AHCCCS Hospital Assessment	Proposed Model for CMS Review
Summary	04/01/2014 Model

Assessment Basis:

Patient Discharges

Assessment Rate Inputs	
SFY 2015	
Urban Acute Provider	
387.00	
Non-CAH Rural Acute Provider	
387.00	
Freestanding Children's Provider	
0.00	
CAH	
387.00	
LTAC Provider	
96.75	
Small Psychiatric Providers and AZ State Hospital	
0.00	
Large Psychiatric Provider	
96.75	
Freestanding Rehabilitation Provider	
0.00	
Pediatric-Intensive  General Acute Hospitals	
309.50	
Medium Pediatric Intensive General Acute Hospitals	
348.25	
Psychiatric Sub-Provider	
96.75	
Rehabilitation Sub-Provider	
0.00	
Short Term Specialty Hospital	
0.00	
High Medicare/Out-of State Patient Utilization Hospital	
0.00	

Assessment Unit Threshold 	29,000
Assessment Unit Rate Above Threshold 	38.75

State Assessment Summary	SFY 2015	
Total Assessments	233,093,405	
State Share of Coverage Payments	232,962,600	
Assessments Net of State Share	130,805	

Hospital Net Gain/Loss Summary	SFY 2015	
Total Projected Coverage Payments (1)	640,474,275	
Estimated Net Gain/Loss	407,380,871	
Number of In-State Hospitals with Estimated Gain	89	
Number of In-State Hospitals with Estimated Loss	3	
Number of In-State Hospitals with $0 Gain or Loss	5	
Number of In-State Hospital Systems with Estimated Loss	0	

Note: (1) Model includes one new urban acute hospital whose benefit from the Medicaid expansion is not expected to increase aggregate statewide projected coverage payments; to avoid duplication this provider's projected benefit has been removed from aggregate statewide projected coverage payments.

AHCCCS Hospital Assessment	Proposed Model for CMS Review
CMS Assessment Tests	04/01/2014 Model

	SFY 2015	
B1 Value	0.0000037465	
B2 Value	0.0000037045	
B1/B2 Value	1.0113259476	

Assessment Basis:

	SFY 2015	
Total Assessment Amount	233,093,405	
Inpatient Net Patient Revenues	6,668,244,493	
Ratio	3.50%	

B Test Calculation

Patient Discharges

Inpatient Hold Harmless Calculation

Tentative and Preliminary	Page - 2	DRAFT - 4/1/2014

AHCCCS Hospital Assessment 	Proposed Model for CMS Review
Summary by Provider Type 	04/01/2014 Model

Assessment  Basis:

Patient Discharges

	Estimated Hospital Net Gain/Loss - SFY 2015	

Provider Type	

Assessment Amount	
Total Projected
Coverage Payments	
Estimated Net
Gain/Loss	
Number of Hospitals with Estimated Gain	
Number of Hospitals with Estimated Loss	

Urban Acute Provider	
141,894,274 	335,862,418 	193,968,143 	26 	2	

Non-CAH Rural Acute Provider	
28,067,175 	91,024,658 	62,957,483 	14 	0	

Freestanding Children's Provider	
- 	1,268,968 	1,268,968 	2 	0	

CAH	
2,830,905 	12,667,726 	9,836,821 	10 	0	

LTAC Provider	
314,244 	5,749,563 	5,435,319 	8 	0	

Small Psychiatric Providers and AZ State Hospital	
- 	2,425,031 	2,425,031 	6 	0	

Large Psychiatric Provider	
1,575,864 	13,989,377 	12,413,513 	4 	0	

Freestanding Rehabilitation  Provider	
- 	2,690,056 	2,690,056 	7 	0	

Pediatric-Intensive General Acute Hospitals	
17,672,105 	49,699,339 	32,027,234 	2 	0	

Medium Pediatric Intensive General Acute Hospitals	
40,738,838 	103,984,438 	63,245,600 	5 	1	

Short Term Specialty Hospital	
- 	3,043,394 	3,043,394 	4 	0	

High Medicare/Out-of  State Patient Utilization Hospital	
- 	2,601,196 	2,601,196 	1 	0	

Border Providers	- 	14,574,841 	14,574,841 	243 	0	
Out of State Providers	
- 	1,318,351 	1,318,351 	530 	0	

New Hospital Adjustment		(425,078)	(425,078)		
Total	233,093,405	640,474,275	407,380,871	862	3	

General Notes: 	(1) Model excludes IHS, 638, and closed providers.
(2) Small Psychiatric Providers and AZ State Hospital are providers with less than 2,500 patient discharges.
(3) Short Term Specialty Hospital defined based on ADHS Type= Hospital, Subtype= Specialty Hospital, License status begins with SH.
(4) Pediatric-Intensive General Acute Hospitals have at least 20% pediatric/NICU  licensed beds and Medium Pediatric Intensive
General Acute Hospitals have at 10-19% licensed pediatric/NICU  beds.
(5) High Medicare/Out-of  State Patient Utilization Hospitals are Hospitals in which on average at least 15 percent of the
Inpatients are from outside of Arizona and at least 50 percent of the Inpatient Discharges are for Medicare beneficiaries. (6) Model includes one new urban acute hospital whose benefit from the Medicaid expansion is not expected to increase
aggregate statewide projected coverage payments; to avoid duplication this provider's projected benefit has been removed
from aggregate statewide projected coverage payments.

	Estimated Hospital Net Gain/Loss - SFY 2015	

Medicare
Provider ID	
Hospital Name	
Provider Type	
Hospital System	
Assessment
Amount	Total Projected Coverage Payments	
Estimated Net
Gain/Loss	
30001 	MARYVALE HOSPITAL MED CTR 	Urban Acute Provider 	Abrazo Health Care	2,255,823 	7,843,424 	5,587,601	
30002 	BANNER GOOD SAM MEDICAL C 	Urban Acute Provider 	Banner Health	11,580,952 	41,238,615 	29,657,663	
30010 	CARONDELET ST MARYS HOSP 	Urban Acute Provider 	Carondelet Health Network	5,229,821 	16,685,352 	11,455,531	
30011 	CARONDELET ST JOSEPHS-TUC 	Urban Acute Provider 	Carondelet Health Network	7,225,484 	13,086,850 	5,861,367	
30014 	JOHN C. LINCOLN HOS N MTN 	Urban Acute Provider 	John C. Lincoln Health Network	6,307,326 	18,621,862 	12,314,536	
30024 	ST JOSEPH'S HOSPITAL-PHX 	Urban Acute Provider 	Dignity	11,442,403 	42,717,665 	31,275,263	
30030 	PHOENIX BAPTIST HOSPITAL 	Urban Acute Provider 	Abrazo Health Care	4,398,642 	16,189,101 	11,790,459	
30036 	CHANDLER REGIONAL MED.CTR 	Urban Acute Provider 	Dignity	6,861,123 	12,964,038 	6,102,915	
30037 	TEMPE ST. LUKE'S HOSPITAL 	Urban Acute Provider 	Iasis Healthcare Corporation	3,417,017 	15,804,152 	12,387,135	
30038 	SCOTTSDALE HLTHCARE-OSBN 	Urban Acute Provider 	Scottsdale Healthcare	6,239,601 	14,652,843 	8,413,242	
30061 	BANNER BOSWELL MED CTR 	Urban Acute Provider 	Banner Health	8,540,703 	6,701,067 	(1,839,636)	
30083 	PARADISE VALLEY HOSPITAL 	Urban Acute Provider 	Abrazo Health Care	2,776,725 	6,513,058 	3,736,333	
30085 	NORTHWEST MEDICAL CENTER 	Urban Acute Provider 	CHS	7,189,686 	10,068,188 	2,878,502	
30088 	BANNER BAYWOOD MEDICAL CN 	Urban Acute Provider 	Banner Health	7,919,568 	8,751,730 	832,162	
30092 	JOHN C LINCOLN-DEER VLLY 	Urban Acute Provider 	John C. Lincoln Health Network	4,734,945 	12,420,280 	7,685,335	
30093 	BANNER DEL E WEBB MED CTR 	Urban Acute Provider 	Banner Health	7,212,906 	7,210,771 	(2,135)	
30094 	ARROWHEAD HOSPITAL 	Urban Acute Provider 	Abrazo Health Care	4,885,488 	7,548,330 	2,662,842	
30110 	WEST VALLEY HOSPITAL MED 	Urban Acute Provider 	Abrazo Health Care	4,120,002 	10,059,355 	5,939,353	
30111 	UNIVERSITY PHYSICIAN HC 	Urban Acute Provider 	UA Healthcare	2,185,099 	12,340,838 	10,155,740	
30114 	ORO VALLEY HOSPITAL 	Urban Acute Provider 	CHS	1,802,259 	2,130,981 	328,722	
30115 	BANNER ESTRELLA MEDICAL 	Urban Acute Provider 	Banner Health	7,274,052 	14,834,326 	7,560,274	
30119 	MERCY GILBERT MED CENTER 	Urban Acute Provider 	Dignity	5,667,615 	9,917,341 	4,249,726	
30120 	GILBERT HOSPITAL, L.L.C. 	Urban Acute Provider 	Gilbert Hospital	739,944 	2,493,933 	1,753,989	
30121 	MOUNTAIN VISTA MED CTR 	Urban Acute Provider 	Iasis Healthcare Corporation	3,930,372 	13,107,254 	9,176,882	
30122 	BANNER GATEWAY MEDICAL CT 	Urban Acute Provider 	Banner Health	5,284,098 	7,322,337 	2,038,239	
30123 	SCOTTSDALE HLTHCARE-THOMP 	Urban Acute Provider 	Scottsdale Healthcare	1,472,535 	2,120,302 	647,767	
30130 	BANNER IRONWOOD MEDICAL CENTER 	Urban Acute Provider 	Banner Health	938,862 	2,093,347 	1,154,485	
30132 	FLORENCE HOSPITAL AT ANTHEM 	Urban Acute Provider 	FLORENCE HOSPITAL AT ANTHEM	261,225 	425,078 	163,853	
30007 	VERDE VALLEY MEDICAL CTR. 	Non-CAH Rural Acute Provider 	N. AZ	1,706,864 	5,860,030 	4,153,166	
30012 	YAVAPAI REG MED CENTER 	Non-CAH Rural Acute Provider 	Yavapai Regional Medical Center West Ca	2,708,226 	5,251,591 	2,543,365	
30016 	CASA GRANDE REG MED CTR 	Non-CAH Rural Acute Provider 	Regional Care Services Corporation	3,474,680 	8,806,152 	5,331,473	
30023 	FLAGSTAFF MEDICAL CENTER 	Non-CAH Rural Acute Provider 	N. AZ	5,080,923 	16,858,741 	11,777,818	
30033 	PAYSON HOSPITAL CORP. 	Non-CAH Rural Acute Provider 	CHS	945,054 	3,955,990 	3,010,936	
30043 	SIERRA VISTA REG HLTH CTR 	Non-CAH Rural Acute Provider 	Sierra Vista Regional Health Center	2,188,872 	3,564,930 	1,376,058	
30055 	KINGMAN REGIONAL MED CTR 	Non-CAH Rural Acute Provider 	Kingman Regional Medical Center	3,044,916 	10,616,148 	7,571,232	
30062 	SUMMIT HEALTHCARE REG.MED 	Non-CAH Rural Acute Provider 	Summit Healthcare	1,436,544 	5,475,007 	4,038,463	
30067 	LA PAZ REGIONAL HOSPITAL 	Non-CAH Rural Acute Provider 	La Paz Regional Hospital	326,241 	1,095,036 	768,795	
30068 	MT. GRAHAM REG. MED. CTR. 	Non-CAH Rural Acute Provider 	Mt. Graham Regional Medical Center	810,765 	3,007,842 	2,197,077	
30069 	HAVASU REG MED CENTER LLC 	Non-CAH Rural Acute Provider 	LifePoint Hospitals, Inc.	2,274,399 	6,752,363 	4,477,964	
30101 	WESTERN AZ REG MED CTR 	Non-CAH Rural Acute Provider 	CHS	2,478,348 	11,723,851 	9,245,503	
30117 	VALLEY VIEW MEDICAL CENT 	Non-CAH Rural Acute Provider 	LifePoint Hospitals, Inc.	1,042,965 	3,845,901 	2,802,936	

Sorted by Provider Type and then by Hospital Name in alphabetical order

	Estimated Hospital Net Gain/Loss - SFY 2015	

Medicare
Provider ID	
Hospital Name	
Provider Type	
Hospital System	
Assessment
Amount	Total Projected Coverage Payments	
Estimated Net
Gain/Loss	
30126 	ARIZONA REGIONAL MED. CTR 	Non-CAH Rural Acute Provider 	Banner Health	548,379 	4,211,074 	3,662,695	
33301 	LOS NINOS HOSPITAL 	Freestanding Children's Provider 	Hacienda Healthcare	- 	7,813 	7,813	
33302 	PHOENIX CHILDREN'S HOSP 	Freestanding Children's Provider 	Phoenix Children's Hospital	- 	1,261,156 	1,261,156	
31300 	WICKENBURG COMMUNITY HOSP 	CAH 	Wickenburg Community Hospital	166,023 	391,788 	225,765	
31301 	BENSON HOSPITAL 	CAH 	Benson Hospital	121,518 	614,154 	492,636	
31302 	NORTHERN COCHISE HOSPITAL 	CAH 	Northern Cochise Community Hospital	191,952 	738,469 	546,517	
31303 	SOUTHEAST MEDICAL CENTER 	CAH 	Southeast Arizona Medical Center	116,100 	1,019,029 	902,929	
31304 	PAGE HOSPITAL 	CAH 	Banner Health	203,175 	1,311,345 	1,108,170	
31311 	LITTLE COLORADO MED CTR 	CAH 	N. AZ	523,611 	2,135,945 	1,612,334	
31312 	COPPER QUEEN HOSPITAL 	CAH 	Copper Queen Community Hospital	158,670 	1,402,282 	1,243,612	
31313 	HOLY CROSS HOSPITAL-ARIZ 	CAH 	Carondelet Health Network	545,283 	2,061,146 	1,515,863	
31314 	COBRE VALLEY COMM HOSP 	CAH 	Cobre Valley Regional Medical Center	662,931 	2,399,296 	1,736,365	
31315 	WHITE MNTN REG MED CNTR 	CAH 	White Mountain Regional Medical Center	141,642 	594,273 	452,631	
32000 	KINDRED HOSP AZ-NORTHWEST 	LTAC Provider 	Kindred Healthcare, Inc.	68,596 	925,433 	856,837	
32001 	SELECT SPECIALTY HOSP-PHX 	LTAC Provider 	Select Specialty Hospital, Arizona, Inc.	44,505 	2,008,178 	1,963,673	
32002 	KINDRED HOSPITAL-TUCSON 	LTAC Provider 	Kindred Healthcare, Inc.	38,797 	355,826 	317,029	
32004 	CORNERSTONE HOSPITAL OF S 	LTAC Provider 	Cornerstone Healthcare Group	22,930 	169,897 	146,968	
32005 	SELECT SPECIALTY-PHX D/T 	LTAC Provider 	Select Specialty Hospital, Arizona, Inc.	54,664 	898,424 	843,761	
32006 	PROMISE HOSPITAL OF PHX 	LTAC Provider 	Promise Healthcare	20,511 	834,365 	813,854	
32007 	RESTORA MESA 	LTAC Provider 	Restora	41,699 	504,006 	462,307	
32008 	SUN CITY 	LTAC Provider 	Restora	22,543 	53,433 	30,890	
34020 	HAVEN SENIOR HORIZONS 	Small Psychiatric Providers and AZ State Hospital 	HAVEN SENIOR HORIZONS	- 	5,098 	5,098	
34021 	AZ STATE HOSPITAL 	Small Psychiatric Providers and AZ State Hospital 	State of Arizona	- 	520,267 	520,267	
34023 	The Guidance Center, Inc. 	Small Psychiatric Providers and AZ State Hospital 	The Guidance Center, Inc.	- 	454,168 	454,168	
34025 	WINDHAVEN PSYCHIATRIC HOS 	Small Psychiatric Providers and AZ State Hospital 	WINDHAVEN PSYCHIATRIC HOS	- 	960,150 	960,150	
34026 	VALLEY HOSPITAL 	Small Psychiatric Providers and AZ State Hospital 	VALLEY HOSPITAL	- 	69,190 	69,190	
34027 	Community Counseling Centers, Inc at PineView Hospital 	Small Psychiatric Providers and AZ State Hospital 	Community Counseling Centers, Inc at Pin	- 	416,158 	416,158	
34028 	Aurora Behavioral Healthcare-Tempe 	Small Psychiatric Providers and AZ State Hospital 	Aurora Behavioral Health System	- 	0 	-	
N/A 	Remuda Ranch Center for Anorexia and bulimia 	Small Psychiatric Providers and AZ State Hospital 	Remuda Ranch Center for Anorexia and bu	- 	0 	-	
34004 	BANNER BEHAVORIAL HEALTH 	Large Psychiatric Provider 	Banner Health	395,030 	2,699,220 	2,304,189	
34013 	ST LUKE'S BEHAVORIAL HOSP 	Large Psychiatric Provider 	Iasis Healthcare Corporation	549,734 	6,035,463 	5,485,730	
34022 	SONORA BEHAVIORAL HEALTH 	Large Psychiatric Provider 	SONORA BEHAVIORAL HEALTH	256,291 	1,790,197 	1,533,907	
34024 	AURORA BEHAVIORAL HEALTH 	Large Psychiatric Provider 	Aurora Behavioral Health System	374,810 	3,464,496 	3,089,686	
33025 	HEALTHSOUTH MERIDIAN PT. 	Freestanding Rehabilitation Provider 	Healthsouth Rehab. Corp.	- 	339,402 	339,402	
33028 	HEALTHSOUTH REHAB INST. 	Freestanding Rehabilitation Provider 	Healthsouth Rehab. Corp.	- 	549,953 	549,953	
33029 	HLTHSOUTH REHAB.HOSP.OF.S 	Freestanding Rehabilitation Provider 	Healthsouth Rehab. Corp.	- 	299,709 	299,709	
33032 	HEALTHSOUTH VALLEY OF SUN 	Freestanding Rehabilitation Provider 	Healthsouth Rehab. Corp.	- 	605,737 	605,737	
33034 	YUMA REHABILITATION HOSPI 	Freestanding Rehabilitation Provider 	Healthsouth Rehab. Corp.	- 	131,298 	131,298	
33036 	MOUNTAIN VALLEY REG REHAB 	Freestanding Rehabilitation Provider 	Ernest Health, Inc.	- 	525,448 	525,448	
33037 	HEALTHSOUTH E.VALLEY REHA 	Freestanding Rehabilitation Provider 	Healthsouth Rehab. Corp.	- 	238,508 	238,508	
30064 	UNIVERSITY MED CTR-AZ 	Pediatric-Intensive General Acute Hospitals 	UA Healthcare	8,189,561 	31,431,078 	23,241,517	

Sorted by Provider Type and then by Hospital Name in alphabetical order

	Estimated Hospital Net Gain/Loss - SFY 2015	

Medicare
Provider ID	
Hospital Name	
Provider Type	
Hospital System	
Assessment
Amount	Total Projected Coverage Payments	
Estimated Net
Gain/Loss	
30065 	BANNER DESERT MEDICAL CEN 	Pediatric-Intensive General Acute Hospitals 	Banner Health	9,482,544 	18,268,261 	8,785,717	
30006 	TUCSON MEDICAL CENTER 	Medium Pediatric Intensive General Acute Hospitals 	TMC Healthcare	10,314,125 	18,317,245 	8,003,120	
30013 	YUMA REGIONAL MED CENTER 	Medium Pediatric Intensive General Acute Hospitals 	Yuma Regional Medical Center	4,520,633 	13,101,926 	8,581,292	
30022 	MARICOPA MEDICAL CENTER 	Medium Pediatric Intensive General Acute Hospitals 	MIHS	6,629,200 	44,075,468 	37,446,268	
30087 	SCOTTSDALE HEALTHCARE - SHEA 	Medium Pediatric Intensive General Acute Hospitals 	Scottsdale Healthcare	7,447,326 	6,709,513 	(737,814)	
30089 	BANNER THUNDERBIRD MEDICA 	Medium Pediatric Intensive General Acute Hospitals 	Banner Health	10,323,113 	18,193,083 	7,869,970	
30118 	YRMC EAST 	Medium Pediatric Intensive General Acute Hospitals 	Yavapai Regional Medical Center West Ca	1,504,440 	3,587,203 	2,082,763	
30105 	BANNER HEART HOSPITAL 	Short Term Specialty Hospital 	Banner Health	- 	1,968,576 	1,968,576	
30107 	ARIZONA SPINE AND JOINT 	Short Term Specialty Hospital 	Arizona Spine and Joint Hospital	- 	16,264 	16,264	
30108 	SURGICAL SPECIALITY HOSP 	Short Term Specialty Hospital 	Surgical Specialty Hospital of Arizona	- 	137,530 	137,530	
30112 	AZ ORTHOPEDIC SURGICAL HO 	Short Term Specialty Hospital 	Orthopedic & Surgical Specialty Company	- 	921,024 	921,024	
30131 	ORTHOPEDIC AND SPINE INPATIENT SURGI 	Short Term Specialty Hospital 	O.A.S.I.S. hospital, Partners are CHW and	- 	0 	-	
N/A 	Cancer Treatment Centers of America - Western Regional Medical Short Term Specialty Hospital 	Cancer Treatment Centers of America - We	- 	0 	-	
N/A 	FREEDOM PAIN HOSPITAL 	Short Term Specialty Hospital 	FREEDOM PAIN HOSPITAL	- 	0 	-	
30103 	MAYO CLINIC HOSPITAL 	High Medicare/Out-of State Patient Utilization Hospita  Mayo	- 	2,601,196 	2,601,196	

Sorted by Provider Type and then by Hospital Name in alphabetical order

Total Border Providers	-	14,574,841	14,574,841	
Total Out of State Providers	-	1,318,351	1,318,351	
New Hospital Adjustment		(425,078.00)	(425,078.00)	
Total	233,093,405	640,474,275	407,380,871	

State Share of Coverage Payments			
232,962,600	
Assessment Net of State Share:			130,805	

Note: (1) New hospital whose benefit from the Medicaid expansion is not expected to increase aggregate statewide projected coverage payments; to avoid duplication this				
provider's projected benefit has been removed from aggregate statewide projected coverage payments.

	
FYE 2011 Patient Discharges
Per Medicare Cost Report		SFY 2015
Non-Psychiatric and Rehabilitation
Discharges Below Threshold	SFY 2015
Non-Psychiatric and Rehabilitation
Discharges Above Threshold	

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	
FYE 2015
Threshold
Units	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

A	B	C	
D	
E	
F	
G	
H	
I	
J = H*I	
K	
L	
M = K*L	
30094	ARROWHEAD HOSPITAL	Urban Acute Provider	12,624	N/A	N/A	29,000	12,624	387.00	4,885,488	-	38.75	-	
30088	BANNER BAYWOOD MEDICAL CN	Urban Acute Provider	20,464	N/A	447	29,000	20,464	387.00	7,919,568	-	38.75	-	
30061	BANNER BOSWELL MED CTR	Urban Acute Provider	22,069	N/A	491	29,000	22,069	387.00	8,540,703	-	38.75	-	
30093	BANNER DEL E WEBB MED CTR	Urban Acute Provider	18,413	900	468	29,000	18,413	387.00	7,125,831	-	38.75	-	
30115	BANNER ESTRELLA MEDICAL	Urban Acute Provider	18,796	N/A	N/A	29,000	18,796	387.00	7,274,052	-	38.75	-	
30122	BANNER GATEWAY MEDICAL CT	Urban Acute Provider	13,654	N/A	N/A	29,000	13,654	387.00	5,284,098	-	38.75	-	
30002	BANNER GOOD SAM MEDICAL C	Urban Acute Provider	36,275	786	1,038	29,000	29,000	387.00	11,223,000	7,275	38.75	281,906	
30130	BANNER IRONWOOD MEDICAL CENTER	Urban Acute Provider	2,426	N/A	N/A	29,000	2,426	387.00	938,862	-	38.75	-	
30011	CARONDELET ST JOSEPHS-TUC	Urban Acute Provider	18,467	814	483	29,000	18,467	387.00	7,146,729	-	38.75	-	
30010	CARONDELET ST MARYS HOSP	Urban Acute Provider	13,203	1,243	500	29,000	13,203	387.00	5,109,561	-	38.75	-	
30036	CHANDLER REGIONAL MED.CTR	Urban Acute Provider	17,729	N/A	N/A	29,000	17,729	387.00	6,861,123	-	38.75	-	
30132	FLORENCE HOSPITAL AT ANTHEM	Urban Acute Provider	675	N/A	N/A	29,000	675	387.00	261,225	-	38.75	-	
30120	GILBERT HOSPITAL, L.L.C.	Urban Acute Provider	1,912	N/A	N/A	29,000	1,912	387.00	739,944	-	38.75	-	
30092	JOHN C LINCOLN-DEER VLLY	Urban Acute Provider	12,235	N/A	N/A	29,000	12,235	387.00	4,734,945	-	38.75	-	
30014	JOHN C. LINCOLN HOS N MTN	Urban Acute Provider	16,298	N/A	N/A	29,000	16,298	387.00	6,307,326	-	38.75	-	
30001	MARYVALE HOSPITAL MED CTR	Urban Acute Provider	5,829	N/A	N/A	29,000	5,829	387.00	2,255,823	-	38.75	-	
30119	MERCY GILBERT MED CENTER	Urban Acute Provider	14,645	N/A	N/A	29,000	14,645	387.00	5,667,615	-	38.75	-	
30121	MOUNTAIN VISTA MED CTR	Urban Acute Provider	10,156	N/A	N/A	29,000	10,156	387.00	3,930,372	-	38.75	-	
30085	NORTHWEST MEDICAL CENTER	Urban Acute Provider	18,578	N/A	N/A	29,000	18,578	387.00	7,189,686	-	38.75	-	
30114	ORO VALLEY HOSPITAL	Urban Acute Provider	4,657	N/A	403	29,000	4,657	387.00	1,802,259	-	38.75	-	
30083	PARADISE VALLEY HOSPITAL	Urban Acute Provider	7,175	N/A	N/A	29,000	7,175	387.00	2,776,725	-	38.75	-	
30030	PHOENIX BAPTIST HOSPITAL	Urban Acute Provider	11,366	N/A	N/A	29,000	11,366	387.00	4,398,642	-	38.75	-	
30038	SCOTTSDALE HLTHCARE-OSBN	Urban Acute Provider	16,123	N/A	407	29,000	16,123	387.00	6,239,601	-	38.75	-	
30123	SCOTTSDALE HLTHCARE-THOMP	Urban Acute Provider	3,805	N/A	N/A	29,000	3,805	387.00	1,472,535	-	38.75	-	
30024	ST JOSEPH'S HOSPITAL-PHX	Urban Acute Provider	34,662	N/A	898	29,000	29,000	387.00	11,223,000	5,662	38.75	219,403	
30037	TEMPE ST. LUKE'S HOSPITAL	Urban Acute Provider	8,739	362	217	29,000	8,739	387.00	3,381,993	-	38.75	-	
30111	UNIVERSITY PHYSICIAN HC	Urban Acute Provider	5,545	405	N/A	29,000	5,545	387.00	2,145,915	-	38.75	-	
30110	WEST VALLEY HOSPITAL MED	Urban Acute Provider	10,646	N/A	N/A	29,000	10,646	387.00	4,120,002	-	38.75	-	
30126	ARIZONA REGIONAL MED. CTR	Non-CAH Rural Acute Provider	1,417	N/A	N/A	29,000	1,417	387.00	548,379	-	38.75	-	
30016	CASA GRANDE REG MED CTR	Non-CAH Rural Acute Provider	8,912	266	N/A	29,000	8,912	387.00	3,448,944	-	38.75	-	

Sorted by Provider Type and then by Hospital Name in alphabetical order

	
FYE 2011 Patient Discharges
Per Medicare Cost Report	
SFY 2015
Psychiatric Subprovider Discharges	
SFY 2015
Rehabilitation Subprovider Discharges		

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	
SFY 2015
Total Assessment Amount	

A	B	C	
D	
E	
F	
N	
O	
P = N*O	
Q	
R	
S = Q*R	
T = J+M+P+S	
30094	ARROWHEAD HOSPITAL	Urban Acute Provider	12,624	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	4,885,488	
30088	BANNER BAYWOOD MEDICAL CN	Urban Acute Provider	20,464	N/A	447	N/A	96.75	N/A	447	0.00	-	7,919,568	
30061	BANNER BOSWELL MED CTR	Urban Acute Provider	22,069	N/A	491	N/A	96.75	N/A	491	0.00	-	8,540,703	
30093	BANNER DEL E WEBB MED CTR	Urban Acute Provider	18,413	900	468	900	96.75	87,075	468	0.00	-	7,212,906	
30115	BANNER ESTRELLA MEDICAL	Urban Acute Provider	18,796	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	7,274,052	
30122	BANNER GATEWAY MEDICAL CT	Urban Acute Provider	13,654	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	5,284,098	
30002	BANNER GOOD SAM MEDICAL C	Urban Acute Provider	36,275	786	1,038	786	96.75	76,046	1,038	0.00	-	11,580,952	
30130	BANNER IRONWOOD MEDICAL CENTER	Urban Acute Provider	2,426	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	938,862	
30011	CARONDELET ST JOSEPHS-TUC	Urban Acute Provider	18,467	814	483	814	96.75	78,755	483	0.00	-	7,225,484	
30010	CARONDELET ST MARYS HOSP	Urban Acute Provider	13,203	1,243	500	1,243	96.75	120,260	500	0.00	-	5,229,821	
30036	CHANDLER REGIONAL MED.CTR	Urban Acute Provider	17,729	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	6,861,123	
30132	FLORENCE HOSPITAL AT ANTHEM	Urban Acute Provider	675	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	261,225	
30120	GILBERT HOSPITAL, L.L.C.	Urban Acute Provider	1,912	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	739,944	
30092	JOHN C LINCOLN-DEER VLLY	Urban Acute Provider	12,235	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	4,734,945	
30014	JOHN C. LINCOLN HOS N MTN	Urban Acute Provider	16,298	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	6,307,326	
30001	MARYVALE HOSPITAL MED CTR	Urban Acute Provider	5,829	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	2,255,823	
30119	MERCY GILBERT MED CENTER	Urban Acute Provider	14,645	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	5,667,615	
30121	MOUNTAIN VISTA MED CTR	Urban Acute Provider	10,156	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	3,930,372	
30085	NORTHWEST MEDICAL CENTER	Urban Acute Provider	18,578	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	7,189,686	
30114	ORO VALLEY HOSPITAL	Urban Acute Provider	4,657	N/A	403	N/A	96.75	N/A	403	0.00	-	1,802,259	
30083	PARADISE VALLEY HOSPITAL	Urban Acute Provider	7,175	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	2,776,725	
30030	PHOENIX BAPTIST HOSPITAL	Urban Acute Provider	11,366	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	4,398,642	
30038	SCOTTSDALE HLTHCARE-OSBN	Urban Acute Provider	16,123	N/A	407	N/A	96.75	N/A	407	0.00	-	6,239,601	
30123	SCOTTSDALE HLTHCARE-THOMP	Urban Acute Provider	3,805	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	1,472,535	
30024	ST JOSEPH'S HOSPITAL-PHX	Urban Acute Provider	34,662	N/A	898	N/A	96.75	N/A	898	0.00	-	11,442,403	
30037	TEMPE ST. LUKE'S HOSPITAL	Urban Acute Provider	8,739	362	217	362	96.75	35,024	217	0.00	-	3,417,017	
30111	UNIVERSITY PHYSICIAN HC	Urban Acute Provider	5,545	405	N/A	405	96.75	39,184	N/A	0.00	N/A	2,185,099	
30110	WEST VALLEY HOSPITAL MED	Urban Acute Provider	10,646	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	4,120,002	
30126	ARIZONA REGIONAL MED. CTR	Non-CAH Rural Acute Provider	1,417	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	548,379	
30016	CASA GRANDE REG MED CTR	Non-CAH Rural Acute Provider	8,912	266	N/A	266	96.75	25,736	N/A	0.00	N/A	3,474,680	

Sorted by Provider Type and then by Hospital Name in alphabetical order

	
FYE 2011 Patient Discharges
Per Medicare Cost Report		

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	

Comment	

A	B	C	
D	
E	
F		
30094	ARROWHEAD HOSPITAL	Urban Acute Provider	12,624	N/A	N/A		
30088	BANNER BAYWOOD MEDICAL CN	Urban Acute Provider	20,464	N/A	447		
30061	BANNER BOSWELL MED CTR	Urban Acute Provider	22,069	N/A	491		
30093	BANNER DEL E WEBB MED CTR	Urban Acute Provider	18,413	900	468		
30115	BANNER ESTRELLA MEDICAL	Urban Acute Provider	18,796	N/A	N/A		
30122	BANNER GATEWAY MEDICAL CT	Urban Acute Provider	13,654	N/A	N/A		
30002	BANNER GOOD SAM MEDICAL C	Urban Acute Provider	36,275	786	1,038		
30130	BANNER IRONWOOD MEDICAL CENTER	Urban Acute Provider	2,426	N/A	N/A		
30011	CARONDELET ST JOSEPHS-TUC	Urban Acute Provider	18,467	814	483		
30010	CARONDELET ST MARYS HOSP	Urban Acute Provider	13,203	1,243	500		
30036	CHANDLER REGIONAL MED.CTR	Urban Acute Provider	17,729	N/A	N/A		
30132	FLORENCE HOSPITAL AT ANTHEM	Urban Acute Provider	675	N/A	N/A	New hospital with no FYE 2011 Medicare cost report; discharges based on 2012 UAR.	
30120	GILBERT HOSPITAL, L.L.C.	Urban Acute Provider	1,912	N/A	N/A		
30092	JOHN C LINCOLN-DEER VLLY	Urban Acute Provider	12,235	N/A	N/A		
30014	JOHN C. LINCOLN HOS N MTN	Urban Acute Provider	16,298	N/A	N/A		
30001	MARYVALE HOSPITAL MED CTR	Urban Acute Provider	5,829	N/A	N/A		
30119	MERCY GILBERT MED CENTER	Urban Acute Provider	14,645	N/A	N/A		
30121	MOUNTAIN VISTA MED CTR	Urban Acute Provider	10,156	N/A	N/A		
30085	NORTHWEST MEDICAL CENTER	Urban Acute Provider	18,578	N/A	N/A		
30114	ORO VALLEY HOSPITAL	Urban Acute Provider	4,657	N/A	403		
30083	PARADISE VALLEY HOSPITAL	Urban Acute Provider	7,175	N/A	N/A		
30030	PHOENIX BAPTIST HOSPITAL	Urban Acute Provider	11,366	N/A	N/A		
30038	SCOTTSDALE HLTHCARE-OSBN	Urban Acute Provider	16,123	N/A	407	Removed 259 inpatient discharges from Greenbaum (exempt provider).	
30123	SCOTTSDALE HLTHCARE-THOMP	Urban Acute Provider	3,805	N/A	N/A		
30024	ST JOSEPH'S HOSPITAL-PHX	Urban Acute Provider	34,662	N/A	898		
30037	TEMPE ST. LUKE'S HOSPITAL	Urban Acute Provider	8,739	362	217		
30111	UNIVERSITY PHYSICIAN HC	Urban Acute Provider	5,545	405	N/A		
30110	WEST VALLEY HOSPITAL MED	Urban Acute Provider	10,646	N/A	N/A		
30126	ARIZONA REGIONAL MED. CTR	Non-CAH Rural Acute Provider	1,417	N/A	N/A	ARMC Mesa campus closed; discharges removed from assessment per 2011 UAR data.	
30016	CASA GRANDE REG MED CTR	Non-CAH Rural Acute Provider	8,912	266	N/A		

Sorted by Provider Type and then by Hospital Name in alphabetical order

	
FYE 2011 Patient Discharges
Per Medicare Cost Report		SFY 2015
Non-Psychiatric and Rehabilitation
Discharges Below Threshold	SFY 2015
Non-Psychiatric and Rehabilitation
Discharges Above Threshold	

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	
FYE 2015
Threshold
Units	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

A	B	C	
D	
E	
F	
G	
H	
I	
J = H*I	
K	
L	
M = K*L	
30023	FLAGSTAFF MEDICAL CENTER	Non-CAH Rural Acute Provider	12,985	576	N/A	29,000	12,985	387.00	5,025,195	-	38.75	-	
30069	HAVASU REG MED CENTER LLC	Non-CAH Rural Acute Provider	5,877	N/A	88	29,000	5,877	387.00	2,274,399	-	38.75	-	
30055	KINGMAN REGIONAL MED CTR	Non-CAH Rural Acute Provider	7,868	N/A	178	29,000	7,868	387.00	3,044,916	-	38.75	-	
30067	LA PAZ REGIONAL HOSPITAL	Non-CAH Rural Acute Provider	843	N/A	N/A	29,000	843	387.00	326,241	-	38.75	-	
30068	MT. GRAHAM REG. MED. CTR.	Non-CAH Rural Acute Provider	2,095	N/A	N/A	29,000	2,095	387.00	810,765	-	38.75	-	
30033	PAYSON HOSPITAL CORP.	Non-CAH Rural Acute Provider	2,442	N/A	N/A	29,000	2,442	387.00	945,054	-	38.75	-	
30043	SIERRA VISTA REG HLTH CTR	Non-CAH Rural Acute Provider	5,656	N/A	N/A	29,000	5,656	387.00	2,188,872	-	38.75	-	
30062	SUMMIT HEALTHCARE REG.MED	Non-CAH Rural Acute Provider	3,712	N/A	N/A	29,000	3,712	387.00	1,436,544	-	38.75	-	
30117	VALLEY VIEW MEDICAL CENT	Non-CAH Rural Acute Provider	2,695	N/A	150	29,000	2,695	387.00	1,042,965	-	38.75	-	
30007	VERDE VALLEY MEDICAL CTR.	Non-CAH Rural Acute Provider	4,370	162	N/A	29,000	4,370	387.00	1,691,190	-	38.75	-	
30101	WESTERN AZ REG MED CTR	Non-CAH Rural Acute Provider	6,404	N/A	N/A	29,000	6,404	387.00	2,478,348	-	38.75	-	
30012	YAVAPAI REG MED CENTER	Non-CAH Rural Acute Provider	6,998	N/A	N/A	29,000	6,998	387.00	2,708,226	-	38.75	-	
33301	LOS NINOS HOSPITAL	Freestanding Children's Provider	268	N/A	N/A	29,000	268	-	-	-	38.75	-	
33302	PHOENIX CHILDREN'S HOSP	Freestanding Children's Provider	13,244	N/A	N/A	29,000	13,244	-	-	-	38.75	-	
31301	BENSON HOSPITAL	CAH	314	N/A	N/A	29,000	314	387.00	121,518	-	38.75	-	
31314	COBRE VALLEY COMM HOSP	CAH	1,713	N/A	N/A	29,000	1,713	387.00	662,931	-	38.75	-	
31312	COPPER QUEEN HOSPITAL	CAH	410	N/A	N/A	29,000	410	387.00	158,670	-	38.75	-	
31313	HOLY CROSS HOSPITAL-ARIZ	CAH	1,409	N/A	N/A	29,000	1,409	387.00	545,283	-	38.75	-	
31311	LITTLE COLORADO MED CTR	CAH	1,353	N/A	N/A	29,000	1,353	387.00	523,611	-	38.75	-	
31302	NORTHERN COCHISE HOSPITAL	CAH	496	N/A	N/A	29,000	496	387.00	191,952	-	38.75	-	
31304	PAGE HOSPITAL	CAH	525	N/A	N/A	29,000	525	387.00	203,175	-	38.75	-	
31303	SOUTHEAST MEDICAL CENTER	CAH	300	N/A	N/A	29,000	300	387.00	116,100	-	38.75	-	
31315	WHITE MNTN REG MED CNTR	CAH	366	N/A	N/A	29,000	366	387.00	141,642	-	38.75	-	
31300	WICKENBURG COMMUNITY HOSP	CAH	429	N/A	N/A	29,000	429	387.00	166,023	-	38.75	-	
32004	CORNERSTONE HOSPITAL OF S	LTAC Provider	237	N/A	N/A	29,000	237	96.75	22,930	-	38.75	-	
32000	KINDRED HOSP AZ-NORTHWEST	LTAC Provider	709	N/A	N/A	29,000	709	96.75	68,596	-	38.75	-	
32002	KINDRED HOSPITAL-TUCSON	LTAC Provider	401	N/A	N/A	29,000	401	96.75	38,797	-	38.75	-	
32006	PROMISE HOSPITAL OF PHX	LTAC Provider	212	N/A	N/A	29,000	212	96.75	20,511	-	38.75	-	
32007	RESTORA MESA	LTAC Provider	431	N/A	N/A	29,000	431	96.75	41,699	-	38.75	-	
32001	SELECT SPECIALTY HOSP-PHX	LTAC Provider	460	N/A	N/A	29,000	460	96.75	44,505	-	38.75	-	

Sorted by Provider Type and then by Hospital Name in alphabetical order

	
FYE 2011 Patient Discharges
Per Medicare Cost Report	
SFY 2015
Psychiatric Subprovider Discharges	
SFY 2015
Rehabilitation Subprovider Discharges		

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	
SFY 2015
Total Assessment Amount	

A	B	C	
D	
E	
F	
N	
O	
P = N*O	
Q	
R	
S = Q*R	
T = J+M+P+S	
30023	FLAGSTAFF MEDICAL CENTER	Non-CAH Rural Acute Provider	12,985	576	N/A	576	96.75	55,728	N/A	0.00	N/A	5,080,923	
30069	HAVASU REG MED CENTER LLC	Non-CAH Rural Acute Provider	5,877	N/A	88	N/A	96.75	N/A	88	0.00	-	2,274,399	
30055	KINGMAN REGIONAL MED CTR	Non-CAH Rural Acute Provider	7,868	N/A	178	N/A	96.75	N/A	178	0.00	-	3,044,916	
30067	LA PAZ REGIONAL HOSPITAL	Non-CAH Rural Acute Provider	843	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	326,241	
30068	MT. GRAHAM REG. MED. CTR.	Non-CAH Rural Acute Provider	2,095	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	810,765	
30033	PAYSON HOSPITAL CORP.	Non-CAH Rural Acute Provider	2,442	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	945,054	
30043	SIERRA VISTA REG HLTH CTR	Non-CAH Rural Acute Provider	5,656	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	2,188,872	
30062	SUMMIT HEALTHCARE REG.MED	Non-CAH Rural Acute Provider	3,712	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	1,436,544	
30117	VALLEY VIEW MEDICAL CENT	Non-CAH Rural Acute Provider	2,695	N/A	150	N/A	96.75	N/A	150	0.00	-	1,042,965	
30007	VERDE VALLEY MEDICAL CTR.	Non-CAH Rural Acute Provider	4,370	162	N/A	162	96.75	15,674	N/A	0.00	N/A	1,706,864	
30101	WESTERN AZ REG MED CTR	Non-CAH Rural Acute Provider	6,404	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	2,478,348	
30012	YAVAPAI REG MED CENTER	Non-CAH Rural Acute Provider	6,998	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	2,708,226	
33301	LOS NINOS HOSPITAL	Freestanding Children's Provider	268	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
33302	PHOENIX CHILDREN'S HOSP	Freestanding Children's Provider	13,244	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
31301	BENSON HOSPITAL	CAH	314	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	121,518	
31314	COBRE VALLEY COMM HOSP	CAH	1,713	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	662,931	
31312	COPPER QUEEN HOSPITAL	CAH	410	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	158,670	
31313	HOLY CROSS HOSPITAL-ARIZ	CAH	1,409	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	545,283	
31311	LITTLE COLORADO MED CTR	CAH	1,353	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	523,611	
31302	NORTHERN COCHISE HOSPITAL	CAH	496	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	191,952	
31304	PAGE HOSPITAL	CAH	525	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	203,175	
31303	SOUTHEAST MEDICAL CENTER	CAH	300	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	116,100	
31315	WHITE MNTN REG MED CNTR	CAH	366	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	141,642	
31300	WICKENBURG COMMUNITY HOSP	CAH	429	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	166,023	
32004	CORNERSTONE HOSPITAL OF S	LTAC Provider	237	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	22,930	
32000	KINDRED HOSP AZ-NORTHWEST	LTAC Provider	709	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	68,596	
32002	KINDRED HOSPITAL-TUCSON	LTAC Provider	401	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	38,797	
32006	PROMISE HOSPITAL OF PHX	LTAC Provider	212	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	20,511	
32007	RESTORA MESA	LTAC Provider	431	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	41,699	
32001	SELECT SPECIALTY HOSP-PHX	LTAC Provider	460	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	44,505	

Sorted by Provider Type and then by Hospital Name in alphabetical order

	
FYE 2011 Patient Discharges
Per Medicare Cost Report		

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	

Comment	

A	B	C	
D	
E	
F		
30023	FLAGSTAFF MEDICAL CENTER	Non-CAH Rural Acute Provider	12,985	576	N/A		
30069	HAVASU REG MED CENTER LLC	Non-CAH Rural Acute Provider	5,877	N/A	88		
30055	KINGMAN REGIONAL MED CTR	Non-CAH Rural Acute Provider	7,868	N/A	178		
30067	LA PAZ REGIONAL HOSPITAL	Non-CAH Rural Acute Provider	843	N/A	N/A		
30068	MT. GRAHAM REG. MED. CTR.	Non-CAH Rural Acute Provider	2,095	N/A	N/A		
30033	PAYSON HOSPITAL CORP.	Non-CAH Rural Acute Provider	2,442	N/A	N/A		
30043	SIERRA VISTA REG HLTH CTR	Non-CAH Rural Acute Provider	5,656	N/A	N/A		
30062	SUMMIT HEALTHCARE REG.MED	Non-CAH Rural Acute Provider	3,712	N/A	N/A		
30117	VALLEY VIEW MEDICAL CENT	Non-CAH Rural Acute Provider	2,695	N/A	150		
30007	VERDE VALLEY MEDICAL CTR.	Non-CAH Rural Acute Provider	4,370	162	N/A		
30101	WESTERN AZ REG MED CTR	Non-CAH Rural Acute Provider	6,404	N/A	N/A		
30012	YAVAPAI REG MED CENTER	Non-CAH Rural Acute Provider	6,998	N/A	N/A		
33301	LOS NINOS HOSPITAL	Freestanding Children's Provider	268	N/A	N/A	No FYE 2011 Medicare cost report; discharges based on data provided directly by hospital.	
33302	PHOENIX CHILDREN'S HOSP	Freestanding Children's Provider	13,244	N/A	N/A		
31301	BENSON HOSPITAL	CAH	314	N/A	N/A		
31314	COBRE VALLEY COMM HOSP	CAH	1,713	N/A	N/A		
31312	COPPER QUEEN HOSPITAL	CAH	410	N/A	N/A		
31313	HOLY CROSS HOSPITAL-ARIZ	CAH	1,409	N/A	N/A		
31311	LITTLE COLORADO MED CTR	CAH	1,353	N/A	N/A		
31302	NORTHERN COCHISE HOSPITAL	CAH	496	N/A	N/A		
31304	PAGE HOSPITAL	CAH	525	N/A	N/A		
31303	SOUTHEAST MEDICAL CENTER	CAH	300	N/A	N/A		
31315	WHITE MNTN REG MED CNTR	CAH	366	N/A	N/A		
31300	WICKENBURG COMMUNITY HOSP	CAH	429	N/A	N/A		
32004	CORNERSTONE HOSPITAL OF S	LTAC Provider	237	N/A	N/A		
32000	KINDRED HOSP AZ-NORTHWEST	LTAC Provider	709	N/A	N/A	Kindred Scottsdale campus closed; discharges removed from assessment per 2011 UAR.	
32002	KINDRED HOSPITAL-TUCSON	LTAC Provider	401	N/A	N/A		
32006	PROMISE HOSPITAL OF PHX	LTAC Provider	212	N/A	N/A		
32007	RESTORA MESA	LTAC Provider	431	N/A	N/A		
32001	SELECT SPECIALTY HOSP-PHX	LTAC Provider	460	N/A	N/A		

Sorted by Provider Type and then by Hospital Name in alphabetical order

	
FYE 2011 Patient Discharges
Per Medicare Cost Report		SFY 2015
Non-Psychiatric and Rehabilitation
Discharges Below Threshold	SFY 2015
Non-Psychiatric and Rehabilitation
Discharges Above Threshold	

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	
FYE 2015
Threshold
Units	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

A	B	C	
D	
E	
F	
G	
H	
I	
J = H*I	
K	
L	
M = K*L	
32005	SELECT SPECIALTY-PHX D/T	LTAC Provider	565	N/A	N/A	29,000	565	96.75	54,664	-	38.75	-	
32008	SUN CITY	LTAC Provider	233	N/A	N/A	29,000	233	96.75	22,543	-	38.75	-	
34028	Aurora Behavioral Healthcare-Tempe	Small Psychiatric Providers and AZ State	2,284	N/A	N/A	29,000	2,284	-	-	-	38.75	-	
34021	AZ STATE HOSPITAL	Small Psychiatric Providers and AZ State	109	N/A	N/A	29,000	109	-	-	-	38.75	-	
34027	Community Counseling Centers, Inc at PineView Hospital	Small Psychiatric Providers and AZ State	387	N/A	N/A	29,000	387	-	-	-	38.75	-	
34020	HAVEN SENIOR HORIZONS	Small Psychiatric Providers and AZ State	719	N/A	N/A	29,000	719	-	-	-	38.75	-	
N/A	Remuda Ranch Center for Anorexia and bulimia	Small Psychiatric Providers and AZ State	92	N/A	N/A	29,000	92	-	-	-	38.75	-	
34023	The Guidance Center, Inc.	Small Psychiatric Providers and AZ State	622	N/A	N/A	29,000	622	-	-	-	38.75	-	
34026	VALLEY HOSPITAL	Small Psychiatric Providers and AZ State	2,125	N/A	N/A	29,000	2,125	-	-	-	38.75	-	
34025	WINDHAVEN PSYCHIATRIC HOS	Small Psychiatric Providers and AZ State	581	N/A	N/A	29,000	581	-	-	-	38.75	-	
34024	AURORA BEHAVIORAL HEALTH	Large Psychiatric Provider	3,874	N/A	N/A	29,000	3,874	96.75	374,810	-	38.75	-	
34004	BANNER BEHAVORIAL HEALTH	Large Psychiatric Provider	4,083	N/A	N/A	29,000	4,083	96.75	395,030	-	38.75	-	
34022	SONORA BEHAVIORAL HEALTH	Large Psychiatric Provider	2,649	N/A	N/A	29,000	2,649	96.75	256,291	-	38.75	-	
34013	ST LUKE'S BEHAVORIAL HOSP	Large Psychiatric Provider	5,682	N/A	N/A	29,000	5,682	96.75	549,734	-	38.75	-	
33037	HEALTHSOUTH E.VALLEY REHA	Freestanding Rehabilitation Provider	869	N/A	N/A	29,000	869	-	-	-	38.75	-	
33025	HEALTHSOUTH MERIDIAN PT.	Freestanding Rehabilitation Provider	1,387	N/A	N/A	29,000	1,387	-	-	-	38.75	-	
33028	HEALTHSOUTH REHAB INST.	Freestanding Rehabilitation Provider	1,496	N/A	N/A	29,000	1,496	-	-	-	38.75	-	
33032	HEALTHSOUTH VALLEY OF SUN	Freestanding Rehabilitation Provider	1,401	N/A	N/A	29,000	1,401	-	-	-	38.75	-	
33029	HLTHSOUTH REHAB.HOSP.OF.S	Freestanding Rehabilitation Provider	1,266	N/A	N/A	29,000	1,266	-	-	-	38.75	-	
33036	MOUNTAIN VALLEY REG REHAB	Freestanding Rehabilitation Provider	780	N/A	N/A	29,000	780	-	-	-	38.75	-	
33034	YUMA REHABILITATION HOSPI	Freestanding Rehabilitation Provider	886	N/A	N/A	29,000	886	-	-	-	38.75	-	
30065	BANNER DESERT MEDICAL CEN	Pediatric-Intensive General Acute Hospita	42,085	N/A	N/A	29,000	29,000	309.50	8,975,500	13,085	38.75	507,044	
30064	UNIVERSITY MED CTR-AZ	Pediatric-Intensive General Acute Hospita	26,294	533	N/A	29,000	26,294	309.50	8,137,993	-	38.75	-	
30089	BANNER THUNDERBIRD MEDICA	Medium Pediatric Intensive General Acut	31,379	1,361	N/A	29,000	29,000	348.25	10,099,250	2,379	38.75	92,186	
30022	MARICOPA MEDICAL CENTER	Medium Pediatric Intensive General Acut	18,067	3,487	N/A	29,000	18,067	348.25	6,291,833	-	38.75	-	
30087	SCOTTSDALE HEALTHCARE - SHEA	Medium Pediatric Intensive General Acut	21,385	N/A	N/A	29,000	21,385	348.25	7,447,326	-	38.75	-	
30006	TUCSON MEDICAL CENTER	Medium Pediatric Intensive General Acut	29,644	1,963	N/A	29,000	29,000	348.25	10,099,250	644	38.75	24,955	
30118	YRMC EAST	Medium Pediatric Intensive General Acut	4,320	N/A	N/A	29,000	4,320	348.25	1,504,440	-	38.75	-	
30013	YUMA REGIONAL MED CENTER	Medium Pediatric Intensive General Acut	12,981	N/A	N/A	29,000	12,981	348.25	4,520,633	-	38.75	-	
30107	ARIZONA SPINE AND JOINT	Short Term Specialty Hospital	865	N/A	N/A	29,000	865	-	-	-	38.75	-	

Sorted by Provider Type and then by Hospital Name in alphabetical order

	
FYE 2011 Patient Discharges
Per Medicare Cost Report	
SFY 2015
Psychiatric Subprovider Discharges	
SFY 2015
Rehabilitation Subprovider Discharges		

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	
SFY 2015
Total Assessment Amount	

A	B	C	
D	
E	
F	
N	
O	
P = N*O	
Q	
R	
S = Q*R	
T = J+M+P+S	
32005	SELECT SPECIALTY-PHX D/T	LTAC Provider	565	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	54,664	
32008	SUN CITY	LTAC Provider	233	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	22,543	
34028	Aurora Behavioral Healthcare-Tempe	Small Psychiatric Providers and AZ State	2,284	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
34021	AZ STATE HOSPITAL	Small Psychiatric Providers and AZ State	109	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
34027	Community Counseling Centers, Inc at PineView Hospital	Small Psychiatric Providers and AZ State	387	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
34020	HAVEN SENIOR HORIZONS	Small Psychiatric Providers and AZ State	719	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
N/A	Remuda Ranch Center for Anorexia and bulimia	Small Psychiatric Providers and AZ State	92	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
34023	The Guidance Center, Inc.	Small Psychiatric Providers and AZ State	622	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
34026	VALLEY HOSPITAL	Small Psychiatric Providers and AZ State	2,125	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
34025	WINDHAVEN PSYCHIATRIC HOS	Small Psychiatric Providers and AZ State	581	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
34024	AURORA BEHAVIORAL HEALTH	Large Psychiatric Provider	3,874	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	374,810	
34004	BANNER BEHAVORIAL HEALTH	Large Psychiatric Provider	4,083	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	395,030	
34022	SONORA BEHAVIORAL HEALTH	Large Psychiatric Provider	2,649	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	256,291	
34013	ST LUKE'S BEHAVORIAL HOSP	Large Psychiatric Provider	5,682	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	549,734	
33037	HEALTHSOUTH E.VALLEY REHA	Freestanding Rehabilitation Provider	869	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
33025	HEALTHSOUTH MERIDIAN PT.	Freestanding Rehabilitation Provider	1,387	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
33028	HEALTHSOUTH REHAB INST.	Freestanding Rehabilitation Provider	1,496	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
33032	HEALTHSOUTH VALLEY OF SUN	Freestanding Rehabilitation Provider	1,401	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
33029	HLTHSOUTH REHAB.HOSP.OF.S	Freestanding Rehabilitation Provider	1,266	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
33036	MOUNTAIN VALLEY REG REHAB	Freestanding Rehabilitation Provider	780	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
33034	YUMA REHABILITATION HOSPI	Freestanding Rehabilitation Provider	886	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
30065	BANNER DESERT MEDICAL CEN	Pediatric-Intensive General Acute Hospita	42,085	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	9,482,544	
30064	UNIVERSITY MED CTR-AZ	Pediatric-Intensive General Acute Hospita	26,294	533	N/A	533	96.75	51,568	N/A	0.00	N/A	8,189,561	
30089	BANNER THUNDERBIRD MEDICA	Medium Pediatric Intensive General Acut	31,379	1,361	N/A	1,361	96.75	131,677	N/A	0.00	N/A	10,323,113	
30022	MARICOPA MEDICAL CENTER	Medium Pediatric Intensive General Acut	18,067	3,487	N/A	3,487	96.75	337,367	N/A	0.00	N/A	6,629,200	
30087	SCOTTSDALE HEALTHCARE - SHEA	Medium Pediatric Intensive General Acut	21,385	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	7,447,326	
30006	TUCSON MEDICAL CENTER	Medium Pediatric Intensive General Acut	29,644	1,963	N/A	1,963	96.75	189,920	N/A	0.00	N/A	10,314,125	
30118	YRMC EAST	Medium Pediatric Intensive General Acut	4,320	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	1,504,440	
30013	YUMA REGIONAL MED CENTER	Medium Pediatric Intensive General Acut	12,981	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	4,520,633	
30107	ARIZONA SPINE AND JOINT	Short Term Specialty Hospital	865	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	

Sorted by Provider Type and then by Hospital Name in alphabetical order

	
FYE 2011 Patient Discharges
Per Medicare Cost Report		

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	

Comment	

A	B	C	
D	
E	
F		
32005	SELECT SPECIALTY-PHX D/T	LTAC Provider	565	N/A	N/A		
32008	SUN CITY	LTAC Provider	233	N/A	N/A		
34028	Aurora Behavioral Healthcare-Tempe	Small Psychiatric Providers and AZ State	2,284	N/A	N/A	No FYE 2011 Medicare cost report; discharges based on 2011 UAR.	
34021	AZ STATE HOSPITAL	Small Psychiatric Providers and AZ State	109	N/A	N/A	No FYE 2011 Medicare cost report; discharges based on data provided directly by hospital.	
34027	Community Counseling Centers, Inc at PineView Hospital	Small Psychiatric Providers and AZ State	387	N/A	N/A	No FYE 2011 Medicare cost report; discharges based on 2011 UAR.	
34020	HAVEN SENIOR HORIZONS	Small Psychiatric Providers and AZ State	719	N/A	N/A		
N/A	Remuda Ranch Center for Anorexia and bulimia	Small Psychiatric Providers and AZ State	92	N/A	N/A	No FYE 2011 Medicare cost report; discharges based on data provided directly by hospital.	
34023	The Guidance Center, Inc.	Small Psychiatric Providers and AZ State	622	N/A	N/A		
34026	VALLEY HOSPITAL	Small Psychiatric Providers and AZ State	2,125	N/A	N/A		
34025	WINDHAVEN PSYCHIATRIC HOS	Small Psychiatric Providers and AZ State	581	N/A	N/A		
34024	AURORA BEHAVIORAL HEALTH	Large Psychiatric Provider	3,874	N/A	N/A		
34004	BANNER BEHAVORIAL HEALTH	Large Psychiatric Provider	4,083	N/A	N/A		
34022	SONORA BEHAVIORAL HEALTH	Large Psychiatric Provider	2,649	N/A	N/A		
34013	ST LUKE'S BEHAVORIAL HOSP	Large Psychiatric Provider	5,682	N/A	N/A		
33037	HEALTHSOUTH E.VALLEY REHA	Freestanding Rehabilitation Provider	869	N/A	N/A		
33025	HEALTHSOUTH MERIDIAN PT.	Freestanding Rehabilitation Provider	1,387	N/A	N/A		
33028	HEALTHSOUTH REHAB INST.	Freestanding Rehabilitation Provider	1,496	N/A	N/A		
33032	HEALTHSOUTH VALLEY OF SUN	Freestanding Rehabilitation Provider	1,401	N/A	N/A		
33029	HLTHSOUTH REHAB.HOSP.OF.S	Freestanding Rehabilitation Provider	1,266	N/A	N/A		
33036	MOUNTAIN VALLEY REG REHAB	Freestanding Rehabilitation Provider	780	N/A	N/A		
33034	YUMA REHABILITATION HOSPI	Freestanding Rehabilitation Provider	886	N/A	N/A		
30065	BANNER DESERT MEDICAL CEN	Pediatric-Intensive General Acute Hospita	42,085	N/A	N/A		
30064	UNIVERSITY MED CTR-AZ	Pediatric-Intensive General Acute Hospita	26,294	533	N/A		
30089	BANNER THUNDERBIRD MEDICA	Medium Pediatric Intensive General Acut	31,379	1,361	N/A		
30022	MARICOPA MEDICAL CENTER	Medium Pediatric Intensive General Acut	18,067	3,487	N/A		
30087	SCOTTSDALE HEALTHCARE - SHEA	Medium Pediatric Intensive General Acut	21,385	N/A	N/A		
30006	TUCSON MEDICAL CENTER	Medium Pediatric Intensive General Acut	29,644	1,963	N/A		
30118	YRMC EAST	Medium Pediatric Intensive General Acut	4,320	N/A	N/A		
30013	YUMA REGIONAL MED CENTER	Medium Pediatric Intensive General Acut	12,981	N/A	N/A		
30107	ARIZONA SPINE AND JOINT	Short Term Specialty Hospital	865	N/A	N/A		

Sorted by Provider Type and then by Hospital Name in alphabetical order

	
FYE 2011 Patient Discharges
Per Medicare Cost Report		SFY 2015
Non-Psychiatric and Rehabilitation
Discharges Below Threshold	SFY 2015
Non-Psychiatric and Rehabilitation
Discharges Above Threshold	

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	
FYE 2015
Threshold
Units	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

A	B	C	
D	
E	
F	
G	
H	
I	
J = H*I	
K	
L	
M = K*L	
30112	AZ ORTHOPEDIC SURGICAL HO	Short Term Specialty Hospital	949	N/A	N/A	29,000	949	-	-	-	38.75	-	
30105	BANNER HEART HOSPITAL	Short Term Specialty Hospital	5,877	N/A	N/A	29,000	5,877	-	-	-	38.75	-	
N/A	Cancer Treatment Centers of America - Western Regional Medi Short Term Specialty Hospital	495	N/A	N/A	29,000	495	-	-	-	38.75	-	
N/A	FREEDOM PAIN HOSPITAL	Short Term Specialty Hospital	14	N/A	N/A	29,000	14	-	-	-	38.75	-	
30131	ORTHOPEDIC AND SPINE INPATIENT SURGI	Short Term Specialty Hospital	481	N/A	N/A	29,000	481	-	-	-	38.75	-	
30108	SURGICAL SPECIALITY HOSP	Short Term Specialty Hospital	1,564	N/A	N/A	29,000	1,564	-	-	-	38.75	-	
30103	MAYO CLINIC HOSPITAL	High Medicare/Out-of State Patient Utiliz	12,315	N/A	150	29,000	12,315	-	-	-	38.75	-	

Sorted by Provider Type and then by Hospital Name in alphabetical order

Border Providers	N/A	N/A	N/A	N/A		-	N/A	-	N/A	
Out of State Providers	N/A	N/A	N/A	N/A		-	N/A	-	N/A	
Total		713,522	12,858	5,918		684,477	230,723,899	29,045	1,125,494	

	
FYE 2011 Patient Discharges
Per Medicare Cost Report	
SFY 2015
Psychiatric Subprovider Discharges	
SFY 2015
Rehabilitation Subprovider Discharges		

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	

Assessment
Units	

Assessment
Rate	

Assessment
Amount	
SFY 2015
Total Assessment Amount	

A	B	C	
D	
E	
F	
N	
O	
P = N*O	
Q	
R	
S = Q*R	
T = J+M+P+S	
30112	AZ ORTHOPEDIC SURGICAL HO	Short Term Specialty Hospital	949	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
30105	BANNER HEART HOSPITAL	Short Term Specialty Hospital	5,877	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
N/A	Cancer Treatment Centers of America - Western Regional Medi Short Term Specialty Hospital	495	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
N/A	FREEDOM PAIN HOSPITAL	Short Term Specialty Hospital	14	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
30131	ORTHOPEDIC AND SPINE INPATIENT SURGI	Short Term Specialty Hospital	481	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
30108	SURGICAL SPECIALITY HOSP	Short Term Specialty Hospital	1,564	N/A	N/A	N/A	96.75	N/A	N/A	0.00	N/A	-	
30103	MAYO CLINIC HOSPITAL	High Medicare/Out-of State Patient Utiliz	12,315	N/A	150	N/A	96.75	N/A	150	0.00	-	-	

Sorted by Provider Type and then by Hospital Name in alphabetical order

Border Providers	N/A	N/A	N/A	N/A	-	N/A	-	N/A	-	
Out of State Providers	N/A	N/A	N/A	N/A	-	N/A	-	N/A	-	

Total		
713,522	
12,858	
5,918	
12,858	
1,244,012	
5,918	
-	
233,093,405	

	
FYE 2011 Patient Discharges
Per Medicare Cost Report		

Medicare
Provider ID	

Hospital Name	

Provider Type	
FYE 2011
Non-Psych and Rehab Patient Discharges	
FYE 2011
Psych Sub- Provider Discharges	
FYE 2011
Rehab Sub- Provider Discharges	

Comment	

A	B	C	
D	
E	
F		
30112	AZ ORTHOPEDIC SURGICAL HO	Short Term Specialty Hospital	949	N/A	N/A		
30105	BANNER HEART HOSPITAL	Short Term Specialty Hospital	5,877	N/A	N/A		
N/A	Cancer Treatment Centers of America - Western Regional Medi Short Term Specialty Hospital	495	N/A	N/A	No FYE 2011 Medicare cost report; discharges based on 2011 UAR.	
N/A	FREEDOM PAIN HOSPITAL	Short Term Specialty Hospital	14	N/A	N/A	New hospital with no FYE 2011 Medicare cost report; discharges based on 2012 UAR.	
30131	ORTHOPEDIC AND SPINE INPATIENT SURGI	Short Term Specialty Hospital	481	N/A	N/A		
30108	SURGICAL SPECIALITY HOSP	Short Term Specialty Hospital	1,564	N/A	N/A		
30103	MAYO CLINIC HOSPITAL	High Medicare/Out-of State Patient Utiliz	12,315	N/A	150		

Sorted by Provider Type and then by Hospital Name in alphabetical order

Border Providers	N/A	N/A	N/A	N/A	
Out of State Providers	N/A	N/A	N/A	N/A	

Total		
713,522	
12,858	
5,918	

Medicare
Provider ID	

Provider Name	

Provider Type	
FYE 2011 Total Patient Discharges	FYE 2011
Medicaid
Discharges
(Per AHCCCS)	

SFY 2015
Total Assessment	
SFY 2015
Proportion of
Total Assessment	
30094 	ARROWHEAD HOSPITAL 	Urban Acute Provider	12,624 	5,539 	4,016,849 	0.0172328	
30088 	BANNER BAYWOOD MEDICAL CN 	Urban Acute Provider	20,911 	2,823 	6,653,702 	0.0285452	
30061 	BANNER BOSWELL MED CTR 	Urban Acute Provider	22,560 	1,025 	7,178,400 	0.0307962	
30093 	BANNER DEL E WEBB MED CTR 	Urban Acute Provider	19,781 	3,147 	6,294,146 	0.0270027	
30115 	BANNER ESTRELLA MEDICAL 	Urban Acute Provider	18,796 	7,292 	5,980,727 	0.0256581	
30122 	BANNER GATEWAY MEDICAL CT 	Urban Acute Provider	13,654 	4,255 	4,344,587 	0.0186388	
30002 	BANNER GOOD SAM MEDICAL C 	Urban Acute Provider	38,099 	13,451 	12,122,778 	0.0520082	
30130 	BANNER IRONWOOD MEDICAL CENTER 	Urban Acute Provider	2,426 	933 	771,933 	0.0033117	
30011 	CARONDELET ST JOSEPHS-TUC 	Urban Acute Provider	19,764 	4,230 	6,288,737 	0.0269795	
30010 	CARONDELET ST MARYS HOSP 	Urban Acute Provider	14,946 	2,451 	4,755,690 	0.0204025	
30036 	CHANDLER REGIONAL MED.CTR 	Urban Acute Provider	17,729 	5,117 	5,641,217 	0.0242015	
30132 	FLORENCE HOSPITAL AT ANTHEM 	Urban Acute Provider	675 	32 	214,779 	0.0009214	
30120 	GILBERT HOSPITAL, L.L.C. 	Urban Acute Provider	1,912 	424 	608,382 	0.0026100	
30092 	JOHN C LINCOLN-DEER VLLY 	Urban Acute Provider	12,235 	2,488 	3,893,073 	0.0167018	
30014 	JOHN C. LINCOLN HOS N MTN 	Urban Acute Provider	16,298 	3,170 	5,185,885 	0.0222481	
30001 	MARYVALE HOSPITAL MED CTR 	Urban Acute Provider	5,829 	3,719 	1,854,738 	0.0079571	
30119 	MERCY GILBERT MED CENTER 	Urban Acute Provider	14,645 	3,141 	4,659,914 	0.0199916	
30121 	MOUNTAIN VISTA MED CTR 	Urban Acute Provider	10,156 	2,555 	3,231,553 	0.0138638	
30085 	NORTHWEST MEDICAL CENTER 	Urban Acute Provider	18,578 	4,242 	5,911,362 	0.0253605	
30114 	ORO VALLEY HOSPITAL 	Urban Acute Provider	5,060 	297 	1,610,049 	0.0069073	
30083 	PARADISE VALLEY HOSPITAL 	Urban Acute Provider	7,175 	2,137 	2,283,024 	0.0097945	
30030 	PHOENIX BAPTIST HOSPITAL 	Urban Acute Provider	11,366 	6,476 	3,616,564 	0.0155155	
30038 	SCOTTSDALE HLTHCARE-OSBN 	Urban Acute Provider	16,789 	2,966 	5,342,117 	0.0229184	
30123 	SCOTTSDALE HLTHCARE-THOMP 	Urban Acute Provider	3,805 	135 	1,210,719 	0.0051941	
30024 	ST JOSEPH'S HOSPITAL-PHX 	Urban Acute Provider	35,560 	13,793 	11,314,889 	0.0485423	
30037 	TEMPE ST. LUKE'S HOSPITAL 	Urban Acute Provider	9,318 	2,631 	2,964,908 	0.0127198	
30111 	UNIVERSITY PHYSICIAN HC 	Urban Acute Provider	5,950 	1,322 	1,893,239 	0.0081222	
30110 	WEST VALLEY HOSPITAL MED 	Urban Acute Provider	10,646 	3,690 	3,387,467 	0.0145327	
30126 	ARIZONA REGIONAL MED. CTR 	Non-CAH Rural Acute Provider	1,417 	157 	450,877 	0.0019343	
30016 	CASA GRANDE REG MED CTR 	Non-CAH Rural Acute Provider	9,178 	2,732 	2,920,362 	0.0125287	
30023 	FLAGSTAFF MEDICAL CENTER 	Non-CAH Rural Acute Provider	13,561 	4,006 	4,314,995 	0.0185119	
30069 	HAVASU REG MED CENTER LLC 	Non-CAH Rural Acute Provider	5,965 	1,471 	1,898,012 	0.0081427	
30055 	KINGMAN REGIONAL MED CTR 	Non-CAH Rural Acute Provider	8,046 	2,180 	2,560,169 	0.0109834	
30067 	LA PAZ REGIONAL HOSPITAL 	Non-CAH Rural Acute Provider	843 	82 	268,235 	0.0011508	
30068 	MT. GRAHAM REG. MED. CTR. 	Non-CAH Rural Acute Provider	2,095 	1,131 	666,611 	0.0028598	

(1)

Medicare
Provider ID	

Provider Name	

Provider Type	
FYE 2011 Total Patient Discharges	FYE 2011
Medicaid
Discharges
(Per AHCCCS)	

SFY 2015
Total Assessment	
SFY 2015
Proportion of
Total Assessment	
30033 	PAYSON HOSPITAL CORP. 	Non-CAH Rural Acute Provider	2,442 	546 	777,024 	0.0033335	
30043 	SIERRA VISTA REG HLTH CTR 	Non-CAH Rural Acute Provider	5,656 	1,431 	1,799,691 	0.0077209	
30062 	SUMMIT HEALTHCARE REG.MED 	Non-CAH Rural Acute Provider	3,712 	1,957 	1,181,127 	0.0050672	
30117 	VALLEY VIEW MEDICAL CENT 	Non-CAH Rural Acute Provider	2,845 	956 	905,255 	0.0038837	
30007 	VERDE VALLEY MEDICAL CTR. 	Non-CAH Rural Acute Provider	4,532 	1,284 	1,442,044 	0.0061865	
30101 	WESTERN AZ REG MED CTR 	Non-CAH Rural Acute Provider	6,404 	1,000 	2,037,698 	0.0087420	
30012 	YAVAPAI REG MED CENTER 	Non-CAH Rural Acute Provider	6,998 	514 	2,226,704 	0.0095528	
33301 	LOS NINOS HOSPITAL 	Freestanding Children's Provider	268 	191 	85,275 	0.0003658	
33302 	PHOENIX CHILDREN'S HOSP 	Freestanding Children's Provider	13,244 	5,883 	4,214,128 	0.0180791	
31301 	BENSON HOSPITAL 	CAH	314 	26 	99,912 	0.0004286	
31314 	COBRE VALLEY COMM HOSP 	CAH	1,713 	786 	545,062 	0.0023384	
31312 	COPPER QUEEN HOSPITAL 	CAH	410 	51 	130,459 	0.0005597	
31313 	HOLY CROSS HOSPITAL-ARIZ 	CAH	1,409 	920 	448,332 	0.0019234	
31311 	LITTLE COLORADO MED CTR 	CAH	1,353 	750 	430,513 	0.0018470	
31302 	NORTHERN COCHISE HOSPITAL 	CAH	496 	35 	157,823 	0.0006771	
31304 	PAGE HOSPITAL 	CAH	525 	432 	167,051 	0.0007167	
31303 	SOUTHEAST MEDICAL CENTER 	CAH	300 	41 	95,457 	0.0004095	
31315 	WHITE MNTN REG MED CNTR 	CAH	366 	65 	116,458 	0.0004996	
31300 	WICKENBURG COMMUNITY HOSP 	CAH	429 	10 	136,504 	0.0005856	
32004 	CORNERSTONE  HOSPITAL OF S 	LTAC Provider	237 	9 	75,411 	0.0003235	
32000 	KINDRED HOSP AZ-NORTHWEST 	LTAC Provider	709 	36 	225,598 	0.0009678	
32002 	KINDRED HOSPITAL-TUCSON 	LTAC Provider	401 	30 	127,595 	0.0005474	
32006 	PROMISE HOSPITAL OF PHX 	LTAC Provider	212 	46 	67,457 	0.0002894	
32007 	RESTORA MESA 	LTAC Provider	431 	37 	137,141 	0.0005884	
32001 	SELECT SPECIALTY HOSP-PHX 	LTAC Provider	460 	74 	146,368 	0.0006279	
32005 	SELECT SPECIALTY-PHX  D/T 	LTAC Provider	565 	48 	179,778 	0.0007713	
32008 	SUN CITY 	LTAC Provider	233 	6 	74,139 	0.0003181	
34028 	Aurora Behavioral Healthcare-Tempe 	Small Psychiatric Providers and AZ State	2,284 	- 	726,749 	0.0031178	
34021 	AZ STATE HOSPITAL 	Small Psychiatric Providers and AZ State	109 	1 	34,683 	0.0001488	
34027 	Community Counseling Centers, Inc at PineView Hospi Small Psychiatric Providers and AZ State	387 	134 	123,140 	0.0005283	
34020 	HAVEN SENIOR HORIZONS 	Small Psychiatric Providers and AZ State	719 	3 	228,780 	0.0009815	
N/A 	Remuda Ranch Center for Anorexia and bulimia 	Small Psychiatric Providers and AZ State	92 	- 	29,274 	0.0001256	
34023 	The Guidance Center, Inc. 	Small Psychiatric Providers and AZ State	622 	168 	197,915 	0.0008491	
34026 	VALLEY HOSPITAL 	Small Psychiatric Providers and AZ State	2,125 	32 	676,157 	0.0029008	
34025 	WINDHAVEN PSYCHIATRIC HOS 	Small Psychiatric Providers and AZ State	581 	310 	184,869 	0.0007931	

Medicare
Provider ID	

Provider Name	

Provider Type	
FYE 2011 Total Patient Discharges	FYE 2011
Medicaid
Discharges
(Per AHCCCS)	

SFY 2015
Total Assessment	
SFY 2015
Proportion of
Total Assessment	
34024 	AURORA BEHAVIORAL HEALTH 	Large Psychiatric Provider	3,874 	1,374 	1,232,674 	0.0052883	
34004 	BANNER BEHAVORIAL HEALTH 	Large Psychiatric Provider	4,083 	1,042 	1,299,176 	0.0055736	
34022 	SONORA BEHAVIORAL HEALTH 	Large Psychiatric Provider	2,649 	710 	842,889 	0.0036161	
34013 	ST LUKE'S BEHAVORIAL HOSP 	Large Psychiatric Provider	5,682 	1,618 	1,807,964 	0.0077564	
33037 	HEALTHSOUTH E.VALLEY REHA 	Freestanding Rehabilitation Provider	869 	21 	276,508 	0.0011863	
33025 	HEALTHSOUTH MERIDIAN PT. 	Freestanding Rehabilitation Provider	1,387 	34 	441,332 	0.0018934	
33028 	HEALTHSOUTH REHAB INST. 	Freestanding Rehabilitation Provider	1,496 	52 	476,014 	0.0020422	
33032 	HEALTHSOUTH VALLEY OF SUN 	Freestanding Rehabilitation Provider	1,401 	64 	445,786 	0.0019125	
33029 	HLTHSOUTH REHAB.HOSP.OF.S 	Freestanding Rehabilitation Provider	1,266 	41 	402,830 	0.0017282	
33036 	MOUNTAIN VALLEY REG REHAB 	Freestanding Rehabilitation Provider	780 	50 	248,189 	0.0010648	
33034 	YUMA REHABILITATION  HOSPI 	Freestanding Rehabilitation Provider	886 	13 	281,918 	0.0012095	
30065 	BANNER DESERT MEDICAL CEN 	Pediatric-Intensive  General Acute Hospita	42,085 	13,162 	13,391,089 	0.0574495	
30064 	UNIVERSITY MED CTR-AZ 	Pediatric-Intensive  General Acute Hospita	26,827 	7,702 	8,536,123 	0.0366210	
30089 	BANNER THUNDERBIRD MEDICA 	Medium Pediatric Intensive General Acute	32,740 	10,308 	10,417,589 	0.0446928	
30022 	MARICOPA MEDICAL CENTER 	Medium Pediatric Intensive General Acute	21,554 	9,870 	6,858,299 	0.0294230	
30087 	SCOTTSDALE HEALTHCARE - SHEA 	Medium Pediatric Intensive General Acute	21,385 	2,581 	6,804,525 	0.0291923	
30006 	TUCSON MEDICAL CENTER 	Medium Pediatric Intensive General Acute	31,607 	11,103 	10,057,078 	0.0431461	
30118 	YRMC EAST 	Medium Pediatric Intensive General Acute	4,320 	1,876 	1,374,587 	0.0058972	
30013 	YUMA REGIONAL MED CENTER 	Medium Pediatric Intensive General Acute	12,981 	5,764 	4,130,444 	0.0177201	
30107 	ARIZONA SPINE AND JOINT 	Short Term Specialty Hospital	865 	1 	275,236 	0.0011808	
30112 	AZ ORTHOPEDIC SURGICAL HO 	Short Term Specialty Hospital	949 	58 	301,964 	0.0012955	
30105 	BANNER HEART HOSPITAL 	Short Term Specialty Hospital	5,877 	265 	1,870,011 	0.0080226	
N/A 	Cancer Treatment Centers of America - Western Region Short Term Specialty Hospital	495 	- 	157,505 	0.0006757	
N/A 	FREEDOM PAIN HOSPITAL 	Short Term Specialty Hospital	14 	- 	4,455 	0.0000191	
30131 	ORTHOPEDIC AND SPINE INPATIENT SURGI 	Short Term Specialty Hospital	481 	- 	153,050 	0.0006566	
30108 	SURGICAL SPECIALITY HOSP 	Short Term Specialty Hospital	1,564 	30 	497,651 	0.0021350	
30103 	MAYO CLINIC HOSPITAL 	High Medicare/Out-of  State Patient Utiliza	12,465 	156 	3,966,257 	0.0170157	
Total	732,557 	200,947 	233,093,405 	1.0000000	

B1	B1 Value	
233,093,405	0.0000037465	
318.191		

Total Proposed Assessment Revenue
Broad-based Uniform Assessment Rate

Note: (1) Total discharges includes 259 Greenbaum discharges exempted from assessment.

Medicare
Provider ID	

Provider Name	

Provider Type	
FYE 2011
Medicaid
Discharges
(Per AHCCCS)	

SFY 2015
Total Assessment	

SFY 2015
Proportion of
Total Assessment	
30094 	ARROWHEAD HOSPITAL 	Urban Acute Provider 	5,539 	4,885,488 	0.0209594	
30088 	BANNER BAYWOOD MEDICAL CN 	Urban Acute Provider 	2,823 	7,919,568 	0.0339759	
30061 	BANNER BOSWELL MED CTR 	Urban Acute Provider 	1,025 	8,540,703 	0.0366407	
30093 	BANNER DEL E WEBB MED CTR 	Urban Acute Provider 	3,147 	7,212,906 	0.0309443	
30115 	BANNER ESTRELLA MEDICAL 	Urban Acute Provider 	7,292 	7,274,052 	0.0312066	
30122 	BANNER GATEWAY MEDICAL CT 	Urban Acute Provider 	4,255 	5,284,098 	0.0226694	
30002 	BANNER GOOD SAM MEDICAL C 	Urban Acute Provider 	13,451 	11,580,952 	0.0496837	
30130 	BANNER IRONWOOD MEDICAL CENTER 	Urban Acute Provider 	933 	938,862 	0.0040278	
30011 	CARONDELET ST JOSEPHS-TUC 	Urban Acute Provider 	4,230 	7,225,484 	0.0309982	
30010 	CARONDELET ST MARYS HOSP 	Urban Acute Provider 	2,451 	5,229,821 	0.0224366	
30036 	CHANDLER REGIONAL MED.CTR 	Urban Acute Provider 	5,117 	6,861,123 	0.0294351	
30132 	FLORENCE HOSPITAL AT ANTHEM 	Urban Acute Provider 	32 	261,225 	0.0011207	
30120 	GILBERT HOSPITAL, L.L.C. 	Urban Acute Provider 	424 	739,944 	0.0031745	
30092 	JOHN C LINCOLN-DEER VLLY 	Urban Acute Provider 	2,488 	4,734,945 	0.0203135	
30014 	JOHN C. LINCOLN HOS N MTN 	Urban Acute Provider 	3,170 	6,307,326 	0.0270592	
30001 	MARYVALE HOSPITAL MED CTR 	Urban Acute Provider 	3,719 	2,255,823 	0.0096778	
30119 	MERCY GILBERT MED CENTER 	Urban Acute Provider 	3,141 	5,667,615 	0.0243148	
30121 	MOUNTAIN VISTA MED CTR 	Urban Acute Provider 	2,555 	3,930,372 	0.0168618	
30085 	NORTHWEST MEDICAL CENTER 	Urban Acute Provider 	4,242 	7,189,686 	0.0308447	
30114 	ORO VALLEY HOSPITAL 	Urban Acute Provider 	297 	1,802,259 	0.0077319	
30083 	PARADISE VALLEY HOSPITAL 	Urban Acute Provider 	2,137 	2,776,725 	0.0119125	
30030 	PHOENIX BAPTIST HOSPITAL 	Urban Acute Provider 	6,476 	4,398,642 	0.0188707	
30038 	SCOTTSDALE HLTHCARE-OSBN 	Urban Acute Provider 	2,966 	6,239,601 	0.0267687	
30123 	SCOTTSDALE HLTHCARE-THOMP 	Urban Acute Provider 	135 	1,472,535 	0.0063174	
30024 	ST JOSEPH'S HOSPITAL-PHX 	Urban Acute Provider 	13,793 	11,442,403 	0.0490893	
30037 	TEMPE ST. LUKE'S HOSPITAL 	Urban Acute Provider 	2,631 	3,417,017 	0.0146594	

Medicare
Provider ID	

Provider Name	

Provider Type	
FYE 2011
Medicaid
Discharges
(Per AHCCCS)	

SFY 2015
Total Assessment	

SFY 2015
Proportion of
Total Assessment	
30111 	UNIVERSITY PHYSICIAN HC 	Urban Acute Provider 	1,322 	2,185,099 	0.0093743	
30110 	WEST VALLEY HOSPITAL MED 	Urban Acute Provider 	3,690 	4,120,002 	0.0176753	
30126 	ARIZONA REGIONAL MED. CTR 	Non-CAH Rural Acute Provider 	157 	548,379 	0.0023526	
30016 	CASA GRANDE REG MED CTR 	Non-CAH Rural Acute Provider 	2,732 	3,474,680 	0.0149068	
30023 	FLAGSTAFF MEDICAL CENTER 	Non-CAH Rural Acute Provider 	4,006 	5,080,923 	0.0217978	
30069 	HAVASU REG MED CENTER LLC 	Non-CAH Rural Acute Provider 	1,471 	2,274,399 	0.0097575	
30055 	KINGMAN REGIONAL MED CTR 	Non-CAH Rural Acute Provider 	2,180 	3,044,916 	0.0130631	
30067 	LA PAZ REGIONAL HOSPITAL 	Non-CAH Rural Acute Provider 	82 	326,241 	0.0013996	
30068 	MT. GRAHAM REG. MED. CTR. 	Non-CAH Rural Acute Provider 	1,131 	810,765 	0.0034783	
30033 	PAYSON HOSPITAL CORP. 	Non-CAH Rural Acute Provider 	546 	945,054 	0.0040544	
30043 	SIERRA VISTA REG HLTH CTR 	Non-CAH Rural Acute Provider 	1,431 	2,188,872 	0.0093905	
30062 	SUMMIT HEALTHCARE REG.MED 	Non-CAH Rural Acute Provider 	1,957 	1,436,544 	0.0061630	
30117 	VALLEY VIEW MEDICAL CENT 	Non-CAH Rural Acute Provider 	956 	1,042,965 	0.0044745	
30007 	VERDE VALLEY MEDICAL CTR. 	Non-CAH Rural Acute Provider 	1,284 	1,706,864 	0.0073227	
30101 	WESTERN AZ REG MED CTR 	Non-CAH Rural Acute Provider 	1,000 	2,478,348 	0.0106324	
30012 	YAVAPAI REG MED CENTER 	Non-CAH Rural Acute Provider 	514 	2,708,226 	0.0116186	
33301 	LOS NINOS HOSPITAL 	Freestanding Children's Provider 	191 	- 	-	
33302 	PHOENIX CHILDREN'S HOSP 	Freestanding Children's Provider 	5,883 	- 	-	
31301 	BENSON HOSPITAL 	CAH 	26 	121,518 	0.0005213	
31314 	COBRE VALLEY COMM HOSP 	CAH 	786 	662,931 	0.0028441	
31312 	COPPER QUEEN HOSPITAL 	CAH 	51 	158,670 	0.0006807	
31313 	HOLY CROSS HOSPITAL-ARIZ 	CAH 	920 	545,283 	0.0023393	
31311 	LITTLE COLORADO MED CTR 	CAH 	750 	523,611 	0.0022464	
31302 	NORTHERN COCHISE HOSPITAL 	CAH 	35 	191,952 	0.0008235	
31304 	PAGE HOSPITAL 	CAH 	432 	203,175 	0.0008716	
31303 	SOUTHEAST MEDICAL CENTER 	CAH 	41 	116,100 	0.0004981	

Medicare
Provider ID	

Provider Name	

Provider Type	
FYE 2011
Medicaid
Discharges
(Per AHCCCS)	

SFY 2015
Total Assessment	

SFY 2015
Proportion of
Total Assessment	
31315 	WHITE MNTN REG MED CNTR 	CAH 	65 	141,642 	0.0006077	
31300 	WICKENBURG COMMUNITY HOSP 	CAH 	10 	166,023 	0.0007123	
32004 	CORNERSTONE HOSPITAL OF S 	LTAC Provider 	9 	22,930 	0.0000984	
32000 	KINDRED HOSP AZ-NORTHWEST 	LTAC Provider 	36 	68,596 	0.0002943	
32002 	KINDRED HOSPITAL-TUCSON 	LTAC Provider 	30 	38,797 	0.0001664	
32006 	PROMISE HOSPITAL OF PHX 	LTAC Provider 	46 	20,511 	0.0000880	
32007 	RESTORA MESA 	LTAC Provider 	37 	41,699 	0.0001789	
32001 	SELECT SPECIALTY HOSP-PHX 	LTAC Provider 	74 	44,505 	0.0001909	
32005 	SELECT SPECIALTY-PHX D/T 	LTAC Provider 	48 	54,664 	0.0002345	
32008 	SUN CITY 	LTAC Provider 	6 	22,543 	0.0000967	
34028 	Aurora Behavioral Healthcare-Tempe 	Small Psychiatric Providers and AZ State 	- 	- 	-	
34021 	AZ STATE HOSPITAL 	Small Psychiatric Providers and AZ State 	1 	- 	-	
34027 	Community Counseling Centers, Inc at PineView Hosp Small Psychiatric Providers and AZ State 	134 	- 	-	
34020 	HAVEN SENIOR HORIZONS 	Small Psychiatric Providers and AZ State 	3 	- 	-	
N/A 	Remuda Ranch Center for Anorexia and bulimia 	Small Psychiatric Providers and AZ State 	- 	- 	-	
34023 	The Guidance Center, Inc. 	Small Psychiatric Providers and AZ State 	168 	- 	-	
34026 	VALLEY HOSPITAL 	Small Psychiatric Providers and AZ State 	32 	- 	-	
34025 	WINDHAVEN PSYCHIATRIC HOS 	Small Psychiatric Providers and AZ State 	310 	- 	-	
34024 	AURORA BEHAVIORAL HEALTH 	Large Psychiatric Provider 	1,374 	374,810 	0.0016080	
34004 	BANNER BEHAVORIAL HEALTH 	Large Psychiatric Provider 	1,042 	395,030 	0.0016947	
34022 	SONORA BEHAVIORAL HEALTH 	Large Psychiatric Provider 	710 	256,291 	0.0010995	
34013 	ST LUKE'S BEHAVORIAL HOSP 	Large Psychiatric Provider 	1,618 	549,734 	0.0023584	
33037 	HEALTHSOUTH E.VALLEY REHA 	Freestanding Rehabilitation Provider 	21 	- 	-	
33025 	HEALTHSOUTH MERIDIAN PT. 	Freestanding Rehabilitation Provider 	34 	- 	-	
33028 	HEALTHSOUTH REHAB INST. 	Freestanding Rehabilitation Provider 	52 	- 	-	
33032 	HEALTHSOUTH VALLEY OF SUN 	Freestanding Rehabilitation Provider 	64 	- 	-	

Medicare
Provider ID	

Provider Name	

Provider Type	
FYE 2011
Medicaid
Discharges
(Per AHCCCS)	

SFY 2015
Total Assessment	

SFY 2015
Proportion of
Total Assessment	
33029 	HLTHSOUTH REHAB.HOSP.OF.S 	Freestanding Rehabilitation Provider 	41 	- 	-	
33036 	MOUNTAIN VALLEY REG REHAB 	Freestanding Rehabilitation Provider 	50 	- 	-	
33034 	YUMA REHABILITATION HOSPI 	Freestanding Rehabilitation Provider 	13 	- 	-	
30065 	BANNER DESERT MEDICAL CEN 	Pediatric-Intensive General Acute Hospita 	13,162 	9,482,544 	0.0406813	
30064 	UNIVERSITY MED CTR-AZ 	Pediatric-Intensive General Acute Hospita 	7,702 	8,189,561 	0.0351342	
30089 	BANNER THUNDERBIRD MEDICA 	Medium Pediatric Intensive General Acute 	10,308 	10,323,113 	0.0442875	
30022 	MARICOPA MEDICAL CENTER 	Medium Pediatric Intensive General Acute 	9,870 	6,629,200 	0.0284401	
30087 	SCOTTSDALE HEALTHCARE - SHEA 	Medium Pediatric Intensive General Acute 	2,581 	7,447,326 	0.0319500	
30006 	TUCSON MEDICAL CENTER 	Medium Pediatric Intensive General Acute 	11,103 	10,314,125 	0.0442489	
30118 	YRMC EAST 	Medium Pediatric Intensive General Acute 	1,876 	1,504,440 	0.0064542	
30013 	YUMA REGIONAL MED CENTER 	Medium Pediatric Intensive General Acute 	5,764 	4,520,633 	0.0193941	
30107 	ARIZONA SPINE AND JOINT 	Short Term Specialty Hospital 	1 	- 	-	
30112 	AZ ORTHOPEDIC SURGICAL HO 	Short Term Specialty Hospital 	58 	- 	-	
30105 	BANNER HEART HOSPITAL 	Short Term Specialty Hospital 	265 	- 	-	
N/A 	Cancer Treatment Centers of America - Western Region Short Term Specialty Hospital 	- 	- 	-	
N/A 	FREEDOM PAIN HOSPITAL 	Short Term Specialty Hospital 	- 	- 	-	
30131 	ORTHOPEDIC AND SPINE INPATIENT SURGI 	Short Term Specialty Hospital 	- 	- 	-	
30108 	SURGICAL SPECIALITY HOSP 	Short Term Specialty Hospital 	30 	- 	-	
30103 	MAYO CLINIC HOSPITAL 	High Medicare/Out-of State Patient Utiliza 	156 	- 	-	
Total 	200,947 	233,093,405 	1.0000000	

B2	B2 Value	
233,093,405	0.0000037045	
318.191		

Total Proposed Assessment Revenue
Broad-based Uniform Assessment Rate

Sorted by Provider Type and then by Hospital Name in alphabetical order

Medicare
Provider ID	

Provider Name	

Provider Type	

FYE 2011 Inpatient Net Patient Revenue (Per UAR)	

SFY 2015
Total Assessment
Amount	

Inpatient Net Patient Revenue For Assessed Hospitals	
30094 	ARROWHEAD HOSPITAL 	Urban Acute Provider	98,608,520 	4,885,488 	98,608,520	
30088 	BANNER BAYWOOD MEDICAL CN 	Urban Acute Provider	177,911,028 	7,919,568 	177,911,028	
30061 	BANNER BOSWELL MED CTR 	Urban Acute Provider	217,018,155 	8,540,703 	217,018,155	
30093 	BANNER DEL E WEBB MED CTR 	Urban Acute Provider	151,834,460 	7,212,906 	151,834,460	
30115 	BANNER ESTRELLA MEDICAL 	Urban Acute Provider	147,118,133 	7,274,052 	147,118,133	
30122 	BANNER GATEWAY MEDICAL CT 	Urban Acute Provider	101,695,004 	5,284,098 	101,695,004	
30002 	BANNER GOOD SAM MEDICAL C 	Urban Acute Provider	481,010,265 	11,580,952 	481,010,265	
30130 	BANNER IRONWOOD MEDICAL CENTER 	Urban Acute Provider	13,072,100 	938,862 	13,072,100	
30011 	CARONDELET ST JOSEPHS-TUC 	Urban Acute Provider	157,852,993 	7,225,484 	157,852,993	
30010 	CARONDELET ST MARYS HOSP 	Urban Acute Provider	117,043,514 	5,229,821 	117,043,514	
30036 	CHANDLER REGIONAL MED.CTR 	Urban Acute Provider	170,127,915 	6,861,123 	170,127,915	
30132 	FLORENCE HOSPITAL AT ANTHEM 	Urban Acute Provider	3,694,649 	261,225 	3,694,649	
30120 	GILBERT HOSPITAL, L.L.C. 	Urban Acute Provider	12,447,162 	739,944 	12,447,162	
30092 	JOHN C LINCOLN-DEER VLLY 	Urban Acute Provider	93,571,440 	4,734,945 	93,571,440	
30014 	JOHN C. LINCOLN HOS N MTN 	Urban Acute Provider	156,595,436 	6,307,326 	156,595,436	
30001 	MARYVALE HOSPITAL MED CTR 	Urban Acute Provider	32,122,288 	2,255,823 	32,122,288	
30119 	MERCY GILBERT MED CENTER 	Urban Acute Provider	130,119,548 	5,667,615 	130,119,548	
30121 	MOUNTAIN VISTA MED CTR 	Urban Acute Provider	93,414,825 	3,930,372 	93,414,825	
30085 	NORTHWEST MEDICAL CENTER 	Urban Acute Provider	162,109,707 	7,189,686 	162,109,707	
30114 	ORO VALLEY HOSPITAL 	Urban Acute Provider	40,255,497 	1,802,259 	40,255,497	
30083 	PARADISE VALLEY HOSPITAL 	Urban Acute Provider	45,621,671 	2,776,725 	45,621,671	
30030 	PHOENIX BAPTIST HOSPITAL 	Urban Acute Provider	67,307,853 	4,398,642 	67,307,853	
30038 	SCOTTSDALE HLTHCARE-OSBN 	Urban Acute Provider	196,162,193 	6,239,601 	196,162,193	
30123 	SCOTTSDALE HLTHCARE-THOMP 	Urban Acute Provider	45,353,357 	1,472,535 	45,353,357	
30024 	ST JOSEPH'S HOSPITAL-PHX 	Urban Acute Provider	587,666,811 	11,442,403 	587,666,811	
30037 	TEMPE ST. LUKE'S HOSPITAL 	Urban Acute Provider	88,711,909 	3,417,017 	88,711,909	
30111 	UNIVERSITY PHYSICIAN HC 	Urban Acute Provider	43,224,492 	2,185,099 	43,224,492	
30110 	WEST VALLEY HOSPITAL MED 	Urban Acute Provider	81,142,089 	4,120,002 	81,142,089	
30126 	ARIZONA REGIONAL MED. CTR 	Non-CAH Rural Acute Provider	12,299,465 	548,379 	12,299,465	
30016 	CASA GRANDE REG MED CTR 	Non-CAH Rural Acute Provider	57,000,484 	3,474,680 	57,000,484	
30023 	FLAGSTAFF MEDICAL CENTER 	Non-CAH Rural Acute Provider	226,026,914 	5,080,923 	226,026,914	
30069 	HAVASU REG MED CENTER LLC 	Non-CAH Rural Acute Provider	75,481,757 	2,274,399 	75,481,757	
30055 	KINGMAN REGIONAL MED CTR 	Non-CAH Rural Acute Provider	87,935,080 	3,044,916 	87,935,080	
30067 	LA PAZ REGIONAL HOSPITAL 	Non-CAH Rural Acute Provider	5,351,050 	326,241 	5,351,050	

Sorted by Provider Type and then by Hospital Name in alphabetical order

Medicare
Provider ID	

Provider Name	

Provider Type	

FYE 2011 Inpatient Net Patient Revenue (Per UAR)	

SFY 2015
Total Assessment
Amount	

Inpatient Net Patient Revenue For Assessed Hospitals	
30068 	MT. GRAHAM REG. MED. CTR. 	Non-CAH Rural Acute Provider	14,844,174 	810,765 	14,844,174	
30033 	PAYSON HOSPITAL CORP. 	Non-CAH Rural Acute Provider	21,463,813 	945,054 	21,463,813	
30043 	SIERRA VISTA REG HLTH CTR 	Non-CAH Rural Acute Provider	39,377,936 	2,188,872 	39,377,936	
30062 	SUMMIT HEALTHCARE REG.MED 	Non-CAH Rural Acute Provider	32,962,637 	1,436,544 	32,962,637	
30117 	VALLEY VIEW MEDICAL CENT 	Non-CAH Rural Acute Provider	24,421,424 	1,042,965 	24,421,424	
30007 	VERDE VALLEY MEDICAL CTR. 	Non-CAH Rural Acute Provider	59,900,227 	1,706,864 	59,900,227	
30101 	WESTERN AZ REG MED CTR 	Non-CAH Rural Acute Provider	75,714,529 	2,478,348 	75,714,529	
30012 	YAVAPAI REG MED CENTER 	Non-CAH Rural Acute Provider	88,279,244 	2,708,226 	88,279,244	
33301 	LOS NINOS HOSPITAL 	Freestanding Children's Provider	4,987,962 	- 	N/A	
33302 	PHOENIX CHILDREN'S HOSP 	Freestanding Children's Provider	279,172,617 	- 	N/A	
31301 	BENSON HOSPITAL 	CAH	2,016,754 	121,518 	2,016,754	
31314 	COBRE VALLEY COMM HOSP 	CAH	11,885,842 	662,931 	11,885,842	
31312 	COPPER QUEEN HOSPITAL 	CAH	1,727,504 	158,670 	1,727,504	
31313 	HOLY CROSS HOSPITAL-ARIZ 	CAH	5,732,435 	545,283 	5,732,435	
31311 	LITTLE COLORADO MED CTR 	CAH	8,873,612 	523,611 	8,873,612	
31302 	NORTHERN COCHISE HOSPITAL 	CAH	3,712,148 	191,952 	3,712,148	
31304 	PAGE HOSPITAL 	CAH	2,644,809 	203,175 	2,644,809	
31303 	SOUTHEAST MEDICAL CENTER 	CAH	1,825,190 	116,100 	1,825,190	
31315 	WHITE MNTN REG MED CNTR 	CAH	3,221,019 	141,642 	3,221,019	
31300 	WICKENBURG COMMUNITY HOSP 	CAH	2,704,060 	166,023 	2,704,060	
32004 	CORNERSTONE HOSPITAL OF S 	LTAC Provider	9,891,662 	22,930 	9,891,662	
32000 	KINDRED HOSP AZ-NORTHWEST 	LTAC Provider	28,288,483 	68,596 	28,288,483	
32002 	KINDRED HOSPITAL-TUCSON 	LTAC Provider	13,834,262 	38,797 	13,834,262	
32006 	PROMISE HOSPITAL OF PHX 	LTAC Provider	12,156,295 	20,511 	12,156,295	
32007 	RESTORA MESA 	LTAC Provider	23,692,592 	41,699 	23,692,592	
32001 	SELECT SPECIALTY HOSP-PHX 	LTAC Provider	20,141,950 	44,505 	20,141,950	
32005 	SELECT SPECIALTY-PHX D/T 	LTAC Provider	21,690,307 	54,664 	21,690,307	
32008 	SUN CITY 	LTAC Provider	18,436,795 	22,543 	18,436,795	
34028 	Aurora Behavioral Healthcare-Tempe 	Small Psychiatric Providers and AZ State	10,025,673 	- 	N/A	
34021 	AZ STATE HOSPITAL 	Small Psychiatric Providers and AZ State	5,912,867 	- 	N/A	
34027 	Community Counseling Centers, Inc at PineView Hospita Small Psychiatric Providers and AZ State	2,503,330 	- 	N/A	
34020 	HAVEN SENIOR HORIZONS 	Small Psychiatric Providers and AZ State	7,959,235 	- 	N/A	
N/A 	Remuda Ranch Center for Anorexia and bulimia 	Small Psychiatric Providers and AZ State	10,618,436 	- 	N/A	
34023 	The Guidance Center, Inc. 	Small Psychiatric Providers and AZ State	4,417,288 	- 	N/A	

Sorted by Provider Type and then by Hospital Name in alphabetical order

Medicare
Provider ID	

Provider Name	

Provider Type	

FYE 2011 Inpatient Net Patient Revenue (Per UAR)	

SFY 2015
Total Assessment
Amount	

Inpatient Net Patient Revenue For Assessed Hospitals	
34026 	VALLEY HOSPITAL 	Small Psychiatric Providers and AZ State	13,344,142 	- 	N/A	
34025 	WINDHAVEN PSYCHIATRIC HOS 	Small Psychiatric Providers and AZ State	4,897,659 	- 	N/A	
34024 	AURORA BEHAVIORAL HEALTH 	Large Psychiatric Provider	19,950,126 	374,810 	19,950,126	
34004 	BANNER BEHAVORIAL HEALTH 	Large Psychiatric Provider	21,144,303 	395,030 	21,144,303	
34022 	SONORA BEHAVIORAL HEALTH 	Large Psychiatric Provider	13,786,786 	256,291 	13,786,786	
34013 	ST LUKE'S BEHAVORIAL HOSP 	Large Psychiatric Provider	34,635,127 	549,734 	34,635,127	
33037 	HEALTHSOUTH E.VALLEY REHA 	Freestanding Rehabilitation Provider	15,860,166 	- 	N/A	
33025 	HEALTHSOUTH MERIDIAN PT. 	Freestanding Rehabilitation Provider	20,344,299 	- 	N/A	
33028 	HEALTHSOUTH REHAB INST. 	Freestanding Rehabilitation Provider	22,382,220 	- 	N/A	
33032 	HEALTHSOUTH VALLEY OF SUN 	Freestanding Rehabilitation Provider	20,568,133 	- 	N/A	
33029 	HLTHSOUTH REHAB.HOSP.OF.S 	Freestanding Rehabilitation Provider	18,302,845 	- 	N/A	
33036 	MOUNTAIN VALLEY REG REHAB 	Freestanding Rehabilitation Provider	15,149,489 	- 	N/A	
33034 	YUMA REHABILITATION HOSPI 	Freestanding Rehabilitation Provider	13,454,028 	- 	N/A	
30065 	BANNER DESERT MEDICAL CEN 	Pediatric-Intensive General Acute Hospita	343,868,046 	9,482,544 	343,868,046	
30064 	UNIVERSITY MED CTR-AZ 	Pediatric-Intensive General Acute Hospita	352,226,741 	8,189,561 	352,226,741	
30089 	BANNER THUNDERBIRD MEDICA 	Medium Pediatric Intensive General Acute	291,954,485 	10,323,113 	291,954,485	
30022 	MARICOPA MEDICAL CENTER 	Medium Pediatric Intensive General Acute	191,266,233 	6,629,200 	191,266,233	
30087 	SCOTTSDALE HEALTHCARE - SHEA 	Medium Pediatric Intensive General Acute	226,556,545 	7,447,326 	226,556,545	
30006 	TUCSON MEDICAL CENTER 	Medium Pediatric Intensive General Acute	269,212,355 	10,314,125 	269,212,355	
30118 	YRMC EAST 	Medium Pediatric Intensive General Acute	30,363,780 	1,504,440 	30,363,780	
30013 	YUMA REGIONAL MED CENTER 	Medium Pediatric Intensive General Acute	146,932,499 	4,520,633 	146,932,499	
30107 	ARIZONA SPINE AND JOINT 	Short Term Specialty Hospital	10,704,992 	- 	N/A	
30112 	AZ ORTHOPEDIC SURGICAL HO 	Short Term Specialty Hospital	10,947,024 	- 	N/A	
30105 	BANNER HEART HOSPITAL 	Short Term Specialty Hospital	91,841,733 	- 	N/A	
N/A 	Cancer Treatment Centers of America - Western Regional  Short Term Specialty Hospital	21,191,404 	- 	N/A	
N/A 	FREEDOM PAIN HOSPITAL 	Short Term Specialty Hospital	2,803,283 	- 	N/A	
30131 	ORTHOPEDIC AND SPINE INPATIENT SURGI 	Short Term Specialty Hospital	7,479,786 	- 	N/A	
30108 	SURGICAL SPECIALITY HOSP 	Short Term Specialty Hospital	15,694,915 	- 	N/A	
30103 	MAYO CLINIC HOSPITAL 	High Medicare/Out-of State Patient Utiliza	326,937,952 	- 	N/A	
Total	7,625,745,971 	233,093,405 	6,668,244,493	

(1)

Note: (1) Includes provider's total net patient revenues; provider did not report inpatient vs. outpatient gross patient revnues in UAR.