CMS Pub. 100-16, ch. mc86c17a, § 20.2

All cost-based HMOs and CMPs must submit an independently certified cost report and

supporting documents to CMS no later than 180 days following the close of each contract

period that detail cost, utilization, and enrollment data for the entire contract period. (See

42 CFR 417.576(b)(1).)

An extension of time (not to exceed 30 days) to submit the report may be granted,

provided the HMO/CMP requests such extension before the due date of the cost report

and shows good cause for the extension. The final cost report shall be in the form and

detail required by CMS. This report will be used to make final settlement for the contract

period and should include, but is not limited to, the following:

The per capita costs incurred for the provision of covered services to the HMO/CMP's

Medicare enrollees during the contract period, including costs incurred by another

organization related to the HMO/CMP through common ownership or control;

• The final report should include a provision for “full reporting”, as required by

42 CFR 417.576(b)(2)(i)(B) and Section 4016 of CMS Pub. 75. (Medicare Health

Maintenance Organization Manual)

• The HMO/CMP's methods of apportioning costs among Medicare and other

enrollees, including non-enrolled patients receiving health care services on a fee-for-service or other basis; and

• Such information on enrollment and other data that CMS may require.

The total reasonable costs, which the HMO/CMP incurs, that are related to the

certification of the cost report are paid in full by CMS. However, other administrative

costs incurred by the HMO/CMP in preparing the cost reports, and other data required by

the program (other than costs related to reporting enrollment information) are included in

Plan Administration. CMS has the right to reject the independently certified cost report if

CMS has reason to believe the certifying firm was not independent of the HMO/CMP or

if CMS believes there are significant deficiencies in the report which have not been

properly addressed by the auditors. In addition, CMS may deny payment for those

additional costs incurred by the HMO/CMP for a deficient certification.

Unless the HMO/CMP requests and receives an extension of time for submitting the

certified cost report, CMS may consider the failure to report timely as evidence of a

likely overpayment and may initiate recovery of amounts previously paid, reduce current

interim payments, or both.