ERS Decision Tree - JE Part A

What term length are you looking for?

Are you a Sole Proprietor?

Required documentation on ERS Request

• Request for Extended Repayment Schedule Application Form
• Demand letter copies
• Amortization Schedule - If there are multiple ARs with multiple interest rates, multiple amortization schedules must be done
• Good faith payment - Equivalent to one-month payment

Required documentation on ERS Request

• Request for Extended Repayment Schedule Application Form
• Demand letter copies
• Amortization Schedule - If there are multiple ARs with multiple interest rates, multiple amortization schedules must be done
• Good faith payment - Equivalent to one-month payment

Are you a Sole Proprietor?

Required documentation on ERS Request

• Request for Extended Repayment Schedule application form
• Demand Letter Copies
• Amortization - If there are multiple ARs with multiple interest rates, multiple amortization schedules must be done
• Good Faith Payment - Equivalent to one-month payment
• A completed Form CMS-379 (Financial Statement of Debtor)
• Income Tax Return from the most recent calendar year
• Financial Statements of the debtor

Required documentation on ERS Request

• Request for Extended Repayment Schedule application form
• Demand Letter Copies
• Amortization - If there are multiple ARs with multiple interest rates, multiple amortization schedules must be done
• Good Faith Payment - Equivalent to one-month payment
• Balance Sheets - Provider's most current balance sheet and balance sheet for last completed balance sheet for most recent fiscal year. Note: If time period between balance sheets is less than 6 months (or provider cannot submit balance sheets prepared by its accountant), must submit balance sheets for last two complete fiscal years
• Income Statements - related to balance sheets. Note: If time period between income statements is less than 6 months (or provider cannot submit income statements prepared by its accountant), must submit income statements for last two complete fiscal years
• Cash Flow Statements - For periods covered by balance sheets. If date of request for an extended repayment plan is more than three (3) months after date of most recent balance sheet, a cash flow statement should be prepared for all months between that date and date of request
• Projected Cash Flow Statement - From date of request and covering remainder of fiscal year. If fewer than six (6) months remain, provider shall include a projected cash flow statement for following year
• List of restricted cash funds - by amounts as of date of request and purpose for which each fund is to be used, if applicable
• List of investments - by type (stock, bond, etc.), amount, and current market value as of date of report, if applicable
• List of notes and mortgages payable - by amounts as of date of report, and their due dates, if applicable
• Schedule showing amounts - due to and from related companies or individuals included in balance sheets. Schedule should show names of related organizations/persons, TIN and NPIs. It shall show where amounts appear on balance sheet, such as Accounts Receivable, Notes Receivable, etc.
• Schedule showing types - amounts of expenses (included in income statements) paid to related organizations. Schedule shall show names of related organizations, TIN and NPIs
• The percentage of occupancy – by type of patient (Medicare, Medicaid, private pay) and total available bed days for the periods the income statements cover, if applicable.
• Note: All financial records must be for the business participating in the program. It should not be for the owner if the business is a partnership or a corporation. If an outside facility manages the financial aspects of the business, the provider shall submit individual financial records as well as the financial records of the outside facility.