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Instructions for Completing the Pro-Forma for Provider Self-Determination of Aggregate Cap Limitation

Ordering Required Reports from EIDM

To complete the Pro-Forma, order the following reports from Enterprise Identify Management System (EIDM), formerly IACS.

  1. The PS&R summary report for the cap period. The cap period is always October 1 – September 30 for the cap year.
    • Choose "Request Report".
    • Choose "Request Summary".
    • If needed, select your provider number and move to box on right. Otherwise, select “By Service Type” drop-down box, select “All” & continue.
    • Please change service period to match the cap period dates for which you’re submitting. Don’t use the default Fiscal service period(s) that match your agency's Fiscal Year End. (Format: MM/DD/CCYY)
      Cap year Payments
      Streamlined method Patient-by-patient proportional method
      2017 (Transition Year) 11/01/2016-09/30/2017 11/01/2016-09/30/2017
      2018 and later 10/01/20XX-09/30/20XX 10/01/20XX-09/30/20XX
    • Don't use the unduplicated Census count from this report as your Beneficiary count. (See #2 below to obtain your Beneficiary count)
    • Change from paid date to 08/01/2007
    • Select Report Format.
    • Select continue and submit to order the report.
    • The Hospice PS&R Summary report will be delivered to the Summary Report Inbox after processing (usually same day).

  2. Hospice Beneficiary Count Summary – Instructions for ordering the correct period are:
    • Choose "Request Report".
    • Choose "Request Miscellaneous".
    • From drop down box, choose "Hospice Cap Report".
    • Enter Beneficiary Identification Period (Format: MM/DD/CCYY).
      Cap year Beneficiaries
      Streamlined method Patient-by-patient proportional method
      2017 (Transition Year) 09/28/2016-09/30/2017 11/01/2016-09/30/2017
      2018 and later 10/01/20XX-09/30/20XX 10/01/20XX-09/30/20XX
    • Paid date: leave at default. Through date: should be left at current; however, must be on or after 12/31 to make a valid reporting.
    • o he Report Type selected should match the method reported on line 1a of the Pro-forma and should match the prior year cap methodology. Note for new providers: The only option is the patient-by-patient proportional method.
    • Select Report Format.
    • Select continue and submit to order the report.
    • The Hospice Beneficiary Count Summary report will be delivered to the Miscellaneous Report Inbox after processing (usually same day).

Completing the Pro-Forma

Section Field Type Details
Header Required Enter your Provider Name, Provider Number and NPI Number.
Cap Year Ending date = 09/30 of the year reported (e.g., For the 2022 cap period, enter 09.30.2022.).
Line 1 Required Enter the total beneficiary count from the Hospice Beneficiary Count Summary report generated in EIDM.
Line 1a Required Enter the method used to count beneficiaries – streamlined or patient-by-patient proportional.
The method used needs to match the method used for the prior cap period.
New providers are required to use the patient-by-patient proportional method.
Line 1b Required Enter the paid through date (12/31 or later) on the Hospice Beneficiary Count Summary report.
Line 2 Required Enter the Statutory Cap Amount for the Cap Year.
CMS publishes the hospice cap amount in the annual final ruleExternal Website. The 2025 cap amount is $34,465.34.
Line 3 Not Required Allowable Medicare Payments:
This is a calculated field; no input is required.
Line 4 Required Enter the net reimbursement + Post-Sequestration Demo Reduction amount (if shown) from the summary PS&R (report types 810, 81A, 820 & 82A) for the cap period.
Note: If sequestration applies for the cap period, CGS will make the adjustment at the final cap determination.
Line 5 Not Required Payments in Excess of the Aggregate Cap Amount:
This is a calculated field; no input is required.
Certification Required An authorized person at the hospice must sign and type or print their name and title.
Enter the name and telephone number of a person at the hospice who CGS may contact for additional information.

Updated: 02.04.2026

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