Medicare Program; Uniform Electronic Cost Reporting System for Hospitals

DEPARTMENT OF HEALTH AND HUMAN SERVICES

42 CFR Part 413

[BPD-689-FC]

RIN 0938-AE80

Medicare Program; Uniform Electronic Cost Reporting System for

Hospitals

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Final rule with comment period.

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SUMMARY: This final rule with comment period implements the provisions

of section 4007(b) of the Omnibus Budget Reconciliation Act of 1987, as

amended by section 411(b)(6) of the Medicare Catastrophic Coverage Act

of 1988, which require the Secretary to place into effect a

standardized electronic cost reporting system for all hospitals under

the Medicare program. Under this final rule with comment period, all

hospitals are required to submit their cost reports, for hospital cost

reporting periods beginning on or after October 1, 1989, in a uniform

electronic format. The Secretary may grant a delay or a waiver of this

requirement where implementation could result in financial hardship for

a hospital.

DATES: Effective date: These rules are effective June 24, 1994.

Comment date: Comments will be considered if we receive them at the

appropriate address, as provided below, no later than 5 p.m. on July

25, 1994. We are accepting comments concerning the requirement in

Sec. 413.24(f)(4)(ii), that cost reporting software be able to detect

changes to the electronic cost report made after the provider has

submitted it to the intermediary.

ADDRESSES: Mail written comments (1 original and 3 copies) to the

following address: Health Care Financing Administration, Department of

Health and Human Services, Attention: BPD-689-FC, P.O. Box 7517,

Baltimore, MD 21207.

If you prefer, you may deliver your written comments (1 original

and 3 copies) to one of the following addresses:

Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,

Washington, DC 20201, or

Room 132, East High Rise Building, 6325 Security Boulevard, Baltimore,

MD 21207.

Because of staffing and resource limitations, we cannot accept

comments by facsimile (FAX) transmission. In commenting, please refer

to file code BPD-689-FC. Comments received timely will be available for

public inspection as they are received, generally beginning

approximately 3 weeks after publication of a document, in room 309-G of

the Department's offices at 200 Independence Avenue, SW., Washington,

DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m.

(phone: (202) 690-7890).

FOR FURTHER INFORMATION CONTACT: Thomas Talbott (410) 966-4592.

SUPPLEMENTARY INFORMATION:

I. Background

Under Medicare, hospitals are paid for inpatient hospital services

that they furnish to beneficiaries under Part A (Hospital Insurance).

Currently, most hospitals are paid for their inpatient hospital

services under the prospective payment systems for operating and

capital costs in accordance with sections 1886(d) and (g) of the Social

Security Act (the Act) and 42 CFR part 412. Under these systems,

Medicare payment is made at a predetermined, specific rate for each

hospital discharge based on the information contained on actual bills

submitted.

Section 1886(f)(1)(A) of the Act provides that the Secretary will

maintain a system for reporting costs of hospitals paid under the

prospective payment systems. Section 412.52 requires all hospitals

participating in the prospective payment systems to meet the

recordkeeping and cost reporting requirements of Secs. 413.20 and

413.24, which include submitting a cost report for each 12-month

period.

The hospitals and hospital units that are excluded from the

prospective payment systems are generally paid an amount based on the

reasonable cost of services furnished to beneficiaries. The inpatient

operating costs of these hospitals and hospital units are subject to

the ceiling on the rate of hospital cost increases in accordance with

section 1886(b) of the Act and Sec. 413.40.

Sections 1815(a) and 1833(e) of the Act provide that no payments

will be made to a hospital unless it has furnished the information,

requested by the Secretary, needed to determine the amount of payments

due the hospital under the Medicare program. In general, hospitals

submit this information through cost reports that cover a 12-month

period.

All hospitals participating in the Medicare program, whether they

are paid on a reasonable cost basis or under the prospective payment

systems, are required under Sec. 413.20(a) to ``maintain sufficient

financial records and statistical data for proper determination of

costs payable under the program.'' In addition, hospitals must use

standardized definitions and follow accepted accounting, statistical,

and reporting practices. Under the provisions of Secs. 413.20(b) and

413.24(f), hospitals are required to submit cost reports annually, with

the reporting period based on the hospital's accounting year.

II. Legislation Concerning Electronic Reporting

On December 22, 1987, the Omnibus Budget Reconciliation Act of

1987, Public Law 100-203, was enacted. Section 4007 of Public Law 100-

203, which was subsequently amended by section 411(b)(6) of the

Medicare Catastrophic Coverage Act of 1988, Public Law 100-360, added

section 1886(f)(1)(B) of the Act, which sets forth several provisions

concerning the reporting of hospital information under the Medicare

program. Section 1886(f)(1)(B) of the Act applies to hospital cost

reporting periods beginning on or after October 1, 1989.

Section 1886(f)(1)(B)(i) of the Act provides that the Secretary

will place into effect a standardized electronic cost reporting format

for hospitals under Medicare. This standardized electronic cost

reporting format does not require any additional data from hospitals.

Section 1886(f)(1)(B)(ii) of the Act provides that the Secretary may

delay or waive the implementation of the electronic format in instances

where such implementation would result in financial hardship for a

hospital. As an example of a financial hardship situation, this section

of the Act specifically mentions hospitals with a small percentage of

inpatients entitled to Medicare benefits.

III. Provisions of the Proposed Regulations

On August 19, 1991, we published a proposed rule (56 FR 41110) to

implement sections 1886(f)(1)(B) (i) and (ii) of the Act. We proposed

that cost reports be submitted in a standardized electronic format. The

hospital's cost report software must be able to produce a standardized

output file in American Standard Code for Information Interchange

(ASCII) format. All intermediaries have the ability to read this

standardized file and produce an accurate cost report. The proposed

rule did not require the reporting of any additional information.

If a hospital refuses to submit the cost reports electronically,

Medicare payments to that hospital may be suspended under the

provisions of sections 1815(a) and 1833(e) of the Act. As explained

above, sections 1815(a) and 1833(e) of the Act provide that no Medicare

payments will be made to a hospital unless it has furnished the

information, requested by the Secretary, needed to determine the amount

of payments due the hospital under the Medicare program. Section

405.371(d) provides for suspension of Medicare payments to a hospital

by the intermediary if the hospital has failed to submit information

requested by the intermediary that is needed to determine the amount

due the hospital under Medicare. The general procedures that are

followed when Medicare payment to a hospital is suspended for failure

to submit information that is needed by the intermediary to determine

Medicare payment (that is, when a hospital fails to furnish a cost

report, furnishes an incomplete cost report, fails to furnish other

needed information, or fails to submit a cost report electronically)

are located in section 2231 of the Intermediary Manual (HCFA Pub. 13).

These procedures include timeframes for ``demand letters'' to

hospitals, which in addition to reminding hospitals to file timely and

complete cost reports, explain possible adjustments of Medicare

payments to a hospital and the right to request a 30-day extension of

the due date. If a hospital believes that implementation of the

electronic submission requirement would cause a financial hardship, the

hospital should submit a written request for a waiver or a delay of

these requirements, with supporting documentation, to the hospital's

intermediary.

IV. Discussion of Public Comments

In response to the proposed rule, we received six timely items of

correspondence. We have summarized the comments and are presenting them

below with our responses.

A. Requirements for Electronic Submission

Comment: A few commenters requested clarification concerning the

format for electronic reporting.

Response: HCFA provided approved vendors of cost reporting software

with a uniform standardized format for the creation of the required

ASCII file. This format shows how each unique record must be displayed

in the electronic file in terms of worksheet, line, and column

position. The specifications required to complete a computerized

Medicare Cost Report have been in effect since the inception of the

Automated Desk Review (ADR) program in 1983. There are presently three

vendors approved by HCFA for the ADR system. Eight other commercial

vendors are approved by HCFA for electronic compilation of the Medicare

cost report. A hospital may use any of the 11 vendors for purposes of

filing an electronically prepared cost report. Each of the 11 vendors

must undergo periodic testing in which it develops and submits to HCFA

a completed cost report to demonstrate its system's ability to conform

to HCFA's display standards. No hospital may file its cost report

electronically unless the commercial software system it uses has

completed the testing process and been approved by HCFA.

In addition, when the provider files the cost report with the

intermediary, the cost report must pass edits specified in the Provider

Reimbursement Manual, Part II, before the intermediary can accept it.

If the cost report fails to pass these edits the intermediary will

immediately reject the cost report and return it to the provider for

correction. The cost report will be considered late if the provider

fails to correct it before the due date. The provider will be subject

to withholding of interim payments until the intermediary receives the

corrected cost report.

Comment: Several commenters questioned the need to file a hard copy

cost report in addition to submitting the electronic cost report.

Additionally, commenters were concerned with the lack of a written

statement certifying the accuracy of the electronic cost report. One

commenter suggested that HCFA require providers to submit a written

certification with the electronic cost report.

Response: We agree with the commenters concerns regarding the need

to file a hard copy cost report and the lack of a statement certifying

the accuracy of the electronic file. Therefore, effective for cost

reporting periods ending on or after October 1, 1994, we are

eliminating the requirement that providers file a hard copy of the cost

report in addition to the electronic file. In new

Sec. 413.24(f)(4)(iii), we specify that instead of a hard copy cost

report, providers must submit a hard copy of the certification

statement, settlement summary, and a statement of certain worksheet

totals found within the cost report file. We note that the

certification statement provides that in signing the statement, the

provider's administrator or chief financial officer is certifying the

accuracy of the data contained in the electronic cost report or, if the

provider has filed a manually prepared report, in the hard copy cost

report.

We believe that these changes will reduce the burden on providers

and ensure the accuracy of the data contained in the electronic file.

However, we also need to ensure that the electronic cost report is not

altered once it leaves the provider. Thus, in conjunction with the

changes made based on public comment, we are implementing a series of

changes designed to preserve the integrity of the electronic cost

report once the provider files it with the intermediary. First, we are

specifying in new Sec. 413.24(f)(4)(ii) that the provider's software

must be capable of disclosing that changes have been made to the cost

report file after the provider has submitted it to the intermediary.

Specifically, electronic cost reporting software will be modified so

that the cost report will calculate a ``hash total'', that is, a number

representing the sum of the worksheet totals (mentioned above)

contained in the provider's as filed cost report. If any data in the

electronic file is changed after the hash total is calculated, the

electronic file will disclose that a change has been made. We will

instruct all automated data reporting vendors to develop the capability

to calculate hash totals and disclose changes for all their provider

clients. Second, we are specifying in regulations that an intermediary

may not alter a cost report once it has been filed by a hospital and

must reject any cost report that does not pass all specified edits and

return it to the provider for correction. Third, HCFA will make

periodic checks to ensure that the totals in the electronic file agree

with those totals certified by the provider's administrator or chief

financial officer.

Because providers may not have anticipated such substantial changes

as a result of this rule, we are soliciting comments concerning the

requirement in new Sec. 413.24(f)(4)(ii) that cost report software be

able to disclose changes to the electronic file made after the provider

has submitted it to the intermediary.

Comment: One commenter requested that the intermediary be required

to report back to the provider in electronic cost reporting format the

audit adjustments made to the provider's cost report. This would allow

providers to readily add the audit adjustments to the electronic cost

report for future reference.

Response: We recognize the merit of this suggestion and will

consider implementing this process in the future. The intermediaries

would need additional computer programming to be able to provide

hospitals with an electronic file of audit adjustments. We will discuss

the commenter's suggestion with the 11 approved vendors of cost report

software to determine the extent of additional programming needed and

the financial implications.

B. Waiver Process

Comment: Several commenters requested guidance concerning the

process for seeking a delay in or waiver from the electronic submission

requirement. The commenters also wanted to know under what

circumstances HCFA would grant a delay or waiver. Commenters suggested

that HCFA define the term ``financial hardship'' as used in the

proposed rule.

Response: The Provider Reimbursement Manual, part II, section 130,

provides the guidelines for requesting a waiver. Basically, the

provider must make a written request to the intermediary at least 120

days before the close of the provider's cost reporting period. The

intermediary reviews the request and forwards it, with a recommendation

for approval or denial, to HCFA's central office within 30 days of

receipt of the request. The central office informs the intermediary

whether the waiver is approved or denied within 60 days of receipt of

the request in the central office.

Because of the varying financial circumstances of hospitals and

other health care providers that participate in the Medicare program,

we believe that it would be inappropriate to establish a definition of

``financial hardship'' or a set of specific criteria that a provider

would need to meet to qualify for a waiver of the electronic cost

reporting requirement. We believe that the best method for determining

whether a provider qualifies for a waiver is to consider requests on a

case by case basis.

To date, we have received only eight requests for waiver. We

believe that the small number of requests indicates that the majority

of providers will not experience financial hardship as a result of

electronic cost reporting. In addition, in an effort to minimize the

number of providers that need a waiver, we developed a software package

that will enable the hospital to file an electronic data set to its

fiscal intermediary in order to generate an electronic cost report. We

are providing the software package to hospitals free of charge.

Therefore, we believe that with the availability of the free software,

it will be difficult for a provider to demonstrate financial hardship.

Comment: A commenter recommended that HCFA provide an automatic

waiver of electronic cost report filing in each instance in which a

waiver of standard or full cost reporting has been granted, including

those cases where full cost reporting has been waived because of a low

percentage of Medicare inpatients.

Response: HCFA will grant an automatic waiver of electronic cost

reporting if a provider is exempt from full or standard cost reporting.

To qualify for an automatic waiver of electronic cost reporting, the

provider must apply and qualify for an exemption from full or standard

cost reporting in accordance with the rules that provide for the

exemption. For example, a provider that does not furnish any covered

services to Medicare beneficiaries is exempt from filing a full cost

report and instead must submit an abbreviated report under

Sec. 413.24(g). Additionally, a provider with low program utilization

may obtain a waiver from filing a full cost report in accordance with

Sec. 413.24(h). When the intermediary notifies a provider that it

qualifies for an exemption from filing a full cost report, the provider

also will be notified of the exemption from electronic filing.

Providers must apply for a waiver of full cost reporting for each new

cost reporting period. Providers that are not exempt from full cost

reporting must file for a waiver according to the procedure set forth

in section 130 of the Provider Reimbursement Manual, part II, as

discussed above.

C. Sanctions

Comment: Commenters requested HCFA's position regarding the

penalties assessed against a provider for failing to file its cost

report electronically.

Response: Sections 1815(a) and 1833(e) of the Act provide that no

payments will be made to a hospital unless it has furnished the

information requested by the Secretary needed to determine the amount

of payments due the hospital under the Medicare program. Section

405.371(d) provides for suspension of Medicare payments to a hospital

by the intermediary if the hospital fails to submit a cost report,

submits an incomplete cost report, or fails to furnish other needed

information. Section 2409.1(A)(1) of the Provider Reimbursement Manual

(PRM 15-I) addresses the procedures an intermediary will follow when a

provider fails to submit a cost report or when the cost report is

overdue. Unless the provider has received a waiver from electronic cost

reporting, the intermediary will consider a timely filed cost report

that is not filed electronically as an overdue cost report for purposes

of section 2409.1(A)(1). We will update this section of the manual to

reflect our position regarding sanctions for failure to file cost

reports electronically.

D. Cost of Implementation

Comment: A commenter disagreed with our statement in the impact

analysis of the proposed rule that hospitals would not be significantly

affected by electronic cost reporting. The commenter stated that some

hospitals had to make expensive changes in personnel or software to

comply with the regulations and that the cost of maintaining the

required software was an additional burden on providers. The commenter

suggested that HCFA pay providers for the cost of implementing the

electronic cost reporting requirement including the cost of equipment,

software, additional personnel, external consultants, and any related

overhead costs.

Response: Section 1886(f)(1)(B) of the Act does not authorize HCFA

to subsidize any of the costs hospitals incur in implementing

electronic cost reporting. However, it does authorize the waiver or

delay of the implementation of the electronic format in cases of

financial hardship. As discussed above, if computer support required

for electronic cost reporting will cause financial hardship, the

hospital may request a waiver from electronic filing.

V. Provisions of the Final Regulations

In this final rule with comment, we are revising the provisions set

forth in the proposed rule. Based on public comment, we are eliminating

the requirement that providers file a hard copy cost report in addition

to the electronic file. Also based on public comment, we are adding a

new paragraph (iii) to Sec. 413.24(f)(4) to provide that in addition to

the electronic file, a hospital must submit hard copies of a settlement

summary, a statement of certain worksheet totals found in the

electronic file, and a signed statement certifying the accuracy of the

electronic file or the manually prepared cost report.

In addition to the changes made based on public comment, we are

adding a new paragraph (ii) to Sec. 413.24(f)(4) to provide the

following:

All cost reporting software must be able to disclose that

changes have been made to the electronic file after the provider has

submitted its cost report to the intermediary.

The intermediary may not alter the cost report once it has

been filed by the provider.

The intermediary rejects any cost report that does not

pass all specified edits and returns it to the provider for correction.

As a result of the above changes to the regulations text, proposed

Sec. 413.24(f)(4)(ii) has been redesignated as Sec. 413.24(f)(4)(iv).

VI. Collection of Information Requirements

Section 413.24 of this final rule with comment contains information

collection and recordkeeping requirements that are subject to review by

the Office of Management and Budget (OMB) under the Paperwork Reduction

Act of 1980 (44 U.S.C. 3501 et seq.). These information collection and

recordkeeping requirements are not effective until they have been

approved by OMB. We have submitted a copy of this final rule with

comment to OMB for review of the information collection requirements.

Approximately 90 percent of hospitals participating in Medicare

have filed electronic cost reports before the effective date of this

regulation, that is with cost reporting periods beginning on or after

October 1, 1989. These providers will now have to file a diskette

containing the required cost report data in a standard format. This

diskette will contain input data only. We believe that minimal time

would be needed for hospitals to become familiar with the revised

software furnished by their cost reporting vendor. The remaining 10

percent of the hospitals previously filed manually prepared cost

reports. While these hospitals will initially experience an additional

reporting burden, we believe that once they are familiar with

electronic reporting, there will no longer be an additional burden and

there may even be a decrease in burden since the time needed to compute

the cost report will no longer be required.

VII. Response to Comments

Because of the number of items of correspondence we normally

receive on Federal Register documents published for comment, we are not

able to acknowledge or respond to them individually. We will consider

comments we receive by the date and time specified in the ``DATES''

section of this preamble, and, if we proceed with a final rule, we will

respond to comments in the preamble to that document. Specifically, we

are soliciting comments concerning the requirement in new

Sec. 413.24(f)(4)(ii) that cost reporting software be able to detect

changes made to the electronic file after the provider has submitted it

to the intermediary. We will not consider comments concerning

provisions that remain unchanged from the August 19, 1991 proposed rule

or provisions that were changed based on public comment.

VIII. Impact Statement

Unless the Secretary certifies that a final rule will not have a

significant economic impact on a substantial number of small entities,

we generally prepare a regulatory flexibility analysis that is

consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601

through 612). For purposes of the RFA, all hospitals and small

businesses that distribute cost-report software to hospitals are

considered to be small entities. Intermediaries are not included in the

definition of a small entity.

Section 1102(b) of the Act requires the Secretary to prepare a

regulatory impact analysis if a final rule may have a significant

impact on the operations of a substantial number of small rural

hospitals. Such an analysis must conform to the provisions of section

603 of the RFA. For purposes of section 1102(b) of the Act, we define a

small rural hospital as a hospital that has fewer than 50 beds and is

located outside of a Metropolitan Statistical Area.

Under the provisions of Secs. 413.20(b) and 413.24(f), hospitals

are required to submit cost reports annually, with reporting periods

based on the hospital's accounting year. This is generally a

consecutive 12-month period. Section 1886(f)(1)(B)(i) of the Act now

requires the use of a standardized electronic cost reporting format for

hospitals. There are approximately 11 national software suppliers that

distribute cost report software packages to hospitals. In addition,

HCFA offers a cost reporting software package that is available at no

expense to any hospital that requests it.

As discussed in the proposed rule, computer software suppliers and

hospitals that purchased their software will not be significantly

affected by these provisions. Suppliers will not need to develop new

software and hospitals will not need to purchase new software but only

revise the software or have the cost report portion of the software

revised based on standard format requirements set by HCFA. Although the

cost report portion of software packages will be exactly the same,

competition among suppliers will not be adversely affected since each

offers other features that make its product unique.

Hospitals that will be most affected by this final rule with

comment period are those that may be unable to afford the equipment to

submit electronically. These hospitals might include hospitals that

have very few Medicare beneficiaries and small rural hospitals.

Hospitals that have access to computer equipment can utilize and

benefit from HCFA's free software if they are unable to afford the

software that is available from suppliers. However, as stated above, we

have received only eight requests for waiver of electronic cost

reporting. We believe that the small number of requests indicates that

the vast majority of hospitals will not experience financial hardship

due to the requirements of this final rule with comment period.

In conclusion, this final rule with comment period will not have a

significant effect on hospital costs since hospitals will not be

required to collect any additional data beyond that which the

regulations currently specify; cost-report software is available at no

cost from HCFA to any hospital that requests it; and most hospitals

have some type of computer equipment through which they are currently

submitting electronically prepared cost reports. Hospitals will only be

affected to the extent that all would be required to submit cost

reports in a standardized electronic format to their respective

intermediary. A hospital that does not comply with the provisions of

this rule, as specified in the preamble, will be subject to sections

1815(a) and 1833(e) of the Act, which provide that no payments will be

made to a hospital unless it has furnished the information requested by

the Secretary that is needed to determine the amount of payments due

the hospital under Medicare.

This final rule with comment period will not have a significant

effect on a substantial number of Medicare participating hospitals or

software suppliers. Therefore, a regulatory flexibility analysis is not

required. We are not preparing a rural impact statement since the

Secretary certifies that this final rule with comment period will not

have a significant economic impact on the operation of a substantial

number of small rural hospitals. In accordance with the provisions of

Executive Order 12866, this regulation was not reviewed by the Office

of Management and Budget.

List of Subjects CFR Part 413

Health facilities, Kidney diseases, Medicare, Puerto Rico,

Reporting and recordkeeping requirements.

42 CFR part 413 is amended as set forth below:

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR

END-STAGE RENAL DISEASE SERVICES

A. The authority citation for part 413 is revised to read as

follows:

Authority: Sec. 1102, 1814(b), 1815, 1833(a), (i), and (n),

1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act (42

U.S.C. 1302, 1395f(b), 1395g, 13951(a), (i), and (n), 1395x(v),

1395hh, 1395rr, 1395tt, and 1395ww) and sec. 104(c) of Pub. L. 100-

360 as amended by sec. 608(d)(3) of Pub. L. 100-485 (42 U.S.C.

1395ww (note)); and sec 101(c) of Pub. L. 101-234 (42 U.S.C. 1395ww

(note)).

B. A new paragraph (f)(4) is added to Sec. 413.24 to read as

follows:

Sec. 413.24 Adequate cost data and cost finding.

* * * * *

(f) Cost reports. * * *

(4) Electronic submission of cost reports. (i) Effective for cost

reporting periods beginning on or after October 1, 1989, a hospital is

required to submit its cost reports in a standardized electronic

format. The hospital's electronic program must be capable of producing

the HCFA standardized output file in a form that can be read by

intermediary's automated system. This electronic file, which must

contain the input data required to complete the cost report and the

data required to pass specified edits, is forwarded to the fiscal

intermediary for processing through its system.

(ii) The fiscal intermediary may not alter the cost report once it

has been filed by the hospital. If a cost report does not pass all

specified edits, the fiscal intermediary rejects the cost report and

returns it to the hospital for correction. The hospital's electronic

program must be able to disclose that changes have been made to the

electronic cost report after the provider has submitted it to the

intermediary.

(iii) Effective for cost reporting periods ending on or after

October 1, 1994, a hospital must submit a hard copy of a settlement

summary, a statement of certain worksheet totals found within the

electronic file, and a statement signed by its administrator or chief

financial officer certifying the accuracy of the electronic file or the

manually prepared cost report. The following statement must immediately

precede the dated signature of the hospital's administrator or chief

financial officer:

I hereby certify that I have read the above certification

statement and that I have examined the accompanying electronically

filed or manually submitted cost report and the Balance Sheet

Statement of Revenue and Expenses prepared by ________ (Provider

Name(s) and Number(s)) for the cost reporting period beginning

________ and ending ________ and that to the best of my knowledge

and belief, this report and statement are true, correct, complete

and prepared from the books and records of the provider in

accordance with applicable instructions, except as noted. I further

certify that I am familiar with the laws and regulations regarding

the provision of health care services, and that the services

identified in this cost report were provided in compliance with such

laws and regulations.

(iv) A hospital may request a delay or waiver of the electronic

submission requirement in paragraph (f)(4)(i) of this section if this

requirement would cause a financial hardship. The hospital must submit

a written request for delay or waiver with necessary supporting

documentation to its intermediary at least 120 days prior to the end of

its cost reporting period. The intermediary reviews the request and

forwards it with a recommendation for approval or denial, to HCFA

central office within 30 days of receipt of the request. HCFA central

office either approves or denies the request and notifies the

intermediary within 60 days of receipt of the request.

* * * * *

(Catalog of Federal Domestic Assistance Program No. 93.773,

Medicare--Hospital Insurance; and Program No. 93.774, Medicare--

Supplementary Medical Insurance Program)

Dated: August 25, 1993.

Bruce C. Vladeck

Administrator, Health Care Financing Administration.

Approved: May 6, 1994.

Donna E. Shalala,

Secretary.

[FR Doc. 94-12459 Filed 5-24-94; 8:45 am]

BILLING CODE 4120-01-P