Fillable Extended Repayment Schedule (ERS) Request Form (Medicare & Medicaid)

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Extended Repayment Schedule (ERS) Request Form (Medicare & Medicaid)

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Extended Repayment Schedule (ERS) Request Form
All elds are required
Provider Name: Provider Number (PTAN): NPI Number:
Provider State: Contact Name: Contact Title:
Contact Email Address: Contact Telephone Number:
Overpayment Type: Date of Demand Letter: Overpayment Amount:
No. of Months Requested for ERS (>6 months - <60 months):
Rationale for ERS Request:
I authorize the MAC to automatically apply underpayments and/or manual refunds
to this Extended Repayment Schedule (Yes/No):
Signature: Date:
55205FC
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55205FC
Extended Repayment Schedule (ERS) Request Form
Part A/B – Sole Proprietor
PTAN: NPI:
A provider is expected to repay any overpayment promptly. If repaying an overpayment within 30 days would
constitute a “hardship” on the provider, a request for an Extended Repayment Schedule (ERS) should be
submitted immediately. However, if the overpayment is outstanding and not referred to Treasury, the provider shall
request an ERS beyond 30 days. An ERS is not a request to delay an overpayment due date.
• In order to qualify for an ERS, the provider must meet the “hardship” rule. Hardship exists
when the total amount of all outstanding overpayments (principal and interest) not included
in an approved, existing repayment schedule is 10 percent or greater than the total Medicare
payments made for: (1) the cost reporting period covered by the most recently submitted cost
report; or (2) the previous calendar year for a non-cost report provider.
• If a complete ERS request with all required documentation and good faith payment are
received, recoupment will be ceased, unless payments are currently being suspended or
withheld for other reasons.
• If an ERS request is received with all documentation but no good faith payment, the provider
will be placed on 30% recoupment, until payment is received.
• If an incomplete ERS request is received, the provider will be placed on no less than 30%
recoupment, until all documentation is received. The Medicare Administrative Contractor (MAC)
will review and request all missing documentation. If information is not received by the 16 day,
the ERS request will be closed and full collection activities will resume.
• Recouped funds that occur while processing an ERS request shall not be refunded.
• Payments must continue to be submitted every 30 days until the provider receives written
approval/denial instructing otherwise. Payments should be made payable to ‘Medicare Part --
(A or B)’ and referenced ‘ERS’.
• ERS requests greater than 36 months will be referred to CMS for nal decision.
All ERS requests and documentation should be submitted to the email: FCSO-ERS@FCSO.com
Payments: ERS Processing
First Coast Service Options, Inc.
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
(via priority mail or commercial carrier)
All items mailed to the above address should also be communicated to the above email.
55205FC
ERS Checklist of Required Documentation
To be considered for an ERS request, the following documentation is required. Required documentation must be submitted to
the contractor in order to begin the process of determining nancial hardship. If you are unable to furnish one or more of
the required documents, please submit a statement explaining the reason for the delay or inability.
Items Included? (Yes, No, N/A = Not Applicable (provide explanation))
For all ERS requests (6 – 60 months):
1. Extended Repayment Schedule (ERS) Request Form – Page 3.
2. Overpayment Notication Letter(s) – Provide a copy of the Overpayment Notication Letter(s) requesting an
ERS on.
3. Signed Proposed Amortization schedule – The schedule should contain the length of proposed repayment,
dates of payment, and payment amounts separated between principal and interest. Applicable interest rate is
indicated within the initial overpayment letter.
4. Installment Payments – Submit the rst installment payment, per the proposed amortization schedule, along
with future payments while under review (every 30 days). Provide check and tracking copies.
For ERS requests 12 months or greater (12 - 60 months):
5. Form CMS-379 – Form must be fully completed and signed by the provider. The information requested on this
form is necessary to determine if the provider will be able to make installment payments on a claim. Form may
be retrieved from the CMS website: www.CMS.gov
6. Financial Statements – of Debtor (to support form CMS-379).
7. Income Tax Return – A copy of the provider’s income tax ling for the most recent calendar year.
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Extended Repayment Schedule (ERS) Request Form (Medicare & Medicaid)

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Completed 10 January 2021

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