Form CMS-685 Network Semi Annual Reprot

End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112

Network Semi Annual Report xlsx.xlsx

End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112

OMB: 0938-0657

Document [xlsx]
Download: xlsx | pdf

Overview

Network Semi Annual Jan-June
Network Semi Annual July-Dec

Sheet 1: Network Semi Annual Jan-June

Network Semi Annual Report January-June



























1. Contract #: 2. Name and Address of ESRD Network:


3. ESRD Network #:
4. Reporting Period Covered:

















































Medicare Costs 5. Transition Costs
6. General Requirements
7. Patient and Family Engagement
8. Evaluate and Resolve Grievances
9. Promote Use of ICH CAHPSs
10. Address Issues Identified
11. Patient Appropriate Access to
12. Vascular Access
13. Patient Safety: HAIs
14. Population Health
15. Support for ESRD QIP & Performance
16. Support for Facility Data Submission
17. BASE CONTRACT ONLY
18. SPECIAL PROJECTS



(C.3)
(C.4.1.A)
(C.4.1.B.1)
(C.4.1.B.3)
through Data Analysis (C.4.1.B.4)
in Center Dialysis Care (C.4.1.C)
Management (C.4.1.D)
(C.4.1.E)
Innovation Projects (C.4.2)
Improvement on QIP Measures (C.4.3.A)
to CROWNWeb and NHSN (C.4.3.B)
(Columns 5 -16)


# of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS
a. Direct Labor



























1. Name (Position)























0 $0.00

2. Name (Position)























0 $0.00

3. Name (Position)























0 $0.00

4. Name (Position)























0 $0.00

5. Name (Position)























0 $0.00

6. Name (Position)























0 $0.00

7. Name (Position)























0 $0.00

8. Name (Position)























0 $0.00

9. Name (Position)























0 $0.00

10. Name (Position)























0 $0.00

11. Name (Position)























0 $0.00

12. Name (Position)























0 $0.00

13. Name (Position)























0 $0.00

14. Name (Position)























0 $0.00

15. Name (Position)























0 $0.00

16. Name (Position)























0 $0.00

17. Name (Position)























0 $0.00

18. Name (Position)























0 $0.00

19. Name (Position)























0 $0.00

20. Additional Staff (attach Schedule)























0 $0.00

21. OT and Bonuses (attach Schedule) Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black
Subtotal Direct Labor 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00
b. Leave Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black



c. Fringe Benefits Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
SUBTOTAL - Leave/Fringe Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black 0 $0.00 0 $0.00
d. Subcontracts: Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
1. Physician/MRB Reviewers























0 $0.00

2. Other Consultants Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
a. Name























0 $0.00

b. Name























0 $0.00

c. Name























0 $0.00

d. Name























0 $0.00

3. Other Subcontractors























0 $0.00

SUBTOTAL - Subcontracts 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00
Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
e. Travel Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black
f. Other Direct Costs Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black
SUBTOTAL - Direct Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black 0 $0.00 0 $0.00
g. G&A Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
1. Rent Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
2. Furniture & Equipment Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
3. Telephone Expenses Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
4. Insurance Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
5. Other (attach Schedule) Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
G&A Subtotal Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black $0.00 Black $0.00

Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
TOTAL COSTS Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black 0 $0.00 Black $0.00





































































































































































































































































`



























Sheet 2: Network Semi Annual July-Dec

Network Semi Annual Report July-December































1. Contract #: 2. Name and Address of ESRD Network:


3. ESRD Network #:
4. Reporting Period Covered:





















































Base Contract (Only)
Base & Special Projects
Medicare Costs 5. Transition Costs
6. General Requirements
7. Patient and Family Engagement
8. Evaluate and Resolve Grievances
9. Promote Use of ICH CAHPSs
10. Address Issues Identified
11. Patient Appropriate Access to
12. Vascular Access
13. Patient Safety: HAIs
14. Population Health
15. Support for ESRD QIP & Performance
16. Support for Facility Data Submission
17. BASE CONTRACT ONLY
18. SPECIAL PROJECTS
19. CUMULATIVE TOTAL
20. CUMULATIVE TOTAL



(C.3)
(C.4.1.A)
(C.4.1.B.1)
(C.4.1.B.3)
through Data Analysis (C.4.1.B.4)
in Center Dialysis Care (C.4.1.C)
Management (C.4.1.D)
(C.4.1.E)
Innovation Projects (C.4.2)
Improvement on QIP Measures (C.4.3.A)
to CROWNWeb and NHSN (C.4.3.B)
(Columns 5 -16)

(January - December)
(January - December)

# of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS HOURS COSTS HOURS COSTS
a. Direct Labor































1. Name (Position)























0 $0.00

0 $0.00 0 $0.00
2. Name (Position)























0 $0.00

0 $0.00 0 $0.00
3. Name (Position)























0 $0.00

0 $0.00 0 $0.00
4. Name (Position)























0 $0.00

0 $0.00 0 $0.00
5. Name (Position)























0 $0.00

0 $0.00 0 $0.00
6. Name (Position)























0 $0.00

0 $0.00 0 $0.00
7. Name (Position)























0 $0.00

0 $0.00 0 $0.00
8. Name (Position)























0 $0.00

0 $0.00 0 $0.00
9. Name (Position)























0 $0.00

0 $0.00 0 $0.00
10. Name (Position)























0 $0.00

0 $0.00 0 $0.00
11. Name (Position)























0 $0.00

0 $0.00 0 $0.00
12. Name (Position)























0 $0.00

0 $0.00 0 $0.00
13. Name (Position)























0 $0.00

0 $0.00 0 $0.00
14. Name (Position)























0 $0.00

0 $0.00 0 $0.00
15. Name (Position)























0 $0.00

0 $0.00 0 $0.00
16. Name (Position)























0 $0.00

0 $0.00 0 $0.00
17. Name (Position)























0 $0.00

0 $0.00 0 $0.00
18. Name (Position)























0 $0.00

0 $0.00 0 $0.00
19. Name (Position)























0 $0.00

0 $0.00 0 $0.00
20. Additional Staff (attach Schedule)























0 $0.00

0 $0.00 0 $0.00
21. OT and Bonuses (attach Schedule) Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black
Black $0.00 Black $0.00
Subtotal Direct Labor 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00
b. Leave Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black



0 $0.00 0 $0.00
c. Fringe Benefits Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
Black $0.00 Black $0.00
SUBTOTAL - Leave/Fringe Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black 0 $0.00 0 $0.00 0 $0.00 0 $0.00
d. Subcontracts: Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
1. Physician/MRB Reviewers























0 $0.00

0 $0.00 0 $0.00
2. Other Consultants Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
a. Name























0 $0.00

0 $0.00 0 $0.00
b. Name























0 $0.00

0 $0.00 0 $0.00
c. Name























0 $0.00

0 $0.00 0 $0.00
d. Name























0 $0.00

0 $0.00 0 $0.00
3. Other Subcontractors























0 $0.00

0 $0.00 0 $0.00
SUBTOTAL - Subcontracts 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00
Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
e. Travel Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black

$0.00 Black $0.00
f. Other Direct Costs Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black

$0.00 Black $0.00
SUBTOTAL - Direct Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black 0 $0.00 0 $0.00 0 $0.00 0 $0.00
g. G&A Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
1. Rent Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
Black $0.00 Black $0.00
2. Furniture & Equipment Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
Black $0.00 Black $0.00
3. Telephone Expenses Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
Black $0.00 Black $0.00
4. Insurance Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
Black $0.00 Black $0.00
5. Other (attach Schedule) Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
Black $0.00 Black $0.00
G&A Subtotal Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black $0.00 Black $0.00 Black $0.00 Black $0.00

Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
TOTAL COSTS Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black 0 $0.00 Black $0.00 Black $0.00 Black $0.00









































































































































































































































































































`































File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00
© 2025 OMB.report | Privacy Policy