Low Volume ESRD Attestation


01 Oct Low Volume ESRD Attestation

It’s that time of year to prepare the attestation to qualify for the low volume add-on adjuster for payment year 2020. 


For consideration the deadline for submission is November 1, 2019. ESRD providers that are currently receiving the low volume adjustment are required to submit an annual attestation prior to November 1st, preceding the next payment year. Attestations will not be accepted after the November 1st deadline.


In order to qualify your facility will need to meet the following requirements:

  • Facility furnished less than 4000 treatments for 3 proceeding cost report years
    (Facility may estimate the 3rd Year)

  • Facility is not located within 5 road miles of another facility of common ownership.
  • Facility has not opened, closed, or had a change of ownership that resulted in a change of PTAN in the 3 preceding years

    Documentation Needed (may vary depending on your MAC requirements):

  • Provider Name:
  • Provider Address:
  • Provider City, State, and Zip Code:
  • Medicare provider number:
  • Has the facility opened, closed or had a change in ownership in the three years preceding the payment year?
  • Is this ESRD part of common ownership? (if yes, please provide the following information)
  • Provider is not located within 5 road miles of another facility under common ownership?
  • Provider contact name, contact phone number and contact email address


In addition to the attestation you will need to provide the following forms:

  • Cost report Form 265 worksheets C for Free Standing providers or worksheet I-4 for hospital based – 3 Cost report years