06-13,,FORM CMS-265-11   ,,,,,4290 (Cont.)
ANALYSIS  OF  PAYMENTS  TO  PROVIDERS,,,  PROVIDER CCN:  , PERIOD: ,, WORKSHEET E-1,
FOR  SERVICES  RENDERED ,,,, From:   ,,,
,,,, To:   ,,,
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 PART  I  -  TO  BE  COMPLETED  BY  CONTRACTOR,,,,,,,
,,,,,Part B,,
,,,,,mm/dd/yyyy,Amount,
,Description,,,,1,,
1, List separately each tentative settlement,,Program, .01,,,1.01
, payment after desk review. Also show,,to, .02,,,1.02
, date of each payment.,,Provider, .03,,,1.03
," If none, write ""NONE,"" or enter a zero. (1)",,Provider, .50,,,1.50
,,,to, .51,,,1.51
,,,Program, .52,,,1.52
, SUBTOTAL (sum of lines 1.01 - 1.49 minus sum of lines 1.50 - 1.98),,, .99,,,1.99
," (Transfer to Wkst E, Part I, line 18)",,,,,,
2, Determine net settlement amount (balance,,Program to provider, .01,,,2.01
, due) based on the cost report. (1),,Provider to program, .50,,,2.50
3, Name of Contractor,,,Contractor Number,,,3
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" (1) On line 2.50, where an amount is due ""Provider to Program,"" show the amount and date on which the provider agrees to the amount of repayment ",,,,,,,
 even though total repayment is not accomplished until a later date.,,,,,,,
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 PART  II  -  TO  BE  COMPLETED  BY  PROVIDER,,,,,,,
4,Low volume payment amount  (see instructions),,,,,,4
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"FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4215)",,,,,,,
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Rev 2,,,,,,,42-317