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:
55203FC
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Extended Repayment Schedule (ERS) Request Form
Part A/B – Not a 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 due
date, 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.
55203FC
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 4.
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. Balance Sheets – The most current balance sheet (within 3 months of the date of the request) and the
balance sheet for the most recent full scal year (preferably prepared by the provider’s accountant).
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 including compilation report, or audited including audit packet) nancial statements for the last two scal year end
reporting periods are required in addition to the current interim nancial statements. This would include Balance Sheets, Income
Statements, and Statements of Cash Flow.
If consolidated statements (including more than one entity) are submitted, separate statements showing the individual provider’s
contribution must also be submitted.
Interim period ending:
Fiscal Year Ending 1:
Fiscal Year Ending 2:
6. Income Statements – Related to each of the balance sheets. Including revenue breakdown by payer (e.g.,
Medicare, Medicaid, Private Pay).
7. Cash Flow Statements – For the periods covered by each of the balance sheets. This statement should
identify beginning and ending cash balances.
If the date of the request for an ERS is more than three months after the date of the most recent balance sheet,
a cash ow statement should be prepared for all months between that date and the date of the request.
55203FC
8. Projected Cash Flow Statement – From the date of the interim period, covering the remainder of the scal
year. If fewer than six (6) months remain, a projected cash ow statement for the following scal year should be
included.
Projected scal year end:
Following scal year end:
9. Certication Statement - The nancial statements submitted must contain a certication regarding
misrepresentation or falsication of information. Page 5.
10. Parent Financial Statements – If an outside facility manages the nancial aspects of the business, nancial
records for the outside facility must be submitted as well, for all periods related to the balance sheets.
Explanation:
11. Occupancy Mix (Part A Only) – by type of patient (e.g., Medicare, Medicaid, Private Pay) total patient days,
available bed days, and number of Medicare certied beds for the periods the income statements cover.
Explanation:
12. 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 AR, Notes Receivable, etc.
Explanation:
13. Schedule showing types and 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.
Explanation:
14. Investments - List of investments by type (stock, bond, etc.), amount, and current market value as of the date
of the report
Explanation:
15. Restricted Cash - List of restricted cash funds by amounts as of the date of the ERS request and the purpose
for which each fund is to be used.
Explanation:
16. Notes and Mortgages - List of notes and mortgages payable by amounts as of the date of the report, and
their maturity dates.
Explanation:
55203FC
Certication Statement
Balance Sheets and Income Statements
For an Extended Repayment Schedule
“MISREPRESENTATION AND FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS BALANCE SHEET OR
INCOME STATEMENT SHALL BE PUNISHABLE BY FINE AND/OR IMPRISIONMENT UNDER FEDERAL LAW.”
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.
CERTIFIED BY:
OFFICER TITLE:
SIGNATURE:
Date:
55203FC
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Extended Repayment Schedule (ERS) Request Form (Medicare & Medicaid)

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Completed 10 January 2021

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