Attachment J 6 A
ESRD Semi-Annual Cost Reporting Instructions
Purpose: The purpose of the CMS voucher form 719 and Semi Annual Cost Report Forms for ESRD Networks is to submit a semi-annual or monthly summary of costs for each subtask or combination of subtasks for a Network Base Contract alone, or the combination of a Network Base Contract and the SIMS contract. Only the Semi Annual Cost Report Form, Network Base Contract Form 719 and the separate SIMS Contract Form 719, if appropriate, should be submitted to CMS accounting. All parts of the Semi Annual Cost Report and Form 719 should be submitted to the Project Officer and electronically to CMS OCSQ Central Office at [email protected].
All Networks are required to complete and submit the Semi Annual Cost Report and Network Base Contract Form 719 no later than the 15th working day of the second month after each semi-annual cost reporting period. Additionally, cost reimbursement networks must submit Form 719 monthly. See the attached deliverable dates on page 8. For example, the due dates for the first year of the contract for cost reporting periods taking place in 2006-2007 are as follows:
Period Covered Report Due Date
July 1- December 31, 2006 February 15, 2007
January 1 – June 30, 2007 August 15, 2007
Cost reimbursement Networks should submit monthly 719 Forms by the 15th working day of the second month after each monthly cost reporting period. Please complete all required information as indicated on the form. The cost information supplied should reflect actual cost incurred for the period and be supported by Network financial records/general ledger. The cumulative cost column is for yearly cumulative costs; therefore, no cumulative cost column will ever have more than 12 months of reported costs.
The tabs on the bottom of the Excel Spreadsheet stand for the following: “NW F719” refers to the voucher form for the Network Base Contract and Special Projects; “SIMS F719” refers to the voucher form for the SIMS contract; and “COMB. NW & SIMS” F719 refers to the combination of the voucher forms for the Network Base Contract/Special Projects and the SIMS Contract.
Fill out the information blocks starting with item “1. RFP Number” and ending with item “4. Month Covered by Voucher.” The number of hours, hourly rates and costs should be completely filled starting with Column 5 on all spreadsheets. Do not fill in any blocks that are shaded, as it is either inappropriate to fill out those blocks, or they represent items which will be calculated automatically by formulas that are built into the form. Detailed instructions can be found below.
The task or subtasks below refer to and are explained in greater detail in Section C.3 of the Network SOW for the Base Contract and in Section II (Tasks) of the Network Information Technology Support SOW Contract.
If you have more employees than the ten positions already listed, please type each position’s title (determined per business proposal instructions) next to the position number in appropriate row of column A (For example: 10. Patient Services Coordinator). If position titles you use do not match those on the form word for word, for each employee use the form line which best fits form’s listed position title as defined below (Position Title General Definitions). If your Network does not utilize a position that fits a listed position, leave that line blank. Note: Do not insert additional position titles on the cost reporting form. Please locate an existing position title on the cost reporting form that best fits the position you are attempting to describe/define.
Please save and maintain at least one copy of this workbook on write-protected floppy disk or CD-ROM (when purchased blank, also known as a “CD-R”). Please do NOT use a re-writable CD (also known as a “CD-RW”).
LABOR COSTS: For employees, enter the end of period basic hourly wage rate, actual hours worked per position and the total costs actually paid to each position over the specified time period (including any regular, overtime and/or bonus pay). DO NOT SEPARATELY REPORT BONUSES OR OVERTIME PAY. DO NOT UTILIZE AVERAGES, OVERTIME OR BONUSES.
Additional Positions: This section should be utilized ONLY for additional Special Projects employees that differ from the core contract labor.
For overtime, specify in supporting narrative which positions worked overtime, how
many hours of overtime each position worked, and the primary cause of the overtime. (An example of a common primary cause for overtime is: in addition to regular time- sensitive duties, employee completed time-sensitive work normally done by someone who was out sick.)
For bonus pay, provide supporting narrative describing for each bonus paid the recipient, the dollar amount, and purpose -- “merit” or “other”; if “other” specify exact purpose.
CONSULTANTS: Enter consultants’ functions followed by their names. Enter actual
hourly rate for each consultant used. Enter actual hours of time provided by each consultant. The formula will automatically tally total consultant hours and costs and compute the average hourly consulting rate on the “subtotal, consultants” line.
G&A: If costs are entered on this line, you must attach a schedule.
The NCC tab is exclusively for the Network that holds the Network Coordinating Center Contract. The tab should be completed exactly like the “NW F719” tab.
POSITION TITLE GENERAL DEFINITIONS
1: PROJECT DIRECTOR/EXECUTIVE DIRECTOR: This is the position most Networks prefer to describe as the “Executive Director” or “ED”. It is the position analogous to “Chief Executive Officer (CEO)” in larger organizations; or to the “full-charge manager” in some smaller organizations. This position has line authority and reports directly to the Board of Directors.
2: QUALITY IMPROVEMENT MANAGER (QID): Most Networks use the term “Quality Improvement Director”. This is the person who leads and oversees all quality improvement efforts. This person reports directly to the Executive Director.
3: RN (NEPHROLOGY): This is an RN with nephrology experience, who usually works on quality-improvement and also on other activities required under the Network contract. This nurse works closely with the QID, perhaps also with the Social Services lead. Most often reports to the ED.
4: OFFC MGR./BOOKKEEPER: This position keeps the office running and/or maintains the general ledger on a daily basis (to the extent the ED delegates such activities as the general ledger and purchasing/logistics management). An “administrative assistant” who does not conduct office-management or bookkeeping activities should be reported under # 9 “EXECUTIVE/ADMINISTRATIVE ASSISTANT”
5: DATA/INFO. SYSTEMS MANAGER: This position should report directly to the ED and should be responsible for day-to-day management of the Network’s Data responsibilities. The Data Manager’s responsibilities may include those of a Local-Area Network (LAN) administrator. If there is a separate LAN administrator or other Information Technology/Systems analyst, that person should be reported separately (as another employee, or as a consultant, as appropriate to reflect Network’s actual operations).
6: DATA ENTRY & TRACKING CLERICAL SUPPORT: If Network has more than one data entry clerk position; this position should be the senior or highest-skill-level data clerk. This position should report to the Data Manager on technical matters. (For time/attendance/leave issues, the position might report to the Data Manager or to the ED, depending on Network organization.) If there are multiple part-time data entry clerks, each should be accounted for individually (use additional lines on report).
7: COMMUNITY OUTREACH COORDINATOR: This position serves as a specialist in partnership, collaboration, and education that will be responsible for enhancing community outreach and collaboration activities of the Network. This position will plan and facilitate education, information dissemination and training to ESRD professionals, patients, and their family members and other members of the renal community, and will be the staff liaison lead to the Patient Advisory Committee. He/she may work with consultants (e.g. website, statistical) and provide support across Network program lines to improve quality of care for patients through education, web site outreach, coalition and partnership building. To adequately perform these responsibilities, the individual must have related experience (e.g., communications, material development, organizing volunteers, etc.) and where possible be a patient with CKD/ESRD, or have personal, first hand experience with a family member, spouse, or other significant individual with CKD/ESRD. Because this position provides support across Network program lines, the Network will determine whether the responsibilities are fulfilled through one dedicated (part or full time position) or shared among other positions.
8: EXECUTIVE/ADMINISTRATIVE ASSISTANT/SECRETARY: If Network has an administrative assistant or executive assistant (not a bookkeeper or office manager), this position should be reported on this line.
9: CLERICAL SUPPORT: This position is the general file clerk/typist. If Network uses more than one person in this position (more than one FTE or an FTE split among part-time persons), list highest-paid here and list others in additional lines. If this position does not also serve as the Network’s Receptionist, the Receptionist position should be reported on one of the additional lines (11 through 20) on the cost report.
10: PATIENT SERVICES COORDINATOR: This position is responsible for resolving patient and/or facility complaints and grievances, conducting educational training on managing difficult situations, and conflict resolution and reports directly to ED.
Note: Receptionist duties are defined as answering the telephone, greeting visitors at the front desk, monitoring entry and exit of visitors, perhaps signing for and logging in packages and correspondence.
NW Voucher Form 719 for Network Base Contract (Fixed Price and Cost Reimbursement Contracts)
Sections 1 – 4: Fill out blocks 1 – 4 on the “NW F719” form with the information requested for RFP Number (1), Name and Address of the ESRD Network (2), ESRD Network Number (3) and the Month Covered by this Voucher (4). In filling out the RFP Number block make sure that the information is placed in the white block on the line directly under the “RFP Number”, not shaded blocks. The information in all four blocks will be automatically transferred to the same spaces on the “SIMS F719” and the “COMB. NW & SIMS” 719 forms, where appropriate.
Column 5: Task 1 – “Network Quality Improvement Program” contains Quality Improvement Projects that are National, local and clinical.
Column 6: Task 2 – “Community Information and Resources” includes the Network’s provision of educational information (patients, facilities and providers) and technical assistance, coalition building activities, responsibilities in a disaster and its resolution of difficult situations, complaints and grievances.
Column 7: Task 3 – “Administration” covers Network administrative activities, including staffing and reporting, specifically mandated by statute or regulation as directed by CMS.
Column 8: Task 4 – “Information Management” includes system development and information management responsibilities applicable to all Network activities.
Column 9: Task 5 – “Special Projects” covers Network special studies as directed or approved by CMS.
Column 10: Monthly Totals – Total costs for each line item for the “Month Covered by Voucher” listed in block 4 at the top of the form. There is no need to fill out anything in this column, as all the items should be calculated automatically by formulas that are built into the form.
Column 11: Cumulative Total to Date – The Network should fill out the white blocks that show zeroes on an unfilled out form by adding the amounts in the “Cumulative Total to Date, Column 11” from the prior month’s voucher (excluding the case of the first voucher of the contract) to the “Monthly Total, Column 10” from the current voucher. The shaded blocks will be calculated automatically based on formulas that are built into the form.
SIMS VOUCHER FORM 719 FOR SIMS CONTRACT
(ONLY FOR USE of Network that has the SIMS Contract
Sections 1 – 4: All shaded blocks will auto fill as long as you have properly completed Sections 1 – 4 “NW F719” Otherwise, fill out blocks 1 – 4 on the “SIMS F719” form with the information requested for RFP Number (1), Name and Address of the ESRD Network (2), ESRD Network Number (3) and the Month Covered by this Voucher (4). In filling out the RFP Number block make sure that the information is placed in the white block on the line directly under the “RFP Number”, not shaded blocks. The information in all four blocks will be automatically transferred to the same spaces on the “SIMS F719” and the “COMB. NW & SIMS” 719 forms, where appropriate.
Column 5: Task 1 – “Administrative, Project Management and Communications” The Contractor shall provide administrative, project management and communication functions to manage software development activities.
Column 6: Task 2 – “CMS Required Systems Architecture Support” The Contractor shall adhere to technical architecture processes as defined by the Division of Systems Architecture and Data Management
Column 7: Task 3 – “Reimbursements and Procurements” The Contractor shall provide the reimbursements and procurements.
Column 8: Task 4 – “ESRD Network Information Technology Infrastructure Support Activities” The Contractor shall provide assistance to the hardware contractors supporting the ESRD Networks.
Column 9: Task 5 – “SIMS Application Development and Maintenance” All SIMS software development and maintenance must follow the general requirements outlined in Section I, General Requirements for all Application Design, Development, Maintenance and Integration Operations of the SOW.
Column 10: Task 6 – “VISION Application Development and Maintenance” All VISION software development and maintenance must follow the general requirements outlined in Section I, General Requirements for all Application Design, Development, Maintenance and Integration Operations of the SOW.
Column 11: Task 7 – “Clinical Performance Measures (CPM) Support” The purpose of this task is to provide support work for the operation of the annual ESRD CPM project activities of the ESRD Networks as required by Section 1881 © of the Social Security Act; the Centers for Medicare and Medicaid Services Quality Improvement Program (HCQIP); and Section 4558 (b) of the Balanced Budget Act of 1997.
Column 12: Task 8 – “Support for Fistula First Breakthrough Initiative” The Contractor shall continue to assist the ESRD Networks and the CMS National Fistula First Project with the implementation and operation of the FF Project.
Column 13: Task 9 – “Phase II of the ESRD Reporting Tool Project” All software development and maintenance for the ESRD Reporting Tool Project must follow the general requirements
outlined in Section I, General Requirements for all Application Design, Development, Maintenance and Integration Operations of the SOW.
Column 14: Monthly Totals – Total costs for each line item for the “Month Covered by Voucher” listed in block 4 at the top of the form. There is no need to fill out anything in this column, as all the items should be calculated automatically by formulas that are built into the form.
Column 15: Cumulative Total to Date – The Network should fill out the white blocks that show zeroes on an unfilled out form by adding the amounts in the “Cumulative Total to Date, Column 11” from the prior month’s voucher (excluding the case of the first voucher of the contract) to the “Monthly Total, Column 10” from the current voucher. The shaded blocks will be calculated automatically based on formulas that are built into the form.
NETWORK BASE & SIMS CONTRACTS COMBINED FORM 719
(ONLY FOR USE of Network that has the SIMS Contract)
The Network holding the SIMS contract is the only Network that will make use of this form. All blocks on this form will be calculated automatically based on formulas built into the form, and based on the information input to the other forms. Therefore, the Network should not fill out anything on this form.
The tabs on the bottom of the Excel Spreadsheet stand for the following: “NW Semi Annual” refers to the Semi Annual form for the Network Base Contract and Special Projects; “SIMS Semi Annual” refers to the Semi Annual form for the SIMS contract; and “COMB. NW & SIMS” refers to the combination of the Semi Annual forms for the Network Base Contract/Special Projects and the SIMS Contract.
Fill out the information blocks starting with item “1. RFP Number” and ending with item “4. Reporting Period Covered.” The number of hours, hourly rates and costs should be completely filled starting with Column 5 on all spreadsheets. Do not fill in any blocks that are shaded, as it is either inappropriate to fill out those blocks, or they represent items which will be calculated automatically by formulas that are built into the form. Detailed instructions can be found below.
The task or subtasks below refer to and are explained in greater detail in Section C.3 of the Network SOW for the Base Contract and in Section II (Tasks) of the Network Information Technology Support SOW Contract.
If you have more employees than the ten positions already listed, please type each position’s title (determined per business proposal instructions) next to the position number in appropriate row of column A (For example: 10. Patient Services Coordinator). If position titles you use do not match those on the form word for word, for each employee use the form line which best fits form’s listed position title as defined below (Position Title General Definitions). If your Network does not utilize a position that fits a listed position, leave that line blank. Note: Do not insert additional position titles on the cost reporting form. Please locate an existing position title on the cost reporting form that best fits the position you are attempting to describe/define.
Please save and maintain at least one copy of this workbook on write-protected floppy disk or CD-ROM (when purchased blank, also known as a “CD-R”). Please do NOT use a re-writable CD (also known as a “CD-RW”).
LABOR COSTS: For employees, enter the end of period basic hourly wage rate, actual hours worked per position and the total costs actually paid to each position over the specified time period (including any regular, overtime and/or bonus pay). DO NOT SEPARATELY REPORT BONUSES OR OVERTIME PAY. DO NOT UTILIZE AVERAGES, OVERTIME OR BONUSES.
Additional Positions: This section should be utilized ONLY for additional Special Projects employees that differ from the core contract labor.
For overtime, specify in supporting narrative which positions worked overtime, how
many hours of overtime each position worked, and the primary cause of the overtime. (An example of a common primary cause for overtime is: in addition to regular time- sensitive duties, employee completed time-sensitive work normally done by someone who was out sick.)
For bonus pay, provide supporting narrative describing for each bonus paid the recipient, the dollar amount, and purpose -- “merit” or “other”; if “other” specify exact purpose.
CONSULTANTS: Enter consultants’ functions followed by their names. Enter actual
hourly rate for each consultant used. Enter actual hours of time provided by each consultant. The formula will automatically tally total consultant hours and costs and compute the average hourly consulting rate on the “subtotal, consultants” line.
G&A: If costs are entered on this line, you must attach a schedule.
The NCC tab is exclusively for the Network that holds the Network Coordinating Center Contract. The tab should be completed exactly like the “NW F719” tab, however, there will not be any Special Projects to break-out.
POSITION TITLE GENERAL DEFINITIONS
1: PROJECT DIRECTOR/EXECUTIVE DIRECTOR: This is the position most Networks prefer to describe as the “Executive Director” or “ED”. It is the position analogous to “Chief Executive Officer (CEO)” in larger organizations; or to the “full-charge manager” in some smaller organizations. This position has line authority and reports directly to the Board of Directors.
2: QUALITY IMPROVEMENT MANAGER (QID): Most Networks use the term “Quality Improvement Director”. This is the person who leads and oversees all quality improvement efforts. This person reports directly to the Executive Director.
3: RN (NEPHROLOGY): This is an RN with nephrology experience, who usually works on quality-improvement and also on other activities required under the Network contract. This nurse works closely with the QID, perhaps also with the Social Services lead. Most often reports to the ED.
4: OFFC MGR./BOOKKEEPER: This position keeps the office running and/or maintains the general ledger on a daily basis (to the extent the ED delegates such activities as the general ledger and purchasing/logistics management). An “administrative assistant” who does not conduct office-management or bookkeeping activities should be reported under # 9 “EXECUTIVE/ADMINISTRATIVE ASSISTANT”
5: DATA/INFO. SYSTEMS MANAGER: This position should report directly to the ED and should be responsible for day-to-day management of the Network’s Data responsibilities. The Data Manager’s responsibilities may include those of a Local-Area Network (LAN) administrator. If there is a separate LAN administrator or other Information Technology/Systems analyst, that person should be reported separately (as another employee, or as a consultant, as appropriate to reflect Network’s actual operations).
6: DATA ENTRY & TRACKING CLERICAL SUPPORT: If Network has more than one data entry clerk position; this position should be the senior or highest-skill-level data clerk. This position should report to the Data Manager on technical matters. (For time/attendance/leave issues, the position might report to the Data Manager or to the ED, depending on Network organization.) If there are multiple part-time data entry clerks, each should be accounted for individually (use additional lines on report).
7: COMMUNITY OUTREACH COORDINATOR: This position serves as a specialist in partnership, collaboration, and education that will be responsible for enhancing community outreach and collaboration activities of the Network. This position will plan and facilitate education, information dissemination and training to ESRD professionals, patients, and their family members and other members of the renal community, and will be the staff liaison lead to the Patient Advisory Committee. He/she may work with consultants (e.g. website, statistical) and provide support across Network program lines to improve quality of care for patients through education, web site outreach, coalition and partnership building. To adequately perform these responsibilities, the individual must have related experience (e.g., communications, material development, organizing volunteers, etc.) and where possible be a patient with CKD/ESRD, or have personal, first hand experience with a family member, spouse, or other significant individual with CKD/ESRD. Because this position provides support across Network program lines, the Network will determine whether the responsibilities are fulfilled through one dedicated (part or full time position) or shared among other positions.
8: EXECUTIVE/ADMINISTRATIVE ASSISTANT/SECRETARY: If Network has an administrative assistant or executive assistant (not a bookkeeper or office manager), this position should be reported on this line.
9: CLERICAL SUPPORT: This position is the general file clerk/typist. If Network uses more than one person in this position (more than one FTE or an FTE split among part-time persons), list highest-paid here and list others in additional lines. If this position does not also serve as the Network’s Receptionist, the Receptionist position should be reported on one of the additional lines (11 through 20) on the cost report.
10: PATIENT SERVICES COORDINATOR: This position is responsible for resolving patient and/or facility complaints and grievances, conducting educational training on managing difficult situations, and conflict resolution and reports directly to ED.
Note: Receptionist duties are defined as answering the telephone, greeting visitors at the front desk, monitoring entry and exit of visitors, perhaps signing for and logging in packages and correspondence.
Semi Annual Cost Reporting Form for Network Base Contract (Fixed Price and Cost Reimbursement Contracts)
Fixed Price Contract Networks have the option of reporting Semi Annual Costs Task by Task or by Total Base Contract and Special Projects. Cost Reimbursement Contract Networks must report their Semi Annual Costs Task by Task. All Networks must report Semi Annual Special Projects Costs separately in column 10.
Sections 1 – 4: Fill out blocks 1 – 4 on the “NW Semi Annual” form with the information requested for RFP Number (1), Name and Address of the ESRD Network (2), ESRD Network Number (3) and the Reporting Period Covered (4). In filling out the RFP Number block make sure that the information is placed in the white block on the line directly under the “RFP Number”, not shaded blocks. The information in all four blocks will be automatically transferred to the same spaces on the “SIMS Semi Annual” and the “COMB. NW & SIMS” Semi Annual forms, where appropriate.
Column 5: Task 1 – “Network Quality Improvement Program” contains Quality Improvement Projects that are National, local and clinical.
Column 6: Task 2 – “Community Information and Resources” includes the Network’s provision of educational information (patients, facilities and providers) and technical assistance, coalition building activities, responsibilities in a disaster and its resolution of difficult situations, complaints and grievances.
Column 7: Task 3 – “Administration” covers Network administrative activities, including staffing and reporting, specifically mandated by statute or regulation as directed by CMS.
Column 8: Task 4 – “Information Management” includes system development and information management responsibilities applicable to all Network activities.
Column 9: Tasks 1 – 4 “Base Contract Only” covers the base contract tasks in total. Fixed Price Contract Networks have the option of reporting Semi Annual Costs Task by Task or Total Base Contract and Special Projects. All Networks must report Semi Annual Special Projects Costs separately in column 10.
Column 10: Task 5 – “Special Projects” covers Network special studies as directed or approved by CMS.
Column 11: Monthly Totals – Total costs for each line item for the “Reporting Period Covered” listed in block 4 at the top of the form. There is no need to fill out anything in this column, as all the items should be calculated automatically by formulas that are built into the form.
Column 12: Cumulative Total to Date – The Network should fill out the white blocks that show zeroes on an unfilled out form by adding the amounts in the “Cumulative Total to Date, Column 12” from the prior month’s voucher (excluding the case of the first voucher of the contract) to the “Monthly Total, Column 11” from the current voucher. The shaded blocks will be calculated automatically based on formulas that are built into the form.
SIMS VOUCHER FORM 719 FOR SIMS CONTRACT
(ONLY FOR USE of Network that has the SIMS Contract
Sections 1 – 4: All shaded blocks will auto fill as long as you have properly completed Sections 1 – 4 “NW Semi Annual.” Otherwise, fill out blocks 1 – 4 on the “SIMS Semi Annual” form with the information requested for RFP Number (1), Name and Address of the ESRD Network (2), ESRD Network Number (3) and the Reporting Period Covered (4). In filling out the RFP Number block make sure that the information is placed in the white block on the line directly under the “RFP Number”, not shaded blocks. The information in all four blocks will be automatically transferred to the same spaces on the “SIMS Semi Annual” and the “COMB. NW & SIMS” Semi Annual forms, where appropriate.
Column 5: Task 1 – “Administrative, Project Management and Communications” The Contractor shall provide administrative, project management and communication functions to manage software development activities.
Column 6: Task 2 – “CMS Required Systems Architecture Support” The Contractor shall adhere to technical architecture processes as defined by the Division of Systems Architecture and Data Management
Column 7: Task 3 – “Reimbursements and Procurements” The Contractor shall provide the reimbursements and procurements.
Column 8: Task 4 – “ESRD Network Information Technology Infrastructure Support Activities” The Contractor shall provide assistance to the hardware contractors supporting the ESRD Networks.
Column 9: Task 5 – “SIMS Application Development and Maintenance” All SIMS software development and maintenance must follow the general requirements outlined in Section I, General Requirements for all Application Design, Development, Maintenance and Integration Operations of the SOW.
Column 10: Task 6 – “VISION Application Development and Maintenance” All VISION software development and maintenance must follow the general requirements outlined in Section I, General Requirements for all Application Design, Development, Maintenance and Integration Operations of the SOW.
Column 11: Task 7 – “Clinical Performance Measures (CPM) Support” The purpose of this task is to provide support work for the operation of the annual ESRD CPM project activities of the ESRD Networks as required by Section 1881 © of the Social Security Act; the Centers for Medicare and Medicaid Services Quality Improvement Program (HCQIP); and Section 4558 (b) of the Balanced Budget Act of 1997.
Column 12: Task 8 – “Support for Fistula First Breakthrough Initiative” The Contractor shall continue to assist the ESRD Networks and the CMS National Fistula First Project with the implementation and operation of the FF Project.
Column 13: Task 9 – “Phase II of the ESRD Reporting Tool Project” All software development and maintenance for the ESRD Reporting Tool Project must follow the general requirements outlined in Section I, General Requirements for all Application Design, Development, Maintenance and Integration Operations of the SOW.
Column 14: Monthly Totals – Total costs for each line item for the “Month Covered by Voucher” listed in block 4 at the top of the form. There is no need to fill out anything in this column, as all the items should be calculated automatically by formulas that are built into the form.
Column 15: Cumulative Total to Date – The Network should fill out the white blocks that show zeroes on an unfilled out form by adding the amounts in the “Cumulative Total to Date, Column 15” from the prior month’s voucher (excluding the case of the first voucher of the contract) to the “Monthly Total, Column 14” from the current voucher. The shaded blocks will be calculated automatically based on formulas that are built into the form.
NETWORK BASE & SIMS CONTRACTS COMBINED SEMI ANNUAL FORM
(ONLY FOR USE of Network that has the SIMS Contract)
The Network holding the SIMS contract is the only Network that will make use of this form. All blocks on this form will be calculated automatically based on formulas built into the form, and based on the information input to the other forms. Therefore, the Network should not fill out anything on this form.
INSTRUCTIONS FOR SF 1034 – PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL
The purpose of Standard Form 1034 is to submit a summary of actual costs incurred in performing each of the contracts. Complete and submit a SF 1034 to request payment for all cost incurred. SF 1034 is the official reimbursement voucher used by all Federal Government agencies. SF 1034 should be completed once DHHS/CMS form 719 is completed for each contract. Each month a separate 1034 should be prepared for the Network base and the SIMS contract, which is in agreement with the monthly total for the separate forms 719’s for each of these contracts. In column “Articles or Services” it should be clearly stated if the SF 1034 is for the Network Base Contract or the SIMS contract. Under the “Cost Column” the Network should separately show on one line all costs excluding fee and on another line only fee costs and these lines should be added together for a total cost.
This document lists the major cost element breakdown of the ESRD Networks contract beginning July 1, 2006, for purposes of titling column headings and drafting cost reporting instructions for cost reports/vouchers for the cost reimbursement Networks.
The cost elements can be matched to task descriptions from the ESRD Statement of Work. Further abbreviation of some titles may be desirable, may require some thought to make logical abbreviations.
Form SF 1034 can be found at the following website:
http://www.gsa.gov/Portal/gsa/ep/formslibrary.do?viewType=DETAIL&formId=57675C8BB6CE880B85256A3F004125BD
ESRD NETWORK ORGANIZATION
SEMI-ANNUAL COST REPORTS:
Fixed Price Contract Networks: Each Semi-Annual and Form 719 Voucher shall be submitted so that they are received by CMS no later than close of business (COB) on the fifteenth (15th) working day following the close of the second reporting period it covers.
Cost Reimbursement Contract Networks: Each Semi Annual Cost Report shall be submitted so that they are received by CMS no later than close of business (COB) on the fifteenth (15th) working day following the close of the second reporting period it covers. Each Form 719 Voucher must be submitted monthly so that they are received by CMS no later than close of business (COB) on the fifteenth (15th) working day following the close of the second reporting period it covers.
Close of business shall for purposes of this requirement be defined as 6 PM local prevailing time at CMS Central Office in Baltimore, MD on the due date. (Eastern Standard or Eastern Daylight Time, as applicable). Working days shall for purposes of this requirement be defined as all calendar days except Saturdays, Sundays and Federal Holidays, as observed by the Federal Government.
Calendar Due Dates for All Semi Annual Costs Reports Under 2006 – 2009 Contract
Cost Report # |
Covering Reporting Period |
Due Date |
1 |
7/1/2006 – 12/31/2006 |
Thursday, 2/15/2007 |
2 |
1/1/2007 – 6/30/2007 |
Wednesday, 8/15/2007 |
3 |
7/1/2007 – 12/31/2007 |
Friday, 2/15/2008 |
4 |
1/1/2008 – 6/30/2008 |
Friday, 8/15/2008 |
5 |
7/1/2008 – 12/31/2008 |
Monday, 2/17/2009 |
6 |
1/1/2009 – 6/30/2009 |
Monday, 8/17/2009 |
Note: The final cost report for the 2003 – 2006 contract, covering the period from January 1, 2005 through June 30, 2006, will be due on Thursday, August 21, 2003.
Attachment J-6 A
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0657. The time required to complete this information collection is estimated to average ( 3 hours) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
| File Type | application/msword |
| File Title | ESRD Semi-Annual Cost Reporting Instructions |
| Author | CMS |
| Last Modified By | CMS |
| File Modified | 2006-06-21 |
| File Created | 2006-06-21 |