"$f":"IF(OR(H14=4),Z22,\"0\")","v":"0"},{"$f":"(N22*O22)*Q22","v":0},null,null,null,null,{"$f":"SUM(D22+E22+F22+G22)","v":0},{"$f":"M22/365","v":0},{"$f":"IF(AND(B14<45351,C14>45351),(C14-B14)-1,C14-B14)","v":0},null,{"$f":"ROUND(C22,0)","v":0},null,null,null,null,"Convalescent",542.65,240.96,301.74,482.43]
[null,"or"]
[null,"Skilled Nursing",null,{"$f":"IF(OR(H14=1),W24,\"0\")","v":"0"},{"$f":"IF(OR(H14=2),X24,\"0\")","v":"0"},{"$f":"IF(OR(H14=3),Y24,\"0\")","v":"0"},{"$f":"IF(OR(H14=4),Z24,\"0\")","v":"0"},{"$f":"(N24*O24)*Q24","v":0},null,null,null,null,{"$f":"SUM(D24+E24+F24+G24)","v":0},{"$f":"M24/365","v":0},{"$f":"IF(AND(B14<45351,C14>45351),(C14-B14)-1,C14-B14)","v":0},null,{"$f":"ROUND(C24,0)","v":0},null,null,null,null,"Skilled Nursing",446.91,198.44,248.48,397.31]
[null,"Nursing Home's Assessment"]
[]
[null,"Prevailing Primary Premium",null,null,null,null,null,{"$f":" (H22+H24)","v":0}]
[]
[null,"Mcare Assessment",null,null,null,null,null,{"$f":"ROUND(L29,0)","v":0},null,null,null,{"$f":"H27*29%","v":0}]

{"sheet":"BC WS","index":6,"n_rows":51,"n_cols":40,"rows_kept":51,"cut":false,"hidden":false,"merged":[[13,1,14,8],[0,1,1,8],[2,2,2,8],[3,2,3,8],[4,2,4,8],[5,2,5,8],[6,2,6,8],[7,2,7,8],[8,1,8,2],[10,1,10,8],[11,7,11,8],[12,7,12,8],[15,2,15,3],[15,7,15,8],[16,2,16,3],[16,7,16,8],[17,2,17,3],[17,7,17,8],[18,2,18,3],[18,7,18,8],[19,2,19,3],[19,7,19,8],[20,2,20,3],[20,7,20,8],[21,2,21,3],[21,7,21,8],[22,2,22,3],[22,7,22,8],[23,2,23,3],[23,7,23,8],[24,2,24,3],[24,7,24,8],[25,2,25,3],[25,7,25,8],[26,2,26,3],[26,7,26,8],[27,2,27,3],[27,7,27,8],[28,2,28,3],[28,7,28,8],[29,2,29,3],[29,7,29,8],[30,2,30,3],[30,7,30,8],[31,2,31,3],[31,7,31,8],[32,2,32,3],[32,7,32,8],[33,2,33,3],[33,7,33,8],[34,2,34,3],[34,7,34,8],[35,2,35,3],[35,7,35,8],[36,2,36,3],[36,7,36,8],[37,2,37,3],[37,7,37,8],[50,1,50,8],[41,2,41,3],[41,7,41,8],[47,7,47,8],[42,2,42,3],[44,7,44,8],[38,2,38,3],[38,7,38,8],[39,7,39,8],[40,2,40,3],[40,7,40,8],[39,2,39,3],[49,2,49,3],[49,7,49,8],[45,7,45,8],[42,7,42,8],[43,7,43,8],[44,2,44,3],[48,2,48,3],[48,7,48,8],[46,2,46,3],[46,7,46,8],[45,2,45,3],[47,2,47,3],[43,2,43,3]]}
[null,"2025 EXHIBIT 9 - BIRTH CENTER WORKSHEET (SPECIALTY CODE 80402)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(C:W)","v":0},null,null,null,"2014-10-27T08:45:00"]
[null,"Primary Insurer",{"$f":"IF('e-216'!G3=\"Please Select Primary Insurer\",\"\",'e-216'!G3)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,80402]
[null,"Insurer Code",{"$f":"'e-216'!Q1","v":" "}]
[null,"Date",{"$f":"IF('e-216'!B2=\"Submission Date\",\"\",'e-216'!B2)","v":""}]
[null,"Birth Center's Name"]
[null,"Birth Center's Address"]
[null,"Birth Ctr's Assigned #"]
[null,"Basic Insurance Coverage Limits:",null,"$   500,000.00 Per Occ."]
[null,null,null,"$1,500,000.00 Per Agg."]
[null,"Entry Worksheets must be transferred to the e-216 by clicking the \"Transfer to e-216\" button."]
[null,"From Date","To Date","Retro Date","Policy #","Policy Type","County Code","Mcare Assessment"]
[null,null,null,null,null,null,null,{"$f":"Q17","v":0}]
[null,"List all shareholders, owners, partners and employed health care providers"]
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[" ","License #","Name",null,"County Code","Specialty Code","HCP's Annual Assessment","Other Rating Factors",null,null,null,null,"Total Assessment","# of Days","Daily Rate","Assessment","Rounded Assessment"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(G17:G50)","v":0},{"$f":"IF(AND(B13<45351,C13>45351),(C13-B13)-1,C13-B13)","v":0},{"$f":"M17/365","v":0},{"$f":"(N17*O17)*25%","v":0},{"$f":"ROUND(P17,0)","v":0}]
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[null,"This worksheet will NOT include health care providers listed below this point in the calculation."]