Palmetto GBA
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Jurisdiction 11 Home Health and Hospice
Conditions Under Which Less Than a Full Cost Report May be Filed: Low/No Utilization Cost Reports

If you did not furnish any covered services to Medicare beneficiaries or had low utilization of such services in a reporting period, a full cost report need not be filed. Conditions for qualifying for a low/no utilization cost report filing are described in the Centers for Medicare & Medicaid Services (CMS) Provider Reimbursement Manual, Publication 15-1, Section 2414.4B, and include the following:

  • There was no Medicare activity during the reporting period. A no-activity filing requires that you submit a statement on the agency's letterhead, signed by an authorized official, identifying the cost report period. This must state 1) no covered services were furnished during the reporting period, and 2) no claims for Medicare reimbursement will be filed for this reporting period. This statement must be accompanied by the signed certification page of the cost report (Worksheet S). The letter and signed cost report statement should be submitted to the intermediary within 30 days of the end of the cost report period. A no-activity report does not need to be filed electronically.
  • There was low Medicare utilization during the reporting period, defined by Palmetto GBA as net Medicare reimbursement less than $200,000. A low utilization filing requires that you submit the S series of the cost report and the worksheets that present the balance sheet and statement of revenues and expenses. A copy of the agency's trial balance should accompany this. By submitting a low-utilization filing, you agree that there will be no retroactive adjustment to the amounts received by your facility for covered services rendered to Medicare beneficiaries during the cost reporting period (as would be determined through a cost report settlement). The low-utilization filing should be submitted to the intermediary by the last day of the 5th month following the fiscal year end. This report does not need to be filed electronically, (The reports can be hand written. )
    • Home Health – Low Utilization – print and complete the forms on the attached file - CMS 1728-94 worksheets S, S-2, S-3, F and F-1
    • Hospice – Low Utilization – print and complete the forms on the attached file – CMS 1984-99 worksheets S, S-1, G, GII and G-2


last updated on 05/29/2012
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