CMS-276 Exhibits 1&2

09-12

FORM CMS-339

1102.3 (Cont.)
EXHIBIT 1
FORM APPROVED
OMB NO. 0938-0301

This questionnaire is required under the authority of sections 1815(a) and 1833(e) of the Social Security
Act. Failure to submit this questionnaire will result in suspension of Medicare payments.
To the degree that the information in CMS-339: 1) constitutes commercial or financial information which
is confidential, and/or 2) is of a highly sensitive personal nature, the information will be protected from
release under the Freedom of Information Act.
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 0938-0301. The time required to complete this information collection is estimated to
average 4 hours and 22 minutes 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, Baltimore, Maryland 21244-1850.
PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
(You MUST USE Instructions For Completing This Form
Located In PRM-II, §§1100ff.)
Provider Name:

Provider Number(s):

______________________________________________________________________________
Filed with Form CMSPeriod:
/1728/ /2088/ /222 /
/216/ /1984/

From _________________
(Other - Specify)

To ____________________

INTENTIONAL MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION
CONTAINED IN THIS QUESTIONNAIRE MAY BE PUNISHABLE BY FINE AND/OR
IMPRISONMENT UNDER FEDERAL LAW
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
information prepared by _____________________________________________
(Provider name(s) and number(s)) for the cost report period beginning _____________________
and ending ________________, and that 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(s) in accordance with applicable
instructions, except as noted.

(Signed)
Officer or Administrator of Provider(s)

Date

Title

Name and Telephone Number of Person to Contact for More Information

11-9

Rev. 7

PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES

NO

N/A

NOTE: 42 CFR 413.20 and instructions contained in the PRM-1
require that the provider maintain adequate financial and
statistical data necessary for the MAC to use for a proper
determination of costs payable under the program. Providers
are, therefore, required to maintain and have available for audit
all records necessary to verify the amounts and allowability of
costs included in the filed cost report. Failure to have such
records available for review by MACs acting under the
authority of the Secretary of the Department of Health and
Human Services will render the amount claimed in the cost
report unallowable.
A.

Provider Organization and Operation
1. The provider has:
a.

Changed ownership.
If "yes", submit name and address of new owner, date of
change, copy of sales agreement, or any similar
agreement affecting change of ownership.

b.

Terminated participation.
If "yes", list date of termination, and reason
(Voluntary/Involuntary).

2. The provider is involved in business transactions, including
management contracts and services under arrangements, with
individuals or entities (e.g., chain home offices, drug or
medical supply companies, etc.) that are 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 similar relationships.
If "yes" attach a list of the individuals, the organizations
involved, and description of the transactions.
B.

Financial Data and Reports
1. During this cost reporting period, the financial statements are
prepared by Certified Public Accountants or Public
Accountants (submit complete copy or indicate available date)
and are:
a.

Audited;

b.

Compiled; and

c.

Reviewed.

NOTE: Where there is no affirmative response to the above
described financial statements, attach a copy of the financial
statements prepared by you and a description of the changes in
accounting policies and practices if not mentioned in those
11-10

Rev. 7

PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES

NO

N/A

statements.
2. Cost report total expenses and total revenues differ from those
on the filed financial statement.
If "yes", submit reconciliation.
C.

Approved Educational Activities
1. Costs were claimed for Nursing School and Allied Health
Programs.
If "yes", attach list of the programs and annotate for each
whether the provider is the legal operator of the program.
2. Approvals and/or renewals were obtained during this cost
reporting period for Nursing School and/or Allied Health
Programs.
If "yes", submit copies.
3. Costs were claimed for Interns and Residents in Approved
Programs on the current cost report.
If “yes” attach a list of the programs and the approval for
each program.

D.

Bad Debts
Do not complete for HHAs and Hospices.
1. The provider seeks Medicare reimbursement for bad debts. If
"yes", complete Exhibit 2 or submit internal schedules
duplicating documentation required on Exhibit 2 to support
bad debts claimed. (see instructions)
2. The provider's bad debt collection policy changed during the
cost reporting period.
If "yes", submit copy.
3. The provider waives patient deductibles and/or copayments.
If yes, insure that they are not included on Exhibit 2.

E.

PS&R Data
1. The cost report was prepared using the PS&R only?
If “yes”, attach, where applicable, a crosswalk between
revenue codes and charges found on the PS&R to the cost
center groupings on the cost report. This crosswalk will
reflect a cost center to revenue code match only.
2. The cost report was prepared using the PS&R for totals and
the provider records for allocation.

11-11

Rev. 7

PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES

NO

N/A

If yes, include, where applicable, a detailed crosswalk between
revenue codes, departments and charges on the PS&R to the
cost center groupings on the cost report. This crosswalk must
include which revenue codes were allocated to each cost
center. Supporting working papers must accompany this
crosswalk to provide sufficient documentation as to the
accuracy of the provider records.
Include working papers supporting the allocation of charges,
patient days, visits, etc. into the various cost centers. If
internal records are used for these allocations, the source of
this information must be included in the documentation.
3. Provider records only were used to complete the cost report?
If yes, attach detailed documentation of the system used to
support the data reported on the cost report. If the detail
documentation was previously supplied, submit only
necessary updated documentation.
The minimum requirements are:
-

Copies of input tables, calculations, or charts supporting
data elements and other claims PRICING information.

-

Log summaries and log detail supporting program
utilization statistics, charges, prevailing rates and
payment information broken into each Medicare bill type
in a consistent manner with the PS&R.

-

Reconciliation of remittance totals to the provider
consolidated log totals.

Additional information may be supplied such as narrative
documentation, internal flow charts, or outside vendor
informational material.
Include the name of the system used and indicate how the
system was maintained (vendor or provider). If the provider
maintained the system, include date of last software update.
4. If yes to questions 1 or 2 above, were any of the following
adjustments made to the Part A PS&R data?
a)

Addition of claims billed but not on PS&R? Indicate the
paid claims through date from the PS&R used and the
final pay date of the claims that supplement the original
PS&R. Also indicate the total charges for the claims
added to the PS&R. Include a summary of the unpaid
claims log.

11-12

Rev. 7

PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
b)

Correction of other PS&R information?

c)

Late charges?

d)

Other (describe)?

NO

N/A

Attach documentation which provides an audit trail from the
PS&R to the cost report. The documentation should include
the details of the PS&R, reclassifications, adjustments, and
groupings necessary to trace to the cost center totals.

11-13

Rev. 7

09-12

EXHIBIT 2
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA

1102.3 (Cont.)

PROVIDER ____________________

PREPARED BY __________________________________

NUMBER ______________________

DATE PREPARED ________________________________

FYE _________________________
(1)
Patient
Name

(2)
HIC. NO.

(3)
DATES OF
SERVICE

FROM

TO

(4)
INDIGENCY &
WEL. RECIP.
(CK IF APPL)
YES

MEDICAID
NUMBER

(5)
DATE FIRST
BILL SENT TO
BENEFICIARY

INPATIENT __________ OUTPATIENT ______________
(7)
(6)
(8)*
(9)*
MEDICARE
DATE
DEDUCT
CO-INS
REMITTANCE
COLLECTION ADVICE DATES
EFFORT
CEASED

* THESE AMOUNTS MUST NOT BE CLAIMED UNLESS THE PROVIDER BILLS FOR THESE SERVICES WITH THE INTENTION OF PAYMENT.
SEE INSTRUCTIONS FOR COLUMN 4 - INDIGENCY/WELFARE RECIPIENT, FOR POSSIBLE EXCEPTION

11-14

Rev. 7

(10)
TOTAL