End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112

Attachment J 6 A

ESRD Network Semi-Annual Cost Reporting Instructions

Purpose

The purpose of the ESRD Network Semi Annual Cost Report Form is to collect a summary of costs incurred by Networks for performance of the CMS ESRD Network contract. The cost information shall reflect actual costs incurred for the period and be supported by Network financial records/general ledger. Network’s shall refer to the CMS contract for reporting due dates. Additionally, Networks shall submit the completed Semi Annual Cost Report to the Contracting Officer’s Representative (COR) and electronically to CMS’ CCSQ Central Office at [email protected].

General Instructions

The ESRD Network Semi Annual Report spreadsheet contains two tabs. Networks should use the first tab titled “January – June” to report all costs for the January – June period of the current contract year. Networks should use the second tab titled July –December to report all costs for the second half of the contract period.

Networks should only complete applicable white cells. Cells in black do not require any data and cells in gray are formulas that calculate automatically based on data from the white cells.

Instructions by Report Section #

1	Enter your CMS contract number
2	Enter the name and address of your Network organization
3	Enter your assigned Network number/area
4	Enter the date range of the reporting period
5 - 16	Enter all hours and costs incurred for each of the Statement of Work sections listed in columns 5 - 16. Networks should refer to the ESRD Network contract for a description of the work for each of columns 5 - 16. Please also refer to specific instructions for lines a –g below.
17	Enter data in all applicable white cells for leave, fringe and G&A. Please note all grey cells are formulas and the Networks do not need to complete them.
18	Enter all hours and costs incurred for any special project that CMS awarded under your Network contract. The column should sum all special project costs. Therefore, if a Network has more than 1 special project they should include costs for all projects in this column. Please also refer to specific instructions for lines a – g below.
19 -20	These columns only appear on the “July – December” report and summarize total costs for the entire 12 month contract period. These columns are formula driven and Networks do not need to enter any data in these columns.

Instructions for Rows a - g

a. 1 -19	Enter the name (and position title) of each staff directly working on the ESRD Network contract. In columns 5 -18 records the number of hours worked and the total labor costs incurred (excluding overtime and bonuses) for each of the identified staff.
a. 20	If the Network utilized more than 19 direct staff for the reporting period, summarize the total hours and costs for all of the positions in excess of 19 and record the hours and costs in columns 5 -18. Additionally, the Network should attach a separate spreadsheet to the cost report submission listing each additional staff. For each staff person the spreadsheet should include hours and costs broken out by columns 5 -18.
a. 21	List the total overtime and bonus/award payments to staff in column 5 -18. Additionally, the Network should attach a separate spreadsheet to their cost report submission listing each staff that received either overtime or bonuses and the amount of overtime and bonuses received for each applicable staff member.
b.	Record the total leave costs for all direct staff in columns 17 and 18 only. For contractors that have an approved leave rate please utilize the appropriate leave rate(s) to calculate leave costs.
c.	Record the total fringe benefit costs for all direct staff in columns 17 and 18 only. For contractors that have an approved fringe benefit rate please utilize the appropriate fringe benefit rate(s) to calculate the reported fringe benefit costs
d.1	Record hours and costs for physician/MRB reviewers in columns 5 -18.
d.2	List each consultants name and function. Additionally, record the hours and costs of each listed consultant in columns 5 -18.
d.3	Record the costs of any other subcontract in columns 5 -18.
e.	Record all travel costs in columns 5 -18
f.	Record all Other Direct Costs in columns 5-18
g.1 - 4	Record all rent, furniture & equipment, telephone, and insurance costs in columns 17 and 18 only. For contractors that have approved indirect and G and A rates please utilize the appropriate indirect/G&A rate(s) to calculate the reported indirect/G&A costs under row g.5.
g.5	Record any other G and A related expenses and attached a separate spreadsheet listing each item of “other” G and A. Organizations that have approved overhead rate(s) should include the costs associated with the approved rate in this row.

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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.