CMS-685 Network Semi-Annual Report

ESRD Network Semi Annual Cost Report (December - May)
Centers for Medicare and Medicaid Services

Network Semi Annual Report December-May
1. Contract #:
2. Name and Address of ESRD Network:
Medicare Costs

5. Transition Costs
# of HOURS

a. Direct Labor
1. Name (Position)
2. Name (Position)
3. Name (Position)
4. Name (Position)
5. Name (Position)
6. Name (Position)
7. Name (Position)
8. Name (Position)
9. Name (Position)
10. Name (Position)
11. Name (Position)
12. Name (Position)
13. Name (Position)
14. Name (Position)
15. Name (Position)
16. Name (Position)
17. Name (Position)
18. Name (Position)
19. Name (Position)
20. Additional Staff (attach schedule)
Black
Subtotal Direct Labor
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave/Fringe
d. Subcontracts:
1. Other Consultants
a. Name
b. Name
c. Name
d. Name
2. Other Subcontractors
SUBTOTAL - Subcontracts
Black
e. Travel
f. Other Direct Costs
1. Postage & Express Mail
2. Meetings & Conferences
3. Printing & Reproduction
4. Teleconferences
5. Other (attach schedule)
SUBTOTAL - Travel & ODCs
SUBTOTAL - Direct
g. Indirect Costs (if applicable)
TOTAL COSTS

COSTS

3. ESRD Network #:

4. Reporting Period Covered:

6. General Requirements 7. Patient Engagement
(C.3)
(C.4.1.A)
# of HOURS
COSTS
# of HOURS
COSTS

8. Patient Experience of Care
(C.4.1.B)
# of HOURS
COSTS

9. Vascular Access Management
(C.4.1.C)
# of HOURS
COSTS

10. Patient Safety: Healthcare
Associated Infections (C.4.1.D)
# of HOURS
COSTS

11. AIM2: Better Health for the ESRD
Population (C.4.2)
# of HOURS
COSTS

12. Support for ESRD QIP & Performance
Improvement on QIP Measures (C.4.3.A)
# of HOURS
COSTS

13. Support for Facility Data Submission 14. BASE CONTRACT ONLY 15. SPECIAL PROJECTS
to CROWNWeb and NHSN (C.4.3.B)
(Columns 5 -13)
# of HOURS
COSTS
# of HOURS
COSTS
# of HOURS
COSTS

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

blalck
$0.00
Black
Black
Black
Black
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Black
0
Black
0
Black
#VALUE!
0
0
0
0
0
0
Black
Black
Black
Black
Black
Black
Black
Black
Black
0
Black
0

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
black
$0.00

$0.00
Black
Black
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Black
$0.00
Black
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

Black
0

black
$0.00

Black
0
Black
Black

$0.00
Black
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
0
Black
0

$0.00
Black
Black

$0.00
$0.00
$0.00

PRA Disclosure Statement
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 (Expires 02/29/2020). 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. ****CMS Disclosure**** 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 Benjamin Bernstein (410)-786-6570.

Semi Annual Cost Reporting Form: Fixed Price Contractors

ESRD_Network_Semi_Annual_Report
1

12/19/2019

ESRD Network Semi Annual Cost Report (June- November)
Centers for Medicare and Medicaid Services

Network Semi Annual Report June-November
1. Contract #:
2. Name and Address of ESRD Network:
Medicare Costs

5. Transition Costs
# of HOURS

a. Direct Labor
1. Name (Position)
2. Name (Position)
3. Name (Position)
4. Name (Position)
5. Name (Position)
6. Name (Position)
7. Name (Position)
8. Name (Position)
9. Name (Position)
10. Name (Position)
11. Name (Position)
12. Name (Position)
13. Name (Position)
14. Name (Position)
15. Name (Position)
16. Name (Position)
17. Name (Position)
18. Name (Position)
19. Name (Position)
20. Additional Staff (attach schedule)
Black
Subtotal Direct Labor
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave/Fringe
d. Subcontracts:
1. Other Consultants
a. Name
b. Name
c. Name
d. Name
2. Other Subcontractors
SUBTOTAL - Subcontracts
Black
e. Travel
f. Other Direct Costs
1. Postage & Express Mail
2. Meetings & Conferences
3. Printing & Reproduction
4. Teleconferences
5. Other (attach schedule)
SUBTOTAL - Travel & ODCs
SUBTOTAL - Direct
g. Indirect Costs (if applicable)
TOTAL COSTS

Black
0
Black
Black
Black
Black
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

COSTS

6. General Requirements
(C.3)
# of HOURS
COSTS

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

Black

$0.00
Black
Black
$0.00

3. ESRD Network #:

4. Reporting Period Covered:

7. Patient Engagement
(C.4.1.A)
# of HOURS
COSTS

8. Patient Experience of Care
(C.4.1.B)
# of HOURS
COSTS

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

Black

$0.00
Black
Black
$0.00

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

Black

$0.00
Black
Black
$0.00

9. Vascular Access Management
(C.4.1.C)
# of HOURS
COSTS

10. Patient Safety: Healthcare
Associated Infections (C.4.1.D)
# of HOURS
COSTS

11. AIM2: Better Health for the ESRD
Population (C.4.2)
# of HOURS
COSTS

12. Support for ESRD QIP & Performance
Improvement on QIP Measures (C.4.3.A)
# of HOURS
COSTS

13. Support for Facility Data Submission
to CROWNWeb and NHSN (C.4.3.B)
# of HOURS
COSTS

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

Black
0
Black
Black
Black
Black
Black

black
$0.00
Black
Black
Black
Black
Black

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
0

$0.00
Black

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

Black

$0.00
Black
Black
$0.00

14. BASE CONTRACT ONLY 15. SPECIAL PROJECTS
(Columns 5 -13)
# of HOURS
COSTS
# of HOURS
COSTS
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Black
0
Black
0
Black
#VALUE!
0
0
0
0
0
0
Black
Black
Black
Black
Black
Black
Black
Black
Black
0
Black
0

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
black
$0.00

$0.00
Black
Black
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Black
$0.00
Black
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

Black
0

black
$0.00

Black
0
Black
Black

$0.00
Black
Black

0
Black
Black
Black
Black
Black
Black
Black
Black
Black
0
Black
0

$0.00
Black

Base Contract (Only)
16. CUMULATIVE TOTAL
(December - November)
HOURS
COSTS
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
black
0
0
Black
0
Black
Black
0
0
0
0
0
0
Black

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
black
$0.00
$0.00
$0.00
$0.00
black
black
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Black
$0.00

Black
Black
Black
Black
Black
Black
0
Black
Black

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

Black

$0.00
$0.00
$0.00

Base & Special Projects
17. CUMULATIVE TOTAL
(December - November)
HOURS
COSTS
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
black
0
0
black
0
black
black
0
0
0
0
0
0
Black
Black
Black
Black
Black
Black
Black
Black
Black
0
Black
Black

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
black
$0.00
$0.00
$0.00
$0.00
black
black
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Black
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

PRA Disclosure Statement
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 expires 02/29/2020). 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. ****CMS Disclosure**** 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 Benjamin Bernstein (410)-786-6570.

Semi Annual Cost Reporting Form: Fixed Price Contractors

ESRD_Network_Semi_Annual_Report
2

12/19/2019