Form CMS-339 Medicare Provider Cost Report Reimbursement Questionnair

Medicare
Provider Reimbursement Manual
Part 2, Provider Cost Reporting Forms and
Instructions, Chapter 11, Form CMS-339
Transmittal 9

Department of Health &
Human Services (DHHS)
Centers for Medicare &
Medicaid Services (CMS)
Date:

HEADER SECTION NUMBERS

PAGES TO INSERT

PAGES TO DELETE

Sections 1100-1102.1(cont.)

11-3 (1 p.)

11-3 (1 p.)

REVISED MATERIAL--EFFECTIVE DATE:
Section 1100 is being revised to identify providers that must continue to complete Form CMS-339 -namely: Community Mental Health Centers (CMHCs), Rural Health Clinics (RHCs), and Organ
Procurement Organizations (OPOs).
DISCLAIMER: The revision date and transmittal number apply to the red italicized material
only. Any other material was previously published and remains unchanged.
CMS-Pub. 15-2-11

CHAPTER 11
PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
FORM CMS-339
Section
General
General……………………………………………………………………… 1100
Filing Requirements of Provider Cost Report
Reimbursement Questionnaire……………………………………………. 1100.1
Instructions
Instructions for Form CMS-339 (Provider Cost Report
Reimbursement Questionnaire)…………………………………………… 1102
Exhibit 1 - General Provider Information………………………………… 1102.1
Certification by Officer or Administrator of
Provider…………………………………………………………………… 1102.2
Reimbursement Information……………………………….……………… 1102.3
Exhibits
Exhibit 1
Exhibit 2

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-

Provider Cost Report Reimbursement Questionnaire (6 pages)
Listing of Medicare Bad Debts and
Appropriate Supporting Data

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FORM CMS-339
1100.

1102.1

GENERAL

Form CMS-339 must be completed by all Community Mental Health Centers (CMHCs), Rural
Health Clinics (RHCs), and Organ Procurement Organizations (OPOs) submitting cost reports to
the Medicare Administrative Contractor (MAC) under Title XVIII of the Social Security Act
(hereafter referred to as "the Act"). Its purpose is to assist you in preparing an acceptable cost report
and to minimize the need for direct contact between you and your MAC. It is designed to answer
pertinent questions about key reimbursement concepts displayed in the cost reports and to gather
information necessary to support certain financial and statistical entries on the cost report. The
questionnaire is a tool used in arriving at a prompt and equitable settlement of your cost report.
To the degree that the information in the Form CMS-339 constitutes commercial or financial
information which is confidential and/or is of a highly sensitive personal nature, the information will
be protected from release under the Freedom of Information Act. If there is any question about
releasing information, the MAC should consult with the CMS Regional Office.
1100.1
Filing Requirements of Provider Cost Report Reimbursement Questionnaire.--Providers
receiving payments and filing a cost report are required to maintain sufficient financial records and
statistical data for the MAC to use for the proper determination of costs payable under the Medicare
program. The Medicare regulations at 42 CFR 413.20 and the related policies issued by CMS in the
Provider Reimbursement Manual set forth the criteria for fulfilling these requirements. The
questionnaire is designed to facilitate this process and must be completed and submitted with each
full cost report. Submit the questionnaire as required by §§1815(a) and 1833(e) of the Act to assure
proper payments by Medicare. Failure to submit this questionnaire and the supporting documents
will result in suspension of payments to you and may result in a determination that all interim
payments made since the beginning of the cost reporting period are overpayments.
Instructions
1102.

INSTRUCTIONS FOR FORM CMS-339
REIMBURSEMENT QUESTIONNAIRE)

(PROVIDER

COST

REPORT

These instructions are furnished to assist you in determining the type of information required by the
questionnaire. Mark as “N/A” those statements in Exhibit 1 sections you are required to complete
that are not applicable to your situation or circumstances. Mark as either "YES" or "NO" those
statements which reflect situations or circumstances applicable to you and submit the necessary
information referred to after each question.
The questionnaire requests providers to submit various listing and summary schedules in lieu of
detailed, and potentially voluminous, supporting documentation. This is done to ease the providers'
filing burden. However, the MAC maintains the right to request, and the provider must submit,
additional detailed supporting documentation as deemed necessary. Requests for additional
information are not intended to be routine. The MAC should request this information only if
necessary to perform a complete review of the provider filing.
1102.1
Exhibit 1 - General Provider Information.--This information identifies the provider and
the cost report with which the questionnaire is to be associated.
Enter your name and CMS certification number (CCN). Information on individual providers in a
chain organization or complex common to all providers reporting to the same MAC can be handled
through one submittal. Indicate those areas of information that are common to all providers and
handled under a single submission.

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FORM CMS-339

The reporting period covered by the information furnished through the questionnaire must be
consistent with the period covered by the cost report.
1102.2
Certification by Officer or Administrator of Provider.--Sign and date this certification
after the questionnaire is completed and specify the title of the signer.
Also enter the name and telephone number of the person that your MAC may contact for additional
information in the designated space provided on Exhibit 1.
1102.3
Reimbursement Information.--Furnish the information in this section as a means of
expediting review and settlement of cost reports. CMS has established a process whereby the
MAC’s field audit effort at your site can be streamlined through completion of a preliminary cost
report review as part of the desk review at the MAC's facilities. The information required by the
questionnaire is readily available since it is the basic type of documentation necessary to fulfill
program recordkeeping requirements. Furnish the information in a single submission with the cost
report rather than sporadically throughout the desk review and field audit process. Complete the
questionnaire annually.
A.
Provider Organization and Operation.--The information gathered through these questions
is designed to alert the MAC of pertinent organizational and/or personnel changes. It will be used to
assess potential effects upon the cost report. The information pertaining to you and your personnel
relationships within your organization and with outside organizations is essential to the MAC’s
evaluation of information obtained through other sections of the questionnaire. The following
instructions will assist you in determining the type of information being solicited.
•

When a change of ownership occurs, the information requested in question 1.a enables
the MAC to determine the party responsible for the cost report.

•

Describe the information on relationships with outside entities requested in question 2 to
enable the MAC to assess whether associated costs are properly handled in the cost
report. This information should generally be available from employment disclosure
statements.
A related organization transaction described in question 2 occurs when services, facilities
or supplies are furnished to the provider by organizations related to the provider through
common ownership or control. (See Provider Reimbursement Manual, Part 1 (PRM-1),
chapter 10 and 42 CFR 413.17.)
Management contracts and services under arrangements with the provider described in
question 2 pertain to those business transactions where services are performed by the
owner or corporation (shareholders) who has common ownership or control over the
provider.

B.
Financial Data and Reports.--The recordkeeping capabilities and system of internal
control is most appropriately expressed through the financial statements. The financial statements,
when prepared in accordance with the standards promulgated by the American Institute of Certified
Public Accountants, can establish your ability to meet the general requirements for proper cost
reporting.
The reliability of the information contained in the cost report can be established, in part, through
financial statement disclosures and the opinion expressed by the independent public accountant.
Submit copies of financial statements that are compiled, reviewed or audited by the independent
public accountant together with the independent public accountant’s opinion and footnotes. If
the audited financial statements are not available for submission with this questionnaire, indicate
when the MAC can expect to receive them.
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1102.3 (Cont.)

Where you do not engage public accountants for this type of service, submit a copy of the financial
statements prepared by you and written statements of significant accounting policy and procedure
changes affecting reimbursement which occurred during the cost reporting period.
This may be accomplished by submitting changes to your accounting or administrative procedures
manual.
Only consolidated statements and not financial statements may be available for individual providers
in a chain organization or complex. In these circumstances, submit the consolidated statements.
Where the provider’s cost report year end and the year end of the audited financial statements differ,
submit the following:
o

The audited financial statements; and

o

Working trial balance and financial statements that were used to prepare the cost report.

If the response to question 2 is “Yes”, submit revenue and expense reconciliations to expedite
completion of the MAC's desk review process.
C. Approved Educational Activities.--Disclose information, as directed, pertaining to nursing
school and allied health/paramedical education programs as well as graduate medical education
programs for which you are claiming reimbursement. Disclose the title and nature of each
educational activity, and where applicable, the costs involved. The listings of educational programs
may be maintained by deleting discontinued activities and adding new ones. Furnish copies of
approvals and renewals for activities requiring certification.
For the purpose of Question 1, the provider is the legal operator of a nursing school or allied health
program if it meets the criteria in 42 CFR 413.85(f)(1) or (f)(2).
D. Bad Debts.--A provider's bad debts resulting from Medicare deductible and coinsurance
amounts which are uncollectible from Medicare beneficiaries are considered in the program's
calculation of reimbursement to the provider if they meet the criteria specified in 42 CFR 413.80ff
and PRM-1, chapter 3, §§ 306-324.
A provider whose Medicare bad debts meet the above criteria should complete Exhibit 2 or submit
internal schedules duplicating the documentation requested on Exhibit 2 to support bad debts
claimed. If the provider claims bad debts for inpatient and outpatient services, complete a separate
Exhibit 2 or internal schedules for each category.
Exhibit 2 of Form CMS-339 which can be used to list the bad debts claimed contains much of the
information the MAC will need in order to determine the allowability of the bad debts. The
submission of this listing may possibly provide the MAC with sufficient information upon which to
base its acceptance of the bad debts claimed on the hospital's cost report without the necessity of an
on-site visit.
Exhibit 2 requires the following documentation:
Columns 1, 2, 3 - Patient Names, HIC NO., Dates of Service (From - To).--The documentation
requested for these columns is derived from the beneficiary's bill. Furnish the patient's name,
health insurance claim number (social security number) and dates of service that correlate to the filed
bad debt. (See PRM-1, §314 and 42 CFR 413.80.)
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FORM CMS-339

Column 4 - Indigency/Welfare Recipient.--If the patient included in column 1 has been deemed
indigent, place a check in this column. If the patient in column 1 has a valid Medicaid number, also
include this number in this column. See the criteria in PRM-1, chapter 3, §§312 and 322 and 42
CFR 413.80 for guidance on the billing requirements for indigent and welfare recipients.
Columns 5 & 6 - Date First Bill Sent to Beneficiary – Date Collection Efforts Ceased.--This
information should be obtained from the provider's files and should correlate with the beneficiary
name, HIC number, and dates of service shown in columns 1, 2, and 3 of this exhibit. The date in
Column 6 represents the date that the unpaid account is deemed worthless, whereby all collection
efforts, both internal and by outside entity, ceased and there is no likelihood of recovery of the
unpaid account. (See CFR 413.89(f) and PRM-1, chapter 3, §§308, 310, and 314.)
Column 7 – Medicare Remittance Advice Dates.--Enter in this column the remittance advice dates
that correlate with the beneficiary name and date of service shown in columns 1, 2, and 3 of this
exhibit. This will enable the MAC to verify the authenticity of the Medicare patient and the related
deductible and coinsurance amounts.
Columns 8 & 9 - Deductible - Coinsurance.--Record in these columns the beneficiary's unpaid
deductible and coinsurance amounts that relate to covered services as instructed in this exhibit.
Column 10 - Total Medicare Bad Debts.—Enter on each line of this column the sum of the amounts
in columns 8 and 9. Calculate the total bad debts by summing up the amounts on all lines of Column
10. This “total” should agree with the bad debts claimed in the cost report. Attach additional
supporting schedules, if necessary, for recoveries of bad debts reimbursed in prior cost reporting
period(s).
E. Medicare Settlement Data (PS&R DATA).--The PS&R system generates several reports
which provide apportionment, statistical, settlement and reimbursement data that can be used in
filing the cost report.
In some cases, the provider may have independent record keeping capabilities which provide them
with the capacity to generate the appropriate cost report data consistent with that contained in the
PS&R. The provider's record keeping capability, relative to cost report preparation, will vary by
provider type and the scope of the services rendered. A provider's system, in order to be effective,
requires all necessary updating of PRICER information, fees, prevailing charges, and other
regulatory changes impacting the resultant PS&R, as well as adjustment claims. This is an ongoing
process that does not end with the filing of the cost report, but continues through final settlement.
The revenue codes on the Form CMS-1450 have been standardized for Medicare billing purposes
without regard to providers' actual revenue and expense accounting process. In many cases,
therefore, there will be differences between the classifications of revenues in the PS&R and the
general ledger classifications that can affect Medicare reimbursement. Providers must
evaluate the impact of these classification differences and maintain accurate Medicare logs which
collect charge data consistent with the general ledger classifications of revenues and expenses, if they
are not using the PS&R in its entirety.

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1102.3 (Cont.)

Several actions are required for providers in filing the cost report, whether they use the PS&R for the
source document or internal log records. Providers must include the summary of their
"unpaid" log as support for any claims not included on the PS&R. The summary should include
totals consistent with the breakdowns on the PS&R. This report should be generated to reflect
claims paid that are unprocessed or unpaid as of the cutoff date of the PS&R. The cut-off date
equates to the paid date reflected on the PS&R.
Using PS&R only - Providers are required to develop a table, where applicable, for inclusion
with the filed cost report which provides a crosswalk between the revenue codes and charges,
patient days, visits, etc. found on the PS&R to the cost center groupings found on the cost
report. This crosswalk reflects a one-on-one match, cost center to revenue code. No overlap
is permitted in this example. Unpaid claims will be added to the PS&R totals, following the
same revenue crosswalk.
Using PS&R for totals, provider records for allocation – Providers are required to
develop and submit with the cost report a table which provides a detailed crosswalk showing
in which cost centers on the cost report the charges, patient days, visits, and any other
utilization statistics (as applicable) identified by various revenue codes on the PS&R were
included. In this instance, there is no requirement for a one on one match for “charges”, but
providers must show total dollars by cost center and the range of revenue codes within each
cost center. The total charges must match those found on the PS&R, plus any claims
reflected on the unpaid log. Supporting working papers must be maintained by the provider
to identify the source of their data in order to attest to its accuracy.
If the MAC finds that the working papers do not provide sufficient documentation and
validation of the provider's records, the PS&R will be used in its entirety. It is the
responsibility of the provider to maintain, furnish, and reasonably demonstrate that its
internal records provide a more accurate allocation for cost report settlement purposes than
the PS&R.
Using provider records only - Providers who use their internal records for filing the cost
report, without reference or cross-reference to the PS&R, are required to provide the MAC
audit staff with detailed documentation of their system flow in order to validate their data.
Documentation of systems flow, at a minimum, should include:
o

Copies of input tables, calculations, or charts supporting data elements

o

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

o

Reconciliation of remittance totals to the provider consolidated log totals.

The provider may supplement this information with a narrative, internal flow charts, or
outside vendor informational material to further describe and validate the reliability of their
system. It is the responsibility of the provider to furnish and maintain reasonable
documentation supporting the accuracy of their data in lieu of the PS&R. In the event the
MAC determines that supporting documentation is insufficient, the MAC must furnish
written discussion detailing weaknesses in the provider's documented system flow prior to
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FORM CMS-339

either a partial or complete disallowance of the provider's records. It is not necessary for the
provider to develop a reconciliation to the PS&R if the work flow demonstrates that the
provider has consistently reconciled their logs to the remittance advices received
from the MAC, either claim by claim or in total. No crosswalk is required for this example,
merely documentation of system flow. Providers will include an unpaid log summary for
review by the MAC, using the date of the last remittance advice posted to the provider log as
the cut-off date.

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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, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850. Please do not send applications, claims, payments, medical records or any documents
containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated
OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have
questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE.
PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
(You MUST USE Instructions for Completing This Form
Located In PRM-2, §§1100ff.)
Provider Name:

CCN(s):

______________________________________________________________________________
Filed with Form CMS- / / 2088 / / 222 / /
Period: From ________
/ / 216 / / (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

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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:

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a.

Audited;

b.

Compiled; and

c.

Reviewed.
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FORM CMS-339

1102.3 (Cont.)

PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
YES

NO

N/A

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
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 graduate
medical education programs on the current cost report.
If “yes” attach a list of the programs and the approval for each
program.

D.

Bad Debts
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

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PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
YES

NO

N/A

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.
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

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1102.3 (Cont.)

PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
YES

NO

N/A

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.

b)

Correction of other PS&R information?

c)

Late charges?

d)

Other (describe)?

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.

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1102.3 (Cont.)

EXHIBIT 2
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA

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

(10)
TOTAL

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

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