ERS Required Documentation– Provider is an Entity Other Than a Sole Proprietor

50.2 - ERS Required Documentation– Provider is an Entity Other Than 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 (NOT a physician/sole proprietor) furnish the following for an 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), 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 (NOT a physician/sole proprietor) furnish the following for 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. Balance sheets - the provider’s most current balance sheet and the balance sheet for the last complete Medicare cost reporting period (or the most recent fiscal year). NOTE: If the time period between the two balance sheets is less than 6 months (or the provider cannot submit balance sheets prepared by its accountant), it must submit balance sheets for the last two complete Medicare cost reporting periods (for providers that file a cost report) or for the last two complete fiscal years (for providers that don’t file a cost report). 4. Income statements - related to the balance sheets. The CMS requires that both the balance sheets and income statements include similar agreement language: MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS BALANCE SHEET OR INCOME STATEMENT SHALL BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. CERTIFICATION BY OFFICER/ADMINISTRATOR OF PROVIDER(S) (For physicians/suppliers, “CERTIFICATION BY OFFICER/OWNER OF DEBTOR(S)) I HEREBY CERTIFY that I have examined the balance sheet and income statement prepared by_______________________ and that, to the best of my knowledge and belief, it is a true, correct and complete statement from the books and records of the provider. Signed Officer/Administrator of Provider(s) Title (For physicians/suppliers: Officer/Owner of Debtor(s) Title) Date 5. Cash flow statements - for the periods covered by the balance sheets (see Exhibit 3 for recommended format). If the date of the provider’s request for an extended repayment schedule is more than 3 months after the date of the most recent balance sheet, a cash flow statement shall be provided for all months between that date and the date of the request. 6. Projected cash flow statement - from the date of the request and covering the remainder of the fiscal year. If fewer than 6 months remain, the provider shall include a projected cash flow statement for the following year. (See Exhibit 3 for recommended format.) 7. List of restricted cash funds - by amount as of the date of request and the purpose for which each fund is to be used (if applicable). 8. List of investments - by type (stock, bond, etc.), amount and current market value as of the date of the report (if applicable). 9. List of notes and mortgages payable - by amounts as of the date of the report, and their due dates (if applicable). 10. Schedule showing amounts - due to and from related companies or individuals included in the balance sheets. The schedule should show the names of related organizations/persons, TIN and NPI numbers. It shall also show where the amounts appear on the balance sheet-- such as Accounts Receivable, Notes Receivable, etc. 11. Schedule showing types - amounts of expenses (included in the income statements) paid to related organizations. The schedule shall show names of the related organizations, TIN and NPI numbers. 12. The percentage of occupancy- by type of patient (e.g., Medicare, Medicaid, private pay) and total available bed days for the periods the income statements cover. All financial records must be for the business participating in the program. It should not be for the owner if the business is a partnership or a corporation. If an outside facility manages the financial aspects of the business, the provider shall submit individual financial records, as well as the financial records of the outside facility.