CMS-265-11 Renal Dialysis Facility Cost Report

FORM CMS-265-11

06-13

4290 (Cont.)

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).
INDEPENDENT RENAL DIALYSIS FACILITY
COST REPORT CERTIFICATION

PROVIDER CCN:

PERIOD:
From:
To:

FORM APPROVED
OMB NO: 0938-0236
EXPIRES: 09/30/2020
WORKSHEET S

PART I - COST REPORT STATUS
Date (mm/dd/yyyy): ___________________Time: ____________________
Provider use only
1. [ ] Electronically filed cost report
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._________
7. [ ] First Cost Report for this Provider CCN
(2) Settled without Audit
(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. (If certified on/after 1/1/2011, see instructions.)
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
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
I HEREBY CERTIFY that I have read the above certification 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 Provider CCN(s)} for the cost reporting
period beginning _______________ and ending _______________ and that to the best of my knowledge and belief, this report and statement are true, correct, complete and
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, and that the services identified in this cost report were provided in compliance with such laws and regulations.
OFFICER OR ADMINISTRATOR OF PROVIDER
Printed Name___________________________________________

Signed________________________________________________

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 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 data resources, gather the data needed,
and complete and review the information collection. If you have concerning 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.
Please do not send applications, claims, payments, medical records, or any other 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 any regarding where to submit your documents,
please contact 1-800-Medicare.

FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4204, 4204.1 AND 4204.2)

Rev. 2

42-303

4290 (Cont.)

FORM CMS-265-11

INDEPENDENT RENAL DIALYSIS FACILITY
STATISTICAL DATA

06-13

PROVIDER CCN:

PERIOD:
From:
To:

WORKSHEET S-1

RENAL DIALYSIS STATISTICS
OUTPATIENT
PERITONEAL
HEMODIALYSIS
DIALYSIS
1
2

TRAINING
PERITONEAL
HEMODIALYSIS
DIALYSIS
3
4

1
2
3
4
5
6
7
8
9
10

Number of treatments not billed to Medicare and furnished directly
Number of treatments not billed to Medicare and furnished under arrangements
Number of patients currently in dialysis program
Average times per week patient receives dialysis
Number of days in an average week for patient dialysis treatments
Average time of patient dialysis treatment including set up time
Number of machines regularly available for use
Number of standby machines
Number of shifts in typical week during regular reporting period
Hours per shift in typical week during regular reporting period
.01 First shift
.02 Second Shift
.03 Third shift
11 Number of treatments provided
.01 One (1) time per week
.02 Two (2) times per week
.03 Three (3) times per week
.04 More than three (3) times per week
.05 Total

1
2
3
4
5
6
7
8
9
10
.01
.02
.03
11
.01
.02
.03
.04
.05
Type of Dialyzers
1

Dialyzer Reuse Count
2

Other Dialyzers
3

12 Column 1: Type of dialyzers used (see instructions)
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)

12

14 Number of units of Epoetin furnished during cost reporting period
15 Number of units of Aranesp furnished during cost reporting period

14
15

13

1

2

15.01 ESA and units furnished to patients during the cost reporting period (see instructions)

15.01

TRANSPLANT STATISTICS
16 Number of patients awaiting transplants
17 Number of patients who received transplants

16
17

HOME PROGRAM
18 Number of patients commencing home dialysis training during this period
19 Number of patients currently in home program

18
19
Type of Dialyzers
1

Dialyzer Reuse Count
2

Other Dialyzers
3

20 Column 1: Type of dialyzers used (see instructions)
Column 2: Number of times dialyzers were reused (see instructions)
Column 3: If column 1 is "Other," enter type of dialyzer used

20

RENAL DIALYSIS FACILITY -- NUMBER OF EMPLOYEES (FULL TIME EQUIVALENTS)
21 Enter the number of hours in your normal work week

21
Staff
1

22
23
24
25
26
27
28
29
30
31

Physicians
Registered Nurses
Licensed Practical Nurses
Nurses Aides
Technicians
Social Workers
Dieticians
Administrative
Management
Other (Specify)

Contract
2

Total
3
22
23
24
25
26
27
28
29
30
31

FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4205)

42-304

Rev. 2

12-11
INDEPENDENT RENAL DIALYSIS FACILITY
REIMBURSEMENT QUESTIONNAIRE

FORM CMS-265-11
PROVIDER CCN:

4290 (Cont.)
PERIOD:
From:
To:

PROVIDER ORGANIZATION AND OPERATION
1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period?
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.
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
(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 similar relationships? Enter "Y" for yes or "N" for no in column 1. (see instructions)

FINANCIAL DATA AND REPORTS
4 Column 1: Were the financial statements prepared by a Certified Public Accountant? Enter "Y" for yes or "N" for no.
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"
for yes or "N" for no in column 1. If yes, submit reconciliation.

BAD
6
7
8

WORKSHEET S-2

Y/N
1

DATE
2

V/I
3
1

2

3

Y/N
1

A/C/R
2

4

5

Y/N

DEBTS
Is the provider seeking reimbursement for bad debts? Enter "Y" for yes or "N" for no. If yes, see instructions.
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.
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.

PS&R REPORT DATA
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
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
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
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
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.
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.
If yes, see instructions.

DATE
3

6
7
8
Y/N
1

DATE
2
9
10
11
12
13
14

FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4205.1)

Rev. 1

42-305

FORM CMS-265-11

4290 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE
OF EXPENSES

FACILITY HEALTH CARE COSTS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

12-11
PROVIDER CCN:

SALARIES
PHYSICIAN
COMPENSATION
OTHER
1
2

OTHER
3

COST CENTERS
0100 Cap Rel Costs-Bldg & Fixt
0200 Cap Rel Costs-Mvble Equip
0300 Operation & Maintenance of Plant
0400 Housekeeping
Subtotal (sum of lines 1 through 4)*
0600 Machine Cap-Rel or Rental & Maint*
0700 Salaries for Direct Patient Care*
0800 EH&W Benefits for Direct Pt. Care
0900 Supplies*
1000 Laboratory*
1100 Administrative & General
1200 Drugs*
1300 Interest Expense
1400 Laundry and Linen
1500 Medical Records
1600 Phy Rout Prof Svcs-Initial Method
1700 Other (Specify)
Subtotal (sum of line 11 plus lines 13 through 17)*
1900 Phy Rout Prof Svcs-MCP Method
2000 Whole Blood & Packed Red Blood Cells*
2100 Vaccines*
NONREIMBURSABLE COSTS CENTERS
2200 Physicians Private Offices*
2300 ESAs (prior to January 1, 2011)
2400 Method II Patients (prior to January 1, 2011)
2500 Other Nonreimbursable (Specify)*
2600 Other Nonreimbursable (Specify)*
Total

TOTAL
( col. 1 through
col. 3 )
4

PERIOD:
From:
To:
RECLASS.
TO EXPENSES
( from
Wkst. A-1 )
5

RECLASSIFIED
ADJUSTMENTS
TRIAL BALANCE TO EXPENSES
( col 4. +/- col. 5 ) ( from Wkst. A-2 )
6
7

WORKSHEET A

NET EXPENSES
FOR COST
ALLOCATION
( col. 6+/-col. 7 )
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

* Transfer the amounts in column 8 to Worksheet B and B-1, as appropriate.

FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4206)

42-306

Rev. 1

FORM CMS-265-11

05-14
RECLASSIFICATIONS

PROVIDER CCN:

EXPLANATION OF ENTRY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100

CODE
(1)
1

COST
CENTER
2

4290 (Cont.)
PERIOD:
From:
To:

INCREASE
LINE
NO.
AMOUNT (2)
3
4

Total Reclassifications (Sum of col. 4 must equal sum of col. 7)

COST
CENTER
5

WORKSHEET A-1

DECREASE
LINE
NO.
AMOUNT (2)
6
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
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 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4207)

Rev. 3

42-307

4290 (Cont.)

FORM CMS-265-11

ADJUSTMENTS TO EXPENSES

DESCRIPTION (1)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20.01
21
22
23
24
100

Investment income on commingled restricted and unrestricted funds (Chapter 2)
Trade, quantity and time discounts on purchases (Chapter 8)
Rebates and refunds of expenses (Chapter 8)
Rental of building or office space to others
Physician non-routine professional patient care services
Home office costs (Chapter 21)
Adjustment resulting from transactions with related organizations (Chapter 10)
Vending machines
Meals served to patients
Physicians' professional services--MCP Method
Services under arrangement
Provision for doubtful accounts
Capital Related--Buildings & Fixtures
Capital Related--Moveable Equipment
Rebates on Epoetin prior to January 1, 2011
Epoetin
Rebates on Aranesp prior to January 1, 2011
Aranesp
Rebates on Epoetin on or after January 1, 2011 (see instructions)
Rebates on Aranesp on or after January 1, 2011 (see instructions)
Rebates on ESA drugs on or after January 1, 2012
Physician malpractice premiums
Other (specify)
Other (specify)
Other (specify)
Total (transfer to Wkst. A, col. 7, line 27)

05-14

PROVIDER CCN:

BASIS FOR
ADJUSTMENT
(2)
1

PERIOD:
From:
To:

AMOUNT
2

WORKSHEET A-2

Expense classification on Worksheet A from which
amount is to be deducted or to which the amount is
to be added
COST CENTER
LINE NO.
3
4

From Wkst. A-3

A

A
A

Physicians' professional services--MCP Me

19

Capital Related--Buildings & Fixtures
Capital Related--Moveable Equipment
Epoetin
Epoetin
Aranesp
Aranesp
Epoetin
Aranesp
Drugs

1
2
23
23
23
23
12
12
12

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20.01
21
22
23
24
100

(1) Description-all chapter references in this column pertain to CMS Pub. 15-1
(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 (05/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4208)

42-308

Rev. 3

FORM CMS-265-11

12-11
STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS

4290 (Cont.)

PROVIDER CCN:

PERIOD:
From:
To:

WORKSHEET A-3

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:
LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COL. 6
LINE NO.
1
1
2
3
4
5

C.

COST CENTER
2

EXPENSES ITEMS
3

AMOUNT
ALLOWABLE
IN COST
4

AMOUNT
NET
INCLUDED IN
ADJUSTWKST. A
MENT (col. 4
COL. 6
minus col. 5)
5
6
1
2
3
4
5

TOTALS (sum of lines 1-4)
(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)

Interrelationship to organizations furnishing services, facilities, or supplies:

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.

SYMBOL
(1)
1

NAME
2

PERCENTAGE
OF
OWNERSHIP
3

NAME
4

RELATED ORGANIZATION(S)
PERCENTAGE
OF
TYPE OF BUSINESS
OWNERSHIP
6
5

1
2
3
4

1
2
3
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 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4209)

Rev. 1

42-309

4290 (Cont.)

FORM CMS-265-11

STATEMENT OF COMPENSATION

12-11

PROVIDER CCN:

PART I - STATEMENT OF TOTAL COMPENSATION TO OWNERS
(Include compensation of employees related to owners)
SOLE
PARTNERS
PROPIETORSHIPS
PERCENTAGE OF
PERCENTAGE
CUSTOMARY
OF CUSTOMARY
WORK WEEK
PERCENT SHARE
WORK WEEK
DEVOTED TO
OF OPERATING
DEVOTED TO
TITLE
FUNCTION (A)
BUSINESS
PROFIT OR (LOSS)
BUSINESS
1
2
3
4A
4B
1
2
3
4
5
6
7
8
9
10

PERIOD:
From:
To:

WORKSHEET A-4

TOTAL
CORPORATION OWNERS
COMPENSATION
PERCENTAGE OF
INCLUDED IN
CUSTOMARY
ALLOWABLE
PERCENTAGE OF
WORK WEEK
COSTS FOR
PROVIDER'S
DEVOTED TO
THE PERIOD
STOCK OWNED
BUSINESS
(B)
5A
5B
6
1
2
3
4
5
6
7
8
9
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
2
3
4
5
6
7
8
9
10

1
2
3
4
5
6
7
8
9
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 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4210)

42-310

Rev. 1

FORM CMS-265-11

06-13
COST ALLOCATION - GENERAL SERVICE COSTS

NET
EXPENSE
FOR
COST ALLOC.
( from Wkst. A, col. 8 )
1

4290 (Cont.)

PROVIDER CCN:

CAP REL
OP & MAINT
& HOUSE
2

STEP DOWN
OF
OF COL. 2
3

MACH CAP
REL OR REN
& MAINT
4

COSTS TO BE ALLOCATED
Drugs Included in Composite Rate
ESAs
ESRD Related Other Drugs
Non-ESRD Related Drugs, Supplies & Lab
Whole Blood and Packed Red Blood Cells
Vaccines
REIMBURSABLE COST CENTERS
8 Maintenance-Hemodialysis
8.01 Maintenance-Hemo Adult
8.02 Maintenance-Hemo Pediatric
9 Maintenance -IPD
9.01 Maintenance-IPD Adult
9.02 Maintenance-IPD Pediatric
10 Training-Hemodialysis
10.01 Training-Hemo Adult
10.02 Training-Hemo Pediatric
11 Training-IPD
11.01 Training-IPD Adult
11.02 Training-IPD Pediatric
12 Training-CAPD
12.01 Training-CAPD Adult
12.02 Training-CAPD Pediatric
13 Training-CCPD
13.01 Training-CCPD Adult
13.02 Training-CCPD Pediatric
14 Home Program-Hemodialysis
14.01 Home Program-Hemo Adult
14.02 Home Program-Hemo Pediatric
15 Home Program-IPD
15.01 Home Program-IPD Adult
15.02 Home Program-IPD Pediatric
16 Home Program-CAPD
16.01 Home Program-CAPD Adult
16.02 Home Program-CAPD Pediatric
17 Home Program-CCPD
17.01 Home Program-CCPD Adult
17.02 Home Program-CCPD Pediatric
18 Subtotal (lines 2-17.02)
NONREIMBURSABLE COST CENTERS
19 Physicians' Private Offices
20 Method II Patients prior to 1/1/2011
21 Other Nonreimbursable
22 Other Nonreimbursable
#N/A
23 Totals (see instructions)
*Transfer the amounts to Wkst. C, col. 2, as appropriate
The total of column 1, line 23 must equal the amount on Wkst. A, col. 8, line 27.
FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

PERIOD:
From:
To:

SALARIES
FOR DIR
PT CARE
5

EH&W BENE
FOR DIR
PT CARE
6

WORKSHEET B

SUPPLIES
7

LABORATORY
8
1
2
3
4
5
6
7

1
2
3
4
5
6
7

Rev. 2

8
8.01
8.02
9
9.01
9.02
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02
14
14.01
14.02
15
15.01
15.02
16
16.01
16.02
17
17.01
17.02
18

#N/A

#N/A

#N/A

#N/A

19
20
21
22
23

42-311

FORM CMS-265-11

4290 (Cont.)
COST ALLOCATION - GENERAL SERVICE COSTS

SUBTOTAL
( col. 1
through col. 8 )
8A

A&G
&
OTHER
COST
CENTERS
9

DRUGS
10

DRUGS
INCLUD. IN
COMP RATE
11

1 COSTS TO BE ALLOCATED
2 Drugs Included in Composite Rate
3 ESAs
4 ESRD Related Other Drugs
5 Non-ESRD Related Drugs, Supplies & Lab
6 Whole Blood and Packed Red Blood Cells
7 Vaccines
REIMBURSABLE COST CENTERS
8 Maintenance-Hemodialysis
8.01 Maintenance-Hemo Adult
8.02 Maintenance-Hemo Pediatric
9 Maintenance -IPD
9.01 Maintenance-IPD Adult
9.02 Maintenance-IPD Pediatric
10 Training-Hemodialysis
10.01 Training-Hemo Adult
10.02 Training-Hemo Pediatric
11 Training-IPD
11.01 Training-IPD Adult
11.02 Training-IPD Pediatric
12 Training-CAPD
12.01 Training-CAPD Adult
12.02 Training-CAPD Pediatric
13 Training-CCPD
13.01 Training-CCPD Adult
13.02 Training-CCPD Pediatric
14 Home Program-Hemodialysis
14.01 Home Program-Hemo Adult
14.02 Home Program-Hemo Pediatric
15 Home Program-IPD
15.01 Home Program-IPD Adult
15.02 Home Program-IPD Pediatric
16 Home Program-CAPD
16.01 Home Program-CAPD Adult
16.02 Home Program-CAPD Pediatric
17 Home Program-CCPD
17.01 Home Program-CCPD Adult
17.02 Home Program-CCPD Pediatric
18 Subtotal (lines 2-17.02)
NONREIMBURSABLE COST CENTERS
19 Physicians' Private Offices
20 Method II Patients prior to 1/1/2011
21 Other Nonreimbursable
22 Other Nonreimbursable
23 Totals (see instructions)
*Transfer the amounts to Wkst. C, col. 2, as appropriate
The total of column 1, line 23 must equal the amount on Wkst. A, col. 8, line 27.
FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

42-312

06-13

PROVIDER CCN:

PERIOD:
From:
To:

SUBTOTAL
( see instructions )
11A

ESA'S
12

WORKSHEET B

ESRD
RELATED
DRUGS
13

TOTAL
EXPENSES
ALL
PAT. SVCS.
( cols. 11A-13 )
13A
1
2
3
4
5
6
7
8
8.01
8.02
9
9.01
9.02
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02
14
14.01
14.02
15
15.01
15.02
16
16.01
16.02
17
17.01
17.02
18
19
20
21
22
23

Rev. 2

FORM CMS-265-11

06-13
COST ALLOCATION - STATISTICAL BASIS

NET
EXPENSES
FOR
COST ALLOC.
1

CAP REL
OP & MAINT
& HOUSE
( SQUARE
FEET ) (1)
2

STEP DOWN
OF COL. 2
( # TREAT
MENTS ) (3)
3

MACH CAP
REL OR RENT
& MAINT
( % TIME )
(3)
4

1 COSTS TO BE ALLOCATED
2 Drugs Included in Composite Rate
3 ESAs
4 ESRD Related Other Drugs
5 Non-ESRD Related Drugs, Supplies & Lab
6 Whole Blood and Packed Red Blood Cells
7 Vaccines
REIMBURSABLE COST CENTERS
8 Maintenance-Hemodialysis
8.01 Maintenance-Hemo Adult
8.02 Maintenance-Hemo Pediatric
9 Maintenance -IPD
9.01 Maintenance-IPD Adult
9.02 Maintenance-IPD Pediatric
10 Training-Hemodialysis
10.01 Training-Hemo Adult
10.02 Training-Hemo Pediatric
11 Training-IPD
11.01 Training-IPD Adult
11.02 Training-IPD Pediatric
12 Training-CAPD
12.01 Training-CAPD Adult
12.02 Training-CAPD Pediatric
13 Training-CCPD
13.01 Training-CCPD Adult
13.02 Training-CCPD Pediatric
14 Home Program-Hemodialysis
14.01 Home Program-Hemo Adult
14.02 Home Program-Hemo Pediatric
15 Home Program-IPD
15.01 Home Program-IPD Adult
15.02 Home Program-IPD Pediatric
16 Home Program-CAPD
16.01 Home Program-CAPD Adult
16.02 Home Program-CAPD Pediatric
17 Home Program-CCPD
17.01 Home Program-CCPD Adult
17.02 Home Program-CCPD Pediatric
18 Subtotal (lines 2-16.02)
NONREIMBURSABLE COST CENTERS
19 Physicians' Private Offices
20 Method II Patients prior to 1/1/2011
21 Other Nonreimbursable
22 Other Nonreimbursable
23 Total (see instructions)
24 Total Costs to be Allocated
25 Unit Cost Multiplier (Line 24 div. by Line 23)
FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

Rev. 2

4290 (Cont.)

PROVIDER CCN:

SALARIES
FOR DIR
PT CARE
( HRS OF
SERVICE ) (3)
5

PERIOD:
From:
To:
EH&W BENE
FOR DIR
PT CARE
( GROSS
SALARIES ) (3)
6

WORKSHEET B-1

SUPPLIES

LABORATORY

( CHARGES )
(3)
7

( CHARGES )
(3)
8
1
2
3
4
5
6
7
8
8.01
8.02
9
9.01
9.02
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02
14
14.01
14.02
15
15.01
15.02
16
16.01
16.02
17
17.01
17.02
18
19
20
21
22
23
24
25

42-313

FORM CMS-265-11

4290 (Cont.)
COST ALLOCATION - STATISTICAL BASIS

UNIT COST
MULTIPLIER

SUBTOTAL
8A

COMPUTATION
9

DRUGS

( CHARGES )
(3)
10

DRUGS
INCLD IN
COMP RATE
( CHARGES )
(3)
11

1 COSTS TO BE ALLOCATED
2 Drugs Included in Composite Rate
3 ESAs
4 ESRD Related Other Drugs
5 Non-ESRD Related Drugs, Supplies & Lab
6 Whole Blood and Packed Red Blood Cells
7 Vaccines
REIMBURSABLE COST CENTERS
8 Maintenance-Hemodialysis
8.01 Maintenance-Hemo Adult
8.02 Maintenance-Hemo Pediatric
9 Maintenance -IPD
9.01 Maintenance-IPD Adult
9.02 Maintenance-IPD Pediatric
10 Training-Hemodialysis
10.01 Training-Hemo Adult
10.02 Training-Hemo Pediatric
11 Training-IPD
11.01 Training-IPD Adult
11.02 Training-IPD Pediatric
12 Training-CAPD
12.01 Training-CAPD Adult
12.02 Training-CAPD Pediatric
13 Training-CCPD
13.01 Training-CCPD Adult
13.02 Training-CCPD Pediatric
14 Home Program-Hemodialysis
14.01 Home Program-Hemo Adult
14.02 Home Program-Hemo Pediatric
15 Home Program-IPD
15.01 Home Program-IPD Adult
15.02 Home Program-IPD Pediatric
16 Home Program-CAPD
16.01 Home Program-CAPD Adult
16.02 Home Program-CAPD Pediatric
17 Home Program-CCPD
17.01 Home Program-CCPD Adult
17.02 Home Program-CCPD Pediatric
18 Subtotal (lines 2-16.02)
NONREIMBURSABLE COST CENTERS
19 Physicians' Private Offices
20 Method II Patients prior to 1/1/2011
21 Other Nonreimbursable
22 Other Nonreimbursable
23 Total (see instructions)
24 Total Costs to be Allocated
25 Unit Cost Multiplier (Line 24 div. by Line 23)
FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

42-313.1

06-13

PROVIDER CCN:

PERIOD:
From:
To:
ESA'S

SUBTOTAL
11A

( CHARGES )
(3)
12

WORKSHEET B-1

ESRD
REL DRUGS
( CHARGES )
(3)
13

TOTAL
EXPENSES
ALL
PATIENT
SERVICES
13A
1
2
3
4
5
6
7
8
8.01
8.02
9
9.01
9.02
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02
14
14.01
14.02
15
15.01
15.02
16
16.01
16.02
17
17.01
17.02
18
19
20
21
22
23
24
25

Rev. 2

05-14

FORM CMS-265-11

4290 (Cont.)

This page intentionally left blank.

FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

Rev. 3

42-313.2

4290 (Cont.)

FORM CMS-265-11

05-14

COMPUTATION OF AVERAGE COST PER TREATMENT
ESRD PPS BUNDLED PAYMENT

PROVIDER CCN:

NUMBER
OF
TREATMENTS
1

TOTAL
COSTS
(Transferred from
Wkst. B, col. 13A)
2

PERIOD:
From:
To:

WORKSHEET C

AVERAGE COST
PER TREATMENT
(col. 2 divided by col. 1)
3

8.01
8.02
9.01
9.02
10.01
10.02
11.01
11.02
12.01
12.02
13.01
13.02
14.01
14.02
15.01
15.02
16.01

Maintenance-Hemo Adult
Maintenance-Hemo Pediatric
Maintenance-IPD Adult
Maintenance-IPD Pediatric
Training-Hemo Adult
Training-Hemo Pediatric
Training-IPD Adult
Training-IPD Pediatric
Training-CAPD Adult
Training-CAPD Pediatric
Training-CCPD Adult
Training-CCPD Pediatric
Home Program-Hemodialysis Adult
Home Program-Hemodialysis Pediatric
Home Program-IPD Adult
Home Program-IPD Pediatric
Home Program-CAPD Adult

Patient Weeks

8.01
8.02
9.01
9.02
10.01
10.02
11.01
11.02
12.01
12.02
13.01
13.02
14.01
14.02
15.01
15.02
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)
(Column 2 - sum of lines 8.01 through 17.02)
19 Total provider treatments
(informational only)

18
19

FORM CMS-265-11 (05/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4212)

42-314

Rev. 3

FORM CMS-265-11

05-14
COMPUTATION OF AVERAGE COST PER TREATMENT
BASIC COMPOSITE COST

4290 (Cont.)
PROVIDER CCN:

WORKSHEET D

TOTAL

TOTAL
NUMBER
OF
TREATMENTS
1

MEDICARE
NUMBER
NUMBER
NUMBER
AVERAGE
OF
OF
OF
AVERAGE AVERAGE AVERAGE
TOTAL
COSTS
COST OF
TREATTREATTREATTOTAL
PAYMENT PAYMENT PAYMENT PAYMENT
( transfer from
TREATMENTS
MENTS
MENTS
EXPENSES
RATE
RATE
RATE
DUE
Wkst. B,
MENT
( see
( see
( see
( see
( see
( see
( see
( col. 4 x
col. 6 )
col. 11A ) ( col 2 / col. 1 ) instructions ) instructions ) instructions ) instructions ) instructions ) instructions ) instructions )
2
3
4
4.01
4.02
5
6
6.01
6.02
7
(line 8.01 and
line 8.02)

PERIOD:
From:
To:

TOTAL
PAYMENT
DUE
( col. 4.01 x
col. 6.01 )
7.01

TOTAL
PAYMENT
DUE
( col. 4.02 x
col. 6.02 )
7.02

TOTAL
PAYMENT
DUE
8

1

Maintenance-Hemodialysis

2

Maintenance-IPD

(line 9.01 and
line 9.02)

2

3

Training-Hemodialysis

(line 10.01 and
line 10.02)

3

4

Training-IPD

(line 11.01 and
line 11.02)

4

5

Training-CAPD

(line 12.01 and
line 12.02)

5

6

Training-CCPD

(line 13.01 and
line 13.02)

6

7

Home Program-Hemodialysis

(line 14.01 and
line 14.02)

7

8

Home Program-IPD

(line 15.01 and
line 15.02)

8

9

Home Program-CAPD

Patient
Weeks

(line 16.01 and
line 16.02)

9

10

Home Program-CCPD

Patient
Weeks

(line 17.01 and
line 17.02)

10

11 Total
(see instructions)

1

11

FORM CMS-265-11 (05/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4213)

Rev. 3

42-315

4290 (Cont.)

FORM CMS-265-11

CALCULATION OF BAD DEBT REIMBURSEMENT

PROVIDER CCN:

05-14
PERIOD:
From:
To:

WORKSHEET E,
PARTS I & II

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

2
2.01
2.02
2.03
3
4
5
6
7
7.01
7.02
7.03
8
9
10
11
12
13
14
15
16
17
18
19
20

Column 2

Total payment due net of Part B deductibles (from Wkst. D, col. 7, line 11) (see instructions)
Total payment due net of Part B deductibles (from Wkst. D. col. 7.01, line 11) (see instructions)
Total payment due net of Part B deductibles (from Wkst. D. col. 7.02, line 11) (see instructions)
Total payment due net of Part B deductibles (see instructions)
Outlier payments

2
2.01
2.02
2.03
3
4
5
6
7
7.01
7.02
7.03
8
9

Program payments (80% of line 2.03, column 2)
Amount of cost to be recovered from Medicare patients (line 1 minus line 5)
Deductibles and coinsurance billed to Medicare Part B patients (see instructions)
Deductibles and coinsurance billed to Medicare Part B patients (see instructions)
Deductibles and coinsurance billed to Medicare Part B patients (see instructions)
Total deductibles and coinsurance billed to Medicare Part B patients for comparison (see instructions)
Bad debts for deductibles and coinsurance net of bad debt recoveries for services rendered prior to 1/1/2011
Transition period 1 (75-25%) bad debts for deductibles and coinsurance net of bad debt recoveries for
services rendered on or after 1/1/2011 but before 1/1/2012
Transition period 2 (50-50%) bad debts for deductibles and coinsurance net of bad debt recoveries for
services rendered on or after 1/1/2012 but before 1/1/2013
Transition period 3 (25-75%) bad debts for deductibles and coinsurance net of bad debt recoveries for
services rendered on or after 1/1/2013 but before 1/1/2014
100% PPS bad debts for deductibles and coinsurance net of bad debt recoveries
(see instructions)
Total bad debts (sum of line 8 through line 12)
Net deductibles and coinsurance billed to Medicare Part B patients (line 7.03 minus line 13, col. 2)
Unrecovered from Medicare Part B patients (line 6 minus line 14) (If line 14 exceeds line 6, do not complete line 16)
Reimbursable bad debts (see instructions)
Reimbursable bad debts for dual eligible beneficiaries (see instructions--informational only)
Tentative adjustment
Sequestration adjustment amount
Balance due provider/program (line 16 minus lines 18 and 19) (Indicate overpayment in parentheses) (see instructions)

PART II - CALCULATION OF FACILITY SPECIFIC COMPOSITE COST PERCENTAGE
1 Total allowable expenses (from Wkst. C, col. 2, line 18)
2 Total composite costs (from Wkst. D, col. 2, line 11)
3 Facility specific composite cost percentage (line 2 divided by line 1)

10
11
12
13
14
15
16
17
18
19
20

1
2
3

FORM CMS-265-11 (05/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4214)

42-316

Rev. 3

06-13
ANALYSIS OF PAYMENTS TO PROVIDERS
FOR SERVICES RENDERED

FORM CMS-265-11
PROVIDER CCN:

4290 (Cont.)
PERIOD:
From:
To:

WORKSHEET E-1

PART I - TO BE COMPLETED BY CONTRACTOR
Part B
Description
1 List separately each tentative settlement
payment after desk review. Also show
date of each payment.
If none, write "NONE," or enter a zero. (1)

SUBTOTAL (sum of lines 1.01 - 1.49 minus sum of lines 1.50 - 1.98)
(Transfer to Wkst E, Part I, line 18)
2 Determine net settlement amount (balance
due) based on the cost report. (1)
3 Name of Contractor

mm/dd/yyyy
1
Program
to
Provider
Provider
to
Program

Program to provider
Provider to program

.01
.02
.03
.50
.51
.52
.99
.01
.50
Contractor Number

Amount
1.01
1.02
1.03
1.50
1.51
1.52
1.99
2.01
2.50
3

(1) On line 2.50, 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 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4215)

Rev 2

42-317

4290 (Cont.)

FORM CMS-265-11

06-13

BALANCE SHEET

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33

34
35
36
37
38
39
40
41
42

ASSETS (omit cents)
CURRENT ASSETS
Cash on hand and in banks
Temporary investments
Notes receivable
Accounts receivable
Other receivables
Less: allowances for uncollectible notes and accounts receivable
Inventory
Prepaid expenses
Other current assets
Due from other funds
TOTAL CURRENT ASSETS (Sum of lines 1 through 10)
FIXED ASSETS
Land
Land improvements
Less: Accumulated depreciation
Buildings
Less Accumulated depreciation
Leasehold improvements
Less: Accumulated Amortization
Fixed equipment
Less: Accumulated depreciation
Automobiles and trucks
Less: Accumulated depreciation
Major movable equipment
Less: Accumulated depreciation
Minor equipment nondepreciable
Other fixed assets
TOTAL FIXED ASSETS (Sum of lines 12 through 26)
OTHER ASSETS
Investments
Deposits on leases
Due from owners/officers
Other assets
TOTAL OTHER ASSETS (Sum of lines 28 through 31)
TOTAL ASSETS (Sum of lines 11, 27, and 32)
LIABILITIES AND FUND BALANCES (omit cents)
CURRENT LIABILITIES
Accounts payable
Salaries, wages & fees payable
Payroll taxes payable
Notes & loans payable (Short term)
Deferred income
Accelerated payments
Due to other funds
Other current liabilities
TOTAL CURRENT LIABILITIES (Sum of lines 34 through 41)
LONG TERM LIABILITIES
Mortgage payable
Notes payable
Unsecured loans
Other long term liabilities

43
44
45
46
47
48 TOTAL LONG TERM LIABILITIES (Sum of lines 43 through 47)
49 TOTAL LIABILITIES (Sum of lines 42 and 48)
CAPITAL ACCOUNTS
50 FUND BALANCES
51 TOTAL LIABILITIES AND FUND BALANCES (Sum of lines 49 and 50)
(

PROVIDER CCN:

PERIOD:
From:
To:

WORKSHEET F

Amount
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51

) = contra amount

FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)

Rev. 2

42-318

06-13
STATEMENT OF REVENUES AND EXPENSES

FORM CMS-265-11

4290 (Cont.)
PROVIDER CCN:

Amount
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Total patient revenues
Less: Allowances and discounts on patients' accounts
Net patient revenues (Line 1 minus line 2)
Operating expenses (From Worksheet A, column 6, line 27)
Additions to operating expenses (Specify)

Subtractions from operating expenses (Specify)

Less total operating expenses (net of lines 4 through 16)
Net income from services to patients (Line 3 minus line 17)
Other income:
Contributions, donations, bequests, etc.
Income from investments
Purchase discounts
Rebates and refunds of expenses
Sale of medical and nursing supplies to other than patients
Sale of durable medical equipment to other than patients
Sale of drugs to other than patients
Sale of medical records and abstracts
Other revenues (Specify)

19
20
21
22
23
24
25
26
27
28
29
30
31
32 Total Other Income (Sum of lines 19 through 31)
33 Net Income or Loss for the period (Line 18 plus line 32)

PERIOD:
From:
To:

WORKSHEET F-1

Amount
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33

FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)

Rev. 2

42-319