ERS Required Documentation --Physician is a Sole Proprietor (Rev. 12346;

50.1 – ERS Required Documentation --Physician is a Sole Proprietor (Rev. 12346; Issued:11-01-23; Effective:10-30-23; Implementation:10-30-23) A. The contractor shall require that the provider (physician/sole proprietor) furnish the following for Extended Repayment Schedule (ERS) request of 15 months or less: 1. Signed Proposed Amortization Schedule – The CMS requires a signed request, including a proposed monthly term and payment installment schedule, as a provider’s agreement to pay its overpayment through installment payments. Signatures submitted in electronic form are permissible. 2. Good Faith Payments – The CMS requires the provider to submit the first good faith payment (per the proposed amortization schedule) with the ERS application, along with any future payments due, while under review. Providers shall submit a good faith payment each month until the ERS review is decided. B. The contractor shall require that the provider (physician/sole proprietor) furnish the following for an ERS request of 16 months or more: 1. Signed Proposed Amortization Schedule – The CMS requires a signed request, including a proposed monthly term and payment installment schedule, as a provider’s agreement to pay its overpayment through installment payments. Signatures submitted in electronic form are permissible. 2. Good Faith Payments – The CMS requires the provider to submit the first good faith payment (per the proposed amortization schedule), along with any future payments due while under review. Providers shall submit a good faith payment each month until the ERS review is decided. 3. CMS-379 Form - a completed CMS -379 Form. The information requested on this form is necessary for the contractor to determine if the physician/sole proprietor will be able to make installment payments on a claim. 4. Financial Statements - of Debtor. 5. Income Tax Return - a copy of the provider’s income tax filing for the most recent calendar year.