Crosswalk: Interim Cost Report

I. Interim Cost Report Crosswalk 508.pdf

Prepaid Health Plan Cost Report (CMS-276)

Crosswalk: Interim Cost Report

OMB: 0938-0165

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Revisions Crosswalk (Form 276-25)
Interim Reporting
Note: In the Changes to Application column, the quoted words are what are to be entered. Example in issue #1 is “276-25”, do not enter the words that
explain the change and that are outside of the quotations.
Issue
Page #
#
1.
Worksheet S

Section

2.

Worksheet S

Row 68

3.

Worksheet C

Row 33

Row 59

Action to be
performed
Change form
number
Remove

Changes to the Application

Reason for the Change

Changed form number 276-22 to “276-25”.

Change form
number

Changed form number 276-22 to “276-25”.

To reflect the most recent change in the
form number/year
This date is not determined until approval
of the PRA package renewal.
To reflect the most recent change in the
form number/year.

Remove Form Expiration Date: : 9/30/2025

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File Typeapplication/pdf
File TitleInterim Reporting Changes from 2022 to 2025
SubjectInterim Reporting Changes from 2022 to 2025
AuthorCMS
File Modified2025-01-22
File Created2025-01-16

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