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

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 “Network Semi Annual Dec – May” to report all costs for the
December – May period of the current contract year. Networks should use the second tab
titled “Network Semi Annual June –Nov 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 - 13 Enter all hours and costs incurred for each of the Statement of Work sections
listed in columns 5 - 13. Networks should refer to the ESRD Network contract
for a description of the work for each of columns 5 - 13. Please also refer to
specific instructions for lines a –g below.
14
Enter data in all applicable white cells for leave, fringe and indirect costs.
Please note all grey cells are formulas and the Networks do not need to
complete them.
15
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.
1
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 09380657 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.

16-17

These columns only appear on the “Network Semi Annual June – Nov” tab to
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. Columns 5 to 15 record 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 to15. 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 - 15.
a. 21
Please do not record any cost in this row. OT and Bonuses should be a cost
element within the fringe pool.
b.
Record the total leave costs for all direct staff in columns 14 and 15 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 14 and 15
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 -15.
d.2
List each consultants name and function. In addition, record the hours and
costs of each listed consultant in columns 5 -15.
e.
Record all travel costs in columns 5 -18
f.
Record all Other Direct Costs in columns 5-15
g.
Record all Indirect Costs in columns 14 and 15 only, if applicable. For
contractors that have approved indirect rates please utilize the appropriate
indirect rate to calculate the reported indirect costs.

2
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 09380657 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.