Hospital Cost Report

Pursuant to Attachment 4.19-A, Page 26 of the North Carolina Medicaid State Plan, hospitals shall file annual Medicaid cost reports with the Division.  Cost reports shall be filed utilizing the CMS2552 format and are due to the Division five (5) months after the provider’s fiscal year end or 37 days from the date of the Medicaid PS&R letter, whichever is later.

Medicaid Cost Report Submission Package

The Annual Medicaid Cost Report Submission Package shall include:

• CMS2552 Electronic Cost Report (ECR) File
• CMS2552 Cost Report Print Image File
• Manual or Electronic Signed Certification Page for CMS2552
• Copy of Provider’s Adjusted Trial Balance for Cost Report Period
• Copy of Provider’s Statement of Revenues and Expenses for Cost Report Period
• Completed and signed Hospital General Information Sheet
• Completed and signed Supplemental Schedule B

The Annual Medicaid Cost Report Package shall be submitted electronically to Medicaid.LTCCostReport@dhhs.nc.gov

Additional Hospital Information

State Owned and Operated Institutions for Mental Disease (IMD’s) may be eligible for Medicaid Disproportionate Share Hospital Payments. These institutions shall complete and sign the:

Rate Adjustment Eligibility Sheet – Due Oct. 1, 2026

Hospitals that undergo a Change in Ownership (CHOW)

• Please refer to the Enrolled Provider Notification Requirements Change of Ownership Medicaid Bulletin.
• Hospitals are also requested to complete the Hospital Change Form to support the Healthcare Access and Stabilization Program (HASP) and Hospital Financing Model.