CMS-265-11 Independent Renal Dialysis Facility Cost Report

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Overview

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S-1
S-2
A
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A-2
A-3
A-4
B
B-1
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E1
F
F-1

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Sheet 1: S

				Form CMS-265-11							4290 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim									FORM APPROVED
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).									OMB NO: 0938-0236
INDEPENDENT RENAL DIALYSIS FACILITY					PROVIDER CCN:		PERIOD:		WORKSHEET S
COST REPORT CERTIFICATION							From:
							To:
PART I - COST REPORT STATUS
Provider use only		1. [ ] Electronically filed cost report		Date (mm/dd/yyyy): ____________________			Time: ____________________
		2. [ ] Manually submitted cost report
		3. If this is an amended report enter the number of times the provider resubmitted this cost report. ______
Contractor		4. [ ] Cost Report Status			5. Date Received: _________
use only		(1) As Submitted			6. Contractor No._________
		(2) Settled without Audit			7. [ ] First Cost Report for this Provider CCN
		(3) Settled with Audit			8. [ ] Last Cost Report for this Provider CCN
		(4) Reopened			9. NPR Date: __________
		(5) Amended			10. If line 4, column 1 is "4", enter number of times reopened _______
					11. Contractor Vendor Code ________
PART II - GENERAL
1	Name:										1
2	Street:						P.O. Box:				2
3	City:			State:			Zip Code:				3
4	County:			CBSA:							4
5	Provider CCN:										5
6	Date Certified:										6
7	Contact Person Name :						Phone Number:				7
8	Cost reporting period (mm/dd/yyyy)		From:		To:						8
							1		2
9	Type of control (see instructions)										9
10	Is this facility approved as a low-volume facility for this cost reporting period? Enter "Y" for yes or "N" for no.										10
							1		2
11	Type of physicians' reimbursement (see instructions)										11
12	Was this facility previously certified as a hospital-based unit? Enter "Y" for yes or "N" for no.										12
13	Did your facility elect 100% PPS effective January 1, 2011? Enter "Y" for yes or "N" for no. See instructions for "new" providers.										13
							1		2
14	If you responded "N" to line 13, enter in column 1 the year of transition for periods prior to January 1 and										14
	enter in column 2 the year of transition for periods after December 31. (see instructions)
15	Malpractice premiums										15
16	Malpractice paid losses										16
17	Malpractice self insurance										17
18	Are malpractice premiums and/or paid losses reported in other than the Administrative and General cost center? Enter "Y" for yes or "N" for no.										18
	If yes, submit a supporting schedule listing cost centers and amounts contained therein.
19	Are you part of a chain organization? Enter "Y" for yes or "N" for no. If yes, complete lines 20 through 22.										19
20	Name:										20
21	Street:						P.O. Box:				21
22	City:			State:			Zip Code:				22
PART III - CERTIFICATION BY OFFICER OR ADMINISTRATOR
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL AND
ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR
PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE
ACTION, FINES, AND/OR IMPRISONMENT MAY RESULT.
			CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
		I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically filed or manually submitted cost
		report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Number(s)}
		for the cost reporting period beginning ______________ and ending ______________ and to the best of my knowledge and belief, it is a true, correct
		and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further
		certify that I am familiar with the laws and regulations regarding the provision of health care services identified in this cost report were provided in
		compliance with such laws and regulations.
				(Signed)	______________________________________________
					Officer or Administrator of Provider
					______________________________________________
					Title
					______________________________________________
					Date
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 0938-0236. The time required to complete this information collection is estimated 65 hours per response, including the time to review instructions, search existing resources, gather the data needed, and
complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
FORM CMS-265-11 ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4204, 4204.1 AND 4204.2)
Rev. 1											42-303

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Sheet 2: S-1

4290 (Cont.)				Form CMS-265-11
INDEPENDENT RENAL DIALYSIS FACILITY					PROVIDER CCN:				PERIOD:				WORKSHEET S-1
STATISTICAL DATA									From:
									To:
RENAL DIALYSIS STATISTICS
				OUTPATIENT						TRAINING
								PERITONEAL						PERITONEAL
					HEMODIALYSIS			DIALYSIS			HEMODIALYSIS			DIALYSIS
					1			2			3			4
1	Number of treatments not billed to Medicare and furnished directly															1
2	Number of treatments not billed to Medicare and furnished under arrangements															2
3	Number of patients currently in dialysis program															3
4	Average times per week patient receives dialysis															4
5	Number of days in an average week for patient dialysis treatments															5
6	Average time of patient dialysis treatment including set up time															6
7	Number of machines regularly available for use															7
8	Number of standby machines															8
9	Number of shifts in typical week during regular reporting period															9
10	Hours per shift in typical week during regular reporting period															10
	.01	First shift														.01
	.02	Second Shift														.02
	.03	Third shift														.03
11	Number of treatments provided															11
	.01	One (1) time per week														.01
	.02	Two (2) times per week														.02
	.03	Three (3) times per week														.03
	.04	More than three (3) times per week														.04
	.05	Total														.05
								Type of Dialyzers			Dialyzer Reuse Count			Other Dialyzers
								1			2			3
12	Column 1: Type of dialyzers used (see instructions)															12
	Column 2: Number of times dialyzers are reused (see instructions)
	Column 3: If column 1 is "Other," enter type of dialyzer used
13	Number of back-up sessions furnished to home patients (see instructions)															13
14	Number of units of Epoetin furnished during cost reporting period															14
15	Number of units of Aranesp furnished during cost reporting period															15
TRANSPLANT STATISTICS
16	Number of patients who are awaiting transplants															16
17	Number of patients who received transplants during this period															17
HOME PROGRAM
18	Number of patients commencing home dialysis training during this period															18
19	Number of patients currently in home program															19
								Type of Dialyzers			Dialyzer Reuse Count			Other Dialyzers
								1			2			3
20	Column 1: Type of dialyzers used (see instructions)															20
	Column 2: Number of times dialyzers are reused (see instructions)
	Column 3: If column 1 is "Other," enter type of dialyzer used
RENAL DIALYSIS FACILITY--NUMBER OF EMPLOYEES (FULL TIME EQUIVALENTS)
21	Enter the number of hours in your normal work week															21
								Staff			Contract			Total
								1			2			3
22	Physicians															22
23	Registered Nurses															23
24	Licensed Practical Nurses															24
25	Nurses Aides															25
26	Technicians															26
27	Social Workers															27
28	Dieticians															28
29	Administrative															29
30	Management															30
31	Other (Specify)															31
FORM CMS 265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2 SECTION 4205)
42-304																Rev. 1

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Sheet 3: S-2

				Form CMS-265-11																		4290 (Cont.)
INDEPENDENT RENAL DIALYSIS FACILITY					PROVIDER CCN:	PERIOD:								WORKSHEET S-2
REIMBURSEMENT QUESTIONNAIRE						From:
						To:
							Y/N					DATE					V/I
PROVIDER ORGANIZATION AND OPERATION									1					2					3
1	Has the provider changed ownership immediately prior to the beginning of the cost reporting period?																					1
	Enter "Y" for yes or "N" for no in column 1. If yes, enter the date (mm/dd/yyyy) of the change in column 2.
	(see instructions)
2	Has the provider terminated participation in the Medicare Program? Enter "Y" for yes or "N" for no in column 1.																					2
	If yes, enter in column 2 the termination date (mm/dd/yyyy); and, enter in column 3, "V" for voluntary or "I"
	for involuntary.
3	Is the provider involved in business transactions, including management contracts, with individuals or entities																					3
	(e.g., chain home offices, drug or medical supply companies) that were related to the provider or its officers,
	medical staff, management personnel, or members of the board of directors through ownership, control, or
	family and other similary relationships? Enter "Y" for yes or "N" for no in column 1. (see instructions)
							Y/N					A/C/R					DATE
FINANCIAL DATA AND REPORTS									1					2					3
4	Column 1: Were the financial statements prepared by a Certified Public Accountant? Enter "Y" for yes or "N" for no.																					4
	Column 2: If yes, enter in column 2: "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy
	of financial statements or enter date available (mm/dd/yyyy) in column 3. (see instructions) If no, see instructions.
5	Are the cost report total expenses and total revenues different from those on the filed financial statements? Enter "Y"																					5
	for yes or "N" for no in column 1. If yes, submit reconciliation.
BAD DEBTS																	Y/N
6	Is the provider seeking reimbursement for bad debts? Enter "Y" for yes or "N" for no. If yes, see instructions.																					6
7	If line 6 is yes, did the provider's bad debt collection policy change during the cost reporting period? "Y" for yes or "N" for no. If yes, submit copy.																					7
8	If line 6 is yes, were patient deductibles and/or co-payments waived? Enter "Y" for yes or "N" for no. If yes, see instructions.																					8
												Y/N					DATE
PS&R REPORT DATA														1					2
9	Was the cost report prepared using the PS&R report only? Enter "Y" for yes or "N" for no in column 1. If yes, enter in column 2 the																					9
	paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions.)
10	Was the cost report prepared using the PS&R report for totals and the provider's records for allocation? Enter "Y" for yes or "N" for no																					10
	in col.1. If yes, enter in col. 2 the paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions)
11	If line 9 or 10 is yes, were adjustments made to PS&R report data for additional claims that have been billed but are not included on the																					11
	PS&R report used to file the cost report? Enter "Y" for yes or "N" for no. If yes, see instructions.
12	If line 9 or 10 is yes, were adjustments made to PS&R report data for corrections of other PS&R report information? Enter "Y" for yes																					12
	or "N" for no. If yes, see instructions.
13	If line 9 or 10 is yes, were adjustments made to PS&R report data for Other? Enter "Y" for yes or "N" for no.																					13
	If yes, describe the other adjustments:		__________________________________________________________________________
14	Was the cost report prepared only using the provider's records? Enter "Y" for yes or "N" for no.																					14
	If yes, see instructions.
FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4205.1)
Rev. 1																						42-305

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Sheet 4: A

4290 (Cont.)					Form CMS-265-11
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE						PROVIDER CCN:		PERIOD:		WORKSHEET A
OF EXPENSES								From:
								To:
							RECLASS.			NET EXPENSES
			SALARIES			TOTAL	TO EXPENSES	RECLASSIFIED	ADJUSTMENTS	FOR COST
		FACILITY HEALTH CARE COSTS	PHYSICIAN			(col. 1 through	(from	TRIAL BALANCE	TO EXPENSES	ALLOCATION
			COMPENSATION	OTHER	OTHER	col. 3)	Wkst. A-1)	(col 4. +/- col. 5)	(from Wkst. A-2)	(col. 6+/-col. 7)
			1	2	3	4	5	6	7	8
		COST CENTERS
1	0100	Cap Rel Costs-Bldg & Fixt									1
2	0200	Cap Rel Costs-Mvble Equip									2
3	0300	Operation & Maintenance of Plant									3
4	0400	Housekeeping									4
5		Subtotal (sum of lines 1 through 4)*									5
6	0600	Machine Cap-Rel or Rental & Maint*									6
7	0700	Salaries for Direct Patient Care*									7
8	0800	EH&W Benefits for Direct Pt. Care									8
9	0900	Supplies*									9
10	1000	Laboratory*									10
11	1100	Administrative & General									11
12	1200	Drugs*									12
13	1300	Interest Expense									13
14	1400	Laundry and Linen									14
15	1500	Medical Records									15
16	1600	Phy Rout Prof Svcs-Initial Method									16
17	1700	Other (Specify)									17
18		Subtotal (sum of line 11 plus lines 13 through 17)*									18
19	1900	Phy Rout Prof Svcs-MCP Method									19
20	2000	Whole Blood & Packed Red Blood Cells*									20
21	2100	Vaccines*									21
		NONREIMBURSABLE COSTS CENTERS
22	2200	Physicians Private Offices*									22
23	2300	ESAs (prior to January 1, 2011)									23
24	2400	Method II Patients (prior to January 1, 2011)									24
25	2500	Other Nonreimbursable (Specify)*									25
26	2600	Other Nonreimbursable (Specify)*									26
27		Total									27
* Transfer the amounts in column 8 to Worksheet B and B-1, as appropriate.
FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4206)
42-306											Rev. 1

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Sheet 5: A-1

		Form CMS-265-11								4290 (Cont.)
RECLASSIFICATIONS					PROVIDER CCN:		PERIOD:		WORKSHEET A-1
							From:
							To:
				INCREASE			DECREASE
			CODE	COST	LINE		COST	LINE
	EXPLANATION OF ENTRY		(1)	CENTER	NO.	AMOUNT (2)	CENTER	NO.	AMOUNT (2)
			1	2	3	4	5	6	7
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
11										11
12										12
13										13
14										14
15										15
16										16
17										17
18										18
19										19
20										20
21										21
22										22
23										23
24										24
25										25
26										26
27										27
28										28
29										29
30										30
31										31
32										32
33										33
34										34
35										35
100	Total Reclassifications (Sum of col. 4 must equal sum of col. 7)									100
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer to Worksheet A, col. 5, line as appropriate.
FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4207)
Rev. 1										42-307

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Sheet 6: A-2

4290 (Cont.)		Form CMS-265-11
ADJUSTMENTS TO EXPENSES		PROVIDER CCN:		PERIOD:		WORKSHEET A-2
				From:
				To:
				Expense classification on Worksheet A from which
		BASIS FOR		amount is to be deducted or to which the amount is
		ADJUSTMENT		to be added
	DESCRIPTION (1)	(2)	AMOUNT	COST CENTER			LINE NO.
		1	2	3			4
1	Investment income on commingled restricted and unrestricted funds (chapter 2)							1
2	Trade, quantity and time discounts on purchases (chapter 8)							2
3	Rebates and refunds of expenses (chapter 8)							3
4	Rental of building or office space to others							4
5	Physician non-routine professional patient care services							5
6	Home office costs (chapter 21)							6
7	Adjustment resulting from transactions with related organizations (chapter 10)	From Wkst. A-3						7
8	Vending machines							8
9	Meals served to patients							9
10	Physicians' professional services--MCP Method	A		Physicians' professional services--MCP Method			19	10
11	Services under arrangement							11
12	Provision for doubtful accounts							12
13	Capital Related--Buildings & Fixtures			Capital Related--Buildings & Fixtures			1	13
14	Capital Related--Moveable Equipment			Capital Related--Moveable Equipment			2	14
15	Rebates on Epoetin prior to January 1, 2011			Epoetin			23	15
16	Epoetin	A		Epoetin			23	16
17	Rebates on Aranesp prior to January 1, 2011			Aranesp			23	17
18	Aranesp	A		Aranesp			23	18
19	Rebates on Epoetin on or after January 1, 2011			Epoetin			12	19
20	Rebates on Aranesp on or after January 1, 2011			Aranesp			12	20
21	Physician malpractice premiums							21
22	Other (specify)							22
23	Other (specify)							23
24	Other (specify)							24
100	Total (Transfer to Wkst. A, col. 7, line 27)							100
	(1) Description-all chapter references in this column pertain to CMS Pub. 15-2
	(2) Basis for adjustment (see instructions)
	A. Costs-if cost, including applicable overhead, can be determined
	B. Amount Received-if cost cannot be determined
FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4208)
42-308								Rev. 1

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Sheet 7: A-3

Form CMS-265-11

4290 (Cont.)

STATEMENT OF COSTS OF SERVICES

PROVIDER CCN:

PERIOD:

WORKSHEET A-3

FROM RELATED ORGANIZATIONS

From:

To:

A.

Are there any costs included on Worksheet A which resulted from transactions with related organizations as defined in CMS Pub. 15-1, Chapter 10?

[ ] Yes (If yes, complete Parts B and C)

[ ] No

B.

Costs incurred and adjustments required as result of transactions with related organizations:

AMOUNT

NET

LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COL. 6

AMOUNT

INCLUDED IN

ADJUSTMENT

ALLOWABLE

WKST. A

(col. 4 minus

LINE NO.

COST CENTER

EXPENSES ITEMS

IN COST

COL. 6

col. 5)

1

2

3

4

5

6

1

1

2

2

3

3

4

4

5

TOTALS (sum of lines 1-4)

5

(Transfer col. 6, lines 1-4 to Wkst. A, col. 7 as appropriate)

(Transfer col. 6, line 5 to Wkst. A-2, col. 2, line 7)

C.

Interrelationship of facility to related organization(s):

The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires the provider to furnish the information requested on Part C of this worksheet.

This information will be used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable to services, facilities, and supplies furnished by

organizations related to the facility by common ownership or control, represent reasonable costs as determined under 1861(v)(1)(a) of the Social Security Act. If the provider does not provide

all or any part of the requested information, the cost report is considered incomplete and not acceptable for purposes of claiming reimbursement under title XVIII.

RELATED ORGANIZATION(S)

PERCENTAGE

PERCENTAGE

SYMBOL

OF

OF

(1)

NAME

OWNERSHIP

NAME

OWNERSHIP

TYPE OF BUSINESS

1

2

3

4

5

6

1

1

2

2

3

3

4

4

(1) Use the following symbols to indicate interrelationship to related organizations:

A.

Individual has financial interest (stockholder, partner, etc.) in both related organization and in the facility

B.

Corporation, partnership, or other organization has financial interest in the facility

C.

Facility has financial interest in corporation, partnership, or other organization(s)

D.

Director, officer, administrator, or key person of the facility or relative of such person has financial interest in related organization

E.

Individual is director, officer, administrator, or key person of the facility and related organization

F.

Director, officer, administrator, or key person of related organization or relative of such person has financial interest in the facility

G.

Other (financial or non-financial) specify _____________________________

FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2,Section 4209)

Rev. 1

42-309

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Sheet 8: A-4

4290 (Cont.)								Form CMS-265-11
STATEMENT OF COMPENSATION												PROVIDER CCN:			PERIOD:			WORKSHEET A-4
															From:
															To:
PART I. STATEMENT OF TOTAL COMPENSATION TO OWNERS
(Include compensation of employees related to owners)
				SOLE														TOTAL
				PROPIETORSHIPS		PARTNERS						CORPORATION OWNERS						COMPENSATION
				PERCENTAGE OF						PERCENTAGE						PERCENTAGE OF		INCLUDED IN
				CUSTOMARY						OF CUSTOMARY						CUSTOMARY		ALLOWABLE
				WORK WEEK			PERCENT SHARE			WORK WEEK			PERCENTAGE OF			WORK WEEK		COSTS FOR
				DEVOTED TO			OF OPERATING			DEVOTED TO			PROVIDER'S			DEVOTED TO		THE PERIOD
	TITLE	FUNCTION (A)		BUSINESS			PROFIT OR (LOSS)			BUSINESS			STOCK OWNED			BUSINESS		(B)
	1	2		3			4a			4b			5a			5b		6
1																			1
2																			2
3																			3
4																			4
5																			5
6																			6
7																			7
8																			8
9																			9
10																			10
PART II. STATEMENT OF TOTAL COMPENSATION TO ADMINISTRATORS, ASSISTANT ADMINISTRATORS AND/OR MEDICAL DIRECTORS OR OTHERS
	PERFORMING THESE DUTIES (OTHER THAN OWNERS) (To be completed by all facilities)
											PERCENTAGE OF						TOTAL COMPENSATION INCLUDED IN
											CUSTOMARY WORK WEEK						ALLOWABLE COSTS FOR THE PERIOD
	TITLE										DEVOTED TO BUSINESS						(B)
	1										2						3
1																			1
2																			2
3																			3
4																			4
5																			5
6																			6
7																			7
8																			8
9																			9
10																			10
	(A) Function or job description of each owner. If employee is related to owner, cite relationship.
	(B) Compensation as used in this worksheet has the same definition as 42 CFR 413.102
FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4210)
42-310																			Rev. 1

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Sheet 9: B

			Form CMS-265-11							4290 (Cont.)
COST ALLOCATION-GENERAL SERVICE COSTS					PROVIDER CCN:		PERIOD:		WORKSHEET B
							From:
							To:
		NET EXP.
		FOR ALLOC		STEP
		(from	CAP REL OP	DOWN	MACH CAP	SALARIES	EH&W BENE
		Wkst. A	OF MAINT	OF	REL OR	FOR DIR	FOR DIR		LABOR-
		col. 8)	& HOUSE	COL. 2	& MAINT	PT CARE	PT CARE	SUPPLIES	ATORY
		1	2	3	4	5	6	7	8
1	COSTS TO BE ALLOCATED			0						1
2	Drugs Included in Composite Rate									2
3	ESAs									3
4	ESRD Related Other Drugs									4
5	Non-ESRD Related Drugs, Supplies & Lab									5
6	Whole Blood and Packed Red Blood Cells									6
7	Vaccines									7
	REIMBURSABLE COST CENTERS
8	Maintenance-Hemodialysis		0							8
8.01	Maintenance-Hemo Adult									8.01
8.02	Maintenance-Hemo Pediatric									8.02
9	Maintenance -IPD									9
9.01	Maintenance-IPD Adult									9.01
9.02	Maintenance-IPD Pediatric									9.02
10	Training-Hemodialysis									10
10.01	Training-Hemo Adult									10.01
10.02	Training-Hemo Pediatric									10.02
11	Training-IPD									11
11.01	Training-IPD Adult									11.01
11.02	Training-IPD Pediatric									11.02
12	Training-CAPD									12
12.01	Training-CAPD Adult									12.01
12.02	Training-CAPD Pediatric									12.02
13	Training-CCPD									13
13.01	Training-CCPD Adult									13.01
13.02	Training-CCPD Pediatric									13.02
14	Home Program-Hemodialysis									14
14.01	Home Program-Hemo Adult									14.01
14.02	Home Program-Hemo Pediatric									14.02
15	Home Program-IPD									15
15.01	Home Program-IPD Adult									15.01
15.02	Home Program-IPD Pediatric									15.02
16	Home Program-CAPD									16
16.01	Home Program-CAPD Adult									16.01
16.02	Home Program-CAPD Pediatric									16.02
17	Home Program-CCPD									17
17.01	Home Program-CCPD Adult									17.01
17.02	Home Program-CCPD Pediatric									17.02
18	Subtotal (lines 2-17.02)									18
	NONREIMBURSABLE COST CENTERS
19	Physicians' Private Offices	0								19
20	Method II Patients prior to 1/1/2011	0								20
21	Other Nonreimbursable									21
22	Other Nonreimbursable									22
23	Totals (see instructions)			0		0	0	0	0	23
*Transfer the amounts to Worksheet C, column 2, as appropriate
The total of column 1, line 23 must equal the amount on Worksheet A, column 8, line 27.
FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)
Rev. 1										42-311
4290 (Cont.)			Form CMS-265-11
COST ALLOCATION-GENERAL SERVICE COSTS						PROVIDER CCN:		PERIOD:		WORKSHEET B
								From:
								To:
			A & G						TOTAL
			&			SUB-			EXPENSES
		SUB-	OTHER		DRUGS	TOTAL		ESRD	ALL
		TOTAL	COST		INCLUD. IN	(see in-		RELATED	PAT. SVCS.
		(cols. 1-8)	CENTERS	DRUGS	COMP RATE	structions)	ESAs	DRUGS	(cols. 11A-13)
		8A	9	10	11	11A	12	13	13A
1	COSTS TO BE ALLOCATED					0	0	0		1
2	Drugs Included in Composite Rate			0						2
3	ESAs			0						3
4	ESRD Related Other Drugs			0						4
5	Non-ESRD Related Drugs, Supplies & Lab	0	0	0		0			0	5
6	Whole Blood and Packed Red Blood Cells		0							6
7	Vaccines		0							7
	REIMBURSABLE COST CENTERS
8	Maintenance-Hemodialysis									8
8.01	Maintenance-Hemo Adult					0			0	8.01
8.02	Maintenance-Hemo Pediatric	0	0			0			0	8.02
9	Maintenance -IPD									9
9.01	Maintenance-IPD Adult	0	0			0			0	9.01
9.02	Maintenance-IPD Pediatric	0	0			0			0	9.02
10	Training-Hemodialysis									10
10.01	Training-Hemo Adult	0	0			0			0	10.01
10.02	Training-Hemo Pediatric	0	0			0			0	10.02
11	Training-IPD									11
11.01	Training-IPD Adult	0	0			0			0	11.01
11.02	Training-IPD Pediatric	0	0			0			0	11.02
12	Training-CAPD									12
12.01	Training-CAPD Adult	0	0			0			0	12.01
12.02	Training-CAPD Pediatric	0	0			0			0	12.02
13	Training-CCPD									13
13.01	Training-CCPD Adult	0	0			0			0	13.01
13.02	Training-CCPD Pediatric	0	0			0			0	13.02
14	Home Program-Hemodialysis									14
14.01	Home Program-Hemo Adult	0	0			0			0	14.01
14.02	Home Program-Hemo Pediatric	0	0			0			0	14.02
15	Home Program-IPD									15
15.01	Home Program-IPD Adult	0	0			0			0	15.01
15.02	Home Program-IPD Pediatric	0	0			0			0	15.02
16	Home Program-CAPD									16
16.01	Home Program-CAPD Adult	0	0			0			0	16.01
16.02	Home Program-CAPD Pediatric	0	0			0			0	16.02
17	Home Program-CCPD									17
17.01	Home Program-CCPD Adult	0	0			0			0	17.01
17.02	Home Program-CCPD Pediatric	0	0			0			0	17.02
18	Subtotal (lines 2-17.02)					0			0	18
	NONREIMBURSABLE COST CENTERS
19	Physicians' Private Offices	0	0			0			0	19
20	Method II Patients prior to 1/1/2011	0	0			0			0	20
21	Other Nonreimbursable	0	0			0			0	21
22	Other Nonreimbursable	0	0			0			0	22
23	Totals (see instructions)	0	0	0	0	0	0	0	0	23
*Transfer the amounts to Worksheet C, column 2, as appropriate
The total of column 1, line 23 must equal the amount on Worksheet A, column 8, line 27.
FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)
42-312										Rev. 1

---

Sheet 10: B-1

							Form CMS-265-11								4290 (Cont.)
COST ALLOCATION-GENERAL SERVICE COSTS							PROVIDER CCN:			PERIOD:			WORKSHEET B-1
										From:
										To:
			CAP REL OP	STEP DOWN	MACH CAP	SALARIES	EH&W BENE	SUPPLIES	LABORATORY	UNIT COST	DRUGS	DRUGS	ESAs	ESRD
			OF MAINT	OF COL 2	REL OR REN	FOR DIR	FOR DIR			MULTI-		INCLUD. IN		RELATED
			& HOUSE		& MAINT	PT CARE	PT CARE			PLIER		COMP RATE		DRUGS
			(SQUARE	(# OF TREAT-	(%TIME)	(HRS. SVC.)	(GROSS	(CHARGES)	(CHARGES)	COMPU-	(CHARGES)	(CHARGES)	(CHARGES)	(CHARGES)
			FEET)	MENTS)			SALARIES)			TATION
			(1)	(3)	(3)	(3)	(3)	(3)	(3)		(3)	(3)	(3)	(3)
		1	2	3	4	5	6	7	8	9	10	11	12	13
1	COSTS TO BE ALLOCATED														1
2	Drugs Included in Composite Rate														2
3	ESAs														3
4	ESRD Related Other Drugs														4
5	Non-ESRD Related Drugs, Supplies & Lab														5
6	Whole Blood and Packed Red Blood Cells														6
7	Vaccines														7
	REIMBURSABLE COST CENTERS
8	Maintenance-Hemodialysis														8
8.01	Maintenance-Hemo Adult														8.01
8.02	Maintenance-Hemo Pediatric														8.02
9	Maintenance -IPD														9
9.01	Maintenance-IPD Adult														9.01
9.02	Maintenance-IPD Pediatric														9.02
10	Training-Hemodialysis														10
10.01	Training-Hemo Adult														10.01
10.02	Training-Hemo Pediatric														10.02
11	Training-IPD														11
11.01	Training-IPD Adult														11.01
11.02	Training-IPD Pediatric														11.02
12	Training-CAPD														12
12.01	Training-CAPD Adult														12.01
12.02	Training-CAPD Pediatric														12.02
13	Training-CCPD														13
13.01	Training-CCPD Adult														13.01
13.02	Training-CCPD Pediatric														13.02
14	Home Program-Hemodialysis														14
14.01	Home Program-Hemo Adult														14.01
14.02	Home Program-Hemo Pediatric														14.02
15	Home Program-IPD														15
15.01	Home Program-IPD Adult														15.01
15.02	Home Program-IPD Pediatric														15.02
16	Home Program-CAPD														16
16.01	Home Program-CAPD Adult														16.01
16.02	Home Program-CAPD Pediatric														16.02
17	Home Program-CCPD														17
17.01	Home Program-CCPD Adult														17.01
17.02	Home Program-CCPD Pediatric														17.02
18	Subtotal (lines 2-16.02)														18
	NONREIMBURSABLE COST CENTERS
19	Physicians' Private Offices														19
20	Method II Patients prior to 1/1/2011														20
21	Other Nonreimbursable														21
22	Other Nonreimbursable														22
23	Total (see instructions)														23
24	Total Costs to be Allocated														24
25	Unit Cost Multiplier (Line 24 div. by Line 23)														25
FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)
Rev. 1															42-313

---

Sheet 11: C

4290 (Cont.)				Form CMS-265-11
COMPUTATION OF AVERAGE COST PER TREATMENT				PROVIDER CCN:			PERIOD:			WORKSHEET C
ESRD PPS BUNDLED PAYMENT							From:
							To:
							TOTAL
				NUMBER			COSTS			AVERAGE COST
				OF			(Transferred from			OF TREATMENTS
				TREATMENTS			Wkst. B, col. 13A)			(col. 2 divided by col. 1)
				1			2			3
8.01	Maintenance-Hemo Adult											8.01
8.02	Maintenance-Hemo Pediatric											8.02
9.01	Maintenance-IPD Adult											9.01
9.02	Maintenance-IPD Pediatric											9.02
10.01	Training-Hemo Adult											10.01
10.02	Training-Hemo Pediatric											10.02
11.01	Training-IPD Adult											11.01
11.02	Training-IPD Pediatric											11.02
12.01	Training-CAPD Adult											12.01
12.02	Training-CAPD Pediatric											12.02
13.01	Training-CCPD Adult											13.01
13.02	Training-CCPD Pediatric											13.02
14.01	Home Program-Hemodialysis Adult											14.01
14.02	Home Program-Hemodialysis Pediatric											14.02
15.01	Home Program-IPD Adult											15.01
15.02	Home Program-IPD Pediatric											15.02
16.01	Home Program-CAPD Adult			Patient Weeks								16.01
16.02	Home Program-CAPD Pediatric			Patient Weeks								16.02
17.01	Home Program-CCPD Adult			Patient Weeks								17.01
17.02	Home Program-CCPD Pediatric			Patient Weeks								17.02
18	Totals	(Column 1 - Sum of Lines 8.01 through 15.02)										18
		(Column 2 - Sum of Lines 8.01 through 17.02)
19	Total provider treatments (informational only)											19
FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4212)
42-314												Rev. 1

---

Sheet 12: D

Form CMS-265-11

4290 (Cont.)

COMPUTATION OF AVERAGE COST PER TREATMENT

PROVIDER CCN:

PERIOD:

WORKSHEET D

BASIC COMPOSITE COST

From:

To:

TOTAL

MEDICARE

NUMBER

NUMBER

NUMBER

TOTAL

AVERAGE

OF

OF

OF

AVERAGE

AVERAGE

AVERAGE

TOTAL

TOTAL

NUMBER

COST OF

TREAT-

TREAT-

TREAT-

TOTAL

PAYMENT

PAYMENT

PAYMENT

TOTAL

PAYMENT

PAYMENT

OF

COSTS

TREAT-

MENTS

MENTS

MENTS

EXPENSES

RATE

RATE

RATE

PAYMENT

DUE

DUE

TOTAL

TREAT-

(Transfer from

MENTS

(see

(see

(see

(see

(see

(see

(see

DUE

(col. 4.01 x

(col. 4.02 x

PAYMENT

MENTS

Wkst. B, col. 11A)

(col 2 / col. 1)

instructions)

instructions)

instructions)

instructions)

instructions)

instructions)

instructions)

(col. 4 x col. 6)

col. 6.01)

col. 6.02)

DUE

1

2

3

4

4.01

4.02

5

6

6.01

6.02

7

7.01

7.02

8

1

Maintenance-Hemodialysis

(line 8.01 and

1

line 8.02)

2

Maintenance-IPD

(line 9.01 and

2

line 9.02)

0

0

3

Training-Hemodialysis

(line 10.01 and

3

line 10.02)

0

4

Training-IPD

(line 11.01 and

4

line 11.02)

0

0

5

Training-CAPD

(line 12.01 and

5

line 12.02)

0

0

6

Training-CCPD

(line 13.01 and

6

line 13.02)

0

7

Home Program-Hemodialysis

(line 14.01 and

7

line 14.02)

0

8

Home Program-IPD

8

line 15.02)

-

0

0

9

Home Program-CAPD

Patient

(line 16.01 and

9

Weeks

line 16.02)

0

0

0

10

Home Program-CCPD

Patient

(line 17.01 and

10

Weeks

line 17.02)

0

0

0

11

Total (see instructions)

0

0

0

11

FORM CMS-265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4213)

Rev. 1

42-315

---

Sheet 13: E

4290 (Cont.)		Form CMS-265-11
CALCULATION OF BAD DEBT REIMBURSEMENT			PROVIDER CCN:		PERIOD:		WORKSHEET E,
					From:		PARTS I & II
					To:
PART I
CALCULATION OF REIMBURSABLE BAD DEBTS TITLE XVIII-PART B
1	Total Expenses Related to Care of Medicare Beneficiaries (from Wkst. D, col. 5, line 11)							1
				Column 1		Column 2
2	Total payment due net of Part B deductibles (from Wkst. D, col. 7, line 11) (see instructions)							2
2.01	Total payment due net of Part B deductibles (from Wkst. D. col. 7.01, line 11) (see instructions)							2.01
2.02	Total payment due net of Part B deductibles (from Wkst. D. col. 7.02, line 11) (see instructions)							2.02
2.03	Total payment due net of Part B deductibles (see instructions)							2.03
3	Outlier payments							3
4								4
5	Program payments (80% of line 2.03, column 2)							5
6	Amount of cost to be recovered from Medicare patients (line 1 minus line 5)							6
				Column 1		Column 2
7	Deductibles and coinsurance billed to Medicare Part B patients (see instructions)							7
7.01	Deductibles and coinsurance billed to Medicare Part B patients (see instructions)							7.01
7.02	Deductibles and coinsurance billed to Medicare Part B patients (see instructions)							7.02
7.03	Total deductibles and coinsurance billed to Medicare Part B patients for comparison (see instructions)							7.03
				Column 1		Column 2
8	Bad debts for deductibles and coinsurance net of bad debt recoveries for services rendered prior to 1/1/2011							8
9	Transition period 1 (75-25%) bad debts for deductibles and coinsurance net of bad debt recoveries for							9
	services rendered on or after 1/1/2011 but before 1/1/2012
10	Transition period 2 (50-50%) bad debts for deductibles and coinsurance net of bad debt recoveries for							10
	services rendered on or after 1/1/2012 but before 1/1/2013
11	Transition period 3 (25-75%) bad debts for deductibles and coinsurance net of bad debt recoveries for							11
	services rendered on or after 1/1/2013 but before 1/1/2014
12	100% PPS bad debts for deductibles and coinsurance net of bad debt recoveries for							12
	services rendered on or after 1/1/2014
13	Total bad debts (sum of line 8 through line 12)							13
14	Net deductibles and coinsurance billed to Medicare Part B patients (line 7.03 minus line 13, col. 2)							14
15	Unrecovered from Medicare Part B patients (line 6 minus line 14) (If line 14 exceeds line 6, do not complete line 16)							15
16	Reimbursable bad debts (lesser of line 13 or line 15)							16
17	Reimbursable bad debts for dual eligible beneficiaries (see instructions--informational only)							17
18	Tentative adjustment							18
19	Other adjustment (see instructions)							19
20	Balance due provider/program (line 16 minus line 18 plus or minus line 19) (Indicate overpayment in parentheses) (see instructions)							20
PART II
CALCULATION OF FACILITY SPECIFIC COMPOSITE COST PERCENTAGE
1	Total allowable expenses (from Wkst. C, col. 2, line 18)			1
2	Total composite costs (from Wkst. D, col. 2, line 11)			2
3	Facility specific composite cost percentage (line 2 divided by line 1)			3
FORM CMS 265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4214)
42-316								Rev. 1

---

Sheet 14: E1

4290 (Cont.)		FORM CMS-265-11
ANALYSIS OF PAYMENTS TO PROVIDERS		PROVIDER CCN:	PERIOD:
FOR SERVICES RENDERED			From:		WORKSHEET E - 1
			To:
PART I				Part B
				mm/dd/yyyy
	Description			1
	TO BE COMPLETED BY CONTRACTOR
1	List separately each tentative settlement	Program to	.01			1.01
	payment after desk review. Also show	Provider	.02			1.02
	date of each payment.		.03			1.03
	If none, write "NONE," or enter a zero.(1)	Provider to	.50			1.5
		Program	.51			1.51
			.52			1.52
	SUBTOTAL (Sum of lines 1.01 - 1.49 minus sum of lines 1.50 - 1.98) (Transfer to		.99			1.99
	Wkst E, Part I, line 18)
2	Determine net settlement amount (balance	Program to provider	.01			2.01
	due) based on the cost report. (1)	Provider to program	.50			2.50
3	Name of Contractor		Contractor Number			3
(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the provider agrees to the amount of repayment
even though total repayment is not accomplished until a later date.
PART II
	TO BE COMPLETED BY PROVIDER
4	LOW VOLUME PAYMENT AMOUNT (see instructions)					4
FORM CMS 265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4215)
42-317						Rev. 1
									Rev. 1

---

Sheet 15: F

		Form CMS-265-11						4290 (Cont.)
BALANCE SHEET				PROVIDER CCN:		PERIOD:	WORKSHEET F
						From:
						To:
	ASSETS (omit cents)
	CURRENT ASSETS
1	Cash on hand and in banks			1
2	Temporary investments			2
3	Notes receivable			3
4	Accounts receivable			4
5	Other receivables			5
6	Less: allowances for uncollectible notes and accounts receivable			6
7	Inventory			7
8	Prepaid expenses			8
9	Other current assets			9
10	Due from other funds			10
11	TOTAL CURRENT ASSETS (Sum of lines 1 through 10)			11
	FIXED ASSETS
12	Land			12
13	Land improvements			13
14	Less: Accumulated depreciation			14
15	Buildings			15
16	Less Accumulated depreciation			16
17	Leasehold improvements			17
18	Less: Accumulated Amortization			18
19	Fixed equipment			19
20	Less: Accumulated depreciation			20
21	Automobiles and trucks			21
22	Less: Accumulated depreciation			22
23	Major movable equipment			23
24	Less: Accumulated depreciation			24
25	Minor equipment nondepreciable			25
26	Other fixed assets			26
27	TOTAL FIXED ASSETS (Sum of lines 12 through 26)			27
	OTHER ASSETS
28	Investments			28
29	Deposits on leases			29
30	Due from owners/officers			30
31	Other assets			31
32	TOTAL OTHER ASSETS (Sum of lines 28 through 31)			32
33	TOTAL ASSETS (Sum of lines 11, 27, and 32)			33
	LIABILITIES AND FUND BALANCES (omit cents)
	CURRENT LIABILITIES
34	Accounts payable			34
35	Salaries, wages & fees payable			35
36	Payroll taxes payable			36
37	Notes & loans payable (Short term)			37
38	Deferred income			38
39	Accelerated payments			39
40	Due to other funds			40
41	Other current liabilities			41
42	TOTAL CURRENT LIABILITIES (Sum of lines 34 through 41)			42
	LONG TERM LIABILITIES
43	Mortgage payable			43
44	Notes payable			44
45	Unsecured loans			45
46	Other long term liabilities			46
47				47
48	TOTAL LONG TERM LIABILITIES (Sum of lines 43 through 48)			48
49	TOTAL LIABILITIES (Sum of lines 42 and 49)			49
	CAPITAL ACCOUNTS
50	FUND BALANCES			50
51	TOTAL LIABILITIES AND FUND BALANCES (Sum of lines 49 and 50)			51
	( ) = contra amount
FORM CMS 265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)
Rev. 1								42-318

---

Sheet 16: F-1

4290 (Cont.)		Form CMS-265-11
STATEMENT OF REVENUES AND EXPENSES			PROVIDER CCN:	PERIOD:	WORKSHEET F-1
				From:
				To:
1	Total patient revenues				1
2	Less: Allowances and discounts on patients' accounts				2
3	Net patient revenues (Line 1 minus line 2)				3
4	Operating expenses (From Worksheet A, column 8, line 27)				4
5	Additions to operating expenses (Specify)				5
6					6
7					7
8					8
9					9
10					10
11	Subtractions from operating expenses (Specify)				11
12					12
13					13
14					14
15					15
16					16
17	Less total operating expenses (net of lines 4 thru 16)				17
18	Net income from service to patients (Line 3 minus line 17)				18
	Other income:
19	Contributions, donations, bequests, etc.				19
20	Income from investments				20
21	Purchase discounts				21
22	Rebates and refunds of expenses				22
23	Sale of Medical and Nursing Supplies to other than patients				23
24	Sale of durable medical equipment to other than patients				24
25	Sale of drugs to other than patients				25
26	Sale of medical records and abstracts				26
27	Other revenues (Specify)				27
28					28
29					29
30					30
31					31
32	Total Other Income (Sum of lines 19 thru 31)				32
33	Net Income or Loss for the period (Line 18 plus line 32)				33
FORM CMS 265-11 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)
42-319						Rev. 1