Bankruptcy Forms

140.1 - Bankruptcy Forms (Rev. 13825; Issued: 06-11-26; Effective:07-13-26; Implementation: 07-13-26) Upon receipt of a bankruptcy notice, Contractors shall do the following: 1. Upon receipt of a bankruptcy notice, Contractors shall send the bankruptcy notice to the OPOLE IFM Bankruptcy mailbox at OPOLE_IFM_Bankruptcy@cms.hhs.gov for review and place the provider in a bankruptcy status in the Health Integrated General Ledger Accounting System (HIGLAS). 2. The servicing CMS Office will review the bankruptcy notice and seek legal advice, if appropriate. 3. The CMS Office will contact the Contractor/s, via e-mail, that services the bankrupt provider/s and provide detailed instructions on the proper handling of the provider/s in the HIGLAS and the System for Tracking Audit & Reimbursement (STAR), if applicable. 4. The Contractor shall provide a Bankruptcy Referral Checklist for the bankrupt provider/s. 5. The Bankruptcy Referral Checklist is now divided into two (2) tiers, each designed to gather the bankruptcy information within a reasonable timeframe. • Tier I - Information shall be submitted to the CMS Office within ten (10) business days of receipt of the CMS instructions regarding the bankruptcy notification. If the CPI Fraud Check results have not been received within the ten (10) business days, the Contractor shall submit the Tier I checklist with all required information and indicate that the CPI Fraud Check results are pending. The Contractor shall forward the CPI Fraud Check results to the CMS Office immediately upon receipt. • Tier II - Information shall be submitted to the CMS Office upon request. Exhibit 1 provides the required information to be submitted for Tier 1 and Exhibit 2 provides examples of required information for Tier II. Exhibit 1 Bankruptcy Referral Checklist Tier I (Submit to the CMS Office as an Excel file, via e-mail, within ten business days from receipt of the CMS Office’s instructions) Description MAC Response MAC Comments BNK Case Number Bankruptcy Court Petition Date Provider Name Provider Number (s) Provider Tax ID Number Any Claims Under Appeal (Y/N)? Any Overpayments in Appeal Status (Y/N)? Open Cost Reports (Y/N or N/A)? (Part A Only) Year & Status of Open Cost Reports? (Part A Only) Pending Cost Reporting Years in Appeal? (Part A Only) Pending Cost Report Reopening(s) (Y/N)? (Part A Only) Any Fraud Overpayments or Investigations (Y/N)? 1 Date of Fraud Cases, if applicable Evidence of a Recent or Pending CHOW (Y/N)? 1 Fraud Check Report Request Instructions 1. The Contractor shall email its fraud check request spreadsheet along with a completed CPI data request form (Attachment #1) to CPIFraudcheck-OFMDebt@cms.hhs.gov with the subject line “Contractor/Jurisdiction Fraud Check Request” (example – ABC/J2 Fraud Check Request). 2. The Contractor should expect to receive the fraud check report from CPI within one week of sending the fraud check request to CPI. The Contractor shall use the fraud check report to determine if the provider/supplier has an open fraud case. The Contractor shall include a copy of CPI’s completed fraud check report for the NPIs that are included in the Bankruptcy on the checklist spreadsheet Tier I that is sent to CMS. *Note: The CPI Fraud check applies to bankrupt providers with NPI’s. Bankrupt providers with no NPI’s should follow the current process of checking for fraud. Attachment #1 – Sample Fraud Check Request Form Exhibit 2 Bankruptcy Referral Checklist Tier II (Submit to the CMS Office upon request, via email) Examples: Provider Participating in Medicaid program? Provide copies of Demand Letters or Intent to Refer Letters Provide copies of ERS approval or Denial Letters Other Documents upon request such as provider agreements, surety bond letters, expected completion of cost report settlement, appeal outcomes, etc. Referral Checklist Instructions for Tier I: Category Data Element Instruction Example Tier I Bankruptcy Case Number Prescribed format for this field is Court Abbreviation + BNK Case Number TNMBKE-19-12345 Tier I Bankruptcy Court Court State and Region (if applicable) Tennessee Middle Tier I Petition Date Date Petition Filed in US Bankruptcy Court 01/01/2019 Tier I Provider Name Tier I Provider Number (s) HIGLAS Provider or Supplier Number 12-3456 Tier I Provider Tax ID Number 12-3456789 Tier I Any Claims Under Appeal (Y/N) Tier I Any Overpayments in Appeal Status (Y/N) If Yes, provide stage of Appeal (Ex: Reconsideration) Tier I Open Cost Reports (Y/N or N/A)? (Part A Only) If not Part A workload, list N/A Tier I Year & Status of Open Cost Reports? (Part A Only) If not Part A workload, list N/A Tier I Cost Reporting Years in Appeal (Part A Only) If not Part A workload, list N/A Tier I Pending Cost Report Reopening(s) (Y/N)? (Part A Only) Tier I Any Fraud Overpayments or Investigations (Y/N)? CPI Fraud Check Request Tier I Date of fraud cases, if applicable CPI Fraud Check Request Tier I Evidence of a Recent or Pending CHOW (Y/N)? Recent = Within a year of the Petition Date