CMS-265-11 Renal Dialysis Facility Cost Report

DRAFT

FORM CMS-265-11

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 mm/dd/yyyy
WORKSHEET S

PART I - COST REPORT STATUS
Provider use only
1. [ ] Electronically prepared cost report
Date (mm/dd/yyyy): ____________________
Time: ____________________
2. [ ] Manually prepared 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: _________
10. If line 4, column 1 is "4", enter number of times reopened _____
11. Contractor Vendor Code ________
use only
(1) As Submitted
6. Contractor No._________
(2) Settled without Audit
7. [ ] First Cost Report for this Provider CCN
12. Medicare Utilization ________
(3) Settled with Audit
8. [ ] Last Cost Report for this Provider CCN
(4) Reopened
9. NPR Date: __________
(5) Amended
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
To:
8
8 Cost reporting period (mm/dd/yyyy)
From:
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
10.01 Is this facility reporting no Medicare utilization for the cost reporting period? Enter "Y" for yes or "N" for no.
10.01
10.02 Is this facility reporting low Medicare utilization for the cost reporting period? Enter "Y" for yes or "N" for no.
10.02
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. (see instructions.)
13
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? See instructions.
18
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 CHIEF FINANCIAL 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 OR PROCURED 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 CHIEF FINANCIAL OFFICER OR ADMINISTRATOR OF PROVIDER(S)
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 submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by ______________________________ {Provider
Name(s) and Number(s)} for the cost reporting period beginning ___________________ and ending ___________________ and 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.

1

2
3
4

SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR
1

CHECKBOX
2

ELECTRONIC
SIGNATURE STATEMENT
I have read and agree with the above certification
statement. I certify that I intend my electronic
signature on this certification be the legally
binding equivalent of my original signature.

1

2
3
4

Signatory Printed Name
Signatory Title
Signature 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 valid
OMB control number for this information collection is 0938-0236. The time required to complete this information collection is estimated to average 66 hours per response,
including the time to review instructions, search existing resources, gather the data needed, and complete and review the information collection. If you have any 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 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.
FORM CMS-265-11 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4204, 4204.1 AND 4204.2)

Rev.

42-303

4290 (Cont.)

FORM CMS-265-11

INDEPENDENT RENAL DIALYSIS FACILITY
STATISTICAL DATA

RENAL DIALYSIS STATISTICS

1
2
3
4
5
6
7
8
9
10
10.01
10.02
10.03
11
11.01
11.02
11.03
11.04
11.05

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
First shift
Second Shift
Third shift
Number of treatments provided
One (1) time per week
Two (2) times per week
Three (3) times per week
More than three (3) times per week
Total

DRAFT

PROVIDER CCN:

PERIOD:
From:
To:

OUTPATIENT
PERITONEAL
HEMODIALYSIS
DIALYSIS
1
2

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)

Type of Dialyzers
1

WORKSHEET S-1

TRAINING
PERITONEAL
HEMODIALYSIS
DIALYSIS
3
4

Dialyzer Reuse Count
2

Other Dialyzers
3

1
2
3
4
5
6
7
8
9
10
10.01
10.02
10.03
11
11.01
11.02
11.03
11.04
11.05

12

13

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

14
15
1

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

2

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

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

22
23
24
25
26
27
28
29
30
31
32
33
34
35

Physicians
Registered Nurses
Licensed Practical Nurses
Nurses Aides
Technicians
Social Workers
Dieticians
Administrative
Management
Other (Specify)
Child Life/Other Specialists for Pediatric Patients
Registered Nurses - Pediatric
Nutritionists and Dieticians - Pediatric
Pediatric Unit Staff

Type of Dialyzers
1

Dialyzer Reuse Count
2

Other Dialyzers
3

Staff
1

Contract
2

Total
3

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

42-304

20

21

22
23
24
25
26
27
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29
30
31
32
33
34
35

Rev.

DRAFT
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

V/I
3

1

2

3

Y/N
1

A/C/R
2

FORM CMS-265-11 (03/2019) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4205.1)

DATE
3

4

5

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 coinsurance 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.

Rev.

DATE
2

Y/N

Y/N
1

DATE
2

6
7
8

9
10
11
12
13
14

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
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

0100
0200
0300
0400
0600
0700
0800
0900
0901
1000
1100
1200
1300
1400
1500
1600
1700
1900
2000
2100
2200
2300
2400
2500
2600

COST CENTERS
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Operation & Maintenance of Plant
Housekeeping
Subtotal (sum of lines 1 through 4)*
Cap Rel Costs-Renal Dialysis Equip*
Salaries for Direct Patient Care*
EH&W Benefits for Direct Pt. Care
Supplies*
Supplies-Pediatric*
Laboratory*
Administrative & General
Drugs*
Interest Expense
Laundry and Linen
Medical Records
Phy Rout Prof Svcs-Initial Method
Other (Specify)
Subtotal (sum of line 11 plus lines 13 through 17)*
Phy Rout Prof Svcs-MCP Method
Whole Blood & Packed Red Blood Cells*
Vaccines*
NONREIMBURSABLE COSTS CENTERS
Physicians Private Offices*
ESAs (prior to January 1, 2011)
Method II Patients (prior to January 1, 2011)
Other Nonreimbursable (specify)*
Other Nonreimbursable (specify)*
Total

DRAFT
PROVIDER CCN:

SALARIES
PHYSICIAN
COMPENSATION
OTHER
1
2

OTHER
3

TOTAL
( col. 1 through
col. 3 )
4

RECLASS.
TO EXPENSES
( from
Wkst. A-1 )
5

PERIOD:
From:
To:
ADJUSTMENTS
RECLASSIFIED
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
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 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4206)

42-306

Rev.

FORM CMS-265-11

02-18
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 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4207)

Rev. 4

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)

02-18

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 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4208)

42-308

Rev. 4

FORM CMS-265-11

03-19
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 a result of transactions with related organizations:
LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COL. 6

1
2
3
4
5

C.

LINE NO.
1

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

TOTALS (sum of lines 1-4)
(Transfer col. 6, lines 1 through 4, to Wkst. A, col. 7, as appropriate)
(Transfer col. 6, line 5, to Wkst. A-2, col. 2, line 7)

1
2
3
4
5

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

1
2
3
4

NAME
2

PERCENTAGE
OF
OWNERSHIP
3

NAME
4

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

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 (03/2019) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4209)

Rev. 5

42-309

4290 (Cont.)

FORM CMS-265-11

STATEMENT OF COMPENSATION

03-19

PROVIDER CCN:

PART I - STATEMENT OF TOTAL COMPENSATION TO OWNERS
(Include compensation of employees related to owners)
SOLE
PROPIETORSHIPS
PARTNERS
PERCENTAGE OF
PERCENTAGE
CUSTOMARY
OF CUSTOMARY
PERCENT SHARE
WORK WEEK
WORK WEEK
OF OPERATING
DEVOTED TO
DEVOTED TO
PROFIT OR (LOSS)
BUSINESS
TITLE
FUNCTION (A)
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

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

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. 5

DRAFT

FORM CMS-265-11

4290 (Cont.)

ANAYSIS OF CAPITAL COSTS CENTERS

PROVIDER CCN:
__________________

PART I - ANALYSIS OF CAPITAL COSTS FROM WORKSHEET A, LINES 1 AND 2

1
2
3

Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Total (sum of lines 1 and 2)

DEPRECIATION
1

PART II - ANALYSIS OF RENAL DIALYSIS EQUIPMENT COSTS FROM WORKSHEET A, LINE 6

1
2
3

Capital Related Costs-Renal Dialysis Equipment - In-Facility
Capital Related Costs-Renal Dialysis Equipment - In-Home
Total (sum of lines 1 and 2)

HEMODIALYSIS
MACHINES
1

SUMMARY OF CAPITAL
LEASE
2

INTEREST
3

DEPRECIATION
PERITONEAL WATER PURDIALYSIS
IFICATION
MACHINES
EQUIPMENT
2
3

INSURANCE
4

TAXES
5

TOTAL
DEPRECIATION
4

HEMODIALYSIS
MACHINES
5

FORM CMS-265-11 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4210.50 THROUGH 4210.52.)

Rev.

PERIOD:
WORKSHEET A-7,
From: ______________ PARTS I & II
To: ________________

OTHER CRC
6

TOTAL
7

CAPITAL LEASE
PERITONEAL WATER PURDIALYSIS
IFICATION
MACHINES
EQUIPMENT
6
7

1
2
3

TOTAL
CAPITAL
LEASE
8

TOTAL
9

1
2
3

42-310.1

4290 (Cont.)

FORM CMS-265-11

DRAFT

This page reserved for future use.

FORM CMS-265-11 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4210.50 THROUGH 4210.52.)

42-310.2

Rev.

DRAFT

FORM CMS-265-11

4290 (Cont.)

COST ALLOCATION - GENERAL SERVICE COSTS

1
2
3
4
4.01
5
5.01
6
7
8
8.01
8.02
8.03
9
9.01
9.02
9.03
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02

COSTS TO BE ALLOCATED
Drugs Included in Composite Rate
ESAs
ESRD Related Other Drugs
AKI Related Other Drugs
Non-ESRD Related Drugs, Supplies & Lab
AKI Non-Renal Related Drugs, Supplies & Lab
Whole Blood and Packed Red Blood Cells
Vaccines
REIMBURSABLE COST CENTERS
Maintenance-Hemodialysis
Maintenance-Hemo Adult
Maintenance-Hemo Pediatric
AKI-Hemodialysis
Maintenance-IPD
Maintenance-IPD Adult
Maintenance-IPD Pediatric
AKI-IPD
Training-Hemodialysis
Training-Hemo Adult
Training-Hemo Pediatric
Training-IPD
Training-IPD Adult
Training-IPD Pediatric
Training-CAPD
Training-CAPD Adult
Training-CAPD Pediatric
Training-CCPD
Training-CCPD Adult
Training-CCPD Pediatric

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

PROVIDER CCN PERIOD:
From:
To:

CAP REL
OP & MAINT
& HOUSE
2

STEP DOWN
OF
OF COL. 2
3

CAP REL
REN DIAL
EQUIP
4

SALARIES
FOR DIR
PT CARE
5

EH&W BENE
FOR DIR
PT CARE
6

SUPPLIES
7

SUPPLIESPEDIATRIC
7.01

WORKSHEET B

LABORATORY
8

1
2
3
4
4.01
5
5.01
6
7
8
8.01
8.02
8.03
9
9.01
9.02
9.03
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02

*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 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

Rev.

42-311

4290 (Cont.)

FORM CMS-265-11

DRAFT

COST ALLOCATION - GENERAL SERVICE COSTS

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

Home Program-Hemodialysis
Home Program-Hemo Adult
Home Program-Hemo Pediatric
Home Program-IPD
Home Program-IPD Adult
Home Program-IPD Pediatric
Home Program-CAPD
Home Program-CAPD Adult
Home Program-CAPD Pediatric
Home Program-CCPD
Home Program-CCPD Adult
Home Program-CCPD Pediatric
Subtotal (lines 2 through 17.02)
NONREIMBURSABLE COST CENTERS
Physicians' Private Offices
Method II Patients prior to 1/1/2011
Other Nonreimbursable
Other Nonreimbursable
Totals (see instructions)

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

PROVIDER CCN PERIOD:
From:
To:

CAP REL
OP & MAINT
& HOUSE
2

STEP DOWN
OF
OF COL. 2
3

CAP REL
REN DIAL
EQUIP
4

SALARIES
FOR DIR
PT CARE
5

EH&W BENE
FOR DIR
PT CARE
6

SUPPLIES
7

SUPPLIESPEDIATRIC
7.01

WORKSHEET B

LABORATORY
8

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

*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 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

42-311.1

Rev.

02-18

FORM CMS-265-11

4290 (Cont.)

COST ALLOCATION - GENERAL SERVICE COSTS

1
2
3
4
4.01
5
5.01
6
7
8
8.01
8.02
8.03
9
9.01
9.02
9.03
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02

COSTS TO BE ALLOCATED
Drugs Included in Composite Rate
ESAs
ESRD Related Other Drugs
AKI Related Other Drugs
Non-ESRD Related Drugs, Supplies & Lab
AKI Non-Renal Related Drugs, Supplies & Lab
Whole Blood and Packed Red Blood Cells
Vaccines
REIMBURSABLE COST CENTERS
Maintenance-Hemodialysis
Maintenance-Hemo Adult
Maintenance-Hemo Pediatric
AKI-Hemodialysis
Maintenance -IPD
Maintenance-IPD Adult
Maintenance-IPD Pediatric
AKI-IPD
Training-Hemodialysis
Training-Hemo Adult
Training-Hemo Pediatric
Training-IPD
Training-IPD Adult
Training-IPD Pediatric
Training-CAPD
Training-CAPD Adult
Training-CAPD Pediatric
Training-CCPD
Training-CCPD Adult
Training-CCPD Pediatric

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

A&G
&
OTHER
COST
CENTERS
9

DRUGS
10

DRUGS
INCLUD. IN
COMP RATE
11

SUBTOTAL
( see instructions )
11A

ESA'S
12

PROVIDER CCN PERIOD:
From:
To:
TOTAL
ESRD REL.
EXPENSES
AND
ALL
AKI REL.
PAT. SVCS.
DRUGS
( cols. 11A-13 )
13
13A

WORKSHEET B

1
2
3
4
4.01
5
5.01
6
7
8
8.01
8.02
8.03
9
9.01
9.02
9.03
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02

*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 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

Rev. 4

42-311.2

4290 (Cont.)

FORM CMS-265-11

02-18

COST ALLOCATION - GENERAL SERVICE COSTS

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

Home Program-Hemodialysis
Home Program-Hemo Adult
Home Program-Hemo Pediatric
Home Program-IPD
Home Program-IPD Adult
Home Program-IPD Pediatric
Home Program-CAPD
Home Program-CAPD Adult
Home Program-CAPD Pediatric
Home Program-CCPD
Home Program-CCPD Adult
Home Program-CCPD Pediatric
Subtotal (lines 2 through 17.02)
NONREIMBURSABLE COST CENTERS
Physicians' Private Offices
Method II Patients prior to 1/1/2011
Other Nonreimbursable
Other Nonreimbursable
Totals (see instructions)

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

A&G
&
OTHER
COST
CENTERS
9

DRUGS
10

DRUGS
INCLUD. IN
COMP RATE
11

SUBTOTAL
( see instructions )
11A

ESA'S
12

PROVIDER CCN PERIOD:
From:
To:
TOTAL
ESRD REL.
EXPENSES
AND
ALL
AKI REL.
PAT. SVCS.
DRUGS
( cols. 11A-13 )
13
13A

WORKSHEET B

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

*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 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

42-312

Rev. 4

DRAFT

FORM CMS-265-11

4290 (Cont.)

COST ALLOCATION - STATISTICAL BASIS

NET
EXPENSES
FOR

1
2
3
4
4.01
5
5.01
6
7
8
8.01
8.02
8.03
9
9.01
9.02
9.03
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02

COSTS TO BE ALLOCATED
Drugs Included in Composite Rate
ESAs
ESRD Related Other Drugs
AKI Related Other Drugs
Non-ESRD Related Drugs, Supplies & Lab
AKI Non-Renal Related Drugs, Supplies & Lab
Whole Blood and Packed Red Blood Cells
Vaccines
REIMBURSABLE COST CENTERS
Maintenance-Hemodialysis
Maintenance-Hemo Adult
Maintenance-Hemo Pediatric
AKI-Hemodialysis
Maintenance -IPD
Maintenance-IPD Adult
Maintenance-IPD Pediatric
AKI-IPD
Training-Hemodialysis
Training-Hemo Adult
Training-Hemo Pediatric
Training-IPD
Training-IPD Adult
Training-IPD Pediatric
Training-CAPD
Training-CAPD Adult
Training-CAPD Pediatric
Training-CCPD
Training-CCPD Adult
Training-CCPD Pediatric

COST ALLOC.
1

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

FEET )
2

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

CAP REL
REN DIAL
EQUIP
( % TIME )

SALARIES
FOR DIR
PT CARE
( HRS OF

EH&W BENE
FOR DIR
PT CARE
( GROSS

(3)

SERVICE )(3)
5

SALARIES )(3)
6

4

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

Rev.

PROVIDER CCN PERIOD:
From:
To:
SUPPLIES
SUPPLIESPEDIATRIC

WORKSHEET B-1

LABORATORY

( CHARGES )

( CHARGES )

( CHARGES )

(3)

(3)

(3)

7

7.01

8

1
2
3
4
4.01
5
5.01
6
7
8
8.01
8.02
8.03
9
9.01
9.02
9.03
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02

42-313

4290 (Cont.)

FORM CMS-265-11

DRAFT

COST ALLOCATION - STATISTICAL BASIS

NET
EXPENSES
FOR

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

Home Program-Hemodialysis
Home Program-Hemo Adult
Home Program-Hemo Pediatric
Home Program-IPD
Home Program-IPD Adult
Home Program-IPD Pediatric
Home Program-CAPD
Home Program-CAPD Adult
Home Program-CAPD Pediatric
Home Program-CCPD
Home Program-CCPD Adult
Home Program-CCPD Pediatric
Subtotal (lines 2 through 17.02)
NONREIMBURSABLE COST CENTERS
Physicians' Private Offices
Method II Patients prior to 1/1/2011
Other Nonreimbursable
Other Nonreimbursable
Total (see instructions)
Total Costs to be Allocated
Unit Cost Multiplier (line 24 divided by line 23)

COST ALLOC.
1

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

FEET )
2

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

CAP REL
REN DIAL
EQUIP
( % TIME )

SALARIES
FOR DIR
PT CARE
( HRS OF

EH&W BENE
FOR DIR
PT CARE
( GROSS

(3)

SERVICE )(3)
5

SALARIES )(3)
6

4

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

42-313.1

PROVIDER CCN PERIOD:
From:
To:
SUPPLIES
SUPPLIESPEDIATRIC

WORKSHEET B-1

LABORATORY

( CHARGES )

( CHARGES )

( CHARGES )

(3)

(3)

(3)

7

7.01

8

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.

02-18

FORM CMS-265-11

4290 (Cont.)

COST ALLOCATION - STATISTICAL BASIS

UNIT COST
MULTIPLIER

1
2
3
4
4.01
5
5.01
6
7
8
8.01
8.02
8.03
9
9.01
9.02
9.03
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02

COSTS TO BE ALLOCATED
Drugs Included in Composite Rate
ESAs
ESRD Related Other Drugs
AKI Related Other Drugs
Non-ESRD Related Drugs, Supplies & Lab
AKI Non-Renal Related Drugs, Supplies & Lab
Whole Blood and Packed Red Blood Cells
Vaccines
REIMBURSABLE COST CENTERS
Maintenance-Hemodialysis
Maintenance-Hemo Adult
Maintenance-Hemo Pediatric
AKI-Hemodialysis
Maintenance -IPD
Maintenance-IPD Adult
Maintenance-IPD Pediatric
AKI-IPD
Training-Hemodialysis
Training-Hemo Adult
Training-Hemo Pediatric
Training-IPD
Training-IPD Adult
Training-IPD Pediatric
Training-CAPD
Training-CAPD Adult
Training-CAPD Pediatric
Training-CCPD
Training-CCPD Adult
Training-CCPD Pediatric

SUBTOTAL
8A

COMPUTATION
9

DRUGS

( CHARGES )

DRUGS
INCLD IN
COMP RATE
( CHARGES )

(3)

(3)

10

11

FORM CMS-265-11 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

Rev. 4

ESA'S

( CHARGES )
SUBTOTAL
11A

PROVIDER CCN PERIOD:
From:
To:
ESRD REL.
TOTAL
AND AKI
EXPENSES
REL. DRUGS
ALL
( CHARGES )
PATIENT

(3)

(3)

12

13

SERVICES
13A

WORKSHEET B-1

1
2
3
4
4.01
5
5.01
6
7
8
8.01
8.02
8.03
9
9.01
9.02
9.03
10
10.01
10.02
11
11.01
11.02
12
12.01
12.02
13
13.01
13.02

42-313.2

4290 (Cont.)

FORM CMS-265-11

02-18

COST ALLOCATION - STATISTICAL BASIS

UNIT COST
MULTIPLIER

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

Home Program-Hemodialysis
Home Program-Hemo Adult
Home Program-Hemo Pediatric
Home Program-IPD
Home Program-IPD Adult
Home Program-IPD Pediatric
Home Program-CAPD
Home Program-CAPD Adult
Home Program-CAPD Pediatric
Home Program-CCPD
Home Program-CCPD Adult
Home Program-CCPD Pediatric
Subtotal (lines 2 through 17.02)
NONREIMBURSABLE COST CENTERS
Physicians' Private Offices
Method II Patients prior to 1/1/2011
Other Nonreimbursable
Other Nonreimbursable
Total (see instructions)
Total Costs to be Allocated
Unit Cost Multiplier (line 24 divided by line 23)

SUBTOTAL
8A

COMPUTATION
9

DRUGS

( CHARGES )

DRUGS
INCLD IN
COMP RATE
( CHARGES )

(3)

(3)

10

11

FORM CMS-265-11 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

42-313.3

ESA'S

( CHARGES )
SUBTOTAL
11A

PROVIDER CCN PERIOD:
From:
To:
ESRD REL.
TOTAL
AND AKI
EXPENSES
REL. DRUGS
ALL
( CHARGES )
PATIENT

(3)

(3)

12

13

SERVICES
13A

WORKSHEET B-1

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. 4

03-19

FORM CMS-265-11

4290 (Cont.)

This page is reserved for future use.

FORM CMS-265-11 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)

Rev. 5

42-313.4

4290 (Cont.)

FORM CMS-265-11

03-19

COMPUTATION OF AVERAGE COST PER TREATMENT -ESRD PPS

8.01
8.02
8.03
9.01
9.02
9.03
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
AKI-Hemo
Maintenance-IPD Adult
Maintenance-IPD Pediatric
AKI-IPD
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

16.02

PROVIDER CCN:

NUMBER
OF
TREATMENTS
1

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

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

Patient Weeks

8.01
8.02
8.03
9.01
9.02
9.03
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

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
19

Totals (Column 1 - sum of lines 8.01 through 15.02)
(Column 2 - sum of lines 8.01 through 17.02)
Total provider treatments
(informational only)

FORM CMS-265-11 (03/2019) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4212)

42-314

PERIOD:
From:
To:

WORKSHEET C

18
19

Rev. 5

FORM CMS-265-11

02-18
COMPUTATION OF AVERAGE COST PER TREATMENT -BASIC COMPOSITE COST

4290 (Cont.)
PROVIDER CCN:

MEDICARE
NUMBER
NUMBER
NUMBER
OF
AVERAGE AVERAGE AVERAGE
TOTAL
TOTAL
AVERAGE
OF
OF
NUMBER
COSTS
COST OF
TREATTREATTREATTOTAL
PAYMENT PAYMENT PAYMENT PAYMENT
OF
( transfer from
TREATMENTS
MENTS
MENTS
EXPENSES
RATE
RATE
RATE
DUE
( see
( see
( col. 4 x
TREATWkst. B,
MENT
( see
( see
( see
( see
( see
MENTS
col. 11A ) ( col 2 / col. 1 ) instructions ) instructions ) instructions ) instructions ) instructions ) instructions ) instructions )
col. 6 )
1
2
3
4
4.01
4.02
5
6
6.01
6.02
7
(line 8.01,
8.02, and 8.03)

PERIOD:
From:
To:

WORKSHEET D

TOTAL

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,
9.02, and 9.03)

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)

FORM CMS-265-11 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4213)

Rev. 4

1

11

42-315

4290 (Cont.)

FORM CMS-265-11

CALCULATION OF BAD DEBT REIMBURSEMENT

PROVIDER CCN:

02-18
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)

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

PART
1
2
3

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

1
Column 1

Column 2

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)

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

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

42-316

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

1
2
3

Rev. 4

DRAFT
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

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)

Program
to
Provider
Provider
to
Program

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

mm/dd/yyyy
1

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

Part B

NPR Date (mm/dd/yyyy)

Amount
2

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
4
5
6
7

II - TO BE COMPLETED BY PROVIDER
Low volume payment amount (see instructions)
TDAPA
HDPA
TPNIES

FORM CMS-265-11 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4215)

Rev.

4
5
6
7

42-317

4290 (Cont.)

FORM CMS-265-11

DRAFT

BALANCE SHEET

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2
3
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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

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

PROVIDER CCN:

Amount

WORKSHEET F

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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 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)

42-318

PERIOD:
From:
To:

Rev.

04-21

FORM CMS-265-11

STATEMENT OF REVENUES AND EXPENSES

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)

4290 (Cont.)
PROVIDER CCN:

Amount

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
31.50 COVID-19 PHE funding
32 Total Other Income (sum of lines 19 through 31)
33 Net Income or Loss for the period (line 18 plus line 32)

FORM CMS-265-11 (04/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)

Rev. 6

PERIOD:
From:
To:
Amount

WORKSHEET F-1

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16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
31.50
32
33

42-319

4290 (Cont.)

FORM CMS-265-11

04-21

This page is reserved for future use.

FORM CMS-265-11 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)

42-320

Rev. 6