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Checklist for Home Health and Hospice Cost Report Submission

The following checklist is intended to help a provider ensure all required items are submitted with a Home Health Agency (HHA) or Hospice cost report. Please ensure that the following items are included with the cost report submission:

  • A CD, flash drive, or diskette containing the Electronic Cost Report (ECR) file prepared on CMS approved vendor software.
  • ECR file must pass ALL Level 1 edits.
  • Print Image (PI) file of the cost report on the CD, flash drive, or diskette.
  • Worksheet S with encryption codes and original signature of Officer or Administrator.
  • The encryption code, date, and time displayed on the certification page must match exactly with that of the ECR and PI encryption code, date and time.
  • CMS Form 339 with original signature of Officer or Administrator and applicable supporting documents.
  • If cost report indicates an amount is due to Medicare, a check made payable to Medicare is mailed under separate cover to the lockbox as follows:

    CGS J15 HH and H Region B
    PO Box 957124
    St. Louis, MO 63195-7124

  • Listing of Medicare bad debts if claimed on the cost report.
  • A copy of the working trial balance to support expenses.
  • Documentation to support reclassification entries, adjustment entries, and related party entries.
  • Documentation to support total flu vaccine cost and charges.

Updated: 12.21.11

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