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Instructions for Completing the Pro-Forma for Provider Self-Determination of Aggregate Cap Limitation

Ordering Required Reports from EIDM

To complete the Pro-Forma, order the following reports from Enterprise Identify Management System (EIDM), formerly IACS.

  1. The PS&R summary report for the cap period. The cap period is always 10/01 through 09/30 for the cap year.
    • Choose "Request Report".
    • Choose "Request Summary".
    • If needed, select your provider number and move to box on right; otherwise select By Service Type, dropdown box select All & continue.
    • Please change service period to match the dates cap period for which you are submitting. Do not use the default Fiscal service period(s) that match your agency's Fiscal Year End. (Format: MM/DD/YYYY)
      Cap year Payments
      Streamlined method Patient-by-patient proportional method
      2017 (Transition Year) 11/1/16-9/30/17 11/1/16-9/30/17
      2018 and later 10/1-9/30 10/1-9/30
    • Do not use the unduplicated Census count from this report as your Beneficiary count. (See #2 below to obtain your Beneficiary count)
    • Change from paid date to 08/01/2007
    • Select Report Format.
    • Select continue and submit to order the report.
    • The Hospice PS&R Summary report will be delivered to the Summary Report Inbox after processing (usually same day).

  2. Hospice Beneficiary Count Summary – Instructions for ordering the correct period are:
    • Choose "Request Report".
    • Choose "Request Miscellaneous".
    • From drop down box, choose "Hospice Cap Report".
    • Enter Beneficiary Identification Period (Format: MM/DD/YYYY).
      Cap year Beneficiaries
      Streamlined method Patient-by-patient proportional method
      2017 (Transition Year) 9/28/16-9/30/17 11/1/16-9/30/17
      2018 and later 10/1-9/30 10/1-9/30
    • Paid date: leave at default. Through date: should be left at current; however, must be on or after 12/31 to make a valid reporting.
    • The Report Type selected should match the method reported on line 1a of the Pro-forma and should match the prior year cap methodology. Note for new providers – The only option is the patient-by-patient proportional method.
    • Select Report Format.
    • Select continue and submit to order the report.
    • The Hospice Beneficiary Count Summary report will be delivered to the Miscellaneous Report Inbox after processing (usually same day).

Completing the Pro-Forma

Section Field Type Details
Header Required Enter your Provider Name, Provider Number and NPI Number.
Cap Year Ending date = 09/30 of the year reported (e.g., For the 2022 cap period, enter 09.30.2022.).
Line 1 Required Enter the total beneficiary count from the Hospice Beneficiary Count Summary report generated in EIDM.
Line 1a Required Enter the method used to count beneficiaries – streamlined or patient-by-patient proportional.
The method used needs to match the method used for the prior cap period.
New providers are required to use the patient-by-patient proportional method.
Line 1b Required Enter the paid through date (12/31 or later) on the Hospice Beneficiary Count Summary report.
Line 2 Required Enter the Statutory Cap Amount for the Cap Year.
CMS publishes the hospice cap amount in the annual final ruleExternal Website. The 2024 cap amount is $33,494.01.
Line 3 Not Required Allowable Medicare Payments:
This is a calculated field; no input is required.
Line 4 Required Enter the net reimbursement + Post-Sequestration Demo Reduction amount (if shown) from the summary PS&R (report types 810, 81A, 820 & 82A) for the cap period.
Note: If sequestration applies for the cap period, CGS will make the adjustment at the final cap determination.
Line 5 Not Required Payments in Excess of the Aggregate Cap Amount:
This is a calculated field; no input is required.
Certification Required An authorized person at the hospice must sign and type or print their name and title.
Enter the name and telephone number of a person at the hospice who CGS may contact for additional information.

Updated: 01.31.2025

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