Riverbend

CMS 222-92

CMS Form 222-92 COST REPORT PACKAGE REQUIREMENTS

• See Vendor Contacts  for information to obtain electronic software
•  A diskette,CD, of Flash Drive containing the ECR and PI files.
•  A printout of Worksheet S with the encryption codes and an original signature of an Officer or Administrator.
•  A completed CMS Form-339. This form should also contain an original signature of an Officer or Administrator. See below for links to the CMS 339 Forms and instructions
• The following is a list of items that are required to be submitted. Please submit this information in electronic format whenever possible.  If these items are not included with your Cost Report Package, we will reduce or withhold your tentative settlement for failure to submit these items: 
  •  The required supporting documentation for Form CMS-339.
  •  One (1) copy of the Working Trial Balance
  •  Documentation to support worksheet A-1 reclassifications
  •  Documentation to support worksheet A-2 adjustments
  •  Documentation to support worksheet A-2-1 related organization cost
  • Bad Debt Log information can be found within FLASH 05-04 on the Riverbend website
  • One (1) copy of your financial auditors’ Management Letter, if available.
  •  Two (2) copies of your Audited Financial Statements, if available.
  •  Logs to support Medicare Pneumococcal and Influenza Vaccine cost 
  •  Sanctioned Certification Statement -- See forms

If your submitted Cost Report shows an overpayment due to Medicare, a check for the total amount is due. 

If any of these items are not submitted, the Cost Report Package will be considered incomplete and the cost report will be rejected.

Mailing Address:
Riverbend Government Benefits Administrator, Inc.
ATTN: Audit & Reimbursement Department
730 Chestnut Street
Floor 3C
Chattanooga, TN  37402-1790