CMS-265-11 Renal Dialysis Facility Cost Report

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Overview

S
S-1
S-2
A
A-1
A-2
A-3
A-4
A-7
B
B-1
C
D
E
E-1
F
F-1

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Sheet 1: S

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												FORM APPROVED
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).												OMB NO: 0938-0236
												Expires mm/dd/yyyy
INDEPENDENT RENAL DIALYSIS FACILITY								PROVIDER CCN:		PERIOD:		WORKSHEET S
COST REPORT CERTIFICATION										From:
										To:
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					_____
use only				(1) As Submitted		6. Contractor No._________			11. Contractor Vendor Code ________
				(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
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
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
	SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR							CHECKBOX			ELECTRONIC
	1							2			SIGNATURE STATEMENT
1														1
2	Signatory Printed Name													2
3	Signatory Title													3
4	Signature date													4
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

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Sheet 2: S-1

4290 (Cont.)			FORM CMS-265-11													DRAFT
INDEPENDENT RENAL DIALYSIS FACILITY					PROVIDER CCN:				PERIOD:				WORKSHEET S-1
STATISTICAL DATA									From:
									To:
RENAL DIALYSIS STATISTICS
				OUTPATIENT						TRAINING
								PERITONEAL						PERITONEAL
					HEMODIALYSIS			DIALYSIS			HEMODIALYSIS			DIALYSIS
					1			2			3			4
1	Number of treatments not billed to Medicare and furnished directly															1
2	Number of treatments not billed to Medicare and furnished under arrangements															2
3	Number of patients currently in dialysis program															3
4	Average times per week patient receives dialysis															4
5	Number of days in an average week for patient dialysis treatments															5
6	Average time of patient dialysis treatment including set up time															6
7	Number of machines regularly available for use															7
8	Number of standby machines															8
9	Number of shifts in typical week during regular reporting period															9
10	Hours per shift in typical week during regular reporting period															10
10.01	First shift															10.01
10.02	Second Shift															10.02
10.03	Third shift															10.03
11	Number of treatments provided															11
11.01	One (1) time per week															11.01
11.02	Two (2) times per week															11.02
11.03	Three (3) times per week															11.03
11.04	More than three (3) times per week															11.04
11.05	Total															11.05
								Type of Dialyzers			Dialyzer Reuse Count			Other Dialyzers
								1			2			3
12	Column 1: Type of dialyzers used (see instructions)															12
	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)															13
14	Number of units of epoetin furnished during cost reporting period															14
15	Number of units of Aranesp furnished during cost reporting period															15
											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															16
17	Number of patients who received transplants															17
HOME PROGRAM
18	Number of patients commencing home dialysis training during this period															18
19	Number of patients currently in home program															19
								Type of Dialyzers			Dialyzer Reuse Count			Other Dialyzers
								1			2			3
20	Column 1: Type of dialyzers used (see instructions)															20
	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															21
								Staff			Contract			Total
								1			2			3
22	Physicians															22
23	Registered Nurses															23
24	Licensed Practical Nurses															24
25	Nurses Aides															25
26	Technicians															26
27	Social Workers															27
28	Dieticians															28
29	Administrative															29
30	Management															30
31	Other (Specify)															31
32	Child Life/Other Specialists for Pediatric Patients															32
33	Registered Nurses - Pediatric															33
34	Nutritionists and Dieticians - Pediatric															34
35	Pediatric Unit Staff															35
FORM CMS-265-11 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4205)																Rev.
42-304

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Sheet 3: S-2

DRAFT

FORM CMS-265-11

4290 (Cont.)

INDEPENDENT RENAL DIALYSIS FACILITY

PROVIDER CCN:

PERIOD:

WORKSHEET S-2

REIMBURSEMENT QUESTIONNAIRE

From:

To:

Y/N

DATE

V/I

PROVIDER ORGANIZATION AND OPERATION

1

2

3

1

Has the provider changed ownership immediately prior to the beginning of the cost reporting period?

1

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.

2

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

3

(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)

Y/N

A/C/R

DATE

FINANCIAL DATA AND REPORTS

1

2

3

4

Column 1: Were the financial statements prepared by a Certified Public Accountant? Enter "Y" for yes or "N" for no.

4

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"

5

for yes or "N" for no in column 1. If yes, submit reconciliation.

BAD DEBTS

Y/N

6

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

6

7

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.

7

8

If line 6 is yes, were patient deductibles and/or coinsurance waived? Enter "Y" for yes or "N" for no. If yes, see instructions.

8

Y/N

DATE

PS&R REPORT DATA

1

2

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

9

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

10

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

11

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

12

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.

13

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.

14

If yes, see instructions.

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

Rev.

42-305

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Sheet 4: A

4290 (Cont.)				FORM CMS-265-11							DRAFT
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE						PROVIDER CCN:		PERIOD:		WORKSHEET A
OF EXPENSES								From:
								To:
							RECLASS.			NET EXPENSES
			SALARIES			TOTAL	TO EXPENSES	RECLASSIFIED	ADJUSTMENTS	FOR COST
		FACILITY HEALTH CARE COSTS	PHYSICIAN			( col. 1 through	( from	TRIAL BALANCE	TO EXPENSES	ALLOCATION
			COMPENSATION	OTHER	OTHER	col. 3 )	Wkst. A-1 )	( col 4. +/- col. 5 )	( from Wkst. A-2 )	( col. 6+/-col. 7 )
			1	2	3	4	5	6	7	8
		COST CENTERS
1	0100	Cap Rel Costs-Bldg & Fixt									1
2	0200	Cap Rel Costs-Mvble Equip									2
3	0300	Operation & Maintenance of Plant									3
4	0400	Housekeeping									4
5		Subtotal (sum of lines 1 through 4)*									5
6	0600	Cap Rel Costs-Renal Dialysis Equip*									6
7	0700	Salaries for Direct Patient Care*									7
8	0800	EH&W Benefits for Direct Pt. Care									8
9	0900	Supplies*									9
9.01	0901	Supplies-Pediatric*									9.01
10	1000	Laboratory*									10
11	1100	Administrative & General									11
12	1200	Drugs*									12
13	1300	Interest Expense									13
14	1400	Laundry and Linen									14
15	1500	Medical Records									15
16	1600	Phy Rout Prof Svcs-Initial Method									16
17	1700	Other (Specify)									17
18		Subtotal (sum of line 11 plus lines 13 through 17)*									18
19	1900	Phy Rout Prof Svcs-MCP Method									19
20	2000	Whole Blood & Packed Red Blood Cells*									20
21	2100	Vaccines*									21
		NONREIMBURSABLE COSTS CENTERS
22	2200	Physicians Private Offices*									22
23	2300	ESAs (prior to January 1, 2011)									23
24	2400	Method II Patients (prior to January 1, 2011)									24
25	2500	Other Nonreimbursable (specify)*									25
26	2600	Other Nonreimbursable (specify)*									26
27		Total									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.

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Sheet 5: A-1

02-18		FORM CMS-265-11							4290 (Cont.)
RECLASSIFICATIONS				PROVIDER CCN:		PERIOD:		WORKSHEET A-1
						From:
						To:
			INCREASE			DECREASE
		CODE	COST	LINE		COST	LINE
	EXPLANATION OF ENTRY	(1)	CENTER	NO.	AMOUNT (2)	CENTER	NO.	AMOUNT (2)
		1	2	3	4	5	6	7
1									1
2									2
3									3
4									4
5									5
6									6
7									7
8									8
9									9
10									10
11									11
12									12
13									13
14									14
15									15
16									16
17									17
18									18
19									19
20									20
21									21
22									22
23									23
24									24
25									25
26									26
27									27
28									28
29									29
30									30
31									31
32									32
33									33
34									34
35									35
100	Total Reclassifications (sum of col. 4 must equal sum of col. 7)								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

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Sheet 6: A-2

4290 (Cont.)		FORM CMS-265-11							02-18
ADJUSTMENTS TO EXPENSES			PROVIDER CCN:		PERIOD:		WORKSHEET A-2
					From:
					To:
					Expense classification on Worksheet A from which
			BASIS FOR		amount is to be deducted or to which the amount is
			ADJUSTMENT		to be added
	DESCRIPTION (1)		(2)	AMOUNT	COST CENTER			LINE NO.
			1	2	3			4
1	Investment income on commingled restricted and unrestricted funds (Chapter 2)								1
2	Trade, quantity and time discounts on purchases (Chapter 8)								2
3	Rebates and refunds of expenses (Chapter 8)								3
4	Rental of building or office space to others								4
5	Physician non-routine professional patient care services								5
6	Home office costs (Chapter 21)								6
7	Adjustment resulting from transactions with related organizations (Chapter 10)		From Wkst. A-3						7
8	Vending machines								8
9	Meals served to patients								9
10	Physicians' professional services--MCP Method		A		Physicians' professional services--MCP Method			19	10
11	Services under arrangement								11
12	Provision for doubtful accounts								12
13	Capital Related--Buildings & Fixtures				Capital Related--Buildings & Fixtures			1	13
14	Capital Related--Moveable Equipment				Capital Related--Moveable Equipment			2	14
15	Rebates on epoetin prior to January 1, 2011				Epoetin			23	15
16	Epoetin		A		Epoetin			23	16
17	Rebates on Aranesp prior to January 1, 2011				Aranesp			23	17
18	Aranesp		A		Aranesp			23	18
19	Rebates on Epoetin on or after January 1, 2011 (see instructions)				Epoetin			12	19
20	Rebates on Aranesp on or after January 1, 2011 (see instructions)				Aranesp			12	20
20.01	Rebates on ESA drugs on or after January 1, 2012				Drugs			12	20.01
21	Physician malpractice premiums								21
22	Other (specify)								22
23	Other (specify)								23
24	Other (specify)								24
100	Total (transfer to Wkst. A, col. 7, line 27)								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

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Sheet 7: A-3

03-19

FORM CMS-265-11

4290 (Cont.)

STATEMENT OF COSTS OF SERVICES

PROVIDER CCN:

PERIOD:

WORKSHEET A-3

FROM RELATED ORGANIZATIONS

From:

To:

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:

AMOUNT

NET

LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COL. 6

AMOUNT

INCLUDED IN

ADJUST-

ALLOWABLE

WKST. A

MENT (col. 4

LINE NO.

COST CENTER

EXPENSES ITEMS

IN COST

COL. 6

minus col. 5)

1

2

3

4

5

6

1

1

2

2

3

3

4

4

5

TOTALS (sum of lines 1-4)

5

(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)

C.

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.

RELATED ORGANIZATION(S)

PERCENTAGE

PERCENTAGE

SYMBOL

OF

OF

(1)

NAME

OWNERSHIP

NAME

OWNERSHIP

TYPE OF BUSINESS

1

2

3

4

5

6

1

1

2

2

3

3

4

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

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Sheet 8: A-4

4290 (Cont.)						FORM CMS-265-11													03-19
STATEMENT OF COMPENSATION										PROVIDER CCN:				PERIOD:				WORKSHEET A-4
														From:
														To:
PART I - STATEMENT OF TOTAL COMPENSATION TO OWNERS
(Include compensation of employees related to owners)
				SOLE														TOTAL
				PROPIETORSHIPS		PARTNERS						CORPORATION OWNERS						COMPENSATION
				PERCENTAGE OF						PERCENTAGE						PERCENTAGE OF		INCLUDED IN
				CUSTOMARY						OF CUSTOMARY						CUSTOMARY		ALLOWABLE
				WORK WEEK			PERCENT SHARE			WORK WEEK			PERCENTAGE OF			WORK WEEK		COSTS FOR
				DEVOTED TO			OF OPERATING			DEVOTED TO			PROVIDER'S			DEVOTED TO		THE PERIOD
	TITLE	FUNCTION (A)		BUSINESS			PROFIT OR (LOSS)			BUSINESS			STOCK OWNED			BUSINESS		(B)
	1	2		3			4A			4B			5A			5B		6
1																			1
2																			2
3																			3
4																			4
5																			5
6																			6
7																			7
8																			8
9																			9
10																			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																			1
2																			2
3																			3
4																			4
5																			5
6																			6
7																			7
8																			8
9																			9
10																			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

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Sheet 9: A-7

DRAFT

FORM CMS-265-11

4290 (Cont.)

ANAYSIS OF CAPITAL COSTS CENTERS

PROVIDER CCN:

PERIOD:

WORKSHEET A-7,

__________________

From: ______________

PARTS I & II

To: ________________

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

SUMMARY OF CAPITAL

DEPRE-

CIATION

LEASE

INTEREST

INSURANCE

TAXES

OTHER CRC

TOTAL

1

2

3

4

5

6

7

1

Capital Related Costs-Buildings and Fixtures

1

2

Capital Related Costs-Movable Equipment

2

3

Total (sum of lines 1 and 2)

3

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

DEPRECIATION

CAPITAL LEASE

HEMO-

PERITONEAL

WATER PUR-

TOTAL

HEMO-

PERITONEAL

WATER PUR-

TOTAL

DIALYSIS

DIALYSIS

IFICATION

DEPRE-

DIALYSIS

DIALYSIS

IFICATION

CAPITAL

MACHINES

MACHINES

EQUIPMENT

CIATION

MACHINES

MACHINES

EQUIPMENT

LEASE

TOTAL

1

2

3

4

5

6

7

8

9

1

Capital Related Costs-Renal Dialysis Equipment - In-Facility

1

2

Capital Related Costs-Renal Dialysis Equipment - In-Home

2

3

Total (sum of lines 1 and 2)

3

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

Rev.

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.

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Sheet 10: B

DRAFT					FORM CMS-265-11							4290 (Cont.)
COST ALLOCATION - GENERAL SERVICE COSTS									PROVIDER CCN:	PERIOD:	WORKSHEET B
										From:
										To:
			NET
			EXPENSE
			FOR	CAP REL	STEP DOWN	CAP REL	SALARIES	EH&W BENE
			COST ALLOC.	OP & MAINT	OF	REN DIAL	FOR DIR	FOR DIR		SUPPLIES-
			( from Wkst. A, col. 8 )	& HOUSE	OF COL. 2	EQUIP	PT CARE	PT CARE	SUPPLIES	PEDIATRIC	LABORATORY
			1	2	3	4	5	6	7	7.01	8
1	COSTS TO BE ALLOCATED				0							1
2	Drugs Included in Composite Rate											2
3	ESAs											3
4	ESRD Related Other Drugs											4
4.01	AKI Related Other Drugs											4.01
5	Non-ESRD Related Drugs, Supplies & Lab											5
5.01	AKI Non-Renal Related Drugs, Supplies & Lab											5.01
6	Whole Blood and Packed Red Blood Cells											6
7	Vaccines											7
	REIMBURSABLE COST CENTERS
8	Maintenance-Hemodialysis			0								8
8.01	Maintenance-Hemo Adult											8.01
8.02	Maintenance-Hemo Pediatric											8.02
8.03	AKI-Hemodialysis											8.03
9	Maintenance-IPD											9
9.01	Maintenance-IPD Adult											9.01
9.02	Maintenance-IPD Pediatric											9.02
9.03	AKI-IPD											9.03
10	Training-Hemodialysis											10
10.01	Training-Hemo Adult											10.01
10.02	Training-Hemo Pediatric											10.02
11	Training-IPD											11
11.01	Training-IPD Adult											11.01
11.02	Training-IPD Pediatric											11.02
12	Training-CAPD											12
12.01	Training-CAPD Adult											12.01
12.02	Training-CAPD Pediatric											12.02
13	Training-CCPD											13
13.01	Training-CCPD Adult											13.01
13.02	Training-CCPD Pediatric											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									PROVIDER CCN:	PERIOD:	WORKSHEET B
										From:
										To:
			NET
			EXPENSE
			FOR	CAP REL	STEP DOWN	CAP REL	SALARIES	EH&W BENE
			COST ALLOC.	OP & MAINT	OF	REN DIAL	FOR DIR	FOR DIR		SUPPLIES-
			( from Wkst. A, col. 8 )	& HOUSE	OF COL. 2	EQUIP	PT CARE	PT CARE	SUPPLIES	PEDIATRIC	LABORATORY
			1	2	3	4	5	6	7	7.01	8
14	Home Program-Hemodialysis											14
14.01	Home Program-Hemo Adult											14.01
14.02	Home Program-Hemo Pediatric											14.02
15	Home Program-IPD											15
15.01	Home Program-IPD Adult											15.01
15.02	Home Program-IPD Pediatric											15.02
16	Home Program-CAPD											16
16.01	Home Program-CAPD Adult											16.01
16.02	Home Program-CAPD Pediatric											16.02
17	Home Program-CCPD											17
17.01	Home Program-CCPD Adult											17.01
17.02	Home Program-CCPD Pediatric											17.02
18	Subtotal (lines 2 through 17.02)											18
	NONREIMBURSABLE COST CENTERS
19	Physicians' Private Offices		0									19
20	Method II Patients prior to 1/1/2011		0									20
21	Other Nonreimbursable											21
22	Other Nonreimbursable											22
23	Totals (see instructions)											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									PROVIDER CCN:	PERIOD:	WORKSHEET B
										From:
										To:
				A & G						TOTAL
				&					ESRD REL.	EXPENSES
			SUBTOTAL	OTHER		DRUGS			AND	ALL
			( col. 1	COST		INCLUD. IN	SUBTOTAL		AKI REL.	PAT. SVCS.
			through col. 8 )	CENTERS	DRUGS	COMP RATE	( see instructions )	ESA'S	DRUGS	( cols. 11A-13 )
			8A	9	10	11	11A	12	13	13A
1	COSTS TO BE ALLOCATED											1
2	Drugs Included in Composite Rate											2
3	ESAs											3
4	ESRD Related Other Drugs											4
4.01	AKI Related Other Drugs											4.01
5	Non-ESRD Related Drugs, Supplies & Lab											5
5.01	AKI Non-Renal Related Drugs, Supplies & Lab											5.01
6	Whole Blood and Packed Red Blood Cells											6
7	Vaccines											7
	REIMBURSABLE COST CENTERS
8	Maintenance-Hemodialysis											8
8.01	Maintenance-Hemo Adult											8.01
8.02	Maintenance-Hemo Pediatric											8.02
8.03	AKI-Hemodialysis											8.03
9	Maintenance -IPD											9
9.01	Maintenance-IPD Adult											9.01
9.02	Maintenance-IPD Pediatric											9.02
9.03	AKI-IPD											9.03
10	Training-Hemodialysis											10
10.01	Training-Hemo Adult											10.01
10.02	Training-Hemo Pediatric											10.02
11	Training-IPD											11
11.01	Training-IPD Adult											11.01
11.02	Training-IPD Pediatric											11.02
12	Training-CAPD											12
12.01	Training-CAPD Adult											12.01
12.02	Training-CAPD Pediatric											12.02
13	Training-CCPD											13
13.01	Training-CCPD Adult											13.01
13.02	Training-CCPD Pediatric											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									PROVIDER CCN:	PERIOD:	WORKSHEET B
										From:
										To:
				A & G						TOTAL
				&					ESRD REL.	EXPENSES
			SUBTOTAL	OTHER		DRUGS			AND	ALL
			( col. 1	COST		INCLUD. IN	SUBTOTAL		AKI REL.	PAT. SVCS.
			through col. 8 )	CENTERS	DRUGS	COMP RATE	( see instructions )	ESA'S	DRUGS	( cols. 11A-13 )
			8A	9	10	11	11A	12	13	13A
14	Home Program-Hemodialysis											14
14.01	Home Program-Hemo Adult											14.01
14.02	Home Program-Hemo Pediatric											14.02
15	Home Program-IPD											15
15.01	Home Program-IPD Adult											15.01
15.02	Home Program-IPD Pediatric											15.02
16	Home Program-CAPD											16
16.01	Home Program-CAPD Adult											16.01
16.02	Home Program-CAPD Pediatric											16.02
17	Home Program-CCPD											17
17.01	Home Program-CCPD Adult											17.01
17.02	Home Program-CCPD Pediatric											17.02
18	Subtotal (lines 2 through 17.02)											18
	NONREIMBURSABLE COST CENTERS
19	Physicians' Private Offices											19
20	Method II Patients prior to 1/1/2011											20
21	Other Nonreimbursable											21
22	Other Nonreimbursable											22
23	Totals (see instructions)											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

---

Sheet 11: B-1

DRAFT					FORM CMS-265-11							4290 (Cont.)
COST ALLOCATION - STATISTICAL BASIS									PROVIDER CCN:	PERIOD:	WORKSHEET B-1
										From:
										To:
				CAP REL	STEP DOWN	CAP REL	SALARIES	EH&W BENE	SUPPLIES	SUPPLIES-	LABORATORY
			NET	OP & MAINT	OF COL. 2	REN DIAL	FOR DIR	FOR DIR		PEDIATRIC
			EXPENSES	& HOUSE		EQUIP	PT CARE	PT CARE
			FOR	( SQUARE	( # TREAT	( % TIME )	( HRS OF	( GROSS	( CHARGES )	( CHARGES )	( CHARGES )
			COST ALLOC.	FEET )(1)	MENTS )(3)	(3)	SERVICE )(3)	SALARIES )(3)	(3)	(3)	(3)
			1	2	3	4	5	6	7	7.01	8
1	COSTS TO BE ALLOCATED											1
2	Drugs Included in Composite Rate											2
3	ESAs											3
4	ESRD Related Other Drugs											4
4.01	AKI Related Other Drugs											4.01
5	Non-ESRD Related Drugs, Supplies & Lab											5
5.01	AKI Non-Renal Related Drugs, Supplies & Lab											5.01
6	Whole Blood and Packed Red Blood Cells											6
7	Vaccines											7
	REIMBURSABLE COST CENTERS
8	Maintenance-Hemodialysis											8
8.01	Maintenance-Hemo Adult											8.01
8.02	Maintenance-Hemo Pediatric											8.02
8.03	AKI-Hemodialysis											8.03
9	Maintenance -IPD											9
9.01	Maintenance-IPD Adult											9.01
9.02	Maintenance-IPD Pediatric											9.02
9.03	AKI-IPD											9.03
10	Training-Hemodialysis											10
10.01	Training-Hemo Adult											10.01
10.02	Training-Hemo Pediatric											10.02
11	Training-IPD											11
11.01	Training-IPD Adult											11.01
11.02	Training-IPD Pediatric											11.02
12	Training-CAPD											12
12.01	Training-CAPD Adult											12.01
12.02	Training-CAPD Pediatric											12.02
13	Training-CCPD											13
13.01	Training-CCPD Adult											13.01
13.02	Training-CCPD Pediatric											13.02
FORM CMS-265-11 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)
Rev.												42-313
4290 (Cont.)					FORM CMS-265-11							DRAFT
COST ALLOCATION - STATISTICAL BASIS									PROVIDER CCN:	PERIOD:	WORKSHEET B-1
										From:
										To:
				CAP REL	STEP DOWN	CAP REL	SALARIES	EH&W BENE	SUPPLIES	SUPPLIES-	LABORATORY
			NET	OP & MAINT	OF COL. 2	REN DIAL	FOR DIR	FOR DIR		PEDIATRIC
			EXPENSES	& HOUSE		EQUIP	PT CARE	PT CARE
			FOR	( SQUARE	( # TREAT	( % TIME )	( HRS OF	( GROSS	( CHARGES )	( CHARGES )	( CHARGES )
			COST ALLOC.	FEET )(1)	MENTS )(3)	(3)	SERVICE )(3)	SALARIES )(3)	(3)	(3)	(3)
			1	2	3	4	5	6	7	7.01	8
14	Home Program-Hemodialysis											14
14.01	Home Program-Hemo Adult											14.01
14.02	Home Program-Hemo Pediatric											14.02
15	Home Program-IPD											15
15.01	Home Program-IPD Adult											15.01
15.02	Home Program-IPD Pediatric											15.02
16	Home Program-CAPD											16
16.01	Home Program-CAPD Adult											16.01
16.02	Home Program-CAPD Pediatric											16.02
17	Home Program-CCPD											17
17.01	Home Program-CCPD Adult											17.01
17.02	Home Program-CCPD Pediatric											17.02
18	Subtotal (lines 2 through 17.02)											18
	NONREIMBURSABLE COST CENTERS
19	Physicians' Private Offices											19
20	Method II Patients prior to 1/1/2011											20
21	Other Nonreimbursable											21
22	Other Nonreimbursable											22
23	Total (see instructions)											23
24	Total Costs to be Allocated											24
25	Unit Cost Multiplier (line 24 divided by line 23)											25
FORM CMS-265-11 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)
42-313.1												Rev.
02-18					FORM CMS-265-11							4290 (Cont.)
COST ALLOCATION - STATISTICAL BASIS									PROVIDER CCN:	PERIOD:	WORKSHEET B-1
										From:
										To:
				UNIT COST	DRUGS	DRUGS		ESA'S	ESRD REL.	TOTAL
				MULTIPLIER		INCLD IN			AND AKI	EXPENSES
						COMP RATE			REL. DRUGS	ALL
					( CHARGES )	( CHARGES )		( CHARGES )	( CHARGES )	PATIENT
			SUBTOTAL	COMPUTATION	(3)	(3)	SUBTOTAL	(3)	(3)	SERVICES
			8A	9	10	11	11A	12	13	13A
1	COSTS TO BE ALLOCATED											1
2	Drugs Included in Composite Rate											2
3	ESAs											3
4	ESRD Related Other Drugs											4
4.01	AKI Related Other Drugs											4.01
5	Non-ESRD Related Drugs, Supplies & Lab											5
5.01	AKI Non-Renal Related Drugs, Supplies & Lab											5.01
6	Whole Blood and Packed Red Blood Cells											6
7	Vaccines											7
	REIMBURSABLE COST CENTERS
8	Maintenance-Hemodialysis											8
8.01	Maintenance-Hemo Adult											8.01
8.02	Maintenance-Hemo Pediatric											8.02
8.03	AKI-Hemodialysis											8.03
9	Maintenance -IPD											9
9.01	Maintenance-IPD Adult											9.01
9.02	Maintenance-IPD Pediatric											9.02
9.03	AKI-IPD											9.03
10	Training-Hemodialysis											10
10.01	Training-Hemo Adult											10.01
10.02	Training-Hemo Pediatric											10.02
11	Training-IPD											11
11.01	Training-IPD Adult											11.01
11.02	Training-IPD Pediatric											11.02
12	Training-CAPD											12
12.01	Training-CAPD Adult											12.01
12.02	Training-CAPD Pediatric											12.02
13	Training-CCPD											13
13.01	Training-CCPD Adult											13.01
13.02	Training-CCPD Pediatric											13.02
FORM CMS-265-11 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)
Rev. 4												42-313.2
4290 (Cont.)					FORM CMS-265-11							02-18
COST ALLOCATION - STATISTICAL BASIS									PROVIDER CCN:	PERIOD:	WORKSHEET B-1
										From:
										To:
				UNIT COST	DRUGS	DRUGS		ESA'S	ESRD REL.	TOTAL
				MULTIPLIER		INCLD IN			AND AKI	EXPENSES
						COMP RATE			REL. DRUGS	ALL
					( CHARGES )	( CHARGES )		( CHARGES )	( CHARGES )	PATIENT
			SUBTOTAL	COMPUTATION	(3)	(3)	SUBTOTAL	(3)	(3)	SERVICES
			8A	9	10	11	11A	12	13	13A
14	Home Program-Hemodialysis											14
14.01	Home Program-Hemo Adult											14.01
14.02	Home Program-Hemo Pediatric											14.02
15	Home Program-IPD											15
15.01	Home Program-IPD Adult											15.01
15.02	Home Program-IPD Pediatric											15.02
16	Home Program-CAPD											16
16.01	Home Program-CAPD Adult											16.01
16.02	Home Program-CAPD Pediatric											16.02
17	Home Program-CCPD											17
17.01	Home Program-CCPD Adult											17.01
17.02	Home Program-CCPD Pediatric											17.02
18	Subtotal (lines 2 through 17.02)											18
	NONREIMBURSABLE COST CENTERS
19	Physicians' Private Offices											19
20	Method II Patients prior to 1/1/2011											20
21	Other Nonreimbursable											21
22	Other Nonreimbursable											22
23	Total (see instructions)											23
24	Total Costs to be Allocated											24
25	Unit Cost Multiplier (line 24 divided by line 23)											25
FORM CMS-265-11 (02/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)
42-313.3												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

---

Sheet 12: C

4290 (Cont.)				FORM CMS-265-11					03-19
COMPUTATION OF AVERAGE COST PER TREATMENT --							PROVIDER CCN:	PERIOD:	WORKSHEET C
ESRD PPS								From:
								To:
				TOTAL
			NUMBER	COSTS	AVERAGE COST
			OF	( Transferred from	PER TREATMENT
			TREATMENTS	Wkst. B, col. 13A )	( col. 2 divided by col. 1 )
			1	2	3
8.01	Maintenance-Hemo Adult					8.01
8.02	Maintenance-Hemo Pediatric					8.02
8.03	AKI-Hemo					8.03
9.01	Maintenance-IPD Adult					9.01
9.02	Maintenance-IPD Pediatric					9.02
9.03	AKI-IPD					9.03
10.01	Training-Hemo Adult					10.01
10.02	Training-Hemo Pediatric					10.02
11.01	Training-IPD Adult					11.01
11.02	Training-IPD Pediatric					11.02
12.01	Training-CAPD Adult					12.01
12.02	Training-CAPD Pediatric					12.02
13.01	Training-CCPD Adult					13.01
13.02	Training-CCPD Pediatric					13.02
14.01	Home Program-Hemodialysis Adult					14.01
14.02	Home Program-Hemodialysis Pediatric					14.02
15.01	Home Program-IPD Adult					15.01
15.02	Home Program-IPD Pediatric					15.02
16.01	Home Program-CAPD Adult		Patient Weeks			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)				18
		(Column 2 - sum of lines 8.01 through 17.02)
19	Total provider treatments					19
	(informational only)
FORM CMS-265-11 (03/2019) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4212)
42-314									Rev. 5

---

Sheet 13: D

02-18

FORM CMS-265-11

4290 (Cont.)

COMPUTATION OF AVERAGE COST PER TREATMENT --

PROVIDER CCN:

PERIOD:

WORKSHEET D

BASIC COMPOSITE COST

From:

To:

TOTAL

MEDICARE

NUMBER

NUMBER

NUMBER

TOTAL

AVERAGE

OF

OF

OF

AVERAGE

AVERAGE

AVERAGE

TOTAL

TOTAL

TOTAL

NUMBER

COSTS

COST OF

TREAT-

TREAT-

TREAT-

TOTAL

PAYMENT

PAYMENT

PAYMENT

PAYMENT

PAYMENT

PAYMENT

OF

( transfer from

TREAT-

MENTS

MENTS

MENTS

EXPENSES

RATE

RATE

RATE

DUE

DUE

DUE

TOTAL

TREAT-

Wkst. B,

MENT

( see

( see

( see

( see

( see

( see

( see

( col. 4 x

( col. 4.01 x

( col. 4.02 x

PAYMENT

MENTS

col. 11A )

( col 2 / col. 1 )

instructions )

instructions )

instructions )

instructions )

instructions )

instructions )

instructions )

col. 6 )

col. 6.01 )

col. 6.02 )

DUE

1

2

3

4

4.01

4.02

5

6

6.01

6.02

7

7.01

7.02

8

1

Maintenance-Hemodialysis

(line 8.01,

1

8.02, and 8.03)

2

Maintenance-IPD

(line 9.01,

2

9.02, and 9.03)

0

0

3

Training-Hemodialysis

(line 10.01 and

3

line 10.02)

0

4

Training-IPD

(line 11.01 and

4

line 11.02)

0

0

5

Training-CAPD

(line 12.01 and

5

line 12.02)

0

0

6

Training-CCPD

(line 13.01, and

6

line 13.02)

0

7

Home Program-Hemodialysis

(line 14.01 and

7

line 14.02)

0

8

Home Program-IPD

(line 15.01 and

8

line 15.02)

0

0

9

Home Program-CAPD

Patient

(line 16.01 and

9

Weeks

line 16.02)

0

0

10

Home Program-CCPD

Patient

(line 17.01 and

10

Weeks

line 17.02)

0

0

11

Total

0

0

0

11

(see instructions)

0

0

0

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

Rev. 4

42-315

---

Sheet 14: E

4290 (Cont.)		FORM CMS-265-11						02-18
CALCULATION OF BAD DEBT REIMBURSEMENT			PROVIDER CCN:		PERIOD:		WORKSHEET E,
					From:		PARTS I & II
					To:
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		Column 2
2	Total payment due net of Part B deductibles (from Wkst. D, col. 7, line 11) (see instructions)							2
2.01	Total payment due net of Part B deductibles (from Wkst. D. col. 7.01, line 11) (see instructions)							2.01
2.02	Total payment due net of Part B deductibles (from Wkst. D. col. 7.02, line 11) (see instructions)							2.02
2.03	Total payment due net of Part B deductibles (see instructions)							2.03
3	Outlier payments							3
4								4
5	Program payments (80% of line 2.03, column 2)							5
6	Amount of cost to be recovered from Medicare patients (line 1 minus line 5)							6
7	Deductibles and coinsurance billed to Medicare Part B patients (see instructions)							7
7.01	Deductibles and coinsurance billed to Medicare Part B patients (see instructions)							7.01
7.02	Deductibles and coinsurance billed to Medicare Part B patients (see instructions)							7.02
7.03	Total deductibles and coinsurance billed to Medicare Part B patients for comparison (see instructions)							7.03
8	Bad debts for deductibles and coinsurance net of bad debt recoveries for services rendered prior to 1/1/2011							8
9	Transition period 1 (75-25%) bad debts for deductibles and coinsurance net of bad debt recoveries for							9
	services rendered on or after 1/1/2011 but before 1/1/2012
10	Transition period 2 (50-50%) bad debts for deductibles and coinsurance net of bad debt recoveries for							10
	services rendered on or after 1/1/2012 but before 1/1/2013
11	Transition period 3 (25-75%) bad debts for deductibles and coinsurance net of bad debt recoveries for							11
	services rendered on or after 1/1/2013 but before 1/1/2014
12	100% PPS bad debts for deductibles and coinsurance net of bad debt recoveries							12
	(see instructions)
13	Total bad debts (sum of line 8 through line 12)							13
14	Net deductibles and coinsurance billed to Medicare Part B patients (line 7.03 minus line 13, col. 2)							14
15	Unrecovered from Medicare Part B patients (line 6 minus line 14) (If line 14 exceeds line 6, do not complete line 16)							15
16	Reimbursable bad debts (see instructions)							16
17	Reimbursable bad debts for dual eligible beneficiaries (see instructions--informational only)							17
18	Tentative adjustment							18
19	Sequestration adjustment amount							19
20	Balance due provider/program (line 16 minus lines 18 and 19) (Indicate overpayment in parentheses) (see instructions)							20
PART II - CALCULATION OF FACILITY SPECIFIC COMPOSITE COST PERCENTAGE
1	Total allowable expenses (from Wkst. C, col. 2, line 18)					1
2	Total composite costs (from Wkst. D, col. 2, line 11)					2
3	Facility specific composite cost percentage (line 2 divided by line 1)					3
FORM CMS-265-11 (05/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4214)
42-316								Rev. 4

---

Sheet 15: E-1

DRAFT				FORM CMS-265-11					4290 (Cont.)
ANALYSIS OF PAYMENTS TO PROVIDERS					PROVIDER CCN:	PERIOD:		WORKSHEET E-1
FOR SERVICES RENDERED						From:
						To:
PART I - TO BE COMPLETED BY CONTRACTOR
							Part B
							mm/dd/yyyy	Amount
	Description						1	2
1	List separately each tentative settlement				Program	.01			1.01
	payment after desk review. Also show				to	.02			1.02
	date of each payment.				Provider	.03			1.03
	If none, write "NONE," or enter a zero. (1)				Provider	.50			1.50
					to	.51			1.51
					Program	.52			1.52
	SUBTOTAL (sum of lines 1.01 through 1.49 minus sum of lines 1.50 through 1.98)					.99			1.99
	(Transfer to Wkst E, Part I, line 18)
2	Determine net settlement amount (balance				Program to provider	.01			2.01
	due) based on the cost report. (1)				Provider to program	.50			2.50
3	Name of Contractor			Contractor Number			NPR Date (mm/dd/yyyy)		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
5	TDAPA								5
6	TPNIES								6
7	CRA TPNIES								7
8	HDPA								8
9	PPA								9
FORM CMS-265-11 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4215)
Rev.									42-317

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Sheet 16: F

4290 (Cont.)		FORM CMS-265-11						DRAFT
BALANCE SHEET				PROVIDER CCN:		PERIOD:	WORKSHEET F
						From:
						To:
	ASSETS (omit cents)
	CURRENT ASSETS		Amount
1	Cash on hand and in banks			1
2	Temporary investments			2
3	Notes receivable			3
4	Accounts receivable			4
5	Other receivables			5
6	Less: allowances for uncollectible notes and accounts receivable			6
7	Inventory			7
8	Prepaid expenses			8
9	Other current assets			9
10	Due from other funds			10
11	TOTAL CURRENT ASSETS (sum of lines 1 through 10)			11
	FIXED ASSETS
12	Land			12
13	Land improvements			13
14	Less: Accumulated depreciation			14
15	Buildings			15
16	Less Accumulated depreciation			16
17	Leasehold improvements			17
18	Less: Accumulated Amortization			18
19	Fixed equipment			19
20	Less: Accumulated depreciation			20
21	Automobiles and trucks			21
22	Less: Accumulated depreciation			22
23	Major movable equipment			23
24	Less: Accumulated depreciation			24
25	Minor equipment nondepreciable			25
26	Other fixed assets			26
27	TOTAL FIXED ASSETS (sum of lines 12 through 26)			27
	OTHER ASSETS
28	Investments			28
29	Deposits on leases			29
30	Due from owners/officers			30
31	Other assets			31
32	TOTAL OTHER ASSETS (sum of lines 28 through 31)			32
33	TOTAL ASSETS (sum of lines 11, 27, and 32)			33
	LIABILITIES AND FUND BALANCES (omit cents)
	CURRENT LIABILITIES
34	Accounts payable			34
35	Salaries, wages & fees payable			35
36	Payroll taxes payable			36
37	Notes & loans payable (Short term)			37
38	Deferred income			38
39	Accelerated payments			39
40	Due to other funds			40
41	Other current liabilities			41
42	TOTAL CURRENT LIABILITIES (sum of lines 34 through 41)			42
	LONG TERM LIABILITIES
43	Mortgage payable			43
44	Notes payable			44
45	Unsecured loans			45
46	Other long term liabilities			46
47				47
48	TOTAL LONG TERM LIABILITIES (sum of lines 43 through 47)			48
49	TOTAL LIABILITIES (Sum of lines 42 and 48)			49
	CAPITAL ACCOUNTS
50	FUND BALANCES			50
51	TOTAL LIABILITIES AND FUND BALANCES (sum of lines 49 and 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								Rev.

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Sheet 17: F-1

04-21					FORM CMS-265-11				4290 (Cont.)
STATEMENT OF REVENUES AND EXPENSES						PROVIDER CCN:	PERIOD:	WORKSHEET F-1
							From:
							To:
						Amount	Amount
1	Total patient revenues							1
2	Less: Allowances and discounts on patients' accounts							2
3	Net patient revenues (line 1 minus line 2)							3
4	Operating expenses (from Worksheet A, column 6, line 27)							4
5	Additions to operating expenses (specify)							5
6								6
7								7
8								8
9								9
10								10
11	Subtractions from operating expenses (specify)							11
12								12
13								13
14								14
15								15
16								16
17	Less total operating expenses (net of lines 4 through 16)							17
18	Net income from services to patients (line 3 minus line 17)							18
	Other income:
19	Contributions, donations, bequests, etc.							19
20	Income from investments							20
21	Purchase discounts							21
22	Rebates and refunds of expenses							22
23	Sale of medical and nursing supplies to other than patients							23
24	Sale of durable medical equipment to other than patients							24
25	Sale of drugs to other than patients							25
26	Sale of medical records and abstracts							26
27	Other revenues (specify)							27
28								28
29								29
30								30
31								31
31.50	COVID-19 PHE funding							31.50
32	Total Other Income (sum of lines 19 through 31)							32
33	Net Income or Loss for the period (line 18 plus line 32)							33
FORM CMS-265-11 (04/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)
Rev. 6									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