CMS Pub. 100-06, ch. 6
(Rev. 12894 ; Issued: 10-17-24)
10 - Monthly Intermediary and Carrier Workload Report (Form CMS-1566 and CMS-1565) - General 10.1 - Purpose and Scope 10.2 - Due Date 20 - Completing Page One of the Monthly Intermediary Workload Report 20.1 - Heading 20.2 - Checking Reports 20.3 - Type of Bill 20.4 - Body of Report 30 - Completing Pages 2 through 21 of Intermediary Workload Report 30.1 - Heading 30.2 - Checking Reports 30.3 - Body of Report 30.4 - Completing Page 22 of Intermediary Workload Report 30.5 - Heading 30.6 - Checking Reports 30.7 - Body of Report 40 - Monthly PRO Adjustment Bill Report (Inactive) 40.1 - Heading 40.2 - Body of Report 40.3 - Checking Reports 40.4 - Report Form 50 - Quarterly Supplement To Intermediary Workload Report (Form CMS-1566A) - General 50.1 - Purpose and Scope 50.2 - Due Date 60 - Completing Quarterly Supplement To The Intermediary Workload Report, CMS-1566A, Pages 1 And 2 60.1 - Heading
60.2 - Checking Reports
60.3 - Type of Bill
60.4 - Body of Report
70 - Completing Quarterly Supplement To The Intermediary Workload Report, CMS-1566A, Page 3
70.1 - Heading
70.2 - Checking Reports
70.3 - Type of Bill
70.4 - Body of Report
70.5 - Completing Medicare Fraud Unit Quarterly Workload Status Report, CMS-1566B - General (Inactive)
70.6 - Heading (Inactive)
70.7 - Checking Reports (Inactive)
70.8 - Type of Fraud Workload Item (Inactive)
70.9 - Body of Report (Inactive)
70.10 - Completing Quarterly Periodic Interim Payment (PIP) Report, CMS-1566C - General
70.11 - Heading
70.12 - Checking Reports
70.13 - PIP Items Reported - The intermediary reports the PIP workload items in the following lines for all columns of Form Q
70.14 - Quarterly Supplement to the Intermediary Workload Report - CMS-1566A, Pages 1,2,3
70.15 - Medicare Fraud Unit Quarterly Workload Status Report - CMS-1566B
70.16 - Quarterly Periodic Interim Payment (PIP) Report - Form CMS-1566C
70.17 - Completing Quarterly Report on Provider Enrollment (Inactive)
70.18 - Heading (Inactive)
70.19 - Checking Reports (Inactive)
70.20 - Type of Provider (Inactive)
70.21 - Completing Lines One through Eleven - Workload Operations (Inactive)
70.22 - Completing Lines Twelve through Seventeen - Reason for Denial Recommendation (Inactive)
70.23 - Completing Lines Eighteen through Twenty-Two - Reason for Return (Inactive)
70.24 - Completing Lines Twenty-Three through Twenty-Six - Application Processing Times (Inactive)
70.25 - Completing Lines Twenty-Seven through Thirty-One - Age of
70.26 - Completing Lines Thirty-Two through Thirty-Seven - CHOW Workloads (Inactive)
70.27 - Exhibits
80 - Monthly Intermediary Report On Medicare Secondary Payer Savings (Form CMS-1563)
80.1 - General
80.2 - Purpose and Scope
80.3 - Due Date
80.4 - Form Heading
80.5 - Savings Calculations
80.6 - Recording Savings
80.7 - Source of Savings
80.8 - Type of Savings
80.9 - Electronic Submission
90 – Monthly Intermediary Part A and Part B Appeals Report (Form CMS-2591)
90.1 – Purpose and Scope
90.2 – Due Date
100 – Completion of Items on Form CMS-2591
100.1 – Heading
100.2 – Section A – Intermediary Appeal Requests
100.3 – Section B – Part B Hearing Results
100.4 – Section C – Part A and Part B ALJ Hearings
100.5 – Section D – Limitation of Liability
100.6 – Section E – Part A and Part B Reopenings
110 – Checking Reports
110.1 – Exhibit 1
110.2 – Exhibit 2
110.3 – Exhibit 3
110.4 – Exhibit 4
110.5 – Exhibit 5
110.6 – Exhibit 6
120 - Completing Page One of the Carrier Performance Report
120.1 - Classification of Claims for Counting
130 - Completion of Items on Page One of Form CMS-1565
130.1 - Heading
130.2 - Part A - Monthly Workload Operations
130.3 - Part B - Inquiries (Inactive)
130.4 - Part C - Miscellaneous Claims Data
270 - Completion of Items on Form CMS-1565C
270.1 - Heading
350.2 - Due Date
360 - Completion of Items on Form CMS-2590
440.6 - Recording Savings
440.7 - Source of Savings
440.8 - Type of Savings
440.9 - Electronic Submission
440.10 - Exhibit
460 - Monthly Statistical Report on A/B and DME Medicare Administrative Contractor (MAC) Part A and Part B Appeals Activity Form (CMS-2592)
460.1 - General
460.2 – Section I - Redeterminations
460.3 – Section II - Qualified Independent Contractor (QIC) Reconsiderations
460.4 – Section III - Administrative Law Judge Results
460.5 – Section IV - Section IV – Medicare Appeals Council Effectuations
460.6 – Clerical Error Reopenings
460.7 – Validation of Reports
460.8 - Exhibit
480 - Special Purpose Data
480.1 - Heading
480.2 - Exhibit
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3892 and B3 13300
Intermediaries and carriers must prepare and submit to CMS each month the appropriate workload report (Form CMS-1566 for intermediaries and Form CMS-1565 for carriers) showing their workloads under the health insurance program. A separate report is required for each office assigned a separate contractor number. A separate report is required for each Business Segment Identifier (BSI) assigned to the contractor, even if a separate contractor number is not assigned.
(Rev. 6, 08-30-02)
A3-3892.1 and B3 13300.1
The monthly Workload Report is the source of current information on the status of workloads. The data derived from the report, together with information from other sources, are used by CMS for such purposes as:
The workload report is designed to serve as a basic management tool for individual contractors. It provides data needed for budgeting, financing, work-planning, progress evaluation, and identification of operating problems.
The form must be submitted in accordance with the following instructions.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3892.2
The report is transmitted to CMS CO via PC or terminal as soon as possible after the end of the month being reported, but no later than the 10th of the following month using instructions in the Contractor Reporting of Operational and Workload Data (CROWD) User Guide available via the CMS Enterprise Portal.
(Rev. 6, 08-30-02)
A3-3893
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3893.1
This report is referenced as Form D for CROWD. The intermediary submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI. It reports the number of working days scheduled for the reporting period, less any days where no claims were processed as a result of a strike, snowstorm, etc. It does not count Saturdays, Sundays, or holidays.
(Rev. 6, 08-30-02)
A3-3893.2
Before submitting Form D to CMS, the intermediary checks its completeness and arithmetical correctness. This check not only ensures accuracy but also uncovers other errors and inconsistencies. It uses the following checklist:
For each column:
Line 28 + 29 + 30 + 31 = 27.
Line 33 must be equal to or less than line 32.
The intermediary bases all data reported on the CMS-1566 on actual counts and not on any types of estimates or samples.
(Rev. 10521; Issued: 12-16-20; Effective: 01-01-21; Implementation: 01-04-21)
The A/B MAC (A) includes provider bills in the following columns of the report:
Column (1) Total - All provider bills.
Column (2) Inpatient Hospital - CMS-1450s submitted by hospitals for inpatient services with the following two-digit classification codes in Form Locator 4: 1-1 (inpatient hospital); and 4-1 (Religious Nonmedical Health Care Hospital- inpatient).
Column (3) Outpatient - CMS-1450s submitted by hospitals or SNFs for outpatient services with the following two-digit classification codes in Form Locator 4: 1-3 (Hospital-outpatient); 2-3 (SNF-outpatient); 4-3 (Religious Nonmedical Health Care Hospital-outpatient); 5-3 (Religious Nonmedical Health Care-SNF-outpatient); and 8-3 (Hospital-outpatient-surgical procedures-ASC).
Column (4) SNF - CMS-1450s with the following two-digit classification codes in Form Locator 4; 1-8 (hospital swing-bed); 2-1 (SNF-inpatient); 2-8 (SNF-swing bed); and 5-1 (Religious Nonmedical Health Care-SNF-inpatient).
Column (5) HHA - CMS-1450s submitted by HHAs, with the following two-digit classification codes in Form Locator 4: 3-2 (HHA-Part B visits and use of DME); 3-3 (HHA-Part A visits and DME); 3-4 (HHA-Other-Part B benefits). Include HH PPS Requests for Anticipated Payment (RAPs) with three-digit classification code 3-2-2 or 3-3-2 with dates of service 10/01/2000 and greater in addition to claims in this column.
Column (6) Other - CMS-1450s with the following two-digit classification codes in Form Locator 4:
1-2 (hospital inpatient-Part B benefits),
1-4 (hospital-Other-Part B benefits),
2-2 (SNF-inpatient-Part B benefits),
2-4 (SNF-Other-Part B benefits),
4-2 (Religious Nonmedical Health Care-inpatient-Part B benefits),
4-4 (Religious Nonmedical Health Care-inpatient-other),
5-2 (Religious Nonmedical Health Care-SNF inpatient-Part B benefits),
5-4 (Religious Nonmedical Health Care-SNF inpatient-other), 7-1, 7-2, 7-3, 7-4, 7-5 (Clinics-provider and independent RHCs, ESRD hospital-based or independent renal dialysis facilities, FQHCs, CMHCs, ORFs, and CORFs), and
8-1 and 8-2 (Hospices)
8-7 (Opioid Treatment Facility)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The intermediary completes every type of bill column (1 through 6) for each reporting item as described below. It includes data on all bills received for initial processing from providers (including all RHCs) directly or indirectly through a RO, another intermediary, etc. It also includes data on demand bills and no-pay bills submitted by providers with no charges and/or covered days/visits. It does not include:
Bills paid by an HMO and processed by the intermediary.
Claims submitted by HHAs under the HH PPS with three-digit classification 3-2-9 or 3-3-9 are processed as adjustments to a previously submitted RAP record. However, the intermediary counts both HHPPS RAPs and claims as initial bills for this report. It does not exempt HH PPS claims as adjustments.
Line 1 - Pending End of Last Month - The system will pre-fill the number pending from line 13 on the previous month's report.
Line 2 - Adjustments - If it is necessary to revise the pending figure for the close of the previous month because of inventories, reporting errors, etc., the intermediary reports the adjustment. It reports bills received near the end of the reporting month and placed under computer control sometime after the reporting month as bills received in the reporting month and not as bills received in the following month. In the event that some bills may not have been counted in the proper month's receipts, it counts them as adjustments to the opening pending in the subsequent month.
It reports on line 2 any necessary adjustments, preceded by a minus sign for negative adjustments, as appropriate.
Line 3 - Adjusted Opening Pending - The system will sum line 1 + line 2 to calculate the adjusted opening pending.
Line 4 - Received During Month – The intermediary reports the total number of bills received for initial processing during the month.
It counts all bills immediately upon receipt regardless of whether or not they are put into the processing operation with the exception of those discussed below.
NOTE: It counts bills submitted by providers electronically after they have passed intermediary consistency edits. Prior to that time, it may return these bills or the entire tape reel (where magnetic tape is the medium of submission) without counting them as 'received.' However, once the bills or tapes have passed consistency edits and are counted as received, it uses the actual receipt date, not the date the edits are passed, in calculating pending and processing times.
If a bill belonging to one of the above-excluded categories is inadvertently counted as an initial bill received (e.g., certain adjustment bills unidentifiable at the time of receipt), the intermediary subtracts it from the receipt count when the bill is correctly identified.
Line 5 - Electronic Media Bills - The intermediary reports the net number of bills included on line 4 which were received in paperless form via electronic media from providers or their billing agencies and read directly into the intermediary claims
processing system. It does not count on this line bills that it received in hardcopy and entered using an Optical Character Recognition (OCR) device. It does not count any bills received in hardcopy and transferred into electronic media by any entity working for it directly or under subcontract.
Line 6 - Total CWF Bills (7 + 8) – The intermediary reports the number of initial bills (described in lines 7 and 8 below) processed through CWF and posted to CWF history. It does not include bills sent to CWF and rejected, unless they were resubmitted and posted to CWF history in the reporting month. It reports these bills in the month that it moves the bill to a processed location in the intermediary system after receipt of the host's response to pay or deny.
Line 7 - Payment Approved (CWF) – The intermediary reports the number of initial bills for which it approved some payment and for which the CWF host responded accepting the intermediary determination. It includes bills for which it approved payment in full or in part as a result of a determination that both the beneficiary and the provider were without fault (liability waiver). (See the Medicare Claims Processing Manual, Chapter 30, Financial Liability Protections.) The intermediary reports here those fully adjudicated, approved-for-payment bills for which it has received a response from the host and are holding only due to the payment floor.
Line 8 - No Payment Approved (CWF) - The intermediary reports the number of initial bills processed through CWF during the month for which it approved no payment. It reports here those bills for which payment is not made because the deductible has not yet been met and payment is therefore applied to the deductible.
Line 9 - Total Non-CWF Bills (10 + 11) - The intermediary reports the number of initial bills (described in lines 10 and 11 below) processed outside CWF. Non-CWF bills are those either rejected by or not submitted to CWF that the intermediary finally adjudicates outside of CWF and, therefore, are not posted to its history in the reporting month. The intermediary reports these bills as non-CWF, even if it plans to submit an informational record in the future. It reports such bills in the month in which it made the determination as to their final disposition.
It does not include home health bills where no utilization is chargeable and no payment has been made, but which it requested only to facilitate record keeping processes.
Line 10 - Payment Approved (Non-CWF) - The intermediary reports the number of initial bills processed outside CWF for which it approved some payment. It includes bills for which it approved payment in full or in part as a result of a determination that both the beneficiary and the provider were without fault (liability waiver). (See the Medicare Claims Processing Manual, Chapter 30, Financial Liability Protections.)
Line 11 - No Payment Approved (Non-CWF) – The intermediary reports the number of initial bills processed outside CWF during the month for which it approved no payment.
Line 12 - Total Processed - The intermediary reports the sum of lines 6 and 9.
NOTE: It reports as processed on line 12 those bills it has moved to a processed location after being accepted by the host and is holding only due to the payment floor. However, for pages 2-12 of this report, it reports these bills as processed in the month during which the scheduled payment date falls (which may be in a subsequent reporting period).
The intermediary reports HMO bills it paid on line 12 and on pages 2-12. It does not report those bills paid by HMOs and processed by the intermediary on line 12 or on pages 2-12. It reports such HMO paid bills only on line 39 of page 1.
Line 13 - Pending End of Month - The system will calculate the number of bills pending at the end of the month by adding line 3 (adjusted opening pending) to line 4 (receipts) and subtracting line 12 (total processed). The intermediary does not report as pending those bills that it has moved to a processed location after being accepted by the host and is holding only due to the payment floor. It reports such bills as processed on line 12.
Line 14 - Pending Longer Than 1 Month – The intermediary reports the number of bills included in line 13 pending longer than 1 month, i.e., those received prior to the reporting month but not processed to completion by the end of the reporting month. For example, for the reporting month of October 2001, it reports the number of bills pending at the end of October 2001 which had been received prior to October 1, 2001. It excludes bills received in the reporting month.
Line 15 - Pending Longer Than 2 Months - The intermediary reports the number of bills included in line 13 pending longer than 2 months, i.e., those received prior to the month preceding the reporting month but not processed to completion by the end of the reporting month. For example, for the reporting month of October 2001, it reports the number of bills pending at the end of October 2001 that had been received prior to September 1, 2001. It excludes bills received in the reporting month and one month prior to the reporting month.
Line 16 - Bill Investigations Initiated - The intermediary reports the number of initial bills that, for purposes of processing the claim to completion, required outside contact (via telephone, correspondence, or on-site visit) with providers, social security offices, or beneficiaries during the month. This includes contacting outside parties to resolve problems with covered level of care determinations, insufficient medical information or
missing, inconsistent, or incorrect items on the bill. It does not count routine submissions by providers of additional medical evidence with bills as investigations in themselves. It counts only the number of bills requiring investigation, not the number of contacts made. It excludes bills reported as investigated in a prior month from this count even if the investigation continued into the reporting month. It does not count as bills investigated those returned to providers because they were incomplete, incorrect or inconsistent, and consequently were not counted as 'receipts.'
This section includes data on the number of adjustment bills processed and pending for the reporting month, including those generated by providers, PROs, or as a result of MSP or other activity. In reporting adjustment bills, the intermediary counts only the number of original bills requiring adjustment, not both the debit and credit.
Claims submitted by HHAs under the HH PPS with three-digit classification 3-2-9 or 3-3-9 are processed as adjustments to a previously submitted RAP record. However, both HHPPS RAPs and claims are counted as initial bills. The intermediary does not report HH PPS claims as adjustments.
Line 17 - Total CWF Processed (18+19+20+21) - The intermediary reports the number of adjustment bills processed through CWF during the month. It counts adjustment bills as processed in final only when acceptance from CWF is received. Since §3664 precludes the processing of a utilization adjustment bill until CWF accepts the bill upon which the adjustment action is based, no utilization adjustment billing action may be processed until CWF has accepted the original bill.
Line 18 - PRO Generated (CWF) - The intermediary reports the number of adjustment bills included in line 17 which were generated by PROs.
Line 19 - Provider Generated (CWF) - The intermediary reports the number of adjustment bills included in line 17 which were generated by providers.
Line 20 - MSP (CWF) - The intermediary reports the number of adjustment bills included in line 17 which were generated as a result of MSP activity.
Line 21 - Other (CWF) - The intermediary reports the number of adjustment bills included in line 17 which were generated by other than PROs, providers, or MSP activity. It includes HMO adjustments where the HMO acted as an intermediary and made payment on the initial bill.
Line 22 - Total Non-CWF Processed (23+24+25+26) - The intermediary reports the number of adjustment bills that it processed outside of CWF during the month. It counts such adjustment bills as processed in final only when no further action is required.
If it receives an adjustment bill from a provider when the original bill is still in its possession, it takes the final adjustment action on the original bill before it is submitted to CWF. It counts the adjustment bill as cleared when acceptance of the original bill is received from CWF.
Line 23 - PRO Generated (Non-CWF) - The intermediary reports the number of adjustment bills included in line 22 which were generated by PROs.
Line 24 - Provider Generated (Non-CWF) - The intermediary reports the number of adjustment bills included in line 22 which were generated by providers.
Line 25 - MSP (Non-CWF) - The intermediary reports the number of adjustment bills included in line 22 which were generated as a result of MSP activity.
Line 26 - Other (Non-CWF) - The intermediary reports the number of adjustment bills included in line 22 that were generated by other than PROs, providers, or MSP activity. It includes HMO adjustments where the HMO acted as an intermediary and made payment on the initial bill.
Line 27 - Total Pending (28+29+30+31) - The intermediary reports the number of adjustment bills which were not processed to completion by the end of the reporting month.
Line 28 - PRO Generated – The intermediary reports the number of adjustment bills included in line 27 which were not processed to completion by the end of the reporting month and which were generated by PROs.
Line 29 - Provider Generated - The intermediary reports the number of adjustment bills included in line 27 which were not processed to completion by the end of the reporting month and which were generated by providers.
Line 30 - MSP - The intermediary reports the number of adjustment bills included in line 27 which were not processed to completion by the end of the reporting month and which were generated by MSP activity.
Line 31 - Other - The intermediary reports the number of adjustment bills included in line 27 which were not processed to completion by the end of the reporting month and which were generated by it or by a source other than PROs, providers, or MSP activity. It includes HMO adjustments not processed to completion where the HMO acted as an intermediary and made payment on the initial bill.
This section presents data on the volume of Medicaid crossover bills sent to Medicaid State agencies or their fiscal agents.
Line 32 - Transmitted to State Agencies - The intermediary reports the total number of Medicaid crossover bills transmitted to State agencies or their fiscal agents in the reporting month.
Line 33 - Transmitted Electronically – The intermediary reports the number of bills included in line 32 which were transmitted via electronic media to State agencies or their fiscal agents.
This section presents data on the volume of provider or beneficiary inquiries that were processed during the reporting month. Include only processed inquiries dealing with Medicare bill processing issues. These issues correspond to the workload budgeted under line 1 of the CMS-1523 budget form.
The intermediary counts inquiries as follows:
Beneficiary - It counts one per contact (telephone, walk-in, or written), regardless of the number of bills being questioned. For example, if a letter from a beneficiary requests information on the status of one or more bills, it counts the response (interim or final) as one written beneficiary inquiry. It counts each completed reply, terminated telephone conversation, or in-person discussion as processed, regardless of the need for subsequent contact on the same issue. Responses resulting from additional intermediary follow up or analysis, or from additional contact by the beneficiary, are separate inquiries. Beneficiary inquiries include those made by anyone on behalf of the beneficiary, except by a provider.
Provider - The intermediary counts one per contact (telephone, walk-in, or written). For example, if a provider calls or writes to obtain the status of 3, 6, or 10 separate bills, it counts the response as 1 provider telephone or written inquiry.
It includes or excludes beneficiary and provider inquiries as follows:
It does not count processed inquiries that are concerned solely with its line of business.
It does not count inquiries concerned with professional relations activities.
Line 34 - Total - It reports in the appropriate column the total number of inquiries processed.
Line 35 - Telephone Inquiries - It reports in the appropriate column the total number of telephone inquiries processed.
Line 36 - Walk-in Inquiries - It reports in the appropriate column the total number of walk-in contacts processed.
Line 37 - Written Inquiries - It reports in the appropriate column the total number of written inquiries responded to.
Line 38 - Total Bills Received - It reports the total number of bills that it received in hardcopy and entered using an OCR device. It does not count these bills as electronic media bills on line 5, page 1, or in column 8, pages 2-11.
Line 39 - Total HMO Bills Processed - It reports the number of bills that were paid by HMOs and processed by it during the reporting month. It reports HMO bills paid by it on line 12 but does not report such bills on line 39.
Line 40 - Total MSNs Mailed - It reports the number of MSNs mailed to beneficiaries during the reporting month.
(Rev. 6, 08-30-02) A3-3894
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3894.1
These pages are referenced as Form U (pages 2-11) and Form E (pages 12-21) for CROWD. The intermediary submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 6, 08-30-02)
A3-3894.2
Before submitting Forms U and E to CMS, check for completeness and arithmetical accuracy, the intermediary uses the following checklist:
• The "Total" pages (pages 11 and 21) must equal the sum of all the bill types (pages 2-10 and 12-20, respectively) for each data element on the page, except line 39.
(Rev. 6, 08-30-02)
A3-3894.3
Pages 2-11 of the CMS-1566 include data on intermediary activity in processing all bills to completion during the reporting period. The intermediary counts the bill as processed to completion on the "scheduled payment date," which is the date the check it issued is mailed, deposited by it in the provider's account, or transferred electronically. For PIP bills and no payment bills, the "scheduled payment date" is the date for payment bills in the same adjudication batch. Base data shown on reliable counts of all bill processing activity. The intermediary does not estimate bill counts. It reports data on initial bills only (including demand bills and no-pay bills submitted by providers with no charges and/or covered days/visits). It does not include:
Apart from these exceptions, it includes in the report all bills (including PIP, EMC, provider and independent RHC, as well as HMO bills paid by it) processed to completion (i.e., paid bills, complete denials, and no payment bills) in the reporting month. It reports bills in the month the scheduled date of payment falls. See The Medicare Claims Processing Manual, Chapter 1, General Billing Requirements for the definition of scheduled payment date for all bills, including PIP and no payment bills. "Clean" bills are those that do not require investigation or development external to the intermediary operation on a prepayment basis. Bills that do not meet the definition of "clean" are
'other' bills. See The Medicare Claims Processing Manual, Chapter 1, General Billing Requirements for examples of 'clean' and 'other.' Bills paid are those for which some payment was made (i.e., payment greater than zero). Bills not paid are those for which no payment was made (i.e., bill charges applied completely toward deductible or fully denied).
On each page 2-11 (there is a separate page for each type of bill category listed below), the intermediary reports:
For each category, it shows the number processed to completion on the line corresponding to the number of days from receipt by it to the scheduled date of payment or other final action, if a no-pay bill. See The Medicare Claims Processing Manual, Chapter 1, General Billing Requirements for definition of receipt date.
NOTE: For bills received by tape, the date the intermediary receives the tape should be used as the receipt date and not the date the tape passes the edits.
To calculate the processing time for a claim, the intermediary subtracts the Julian receipt date from the processed to completion Julian date. When the processed to completion date falls in the year following the year of receipt, it adds to the Julian date of completion 365 (or 366 if the year of receipt is a leap year). If a claim is processed to completion on the same day it is received, the processing time is one day. This definition applies to all lines of the report, including line 39.
On line 39 the intermediary reports the mean processing time (PT) to one decimal place for each column. To calculate the mean PT, it adds the processing times for all the bills shown in lines 1-37 of that column and divides by line 38. It does not use the categories on the report to calculate the mean PT. Because of the aggregation of claims in lines 34-37, it must use the processing times for the individual claims as explained below to make this calculation.
| Claim | Julian Date Receipt | Paid | Counter by Days | Counter by Claims |
|---|---|---|---|---|
| A | 91103 | 91133 | 30 | 1 |
| B | 91105 | 91206 | 101 | 2 |
| C | 91115 | 91177 | 62 | 3 |
| D | 91120 | 91213 | 93 | 4 |
| E | 91122 | 91215 | 93 | 5 |
| F | 91130 | 91223 | 93 | 6 |
Total Days = 30 + 101 + 62 + 93 + 93 + 93 = 472
Mean = 472/6 = 78.6666 = 78.7
The intermediary completes the report for each bill type:
Care Facility - Hospital-outpatient); 5-3 (Religious Nonmedical Health Care Facility - SNF-outpatient); and 8-3 (hospital-outpatient surgical procedures - ASC),
Pages 12-21 of the CMS-1566 the intermediary includes data on the non-PIP bills paid during the month they were received via electronic media. The basic instructions and definitions that apply to pages 2-11 (see above) also apply to pages 12-21. For each bill type, it reports the following information:
For each bill type on pages 12-21, it reports the following adjustments for CPEP CPT calculations:
CWF - Claims that were beyond its control due to CWF. (See The Medicare Claims Processing Manual, Chapter 1, General Billing Requirements for definition of claims meeting this criteria.)
A. The number of EMC non-PIP clean claims paid beyond the EMC ceiling. B. The number of paper non-PIP clean claims paid beyond the paper ceiling. C. The number of all claims processed beyond 60 days.
WAIVER - Non-PIP claims paid under the claims payment floor for which the intermediary had a waiver from CMS.
D. The number of EMC non-PIP clean claims paid under the EMC floor. E. The number of paper non-PIP clean claims paid under the paper floor. F. The number of EMC non-PIP claims (clean and other) paid under the EMC floor plus the number of paper non-PIP claims (clean and other) paid under the paper floor.
(Rev. 6, 08-30-02)
A3-3894.4
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3894.5
This page is referenced as Form W for CROWD. The intermediary submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 6, 08-30-02)
A3-3894.6
Before transmitting page 22 to CMS, the intermediary checks its completeness and arithmetical accuracy. It uses the following checklist:
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
The intermediary reports on Page 22 of the CMS-1566 data on the bills on which it paid interest because it paid the bills after the required payment date per §9311 of the Omnibus Budget Reconciliation Act of 1986. Counts of bills processed reflect their status as of the last workday of the reporting calendar month. The intermediary bases data shown on reliable counts of all bill processing activity and not on estimates. It reports data on initial bills only. Note that HH PPS RAPs with three-digit classification code 3-2-2 or 3-3-2 with dates of service 10/01/2000 and greater are not subject to interest payment and should be excluded from this section. The intermediary includes all bills requiring interest payments in the month. It reports bills in the month the scheduled date of payment falls. See The Medicare Claims Processing, Chapter 1, General Billing Requirements, for a discussion of interest payments and the definition of scheduled payment date.
It the report for each column as follows:
1-8 (hospital swing-bed) 2-1 (SNF - inpatient) 2-2 (SNF - inpatient Part B benefits) 2-3 (SNF - outpatient) 2-4 (SNF - other Part B benefits) 2-8 (SNF-swing-bed) 5-1 (Religious Nonmedical Health Care SNF - inpatient) 5-2 (Religious Nonmedical Health Care SNF - inpatient Part B benefits) 5-3 (Religious Nonmedical Health Care SNF - outpatient) 5-4 (Religious Nonmedical Health Care SNF - inpatient other)
On line 1, it shows the number of claims on which it paid interest in the reporting month. It reports on line 2 the number of claims included in line 1 for which it made payment one day after the required payment date (e.g., the required payment date is 25 days in FY 1999). Data for lines 3-10 are similar to those for line 2. It calculates the number of days late by subtracting the Julian date of receipt of the bill from the Julian scheduled payment date and then subtracting the required payment date (i.e., 25 in FY 1999). If the bill is paid in the year following the year of receipt, it adds 365 or 366 (if the year of receipt is a leap year) to the result, as appropriate.
On line 11, it shows the amount paid in interest on the bills reported in line 1. See The Medicare Claims Processing Manual, Chapter 1, General Billing Requirements on how to calculate interest payments. On lines 12-20 it shows the amounts paid in interest for bills reported in lines 2-10, respectively. It shows payment amounts on lines 11-20 to the nearest penny, including the decimal point.
| Intermediary Name: | Reporting Period: | |||||
|---|---|---|---|---|---|---|
| Intermediary Number: | Number of Working Days: | |||||
| SECTION A: INITIAL BILL PROCESSING | TOTAL (1) | INPATIENT (2) | OUTPATIENT (3) | SNF (4) | HHA (5) | OTHER (6) |
| Opening Pending | ||||||
| 1. Opening Pending | ||||||
| 2. Adjustments (+ or -) | ||||||
| 3. Adj Opening Pending | ||||||
| Receipts | ||||||
| 4. Received during Month | ||||||
| 5. Electronic Media | ||||||
| Clearances | ||||||
| 6. Total CWF Bills | ||||||
| 7. Payment Approved | ||||||
| 8. No Payment Approved | ||||||
| 9. Total Non-CWF Bills | ||||||
| 10. Payment Approved | ||||||
| 11. No Payment Approved | ||||||
| 12. Total Processed | ||||||
| Closing Pending | ||||||
| 13. Pending End of Month | ||||||
| 14. Longer than 1 Month | ||||||
| 15. Longer than 2 Months |
| Intermediary Name: | Reporting Period: | |||||
|---|---|---|---|---|---|---|
| Intermediary Number: | Number of Working Days: | |||||
| SECTION A: INITIAL BILL PROCESSING | TOTAL (1) | INPATIENT (2) | OUTPATIENT (3) | SNF (4) | HHA (5) | OTHER (6) |
| Bill Investigations | ||||||
| 16. Investigations Init | ||||||
| SECTION B: ADJUSTMENT BILLS | ||||||
| CWF Clearances | ||||||
| 17. Total CWF Processed | ||||||
| 18. PRO Generated | ||||||
| 19. Provider Generated | ||||||
| 20. MSP | ||||||
| 21. Other | ||||||
| Non-CWF Clearances | ||||||
| 22. Total Non-CWF Prcsd | ||||||
| 23. PRO Generated | ||||||
| 24. Provider Generated | ||||||
| 25. MSP | ||||||
| 26. Other |
| Intermediary Name: | Reporting Period: | |||||
|---|---|---|---|---|---|---|
| Intermediary Number: | Number of Working Days: | |||||
| SECTION B: ADJUSTMENT BILLS | TOTAL (1) | INPATIENT (2) | OUT PATIENT (3) | SNF (4) | HHA (5) | OTHER (6) |
| Pending | ||||||
| 27. Total Pending | ||||||
| 28. PRO Generated | ||||||
| 29. Provider Generated | ||||||
| 30. MSP | ||||||
| 31. Other | ||||||
| SECTION C: MEDICAID CROSSOVER BILLS | ||||||
| Clearances | ||||||
| 32. Trans to St Agencies | ||||||
| 33. Trans Electronically | ||||||
| SECTION D: | ||||||
| MISCELLANEOUS DATA | TOTAL | BENEFICIARY | PROVIDER | |||
| Inquiries | ||||||
| 34. Total Inquiries | ||||||
| 35. Telephone | ||||||
| 36. Walk-In | ||||||
| 37. Written |
| Intermediary Name: | Reporting Period: | |||||
|---|---|---|---|---|---|---|
| Intermediary Number: | Number of Working Days: | |||||
| SECTION D: MISCELLANEOUS DATA | TOTAL (1) | INPATIENT (2) | OUTPATIENT (3) | SNF (4) | HHA (5) | OTHER (6) |
| OCR Bills | ||||||
| 38. Total Received | ||||||
| Bills Paid by HMOs | ||||||
| 39. Total Processed | ||||||
| Medicare Summary Notices | ||||||
| 40. Total MSNs Mailed |
Form CMS 1566 - Medicare Program Intermediary Workload Report, Pages 2-11
| Intermediary Number: | Bill Type: | Report Month: | ||||||
|---|---|---|---|---|---|---|---|---|
| * | * | PAID | * | NOT PAID | ||||
| Non-PIP | PIP | |||||||
| DAYS TO PROCESS | TOTAL (1) | CLEAN (2) | OTHER (3) | CLEAN (4) | OTHER (5) | CLEAN (6) | OTHER (7) | EMC (8) |
| 1.1 | ||||||||
| 2. 2 | ||||||||
| 3. 3 | ||||||||
| 4. 4 | ||||||||
| 5. 5 | ||||||||
| 6. 6 | ||||||||
| 7. 7 | ||||||||
| 8. 8 | ||||||||
| 9. 9 | ||||||||
| 10. 10 | ||||||||
| 11. 11 | ||||||||
| 12. 12 |
Form CMS 1566 - Medicare Program Intermediary Workload Report, Pages 2-11
| Intermediary Number: | Bill Type: | Report Month: | ||||||
|---|---|---|---|---|---|---|---|---|
| *** | *** | PAID | NOT PAID | |||||
| Non-PIP | PIP | |||||||
| DAYS TO PROCESS | TOTAL (1) | CLEAN (2) | OTHER (3) | CLEAN (4) | OTHER (5) | CLEAN (6) | OTHER (7) | EMC (8) |
| 13. 13 | ||||||||
| 14. 14 | ||||||||
| 15. 15 | ||||||||
| 16. 16 | ||||||||
| 17. 17 | ||||||||
| 18. 18 | ||||||||
| 19. 19 | ||||||||
| 20. 20 | ||||||||
| 21. 21 | ||||||||
| 22. 22 | ||||||||
| 23. 23 |
Form CMS 1566 - Medicare Program Intermediary Workload Report, Pages 2-11
| Intermediary Number: | Bill Type: | Report Month: | ||||||
|---|---|---|---|---|---|---|---|---|
| *** | *** | PAID | NOT PAID | |||||
| Non-PIP | PIP | |||||||
| DAYS TO PROCESS | TOTAL (1) | CLEAN (2) | OTHER (3) | CLEAN (4) | OTHER (5) | CLEAN (6) | OTHER (7) | EMC (8) |
| 24. 24 | ||||||||
| 25. 25 | ||||||||
| 26. 26 | ||||||||
| 27. 27 | ||||||||
| 28. 28 | ||||||||
| 29. 29 | ||||||||
| 30. 30 | ||||||||
| 31. 31 | ||||||||
| 32. 32 | ||||||||
| 33. 33 |
Form CMS 1566 - Medicare Program Intermediary Workload Report, Pages 2-11
| Intermediary Number: | Bill Type: | Report Month: | ||||||
|---|---|---|---|---|---|---|---|---|
| *** | *** | PAID | NOT PAID | |||||
| Non-PIP | PIP | |||||||
| DAYS TO PROCESS | TOTAL (1) | CLEAN (2) | OTHER (3) | CLEAN (4) | OTHER (5) | CLEAN (6) | OTHER (7) | EMC (8) |
| 34. 34-45 | ||||||||
| 35. 46-60 | ||||||||
| 36. 61-90 | ||||||||
| 37. 91+ | ||||||||
| 38. Total | ||||||||
| 39. Mean PT |
CMS-1566, Page
Page number and bill type to be reported as follows:
| Page 2 - Inpatient Hospital (INP) | Page 7 - CORF (COR) |
|---|---|
| Page 3 - Outpatient (OUT) | Page 8 - ESRD (ERD) |
| Page 4 - SNF (SNF) | Page 9 - Lab (LAB) |
| Page 5 - HHA (HHA) | Page 10 - Other (OTH) |
| Page 6 - Hospice (HPC) | Page 11 - Total (TOT) |
| Intermediary Number: | Report Month: | |||||
|---|---|---|---|---|---|---|
| BILLS/PAYMENTS DAYS LATE | TOTAL (1) | HOSPITAL (2) | SNF (3) | HHA (4) | HOSPICE (5) | REMAINDER (6) |
| 1. Total Bills | ||||||
| 2. 1 | ||||||
| 3. 2 | ||||||
| 4. 3 | ||||||
| 5. 4 | ||||||
| 6. 5 | ||||||
| 7. 6-15 | ||||||
| 8. 16-30 | ||||||
| 9. 31-60 | ||||||
| 10. 61+ | ||||||
| 11. Total Paid | ||||||
| 12. 1 | ||||||
| 13. 2 | ||||||
| 14. 3 | ||||||
| 15. 4 |
| Intermediary Number: | Report Month: | |||||
|---|---|---|---|---|---|---|
| BILLS/PAYMENTS DAYS LATE | TOTAL (1) | HOSPITAL (2) | SNF (3) | HHA (4) | HOSPICE (5) | REMAINDER (6) |
| 16. 5 | ||||||
| 17. 6-15 | ||||||
| 18. 16-30 | ||||||
| 19. 31-60 | ||||||
| 20. 61+ |
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
The intermediary prepares and submits to CMS, by the 10th of each month following the reporting month, a PRO Adjustment Bill Report using the CROWD system. It submits a total page showing contractor activity for all PROs in the contractor's area. In addition, it submits a separate report for each PRO/State. For example, if the intermediary handles adjustment records for a PRO involving separate States, it should submit a separate report for each State. It reports all tape adjustment requests as well as hardcopy adjustment request records which the PRO has designated XXP (where XX is a two-digit numeric identifier) in accordance with the Medicare Claims Processing Manual, Chapter 4, Outpatient Billing. If the intermediary does not have activity for a certain PRO/State combination in a month, it shall not submit a report.
(Rev. 6, 08-30-02)
A3-3895.1
The intermediary enters the contractor's assigned 5-digit ID and the PRO's 5-digit ID number in the indicated spaces. It shows the 2-digit State abbreviation. For the total page show "Total" in the PRO space. In the space labeled "Report Month/Year" enter the calendar month and year reported, e.g., show 0692 for June 1992.
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
For all PRO adjustments, determine the appropriate column. Complete the report for each line as follows:
Line 5 - Electronic Adjustment Request Records Rejected - The intermediary enters the number of electronic adjustment request records reported on line 4 that failed contractor front end edits.
• Line 6 - Electronic Adjustment Request Records Accepted - The intermediary enters the difference of line 4 minus line 5.
(Rev. 6, 08-30-02)
A3-3895.3
Before transmitting the report, the intermediary checks for completeness and arithmetical accuracy. The line item edits apply to all columns. It uses the following checklist:
(Rev. 6, 08-30-02)
A3-3895.4
| MONTHLY PRO ADJUSTMENT BILL REPORT | |||
|---|---|---|---|
| INTERMEDIARY ID: | PRO ID: STATE: | MONTH/YEAR: | |
| TOTAL (A) | INPATIENT (B) | OUTPATIENT (C) | |
| 1.Opening Pending | |||
| 2.Revisions to Opening Pending | |||
| 3.Revises Opening Pending | |||
| 4.Elec. Adj. Req. Rec. Received | |||
| 5.Elec. Adj. Rec. Rec. Rejected | |||
| 6.Elec. Adj. Rec. Received | |||
| 7.Hard-Copy Adj. Req. Rec. Accepted | |||
| 8.Addtl. Bills to be Proc. Due to Interim Bills | |||
| 9.Total Adj. Bills to be Proc. |
| MONTHLY PRO ADJUSTMENT BILL REPORT | |||
|---|---|---|---|
| INTERMEDIARY ID: | PRO ID: STATE: | MONTH/YEAR: | |
| TOTAL (A) | INPATIENT (B) | OUTPATIENT (C) | |
| 10.Nonprocessable Adjustment Bills-Failed Batch/System Edits | |||
| 11.Total Adj. Bills Processed | |||
| 12.No. Compl. in 60 Days or Less | |||
| 13.No. Compl. in 61-90 Days | |||
| 14.No. Compl. in 91-120 Days | |||
| 15.No. Compl. Over 120 Days | |||
| 16.Closing Pending |
(Rev. 6, 08-30-02)
A3-3896
In addition to the monthly workload report, prepare and transmit to CMS a Quarterly Supplement to the Intermediary Workload Report showing the status and disposition of selected workloads. Complete a separate report for each office assigned a separate intermediary number.
(Rev. 6, 08-30-02)
A3-3896.1
The Quarterly Supplement to the Intermediary Workload Report - Pages 1 and 2, supplies CMS with current data on the number of bills processed for each State for which you service one or more providers. The Quarterly Supplement to the Intermediary Workload Report - Page 3, provides data on denials, HHA visits and waivers of liability.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3896.2
Transmit the Quarterly Supplement to CMS CO via PC or terminal as soon as possible after the reporting quarter but no later than the 15th of the following month. Use instructions in the CROWD User Guide available via the CMS Enterprise Portal.
(Rev. 6, 08-30-02)
A3-3897
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3897.1
These pages are referenced as Form C for CROWD. It submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 6, 08-30-02)
A3-3897.2
Before submitting Form C to CMS, check its completeness and arithmetical accuracy. Use the following checklist:
(Rev. 10521; Issued: 12-16-20; Effective: 01-01-21; Implementation: 01-04-21)
The A/B MAC (A) reports counts in total and by type of bill as shown below:
| Column | (1) | Total--All provider bills. |
|---|---|---|
| Column | (2) | Inpatient Hospital--CMS-1450s submitted by hospitals for inpatient services, with the following two-digit classification codes in Form Locator 4: 1-1 (inpatient hospital); and 4-1 (Religious Nonmedical Health Care Hospital-inpatient). |
| Column | (3) | Outpatient--CMS-1450s submitted by hospitals or SNFs for outpatient services with the following two-digit classification codes in Form Locator 4: 1-3 (hospital-outpatient); 2-3 (SNF-outpatient); 4-3 Religious Nonmedical Health Care Hospital- outpatient); 5-3 (Religious Nonmedical Health Care SNF-outpatient); and 8- 3 (hospital- outpatient surgical procedures - ASC) |
| Column | (4) | SNF--CMS-1450s with the following two-digit classification codes in Form Locator 4: 1-8 (hospital-swing-bed); 2-1 (SNF-inpatient); 2-8 (SNF swing- bed); and 5-1 (Religious Nonmedical Health Care-SNF-inpatient). |
| Column | (5) | HHA--CMS-1450s submitted by HHAs with the following two digit classification codes in Form Locator 4: 3-2 (HHA-Part B visits and use of DME); 3-3 (HHA-Part A visits and DME); 3-4 (HHA-other-Part B-benefits) |
| Column | (6) | Other--CMS-1450s with the following two-digit classification codes in Form Locator 4: 1-2 (hospital inpatient-Part B benefits); 1-4 (hospital-other-Part B benefits); 2-2 (SNF-inpatient-Part B benefits); 2-4 (SNF-other-Part B benefits); 4-2 (Religious Nonmedical Health Care-inpatient-Part B benefits); 4-4 (Religious Nonmedical Health Care-inpatient-other); 5-2 (Religious Nonmedical Health Care-SNF inpatient-Part B benefits); 5-4 (Religious Nonmedical Health Care-SNF inpatient-other); 7-1, 7-2, |
| 7-3, 7-4, 7-5 (Clinics - provider and independent RHCs, FQHCs, ESRD hospital- based or independent renal dialysis facilities, FQHCs, CMHCs, ORFs and CORFs); 8-1 and 8-2 (Hospices); and 8-7 (Opioid Treatment Programs) | |
|---|---|
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3897.4
Section A: Bills Processed by State of Provider - The intermediary reports in this section the claims workload for each State for which you service one or more providers. Break out by State the number of initial bills (including demand and no-pay bills) reported as processed on line 12 of Form D (see §20.4) over the 3 months of the reporting quarter.
NOTE: Categorize the information reported by the State of the individual provider, not the home office, if it is part of a chain organization.
Line 1 - All - For each column 1 through 6, the system will sum the number of claims reported on the individual State lines completed below. The numbers so calculated by the system must equal the sum of the numbers reported on line 12 of Form D for the 3 months of the reporting quarter.
State Lines - In the column just left of column (1), the intermediary reports the two-digit postal abbreviation of each State (or FO for foreign claims) which includes at least one provider for which you processed claims during the quarter.
It reports opposite each listed State the number of initial bills processed during the reporting quarter for providers located in the State. It reports the data in total in column 1, and by type of bill in columns 2 through 6.
(Rev. 6, 08-30-02)
A3-3898
(Rev.)
A3-3898.1
This page is referenced as Form I for CROWD. It submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 6, 08-30-02)
Before submitting Form I to CMS, check for completeness and arithmetical accuracy. Use the following checklist:
(Rev. 6, 08-30-02)
A3-3898.3
The intermediary reports counts in total and by type of bill as outlined in §60.3 for Form C.
(Rev. 6, 08-30-02)
A3-3898.4
Line 1: Bills Denied-Total - The intermediary reports all full and partial denial determinations that it made during the reporting period. It reports only denial determinations resulting in its preparing and sending a notice to the beneficiary. It counts a denial when it denies (either in full or in part) bills submitted as covered. It includes counts where it made a denial determination but found both the beneficiary and the provider to be without fault under §213 of Public Law 92-603 and, therefore, made a determination to waive liability in full.
Also, it includes counts when it found only the provider to be at fault (i.e., it waived the beneficiary's liability). It does not count:
Line 2: Bills Paid Under Waiver-Total - The intermediary reports the total number of bills on which you made a determination to waive the liability of both the beneficiary and the provider. Count determinations made at:
The intermediary does not count waiver determinations made by PROs.
Line 2A: Initial Bills Paid Under Waiver - The intermediary reports the number of bills on which you made a decision to waive the liability of both the beneficiary and the provider during the initial adjudication of the bills.
Line 3: Amount Reimbursed Under Waiver - The intermediary reports the amounts paid (to the nearest dollar) under the waiver provision for the bills reported on line 2. Do not include coinsurance amounts, charges applied toward the deductible, or reimbursement for services not under consideration with respect to the waiver provision. Where all services on a bill are paid in full (excluding the applicable deductible and coinsurance) as a combination of covered services and noncovered services paid under waiver and the exact dollar amount of the waiver payment is not available without contacting the provider, it reports an approximation of the waiver payment. In calculating this approximation, apply to total charges the proportion of waiver days to total days included on the bill, and subtract any applicable deductible or coinsurance for the waiver period.
Line 3A: Amount on Initial Bills - The intermediary reports the amounts paid (to the nearest dollar) under the waiver provision for the bills reported on line 2A.
Line 4: Days/Visits Processed - The intermediary reports under column 4 the total number of days (both covered and noncovered) for SNF bills shown as processed in column 4, line 1 of Form C, for the same reporting period. It reports under column 5 the number of billed visits for HHA bills shown as processed in column 5, line 1 of Form C, for the same reporting period.
Line 5: Days/Visits Denied-Total - The intermediary reports under column 4 the number of SNF days denied on the bills reported on line 1. It reports under column 5 the number of HHA visits denied on the bills reported on line 1. Denied days/visits are those billed as covered which you determine to be noncovered.
Line 6: Days/Visits Paid Under Waiver of Liability - The intermediary reports under column 4 the number of SNF days on the bills reported on line 2 that were paid under the waiver provision. It reports under column 5 the number of HHA visits on the bills reported on line 2 that were paid under the waiver provision.
Line 6A: Days/Visits Paid Under Waiver on Initial Bills - The intermediary reports under column 4 the number of SNF days on the bills reported on line 2A that were paid under the waiver provision. It reports under column 5 the number of HHA visits on the bills reported on line 2A that were paid under the waiver provision.
Line 7: Total Demand Bills - The intermediary reports under the appropriate column bills which the provider determined to be for noncovered services but which the beneficiary or his representative requested be filed in order to obtain a Medicare decision. It reports only bills identified by condition code 20. (See The Medicare Claims
Processing Manual, Chapter 1, General Billing Requirements.) It reports the total number of bills processed during the reporting quarter, even if not manually reviewed.
Line 7A: Full/Partial Reversals - The intermediary reports the number of demand bills on which you fully or partially reversed the provider's decision that the services were noncovered.
Line 7B: Days/Visits on Reversals - The intermediary reports under column 4 the number of SNF days on the demand bills reported on line 7A. It reports under column 5 the number of HHA visits on the demand bills reported on line 7A (i.e., report days/visits for which you fully or partially reversed the provider's decision that they were noncovered).
Line 8: Total No-Pay Bills - The intermediary reports under the appropriate column the total number of no-pay bills (excluding the demand bills reported on line 7 Section D) which are included in the total bills processed reported on line 1, page 1 of the Quarterly Supplement for the same reporting period. No-pay bills are those submitted by providers with no charges and/or covered days/visits. It does not report HHA bills where no utilization is chargeable and no payment has been made, but which you have requested only to facilitate recordkeeping processes.
Line 8A: Days/Visits on No-Pay Bills - The intermediary reports under column 4 the number of SNF days on the no-pay bills reported on line 8. It reports under column 5 the number of HHA visits on the no-pay bills reported on line 8.
Line 8B: MSP No-Pay Bills - The intermediary reports the number of no-pay bills included on line 8 where payment has been made in full by another insurer as primary payer.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.5
The intermediary prepares and submits to CMS each quarter a report on the number of fraud workload items handled by your Medicare fraud unit. This information is required by CMS to budget for fraud and abuse activities, as well as to monitor the flow of work through the fraud units. Submit this form via CROWD no later than the 15th day following the close of the reporting quarter.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.6
This page is referenced as Form M in the CROWD system. Complete the ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the reporting format to your screen.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.7
Before submitting Form M to CMS, check for completeness and arithmetical accuracy. Use the following checklist:
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.8
The intermediary reports fraud workload items in the following columns for all lines of Form M:
Column (1) – Total – All fraud workload items.
Column (2) – Beneficiary Complaints – The intermediary reports the number of complaints received from, or on behalf of, beneficiaries alleging fraud. Do not include complaints filed with the Office of the Inspector General (OIG) Hotline.
Column (3) – OIG Hotline – The intermediary reports the number of complaints received via the OIG Hotline.
Column (4) – Referrals and Other – The intermediary reports referrals and any other workload received by the fraud unit (e.g., provider complaints, internally generated referrals from medical review, special requests from OIG or CMS).
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.9
Line 1 – Opening Pending – The system will pre-fill the number pending from line 8 of the previous quarter’s report.
Line 2 – Adjustments – If it is necessary to revise the pending figure for the close of the previous quarter because of inventories, reporting errors, etc., enter the adjustment on this line. Precede negative adjustments with a minus sign.
Line 3 – Adjusted Pending – The system will sum line 1 + line 2 to calculate the adjusted opening pending.
Line 4 – Workload Received – The intermediary reports the number of complaints and referrals received in the fraud unit during the reporting period.
Line 5 – Total Cleared – The system will sum line 6 + line 7 to calculate the total number of complaints and referrals cleared by the fraud unit during the reporting period.
Line 6 – Cleared by Contractor – The intermediary reports the number of complaints and referrals cleared by the fraud unit by means other than referral to the OIG or designated agency. Include those that were:
Line 7 – Cleared by Referral – The intermediary reports the number of complaints and referrals that were incorporated into cases referred formally to the OIG or designated agency for action (e.g., sanctions or prosecution).
Line 8 – Closing Pending – The system will calculate the closing pending for the quarter by adding line 3 to line 4 and subtracting line 5.
70.10 – Completing Quarterly Periodic Interim Payment (PIP) Report, CMS-1566C – General
(Rev12894; Issued:10-17-24-Effective: 11-01-24; Implementation:11-01-24)
A3-3898.10
The intermediary prepares and submits to CMS each quarter a report on the number of providers that you pay using the PIP method. This information is required so that CMS
can monitor the number of providers being paid using the PIP method at each intermediary and nationally. Submit the form via CROWD no later than the 15th day following the close of the reporting quarter.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.11
This page is referenced as Form Q for CROWD. It submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 6, 08-30-02)
A3-3898.12
Before submitting Form Q to CMS, check for completeness and arithmetical accuracy. Use the following checklist:
(Rev. 6, 08-30-02)
A3-3898.13
Line 1 - PIP Providers - Beginning of Quarter - The intermediary reports the number of PIP providers by type (hospital, SNF and HHA) and total at the beginning of the quarter.
Line 2 - PIP Providers - Accretions - The intermediary reports the number of providers by type (hospital, SNF and HHA) and total who elected during the reporting quarter to be paid under PIP.
Line 3 - PIP Providers - Deletions - The intermediary reports the number of providers by type (hospital, SNF and HHA) and total who elected during the reporting quarter to discontinue being reimbursed under the PIP method.
Line 4 - PIP Providers - End of Quarter - The intermediary reports the number of PIP providers by type (hospital, SNF and HHA) and total at the end of the quarter.
(Rev. 12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.14
HFCA-1566A, PAGES 1 & 2 (CROWD FORM C)
INTERMEDIARY NUMBER __ REPORT PERIOD ____
| SECTION A: BILLS PROCESSED BY STATE OF PROVIDER | TOTAL 1 | INP HOSP 2 | OUTPATIENT 3 | SNF 4 | HHA 5 | OTHER 6 | |
|---|---|---|---|---|---|---|---|
| 1 . | TOTAL - ALL | ||||||
| STATE CODE | XXXXXXXXXX | XXXXXXXXX | XXXXXXXXXXXXX | XXXX | XXXXX | XXXXXX | |
HFCA-1566A, PAGE 3 (CROWD FORM I)
INTERMEDIARY NUMBER ______
| TOTAL 1 | INPATIENT 2 | OUTPATIENT 3 | SNF 4 | HHA 5 | OTHER 6 | |
|---|---|---|---|---|---|---|
| SECTION B: BILL DENIAL DATA | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXX | XXXX | XXXXX |
| 1. BILLS DENIED - TOTAL | ||||||
| 1A. MEDICAL - SUBJECT TO WAIVER | XXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXXX | XXXXXX | XXXXXX |
| 1B. MEDICAL - NOT SUBJECT TO WAIVER | XXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXXX | XXXXXX | XXXXXX |
| 1C. NONMEDICAL TOTAL | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXXX | XXXXXX | XXXXXX |
| 1D. NONMEDICAL MSP | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXXX | XXXXXX | XXXXXX |
| 2. BILLS PAID UNDER WAIVER TOTAL | ||||||
| 2A. INITIAL BILLS PAID UNDER WAIVER |
HFCA-1566A, PAGE 3 (CROWD FORM I)
INTERMEDIARY NUMBER ______
| TOTAL 1 | INPATIENT 2 | OUTPATIENT 3 | SNF 4 | HHA 5 | OTHER 6 | |
|---|---|---|---|---|---|---|
| 3. AMOUNT REIMBURSED UNDER WAIVER | ||||||
| 3A. AMOUNT ON INITIAL BILLS | ||||||
| SECTION C: DAY/VISIT DATA | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXX | XXXX | XXXXX |
| 4. DAYS/VISITS PROCESSED | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXX | ||
| 5. DAYS/VISITS DENIED TOTAL NO-PAY BILLS | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXX | ||
| 5A. MEDICAL - SUBJECT TO WAIVER | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXX | ||
| 5B. MEDICAL - NOT SUBJECT TO WAIVER | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXX | ||
| 5C. NONMEDICALS | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXX |
HFCA-1566A, PAGE 3 (CROWD FORM I)
INTERMEDIARY NUMBER______
REPORT PERIOD______
| TOTAL 1 | INPATIENT 2 | OUTPATIENT 3 | SNF 4 | HHA 5 | OTHER 6 | |
|---|---|---|---|---|---|---|
| 6. DAYS/VISITS PAID UNDER WAIVER - TOTAL | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXX | ||
| 6A. DAYS/VISITS ON INITIAL BILLS | XXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXX |
HFCA-1566A, PAGE 3 (CROWD FORM I)
INTERMEDIARY NUMBER _____ REPORT PERIOD _____
| TOTAL 1 | INPATIENT 2 | OUTPATIENT 3 | SNF 4 | HHA 5 | OTHER 6 | |
|---|---|---|---|---|---|---|
| SECTION D: DEMAND BILL DATA | XXXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXX | XXXX | XXXXX |
| 7. TOTAL DEMAND BILLS | ||||||
| 7A. FULL/PARTIAL REVERSALS | ||||||
| 7B. DAYS/VISITS ON REVERSALS | XXXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXX | ||
| SECTION E: NO-PAY BILLS | XXXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXX | XXXX | XXXXX |
| 8. TOTAL NO-PAY BILLS | ||||||
| 8A. DAYS/VISITS ON NO-PAY BILLS | XXXXXXXX | XXXXXXXXXX | XXXXXXXXXX | XXXXX | ||
| 8B. MSP NO-PAY BILLS |
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.15
HFCA-1566B (CROWD FORM M)
INTERMEDIARY NUMBER_ REPORT PERIOD_
| FRAUD WORKLOAD ITEM | TOTAL 1 | BENEFICIARY COMPLAINT 2 | OIG HOTLINE 3 | REFERRAL & OTHERS 4 |
|---|---|---|---|---|
| 1. OPENING PENDING | ||||
| 2. ADJUSTMENTS | ||||
| 3. ADJUSTED PENDING | ||||
| 4. WORKLOAD RECEIVED | ||||
| 5. TOTAL CLEARED | ||||
| 6. BY CONTRACTOR | ||||
| 7. BY REFERRAL | ||||
| 8. CLOSING PENDING |
(Rev. 6, 08-30-02)
A3-3898.16
FORM CMS-1566C (CROWD FORM Q)
INTERMEDIARY NUMBER_
REPORT PERIOD
| PIP PROVIDERS | HOSP. (1) | SNF (2) | HHA (3) | TOTAL (4) |
|---|---|---|---|---|
| 1. BEGINNING OF QUARTER | ||||
| 2. ACCRETIONS | ||||
| 3. DELETIONS | ||||
| 4. END OF QUARTER | ||||
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
Each quarter, the intermediary prepares and submits to CMS a report on the number of provider enrollment applications received, processed, and pending during the quarter. Include in your counts of provider enrollment applications, any change of ownership (CHOW) notices handled by you. It submits this report via the Contractor Reporting of Operational and Workload Data (CROWD) system no later than the fifteenth day following the close of the reporting quarter.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
This report is referenced as Form 3 in the CROWD system. Complete the ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the reporting format to your screen.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
Before submitting Form 3 to CMS, check for completeness and arithmetical accuracy. Use the following checklist:
• For all columns, the sum of lines 27-31 must equal line 11.
• For all columns, line 32 must equal line 37 from the previous quarter.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.20
The intermediary reports provider enrollment application data in the following columns for all lines on Form 3.
Column (1) - Total - The sum of columns 2-16 for each line.
Column (2) - Accredited Hospital - Provider applications indicating provider type as an accredited hospital.
Column (3) - Non-Accredited Hospital - Provider applications indicating provider type as a non-accredited hospital.
Column (4) - Religious Nonmedical Health Care Facility - Hospital - Provider applications indicating provider type as a Religious Nonmedical Health Care Facility - hospital.
Column (5) - Rural Primary Care Hospital - Provider applications indicating provider type as a rural primary care hospital.
Column (6) - SNF - Provider applications indicating provider type as a skilled nursing facility (i.e., long term care facility).
Column (7) - HHA. - Provider applications indicating provider type as a home health agency.
Column (8) - Hospice - Provider applications indicating provider type as a hospice facility.
Column (9) - ESRD - Provider applications indicating provider type as an end stage renal disease dialysis facility.
Column (10) - CORF - Provider applications indicating provider type as a comprehensive outpatient rehabilitation facility.
Column (11) - RHC - Provider applications indicating provider type as a rural health clinic.
Column (12) - FQHC - Provider applications indicating provider type as a federally qualified health center.
Column (13) - CMHC - Provider applications indicating provider type as a community mental health center.
Column (14) - IHS - Provider applications indicating provider type as an Indian Health Service facility.
Column (15) - Outp. Speech Path./Phy.Ther - Provider applications indicating provider type as either outpatient speech pathology or outpatient physical therapy facility.
Column (16) - Other - Provider applications indicating provider type other than those defined for columns 1 through 15.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.21
Line 1 - Pending End of Last Quarter - The CROWD system will automatically enter the value from line 11 on the previous quarter's report.
Line 2 - Adjustments to Pending - If it is necessary to revise the pending figure for the close of the previous quarter because of inventories taken or reporting errors discovered, enter the adjustment here. Adjustments can be positive or negative values. If entering a negative value, precede the number with a minus (-) sign.
Line 3 - Adjusted Opening Pending -The CROWD system will automatically sum the values on lines 1 and 2.
Line 4 - New Applications Received - The intermediary enters the number of applications received for the first time during the reporting quarter.
Line 5 - Returned Applications Resubmitted - The intermediary enters the number of applications received during the reporting quarter that had previously been received and returned to the applicant for correction/completion.
Line 6 - Total Applications Received -The CROWD system will automatically sum the values and lines 4 and 5.
Line 7 - Applications Recommended for Approval - The intermediary enters the number of applications that you recommended for approval (i.e., Medicare number issued) during the reporting quarter.
Line 8 - Applications Recommended for Denial - The intermediary enters the number of applications that you recommended for denial during the reporting quarter.
Line 9 - Applications Returned - The intermediary enters the number of applications returned to the applicant for corrections/completion during the reporting quarter.
Line 10 - Total Applications Processed -The CROWD system will automatically sum the values on lines 7, 8, and 9.
Line 11 - Pending End of Quarter -The CROWD system will automatically compute the number of applications pending at the end of the reporting quarter by adding the value on line 3 to the value on line 6 and then subtracting the value on line 10.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.22
Line 12 - Sanctioned From Medicare - The intermediary enters the number of applications that you recommended for denial because the applicant is currently excluded/sanctioned from Medicare.
Line 13 - Debarred/Excluded by Other Federal Agency - The intermediary enters the number of applications that you recommended for denial because the applicant had been disbarred, suspended, or excluded by any other Federal agency.
Line 14 - Not Professionally Licensed - The intermediary enters the number of applications that you recommended for denial because the applicant was not professionally licensed.
Line 15 - Business Address Invalid - The intermediary enters the number of applications that you recommended for denial because the applicant had an invalid business address.
Line 16 - Business Location Not Licensed - The intermediary enters the number of applications that you recommended for denial because the applicant=s business location was not properly licensed.
Line 17 - CMS Requirements Not Met - The intermediary enters the number of applications that you recommended for denial because the applicant did not meet all CMS requirements.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.23
Line 18 - Incomplete - The intermediary enters the number of applications returned to the applicant because the application was incomplete.
Line 19 - Unverifiable Information - The intermediary enters the number of applications returned to the applicant because the application included unverifiable information.
Line 20 - Not Signed - The intermediary enters the number of applications returned to the applicant because the applicant did not sign the certification statement.
Line 21 - Invalid Billing Agreement - The intermediary enters the number of applications returned to the applicant because the billing agreement did not meet CMS requirements.
Line 22 - Other - The intermediary enters the number of applications returned to the applicant for any reason other than the ones indicated on lines 18 through 21.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.24
Line 23 - Number Under 21 Days - The intermediary enters the number of applications processed in less than 21 days from the date of receipt.
Line 24 - Number in 21-30 Days - The intermediary enters the number of applications processed in 21 through 30 days from the date of receipt.
Line 25 - Number in 31-40 Days - The intermediary enters the number of applications processed in 31 through 40 days from the date of receipt.
Line 26 - Number Over 40 Days - The intermediary enters the number of applications processed in more than 40 days from the date of receipt.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.25
Line 27 - Number Under 11 Days Old - The intermediary enters the number of applications included in line 11 which are 1-10 days old.
Line 28 - Number 11-20 Days Old - The intermediary enters the number of applications included in line 11 which are 11-20 days old.
Line 29 - Number 21-30 Days Old - The intermediary enters the number of applications included in line 11 which are 21-30 days old.
Line 30 - Number 31-40 Days Old - The intermediary enters the number of applications included in line 11 which are 31-40 days old.
Line 31 - Number Over 40 Days Old - The intermediary enters the number of applications included in line 11 which are over 40 days old.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The intermediary reports in this section counts of your workloads dealing with CHOW notices included in lines 1, 2, 3, 6, 10, and 11.
Line 32 - Pending End of Last Quarter - The CROWD system will automatically enter the value from line 37 on the previous quarter's report. (This count represents the number of CHOWs included in line 1.)
Line 33 - Adjustments to Pending - If it is necessary to revise the pending figure for the close of the previous quarter because of inventories taken or reporting errors discovered, enter the adjustment here. Adjustments can be positive or negative values. If entering a negative value, precede the number with a minus (-) sign. (This count represents the number of CHOWs included in line 2.)
Line 34 - Adjusted Opening Pending -The CROWD system will automatically sum the values in lines 32 and 33. (This count represents the number of CHOWs included in line 3.)
Line 35 - CHOWs Received - The intermediary enters the number of applications shown in line 6 that represents CHOWs received during the reporting quarter.
Line 36 - CHOWs Processed - The intermediary enters the number of applications shown in line 10 that represents CHOWs processed during the reporting quarter.
Line 37 - Pending End of Quarter -The CROWD system will automatically compute the number of CHOWs pending at end of the reporting quarter by adding the value on line 34 to the value on line 35 and then subtracting the value on line 36. (This count represents the number of CHOWs included in line 11.)
(Rev. 6, 08-30-02) A3-3898.27
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| Application Workloads | Total (1) | Accrued Hospital (2) | Non- Accrued Hospital (3) | Religious Nonmedical Health Care Hospital (4) | Rural Prim Care Hospital (5) |
|---|---|---|---|---|---|
| 1. Pending End of Last Quarter | |||||
| 2. Adjustments to Pending | |||||
| 3. Adjusted Opening Pending | |||||
| 4. New Applications Received | |||||
| 5. Returned Appls Resubmitted | |||||
| 6. Total Applications Received | |||||
| 7. Applications Approval Recmd | |||||
| 8. Applications Denial Recmd | |||||
| 9. Applications Returned | |||||
| 10. Total Applications Processed | |||||
| 11. Pending End of Quarter |
SCREEN 1
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| Application Workloads | SNF (6) | HHA (7) | Hospice (8) | ESRD (9) | CORF (10) |
|---|---|---|---|---|---|
| 1. Pending End of Last Quarter | |||||
| 2. Adjustments to Pending | |||||
| 3. Adjusted Opening Pending | |||||
| 4. New Applications Received | |||||
| 5. Returned Appls Resubmitted | |||||
| 6. Total Applications Received | |||||
| 7. Applications Approval Recmd | |||||
| 8. Applications Denial Recmd | |||||
| 9. Applications Returned | |||||
| 10. Total Applications Processed | |||||
| 11. Pending End of Quarter |
SCREEN 2
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| Application Workloads | RHC (11) | FQH C (12) | CMHC (13) | IHS (14) | Outpatient Speech Pathology PhysicalTherapy (15) | Other (16) |
|---|---|---|---|---|---|---|
| 1. Pending End of Last Quarter | ||||||
| 2. Adjustments to Pending | ||||||
| 3. Adjusted Opening Pending | ||||||
| 4. New Applications Received | ||||||
| 5. Returned Appls Resubmitted | ||||||
| 6. Total Applications Received | ||||||
| 7. Applications Approval Recmd | ||||||
| 8. Applications Denial Recmd | ||||||
| 9. Applications Returned | ||||||
| 10. Total Applications Processed | ||||||
| 11. Pending End of Quarter |
SCREEN 3
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| Application Workloads | Total (1) | Accrued Hospital (2) | Non- Accrued Hospital (3) | Religious Nonmedical Health Care Hospital (4) | Rural Prime Care Hospital (5) |
|---|---|---|---|---|---|
| Reason for Denial Recommendation | |||||
| 12. Sanctioned from Medicare | |||||
| 13. Debarred/Excluded by Other Fed | |||||
| 14. Not Professionally Licensed | |||||
| 15. Business Address Invalid | |||||
| 16. Business Location Not Licensed | |||||
| 17. CMS Requirements Not Met | |||||
| Reason for Return | |||||
| 18. Incomplete | |||||
| 19. Unverifiable Information | |||||
| 20. Not Signed | |||||
| 21. Invalid Billing Agreement | |||||
| 22. Other |
SCREEN 4
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| Application | SNF (6) | HHA (7) | Hospice (8) | ESRD (9) | CORF (10) |
|---|---|---|---|---|---|
| Reason for Denial Recommendation | |||||
| 12. Sanctioned from Medicare | |||||
| 13. Debarred/Excluded by Other Fed | |||||
| 14. Not Professionally Licensed | |||||
| 15. Business Address Invalid | |||||
| 16. Business Location Not Licensed | |||||
| 17. CMS Requirements Not Met | |||||
| Reason for Return | |||||
| 18. Incomplete | |||||
| 19. Unverifiable Information | |||||
| 20. Not Signed | |||||
| 21. Invalid Billing Agreement | |||||
| 22. Other |
SCREEN 5
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| Application Workloads | RHC (11) | FQHC (12) | CMHC (13) | IHS (14) | Outpatient Speech Pathology/ Physical Therapy (15) | Other (16) |
|---|---|---|---|---|---|---|
| Reasons for Denial Recommendation | ||||||
| 12. Sanctioned from Medicare | ||||||
| 13. Debarred/Excld by Other Fed | ||||||
| 14. Not Professionally Licensed | ||||||
| 15. Business Address Invalid | ||||||
| 16. Business Location Not Licens | ||||||
| 17. CMS Requirements Not Met | ||||||
| Reason for Return | ||||||
| 18. Incomplete | ||||||
| 19. Unverifiable Information | ||||||
| 20. Not Signed | ||||||
| 21. Invalid Billing Agreement | ||||||
| 22. Other |
SCREEN 6
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| Application Workloads | Total (1) | Accrued Hospital (2) | Non- Accrued Hospital (3) | Religious Nonmedical Health Care Hospital (4) | Rural Prime Care Hospital (5) |
|---|---|---|---|---|---|
| Application Processing Times | |||||
| 23. Number Under 21 Days | |||||
| 24. Number in 21-30 Days | |||||
| 25. Number in 31-40 Days | |||||
| 26. Number Over 40 Days | |||||
| Age of Applications Pending | |||||
| 27. Number Under 11 Days Old | |||||
| 28. Number 11-20 Days Old | |||||
| 29. Number 21-30 Days Old | |||||
| 30. Number 31-40 Days Old | |||||
| 31. Number Over 40 Days Old |
SCREEN 7
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| Application Workloads | SNF (6) | HHA (7) | Hospice (8) | ESRD (9) | CORF (10) |
|---|---|---|---|---|---|
| Application Processing Times | |||||
| 23. Number Under 21 Days | |||||
| 24. Number in 21-30 Days | |||||
| 25. Number in 31-40 Days | |||||
| 26. Number Over 40 Days | |||||
| Age of Applications Pending | |||||
| 27. Number Under 11 Days Old | |||||
| 28. Number 11-20 Days Old | |||||
| 29. Number 21-30 Days Old | |||||
| 30. Number 31-40 Days Old | |||||
| 31. Number Over 40 Days Old |
SCREEN 8
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| Application Workloads | RHC (11) | FQHC (12) | CMHC (13) | IHS (14) | Outpatient Speech Pathology/ Physical Therapy (15) | Other (16) |
|---|---|---|---|---|---|---|
| Application Processing Times | ||||||
| 23. Number Under 21 Days | ||||||
| 24. Number in 21-30 Days | ||||||
| 25. Number in 31-40 Days | ||||||
| 26. Number Over 40 Days | ||||||
| Age of Applications Pending | ||||||
| 27. Number Under 11 Days Old | ||||||
| 28. Number 11-20 Days Old | ||||||
| 29. Number 21-30 Days Old | ||||||
| 30. Number 31-40 Days Old | ||||||
| 31. Number Over 40 Days Old |
SCREEN 9
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| CHOW Workloads | Total (1) | Accrued Hospital (2) | Non- Accrued Hospital (3) | Religious Nonmedical Health Care Hospital (4) | Rural Prime Care Hospital (5) |
|---|---|---|---|---|---|
| 32. Pending End of Last Quarter | |||||
| 33. Adjustments to Pending | |||||
| 34. Adjusted Opening Pending | |||||
| 35. CHOWs Received | |||||
| 36. CHOWs Processed | |||||
| 37. Pending End of Quarter |
Exhibit 10 (Cont.)
SCREEN 11
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| CHOW Workloads | SNF (6) | HHA (7) | Hospice (8) | ESRD (9) | CORF (10) |
|---|---|---|---|---|---|
| 32. Pending End of Last Quarter | |||||
| 33. Adjustments to Pending | |||||
| 34. Adjusted Opening Pending | |||||
| 35. CHOWs Received | |||||
| 36. CHOWs Processed | |||||
| 37. Pending End of Quarter |
INTERMEDIARY NAME: REPORT PERIOD:
INTERMEDIARY NUMBER: CROWD FORM 3
| CHOW Workloads | RHC (11) | FQHC (12) | CMHC (13) | IHS (14) | Outpatient Speech Pathology/Physical Therapy (15) | Other (16) |
|---|---|---|---|---|---|---|
| 32. Pending End of Last Quarter | ||||||
| 33. Adjustments to Pending | ||||||
| 34. Adjusted Opening Pending | ||||||
| 35. CHOWs Received | ||||||
| 36. CHOWs Processed | ||||||
| 37. Pending End of Quarter |
SCREEN 12
(Rev. 6, 08-30-02)
A3-3899
(Rev. 188, Issued: 04-22-11, Effective: 07-01-11, Implementation: 07-05-11)
NOTE: For MSP reporting effective April 2005, refer to the manual instructions located within Publication 100-05, Chapter 5, Section 60 (MSP Reports).
Each month the intermediary electronically transmits to CO a Monthly Intermediary Report on Medicare Secondary Payer Savings (CMS-1563) via the IBM PC. It continues to use existing dialup instructions and the RLINK software sent to it. (See §80.9). Hardcopy reports are not required. It transmits a separate report for each office assigned a separate intermediary number and also, for each State for which it have been designated the servicing intermediary for one or more providers. It is not required to complete an individual State report for those States in which it has had no MSP activity during the month (reports that would show zeros in every category, including pending).
(Rev. 6, 08-30-02)
A3-3899.2
The Monthly Intermediary Report on Medicare Secondary Payer Savings supplies CMS with current data on MSP savings and MSP pending workloads.
(Rev. 6, 08-30-02)
A3-3899.3
Form CMS-1563 is due in CO as soon as possible after the end of the month being reported, but not later than the 15th of the following month. Nonreceipt of the report by the 15th will result in a telephone contact with the intermediary to obtain required information.
(Rev. 6, 08-30-02)
A3-3899.4
The intermediary enters its name, assigned number and the State in which the provider is located. In the space labeled 'Reporting Period', it enters the numeric designation for month and year for which the report is being prepared, e.g., it shows 01/02 for January 2002.
(Rev. 6, 08-30-02)
A3-3899.5
A. Reporting Dollar Values - The intermediary rounds all values to nearest whole dollar. This includes all amounts shown on lines 2, 4, 6, 8 and 80.
B. Checking Reports - Before mailing the reports, it checks their completeness and arithmetical accuracy as follows:
(Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
The intermediary controls all claims from which it extracts MSP savings and is able to verify all amounts recorded on the CMS-1563.
A. MSP Savings File - It retains claims specific key identifying information on each claim counted as savings on the CMS-1563. At a minimum, it records the beneficiary's name, Medicare beneficiary identifier, type/dates of service, claim control number, billed charges and savings amounts reported.
B. Savings Data From Non-Medicare Sources - If it records savings from data it obtained from its "private side" records or any other "outside" source, it must be able to extract the same claims specific information noted above, i.e., it must verify that Medicare covered services are involved and be able to calculate "what Medicare would have paid." In addition, it must compare this data with the data contained in its MSP savings file to ensure that savings have not previously been recorded for the same claims. If savings have not previously been taken for the claim, it counts them as savings on the CMS-1563 and enters them into its MSP savings file.
80.7 - Source of Savings - The intermediary reports data by total and by source as shown below:
(Rev. 6, 08-30-02)
A3-3899.7
Column (i) Total--All MSP savings regardless of source.
Column (ii) Workers' Compensation, Black Lung, and VA - It includes data related to all MSP savings resulting from medical benefits provided by the WC Plans of the 50 States, the District of Columbia, Guam and Puerto Rico. It also includes Federal WC provided under the Federal Employee's Compensation Act, the U. S. Longshoremen's and Harborworkers' Compensation Act and its extensions, the Federal Coal Mine Health and Safety Act of 1969 as amended (the Federal BL Program), and any fee-for-service medical care paid for by the VA. It keeps separate records for each distinct category (WC, BL or VA) as this may become a reporting requirement in the future.
Column (iii) Working Aged - It includes data related to all MSP savings resulting from benefits payable under an EGHP for beneficiaries aged 65 and older who are covered by reason of their own employment or the employment of a spouse of any age. Section 3491 further defines the working aged provisions.
Column (iv) ESRD - It includes data related to all MSP savings resulting from benefits payable under an EGHP for individuals who are entitled to Medicare benefits solely on the basis of ESRD during a period of up to 12 months. The period during which Medicare pays secondary benefits is defined in the Medicare Claims Processing Manual, Chapter 29, Coordination with Medigap insurers.
Column (v) Auto Medical, No Fault and Liability Insurance - It includes data related to all MSP savings resulting from:
Automobile Medical or No Fault Insurance - Insurance coverage (including a self-insured plan) that pays for all, or part, of the medical expenses for injuries sustained in the use of, or occupancy of, an automobile, regardless of who may have been responsible for the accident. (This insurance is sometimes called "personal injury protection," "medical payments coverage" or "medical expense coverage.")
Liability Insurance - Insurance (including a self-insured plan) that provides payment based on legal liability for injury, illness or damage to property. It includes, but is not limited to, automobile liability insurance, uninsured motorist insurance, homeowners' liability insurance, malpractice insurance, product liability insurance, and general casualty insurance. It does not include situations where a beneficiary receives medical payment under his or her own homeowners' insurance.
Column (vi) Disabled - It includes data related to all MSP savings resulting from situations where Medicare is the secondary payer for disabled beneficiaries under age 65 (except ESRD beneficiaries) who elect to be covered by a large group health plan (LGHP) as a current employee or
family member of such employee. A LGHP is any health plan that covers employees of at least one employer who normally employs 100 or more employees. The disabled provisions apply to items and services furnished on or after January 1, 1987 and before January 1, 1992
Unpaid (cost avoided) claims are those that the intermediary has returned without payment because it has strong evidence that another insurer is the primary payer and there is no indication that payment has been requested from that payer. The information indicating MSP involvement may be contained in the intermediary's files, on the query reply, or on the claim itself. In addition, any information it obtains from a non-Medicare source and uses as the basis for claiming cost avoidance savings must meet the criteria in §80.6B.
Information considered adequate for claiming cost avoidance savings includes statements on the claim noting 'automobile accident,' 'collision', or the name of the automobile insurer. Another example would be previous information obtained showing EGHP coverage exits. The intermediary does not count claims it develops as 'possible' MSP situations based on routine edits as cost avoidance savings unless it has previous information that another payer has primary responsibility. For example, 'trauma code' edits are not, by themselves, considered strong evidence that Medicare is the secondary payer.
Line 1 - Number - The intermediary reports the total number of cost avoided claims from which it is recording savings on the report.
Line 2 - Dollar Value - The intermediary reports the total dollar value of the potential Medicare payments calculated for the claims on Line 1 that will be saved if the primary payer makes a payment which relieves Medicare of all payment liability.
It shows as the amount cost avoided what Medicare would have paid. It does not count total charges as cost avoided savings. The cost avoided amount is the 'Medicare payment rate' or the 'current Medicare interim reimbursement amount' less any co-insurance amount applicable. It reduces Part B services subject to coinsurance for the coinsurance amount or it may use a 'coinsurance reduction factor' of 19 percent to calculate coinsurance charges for all Part B services. It does not have to query for deductible status, but may assume that the deductible has been met.
Cost avoidance savings may not duplicate savings reported as full or partial recoveries and may not be shown where Medicare ultimately makes primary payment. To prevent duplicate counting, the intermediary suspends all claims it returns unpaid. It sets up a control on each claim returned for development. It maintains this control for 75 days, unless it receives further information before
that time which allows it to process the claim. If no further information on the claim is received, it may deny the claim after 75 days. It is not required to continue tracking the claim, but retains the key identifying information on the claim, as described in §80.6A.
CMS prefers the intermediary to show cost avoidance savings only after 75 days have elapsed. However, it has the option of counting the savings when the claim is initially suspended or at any time during the suspension period. If it chooses the latter alternative, it must adjust its cost avoidance savings if the claim is resubmitted during the suspension period with information showing it is not a legitimate cost avoidance.
The following situations require special consideration if cost avoidance savings are counted before the 75 day suspense period has ended:
In these situations, it adjusts its cost avoidance savings figures by deducting or "backing out" the applicable amounts. It makes the adjustments in the reporting month in which a final determination is rendered. The following chart outlines the correct reporting of savings in each situation.
| Cost Avoidance | Partial Recoveries | Full Recoveries | ||
|---|---|---|---|---|
| I. | Partial Recovery Adjustment | |||
| o MSP situation indicated. Medicare payment calculated to be $1200 if Medicare was primary payer. Claim is returned to provider. | $ 1,200 | |||
| o Provider resubmits the claim showing $900 paid by the other insurer. Medicare secondary payment of $300 is made. | $ (1,200) * | $ 900 | ||
| II. | 'Other Payer Denial' Adjustment | |||
| • MSP situation indicated - Medicare 'primary' payment, $2,000. Claim is returned to provider. | $ 2,000 | |||
| • Other payer denies claim. Medicare found to be primary and Medicare payment of $2,000 is made. | $ (2,000) * | |||
| III. | Full Recovery Adjustment | |||
| • MSP situation indicated - Medicare 'primary' payment, $900. Claim is returned to provider. | $ 900 | |||
| • Provider submits a 'no-payment' bill showing full payment by the other payer. | $ (900) * | $ 900 |
*Amounts 'backed out' of cost avoidance savings figures.
Line 3 - Number - The intermediary reports the number of full recoveries made during the month.
Line 4 - Dollar Value - The intermediary reports the dollar value of full recoveries made during the month.
Full Recoveries are claims where the primary payer made a payment that relieved Medicare of all payment liability. Full recoveries can be either prepayment or postpayment. The intermediary counts full recoveries in the month in which it recovers the full payment or receives a no-payment bill for prepayment full recovery cases. Where the 'full recovery' is paid in installments, it counts the claim as pending until all monies have been received. Instructions for processing full recovery claims are in the Medicare Claims Processing Manual, Chapter 29, Coordination with Medigap insurers.
A. Prepayment Full Recovery - A prepayment full recovery occurs when a primary payer makes full payment on a charge before Medicare makes any payment.
EXAMPLE: A hospital identifies an EGHP as the primary payer, submits its charge to that insurer, and the EGHP pays the hospital's full cost. The intermediary subsequently receive a 'no pay' bill in accordance with the Medicare Claims Processing Manual, Chapter 29, Coordination with Medigap insurers. It determines what it would have paid if the EGHP had not made payment and records that total as a full recovery savings.
B. Postpayment Full Recovery - A postpayment full recovery occurs when a primary payer makes full payment on a charge after Medicare has paid.
EXAMPLE: Medicare paid a hospital bill for charges incurred as a result of an automobile accident. Subsequently, an auto liability insurer reimburses the Medicare beneficiary for the full amount of the medical expenses and the beneficiary refunds that amount to the program. The intermediary counts the amount of Medicare's initial payment as a postpayment full recovery.
The intermediary records as savings, that portion of a full recovery paid to an attorney or other agent as Medicare's share of the recovery cost. Consequently, there may be instances where it has made a full recovery but does not get back the full amount paid. When it refers a case to the RO for recovery action, however, it does not record any savings at that point. Savings from a compromise or 'subrogation' case may be recorded only after a final determination. The intermediary does not count these cases for CPEP credit prior to final settlement.
EXAMPLE: A beneficiary incurs a $1,000 physician's bill and a $5,000 hospital bill as a result of injuries sustained in an automobile accident. Assuming that all deductibles are satisfied, Part B pays $800 toward the physician's charges, and Part A covers the hospital bill in full. After litigation, a liability insurer agrees to pay $6,000 for the beneficiary's medical expenses from which the attorney takes a fee. (If the attorney's fee were 33 percent, the dollar recovery would be $4,000.) The Part B contractor can record $800 in Full Recovery savings. The intermediary is also allowed to count its payment as a Full Recovery savings even though the amount recovered, due to attorney's fees, does not equal what was paid.
Line 5 - Number - The intermediary reports the number of partial recoveries made during the month.
Line 6 - Dollar Value - The intermediary reports the dollar value of partial recoveries made during the month.
Partial recoveries are those savings realized when a primary payer makes a payment which covers only a part of the Medicare allowable charge, leaving Medicare with a balance to pay. The intermediary uses the following formula in computing the savings from a partial recovery:
The intermediary counts partial recoveries in the month when it takes final action on the claim (either making a payment supplemental to that of the primary payer or making a partial recovery from a payment by the primary payer). Instructions for processing partial recovery claims are in the Medicare Claims Processing Manual, Chapter 29, Coordination with Medigap insurers.
It records as savings, that portion of a partial recovery paid to an attorney or other agent as Medicare's share of the recovery cost. When it refers a case to the RO for recovery action, however, It does not record any savings at that point. Savings from a compromise or 'subrogation' case may be recorded only after a final determination. These cases may not be counted for CPEP credit prior to final settlement.
In this part of the report (lines 7 and 8), the intermediary reports data on the totals of unpaid claims plus full and partial recoveries.
Line 7 - Claims - The intermediary reports the total number of MSP claims handled during the month.
Line 8 - Dollar Value - The intermediary reports the total dollar value associated with MSP claims during the month.
Line 9 - Number - The intermediary reports the number of pending claims/cases as of the close of the reporting month. It includes claims/cases for which 'Full Recovery' is expected but all money due has not been received.
Line 10 - Estimated Value - The intermediary reports the gross charges for all claims/cases reported as pending on line 9. Where 'Full Recovery or Partial Recovery' has been determined, but all monies have not been received, it reports the gross charges until it receives the full amount due or it is reasonable not to expect further payments.
A case is defined as one or more claims filed on behalf of an individual and related to one specific occurrence that necessitated medical care. When recording data for column 1 concerning WC and Auto Liability, and No Fault Insurance, the intermediary counts only cases. For Working Aged (column iii), ESRD (column iv), and Disabled (column vi), it counts each individual claim.
A case/claim is pending only after it has been developed to the point where it is determined to be an MSP claim and no final resolution has been made. A partial or interim payment is not sufficient to remove a case/claim from the pending rolls. Final resolution occurs when there is no longer a practical expectation of further reimbursement.
Remarks - The intermediary enters any comments relevant to the interpretation and analysis of the report.
Signature - The report is signed by the individual responsible for its compilation.
Date - The intermediary enters the Date that the report is completed and signed.
(Rev. 6, 08-30-02)
A3-3899.9
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
At the end of each month, prepare and transmit to CMS a report summarizing activity on Part A reconsiderations, Part A Administrative Law Judge (ALJ) hearings, Part B reviews, and Part B hearings during the month. Complete a separate report for each office assigned a separate intermediary number.
Form CMS-2591 is subject to the Paperwork Reduction Act and requires approval by the Office of Management and Budget (OMB). OMB approval has been requested.
The CMS-2591 (see §3890 - Exhibits 1 thru 6) enables CMS to tabulate data for administrative purposes on the following information:
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
Transmit the CMS-2591 to CO via PC or terminal. Use instructions in the CROWD User Guide available via the CMS Enterprise Portal.
The report is due as soon as possible after the end of the reporting month but no later than the 15th of the month following the end of the reporting month.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
This report is referenced as Form J for CROWD. It submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
This part concerns data from Part A and Part B appeals processes. The number of appeals requested (received), completed, and pending reflects the status of the workload as of the last day of the reporting month. Base data on actual counts of each activity and not on sampling or other estimating techniques.
Appeals fall into the following categories:
1. Part A Reconsideration.--This is the first level of appeal following denial of a Part A claim. It is a re-evaluation of the facts and findings of a claim to determine whether the initial decision was correct. (See §3781.)
Do not count duplicate reconsideration requests or reconsideration requests received before you have made an initial determination on a claim. Do not count telephone requests for reconsiderations or inquiries. Count one reconsideration per request received. With the exception of line 7 of the CMS-2591, do not count the number of claims or beneficiaries involved in the requests.
2. Part B Review.--This is the first formal level of appeal following denial of a Part B claim. It is a second look by a different employee at the claim and supporting evidence. (See §§3792 ff.)
3. Part B Hearing.--This is an independent determination resulting from an appeal of your review decision. This independent determination is rendered by a Hearing Officer (HO) you assigned. The amount in controversy must be at least $100. (See §§3794ff.)
Definition of Columns:
Column (1) TOTAL--All Part A reconsiderations. Column 1 must equal the sum of columns 2, 3 and 4.
Column (2) SNF.--All skilled nursing facility reconsiderations.
Column (3) HHA/HOSPICE.--All home health agency and hospice reconsiderations.
Column (4) OTHER.--All other Part A reconsiderations.
Column (5) PART B REVIEWS.--Count one review per request received (i.e., Form CMS-1964 or equivalent written request). Do not count duplicate review requests or review requests received before you have made an initial determination on a claim. With the exception of line 7 of the CMS-2591, do not count the number of claims or beneficiaries involved in the requests. (Report claim counts in line 7.)
Column (6) PART B HEARINGS.--Count one hearing per request received (i.e., Form CMS-1965 or equivalent written request). Include hearings requested that do not meet the minimum $100 requirements and are subsequently dismissed. With the exception of line 7 of the CMS-2591, do not count the number of claims or beneficiaries involved in the requests. (Report claim counts in line 7.) Do not count hearing requests that qualify for a Part B ALJ hearing. (Part B intermediary hearings are those Part B hearings that a hearing officer adjudicates, as opposed to an ALJ). See definition for Section C.
Do not count requests for HO hearings received after you rendered an on-the-record (OTR) decision in lines 1-44 of the report. Count these cases only in lines 45, 46, 47, 48 and 50 as appropriate.
Line 1. Opening Pending.--Show under columns 1-4, the number of reconsiderations reported on line 19 as the closing pending on the previous month's report. Show under column 5 the number of reviews reported on line 30 as the closing pending on the previous month's report. Show under column 6 the number of hearings reported on line 40 as the closing pending on the previous month's report.
Line 2. Adjustments to Pending.--If it is necessary to revise the pending figure for the close of the previous month because of inventories or reporting errors, enter the adjustment. Report requests received near the end of the reporting month and placed under control in the subsequent month as received in the reporting month, not as requests received in the subsequent month. If some cases were not counted in the proper month's receipts, count them as adjustments to the opening pending in the subsequent month.
If line 3 of the current month differs from the closing pending of the previous month, there must be an entry in line 2 for the current month. Precede the entry by a "+" or "-", as appropriate.
Line 3. Adjusted Pending.--Enter the result of line 1 + line 2 (taking into account the "-" sign, if any).
Line 4. Requests Received.--Show, under the appropriate columns, the number of requests for reconsiderations, reviews, and Part B intermediary hearings received during the reporting month.
Include requests transferred to you by other intermediaries if you incur administrative costs for processing the appeals and you report the cost on the Interim Expenditure Report (Form CMS-1523).
If an appellant submits one request involving several different claims (and several different beneficiaries), count it as one request. If an appellant submits more than one request (for different claims) at different times, count each request.
NOTE: See definition of column (6) for instructions on hearings requested subsequent to OTR decisions.
Line 4A. Medical Necessity Documentation Denials.--Show the number of requests included in line 4 that involved initial claim denials for lack of medical documentation.
Line 5. Requests Transferred.--Show under columns 1 thru 5 the number of reconsiderations and review requests you transferred to other contractors because you did not process the original claim(s). Report under column 6 the number of Part B hearing requests transferred to other contractors because the claimant is not within your geographical area (See §3794.3B) or transferred to ROs because the issues are outside the HO's responsibilities. (See §3794.2.) For columns 1-6, if you have reported a reconsideration, review or Part B hearing as transferred, do not report any information regarding it on lines 6-51. The transfer is the final action.
Line 6. Requests Cleared.--Show, under the appropriate columns, the total numbers of reconsiderations, reviews, and Part B hearings completed during the month. Report all completed appeals, regardless if final outcome was affirmation, reversal, withdrawal, or dismissal.
Consider a reconsideration or review cleared when the final determination (EOMB or other notice, including dismissal) is printed or typed, or upon notification of withdrawal by the appellant. In the case of a reversal, consider the case cleared when you initiate the adjustment action.
A Part B hearing may be considered cleared when the decision is signed, or the following conditions exist:
Do not consider a hearing completed upon release of an OTR decision unless the appellant specifically requested an OTR hearing. Do not count the OTR hearing as completed until you have completed all follow-up actions as required in §3794.9. If as a result of the follow-up actions, the appellant requests an in-person or telephone hearing after release of the OTR decision, the OTR hearing and decision are not counted on the report with the exception noted below. If the appellant does not appear for the subsequent hearing, dismiss the hearing. (See §3794.3K.) For
processing time purposes, the case is completed when you dismiss it; however, the decision to record in lines 9-11 is the OTR decision.
NOTE: If you close a reconsideration, review or hearing after the end of a reporting month but before the report is due on the fifteenth of the subsequent month, do not count it until the subsequent month's report.
Line 7. No. of Claims Involved.--Show on line 6 the total number of claims involved in the appeals reported as cleared during the month. For example, if you process one HHA reconsideration decision which involves five claims, report five claims under column (3), or if you process decisions for two Part B hearings in the month, one of which involved three claims and the other seven, report 10 claims under column (6).
Line 8. Amount in Controversy.--For Part B hearings reported as affirmed (line 9) or reversed (line 11) during the month, show the total dollar amount in controversy on the initial requests. The amount in controversy is the difference between the amount billed (less any reductions required by legislation, e.g., Gramm-Rudman-Hollings) and the amount you originally allowed less any unmet deductible and coinsurance amounts. In effect, the amount in controversy is the amount of payment that the claimant would receive if the denial(s) was fully reversed. Show results rounded to the nearest dollar.
Line 9. Affirmations.--Under the appropriate columns, show the number of completed reconsiderations, reviews, and Part B hearings in which the previous determinations were completely upheld; i.e., no change was made. All parts of all claims in a case must be upheld in order for the case to be counted as an affirmation. An OTR hearing decision does not count as a previous decision if the appellant subsequently requests an in-person or telephone hearing. If the in-person/telephone hearing is dismissed because the appellant did not appear, or the request was withdrawn, use the OTR decision to determine if the case is counted here. (See line 11 for partial affirmations. Do not include them here.)
If you uphold your original determination, but pay under limitation of liability, count the determination as an affirmation. Report the appropriate information in Section D of the CMS-2591.
Line 10. Dism./Withdr.--Report, under the appropriate column, the number of completed reconsiderations, reviews, and Part B hearings that were withdrawn by the appellant or dismissed (before determination) by you or the HO. Report here and in lines 4 and 6 an appeal that is requested and withdrawn or dismissed within the same month. If the appellant requests an in-person or telephone hearing after receiving an OTR decision, and you dismiss the hearing because the appellant failed to appear, the OTR decision is the final decision, not the dismissal. Similarly, for a withdrawal, use the OTR decision.
A dismissal at the reconsideration or review level is done when written correspondence has been identified as an appeal request, but the claimant does not have the right to an appeal. Misrouted correspondence and duplicate requests are not dismissals.
If you have incorrectly counted such correspondence as an appeal on a previous report, use line 2 (adjustments to pending) to correct the count. Do not count a duplicate request for appeal
anywhere on the report. Likewise, do not count on the report a request for appeal received before an initial claim determination has been rendered. (Consider the request an inquiry.)
Line 11. Reversals (Full or Part).--Under the appropriate columns, show the total number of completed reconsiderations, reviews, and Part B hearings in which at least part of the prior determination was reversed. That is, a change was made and some or all of the new determination was in favor of the appellant.
If a reconsideration, review, or Part B hearing involves several claims, and the initial determinations for some are affirmed and some are reversed, consider the decision a reversal. An OTR hearing decision does not count as a previous decision if the appellant subsequently requests an in-person or telephone hearing. If the in-person/telephone hearing is dismissed because the appellant did not appear, or the request was withdrawn, use the OTR decision to determine if the case is counted here.
Line 12. Amount Awarded.--For cases included in line 11, show the amount of submitted charges for services where the determination was reversed. Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.
Processing and Pending Times.--This deals with processing and pending times for Part A and Part B appeals.
Computing Time to Process Part A Reconsiderations and Part B Reviews for (Lines 13-18 and 25-29)
For lines 13-18 and 25-29, use the matrix below to determine the number of days from receipt to completion of reconsiderations and reviews. The date of receipt in all cases is the day the processing contractor received it in its corporate mailroom.
Situation
Date Completed
The date you were notified of the withdrawal.
The date of the notice.
The date when you submit the claim to CWF if payment can be made without further development, or when you initiate development; e.g., when you must ascertain whether or not the provider has refunded payment to the beneficiary.
Computing Time to Process Part B Hearings for Lines 35-39
For lines 35-39, use the matrix below to determine the number of days from receipt to completion of Part B hearings. The date of receipt, in all cases, is the day you receive the appeal request in its corporate mailroom. In out-of-area cases, it is the date that the second intermediary receives the request.
An OTR decision is made and the appellant accepts the decision or decided to go directly to an ALJ hearing.
An OTR decision is made and the appellant chooses in a timely fashion to proceed with the in-person or telephone hearing.
An in-person or telephone hearing is held without an OTR decision.
The appellant withdraws the hearing request.
The HO dismisses the hearing request.
The date of the OTR decision.
The date of the second decision. If the appellant appears, and you dismiss the hearing, use the date of notice of dismissal.
The date of the decision.
The date you are notified of the withdrawal.
The date of the dismissal notice.
Line 13. Processing Time - Average.--Report under the appropriate columns the average number of days from receipt of the reconsideration to the date of completion.
To compute the average number of days from request to completion, divide the total days elapsed for all requests cleared in the month by the number of requests cleared. Round results to the nearest day. Calculate the days elapsed for an individual request by subtracting the Julian date of receipt from the Julian date of completion. If the request is cleared in the year following the year of receipt, add 365 or 366 to the result, as appropriate. (Otherwise, you will get a negative number.) If a case is cleared the same day it is received, consider it to require 1 day.
NOTE: Include all cases cleared, regardless of whether they were affirmed, reversed, dismissed, or withdrawn.
Line 14. Reconsiderations Completed 1-45 Days.--Show the number of reconsiderations that required 1-45 days, to complete. If a case is cleared the same day it is received, consider it to require 1 day.
Line 15. Reconsiderations Completed 46-60 Days.--Show the number of reconsiderations that required 46-60 days to complete.
Line 16. Reconsiderations Completed 61-90 Days.--Show the number of reconsiderations that required 61-90 days to complete.
Line 17. Reconsiderations Completed 91-120 Days.--Show the number of reconsiderations that required 91-120 days to complete.
Line 18. Reconsiderations Completed over 120 Days.--Show the number of reconsiderations that required more than 120 days to complete.
Line 19. Closing Pending Reconsiderations.--Show, under the appropriate columns, the total number of reconsiderations that have not been completed by the end of the reporting month.
Line 20. Reconsiderations Pending 1-45 Days.--Show the number of reconsiderations included in line 19 that have been pending 1-45 days, inclusive, at the end of the reporting month.
Line 21. Reconsiderations Pending 46-60 Days.--Show the number of reconsiderations included in line 19 that have been pending 46-60 days, inclusive, at the end of the reporting month.
Line 22. Reconsiderations Pending 61-90 Days.--Show the number of reconsiderations included in line 19 that have been pending 61-90 days, inclusive, at the end of the reporting month.
Line 23. Reconsiderations Pending 91-120 Days.--Show the number of reconsiderations included in line 19 which have been pending 91-120 days, inclusive, at the end of the reporting month.
Line 24. Reconsiderations Pending Over 120 Days.--Show the number of reconsiderations included in line 19 which have been pending more than 120 days at the end of the reporting month.
Line 25. Processing Time - Average.--Report here the average number of days from the receipt of the review to the date of completion.
To compute the average number of days from request to completion, divide the total days elapsed for all requests cleared in the month by the number of requests cleared. Round results to the nearest day. Calculate the days elapsed for an individual request by subtracting the Julian date of receipt from the Julian date of completion.
If the request is cleared in the year following the year of receipt, add 365 or 366 to the result, as appropriate. (Otherwise, you will get a negative number.) If a case is cleared the same day it is received, consider it to require 1 day.
NOTE: Include all cases cleared, regardless of whether they were affirmed, reversed, dismissed, or withdrawn.
Line 26. Reviews Completed in 1-30 Days.--Show the number of cases that required 1-30 days to complete. If a case is cleared the same day it is received, consider it to require 1 day.
Line 27. Reviews Completed in 31-45 Days.--Show the number of reviews that required 31-45 days to complete.
Line 28. Reviews Completed in 46-60 Days.--Show the number of reviews that required 46-60 days to complete.
Line 29. Reviews Completed in 61+ Days.--Show the number of reviews that required more than 60 days to complete.
Line 30. Closing Pending-Reviews.--Show the total number of reviews that have not been completed by the end of the reporting month.
Line 31. Reviews Pending 1-30 Days.--Show the number of reviews included in line 30 that have been pending 1-30 days, inclusive, at the end of the reporting month.
Line 32. Reviews Pending 31-45 Days.--Show the number of reviews included in line 30 that have been pending 31-45 days, inclusive, at the end of the reporting month.
Line 33. Reviews Pending 46-60 Days.--Show the number of reviews included in line 30 that have been pending 46-60 days, inclusive, at the end of the reporting month.
Line 34. Reviews Pending Over 60 Days.--Show the number of reviews included in line 30 that have been pending more than 60 days at the end of the reporting month.
Line 35. Hearing Processing Time - Average.--Report the average number of days from receipt of the hearing request to date of completion. See methodology under line 25.
Line 36. Hearings Completed in 60 Days.--Show the number of hearings that required 1-60 days to complete. If a case is cleared the same day it is received, consider it to require 1 day.
Line 37. Hearings Completed in 61-90 Days.--Show the number of hearings that required 61-90 days to complete.
Line 38. Hearings Completed 91-120 Days.--Show the number of hearings that required 91-120 days to complete.
Line 39. Hearings Completed Over 120 Days.--Show the number of hearings that required more than 120 days to complete.
Line 40. Closing Pending-Hearings.--Show the total number of hearings that have not been completed by the end of the reporting month. You may not consider a hearing completed upon release of an OTR decision unless the appellant specifically requested an OTR hearing. See definition for line 6.
Line 41. Hearings Pending 1-60 Days.--Show the number of hearings included in line 40 that have been pending 1-60 days, inclusive, at the end of the reporting month.
Line 42. Hearings Pending 61-90 Days.--Show the number of hearings included in line 40 which have been pending 61-90 days, inclusive, at the end of the reporting month.
Line 43. Hearings Pending 91-120 Days.--Show the number of hearings included in line 40 which have been pending 91-120 days, inclusive, at the end of the reporting month.
Line 44. Hearings Pending Over 120 Days.--Show the number of hearings included in line 40 that have been pending more than 120 days at the end of the reporting month.
Section B deals with data on Part B hearings completed during the month. Base data shown on actual counts of each activity and not derived from sampling or other estimating techniques.
HEARINGS FALL INTO THE FOLLOWING CATEGORIES:
Column (1) On-the-Record with No Subsequent Hearing.--Include in column 1 hearings held where the appellant originally requested an OTR hearing, indicates that he/she is satisfied with the OTR decision, that he/she wishes to proceed with an ALJ hearing (if the amount in controversy is $500 or more), or fails to respond to the OTR within the required time frame. In addition, if the appellant requests an in-person or telephone hearing subsequent to an OTR decision, but the hearing is dismissed or withdrawn, include it here and not in columns (2) or (3).
Column (2) All Telephone.--Include in column 2, hearings where the appellant requested and had a telephone hearing subsequent to an OTR hearing decision, or a telephone hearing was held without a prior OTR decision. Count all telephone hearings including those where the appellant did not follow-up timely to the OTR notice, but later requested a telephone hearing.
Column (3) All In-Person.--Include in column 3 hearings where the appellant requested and had an in-person hearing subsequent to an OTR hearing decision, or an in-person hearing was held without a prior OTR decision. Count all in-person hearings including those where the appellant did not follow-up timely to the OTR notice but later requested an in-person hearing.
Column (4) Number in 120 Days.--For the total cases included in line 47, columns 2 and 3, (e.g., the sum) show for lines 49-51 the numbers that were completed within 120 days of receipt. Use the methodology shown above the explanation for line 13 to determine the completion date. Where an OTR decision is made and the appellant chooses to not follow-up timely and later requests either an in-person or telephone hearing, completion time for this second reported hearing is measured from the date of receipt of original request to the date of the second decision. If the appellant does not appear, dismiss the hearing in accordance with §3794.3k, and use the date of notice of dismissal as your date completed.
Line 45. Reversals.--Under the appropriate columns, show the number of OTR, telephone, and in-person hearings completed in the month in which at least part of the review determination was reversed i.e., a change was made and some, or all, of the new determination was in favor of the appellant. (See the definition for line 11.)
Line 46. Affirmations.--Under the appropriate columns, show the number of OTR, telephone, and in-person hearings completed in the month in which the review determination was completely upheld, i.e., no change was made. All parts of all claims must be upheld in order for the case to be counted as an affirmation. (See the definition for line 9.)
Line 47. Total Decisions.--Show the total number of hearing decisions completed during the month that resulted in a reversal or affirmation, excluding dismissals and withdrawals.
Line 48. Number in 120 Days.--For cases included in line 47, show the number that were completed within 120 days of receipt. See methodology for column 4 to determine the completion date.
Line 49. No Previous OTR Held.--For cases included in line 47, columns (2) and (3), report the number where you held the telephone or in-person hearing without first making an OTR decision, i.e., the OTR hearing was bypassed.
In column (4), report the number of cases included in either column (2) or (3) which were completed within 120 days.
Line 50. Previous OTR Counted.--For the cases included in line 47, columns (2) and (3), report the number where you included the OTR count on a previous report. In column (4), report the number of cases included in either column (2) or (3) that were completed within 120 days.
Cases reported in line 50 are those where an OTR decision was made and the appellant either accepted the OTR decision, did not respond timely, or decided to go directly from the OTR decision to an ALJ hearing. Then, subsequent to this OTR decision "acceptance," the appellant changed his/her mind and decided that he/she wanted a telephone or in-person hearing. Do not include these cases in line 6.
Line 51. Previous OTR Not Counted.--For cases included in line 47, columns (2) and (3), report the number where you did not include the OTR count on a previous report. These are cases where you made the OTR decision first, and the appellant indicated in a timely fashion (see §3794.9) that he/she wanted a telephone or in-person hearing. In column (4), report the number of cases included in either column (2) or (3) that were completed within 120 days.
Use Section C to report requests for ALJ hearings, including those expected to be dismissed for failure to meet the amount in controversy requirement or for any other reason, such as the lack of a fair hearing in Part B cases.
ALJ HEARINGS FALL INTO THE FOLLOWING CATEGORIES:
Column (1) TOTAL.--All Part A ALJ hearing requests as originally filed. Column 1 must equal the sum of columns 2, 3 and 4.
Column (2) SNF.--All skilled nursing facility (SNF) hearings.
Column (3) HHA/HOSPICE.--All home health agency (HHA) and hospice hearings.
Column (4) OTHER.--All other hearings.
Column (5) PART B.--All Part B ALJ hearings.
Line 52. Opening Pending.--Show the number of ALJ hearings reported on Line 67 as the closing pending on the previous month's report.
Line 53. Adjustments to Pending.--See definition for line 2. If line 54 of the current month differs from data in line 67 of the previous month, there must be an entry in line 53 for the current month. Precede the entry by a '+' or '-' as appropriate.
Line 54. Adjusted Pending.--Show the result of line 52 + line 53 (taking into account the '-' sign, if any).
Line 55. Requests Received.--Show the number of ALJ hearings requested during the month. (See §3797)
Line 56. Requests Forwarded to ALJ.--Show the number of ALJ hearing requests forwarded to ALJs during the month. Consider the case forwarded when all necessary material has been mailed to the ALJ.
Line 57. No. of Claims Involved.--Show the number of claims involved in the ALJ hearing requests forwarded to ALJs as reported on line 56.
Line 58. In 1-7 Calendar Days.--Show the number of ALJ hearing requests forwarded to ALJs within 7 calendar days from receipt of the request in the corporate mailroom to mailing of the necessary information. Show data for all cases mailed during the month. The number must be less than, or equal to, the number shown in line 56.
Line 59. In 1-14 Calendar Days.--Show the number of ALJ hearing requests forwarded to ALJs within 14 calendar days from receipt of the request in the corporate mailroom to mailing of the necessary information to the ALJ. Show data for all cases mailed during the month. Note that the number in this line must be less than or equal to the number shown in line 56.
Line 60. Average Time to Forward.--Report the average number of calendar days from receipt of the ALJ request to the date of mailing of the necessary information. Use the methodology discussed in §3888.2 for line 13.
Line 61. Completed.--Show the number of ALJ hearing requests completed during the month. Consider a case completed when you have received the completed decision from the ALJ for all parts of the case.
Line 62. Amount in Controversy.--For ALJ hearings reported as affirmed (line 63) or reversed (line 65), during the month, show the total dollar amount in controversy according to the initial ALJ hearing request. This should be the amount remaining after previous appeals decisions. Round results to the nearest dollar.
Line 63. Affirmations.--Show the number of completed ALJ hearings in which the previous determination was completely upheld, i.e., no change was made. All parts of all claims in a case must be upheld in order for the case to be counted as an affirmation. See line 65 for partial affirmations. (Do not include partial affirmations on this line.)
If the prior determination was upheld, but payment was made under limitation of liability, count the ALJ hearing determination as an affirmation. Report the appropriate information in lines 77 and 78.
Line 64. Dismissals/Withdrawals.--Show the number of completed hearings that were withdrawn by the appellant or dismissed (before determination) by the ALJ. Report an appeal that was requested and withdrawn or dismissed within the same month here and in lines 55, 56, and 61.
Line 65. Reversals (Full or Part).--Show the total number of completed ALJ hearings in which at least part of the prior determination was reversed; i.e., a change was made and some or all of the new determination was in favor of the appellant. For example, if an ALJ hearing involved several claims, and the initial determinations for some were affirmed and some were reversed, consider the decision to be a reversal.
Line 66. Amount Awarded.--For cases included in line 65, show the amount of submitted charges for services where the determination was reversed. Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.
Line 67. Closing Pending.--Show the total number of ALJ hearing requests that were not completed by the end of the reporting month. Consider a case transferred to an ALJ as pending until you have received the completed decision from the ALJ for all parts of the case.
Line 68. Number of Dispositions.--Report the number of dispositions rendered by the ALJ(s) in cases reported as cleared for the month in Line 61. There will usually be more ALJ dispositions than cases counted in line 61. Do not count a case in line 61 until the ALJ has cleared all of the claims included in the request for hearing.
EXAMPLE: You forwarded one request to an ALJ involving 20 claims. The ALJ dismisses 10 claims at once. A month later, the ALJ decides to affirm the original decision on 5 others as one group. The other five claims receive separate determinations. This would be counted as seven dispositions.
Line 69. Affirmations.--Of those dispositions shown in line 68, report the number of decisions rendered by the ALJ(s) that were completely upheld.
Line 70. Dismissals/Withdrawals.--Of those dispositions shown in line 68, report the number of dismissals and withdrawals issued by the ALJ(s).
Line 71. Reversals.--Of those dispositions shown in line 68, report the number of decisions rendered by the ALJ (s) in which at least part of the prior determination was reversed.
Line 72. Total Effectuations.--Show the number of ALJ hearing decisions for which you initiated effectuation during the month. Consider effectuation of a decision to be initiated when you:
o Submit the claim to CWF if payment can be made without further development; or o Initiate development, e.g., when you must determine whether or not the provider has refunded payment to the beneficiary.
Line 73. Number 1-7 Days.--Show the number of cases where you effectuated the decision within 7 days. Effectuation days include day of receipt of the decision in your corporate mailroom.
Line 74. Number 8-15 Days.--Show the number of cases where you effectuated the decision within 8-15 days.
Line 75. Number 16-30 Days.--Show the number of cases where you effectuated the decision within 16-30 days.
Line 76. Number Over 30 Days.--Show the number of cases where you effectuated the decision in more than 30 days.
Line 77. No, Waived - Ben. and Prov.--Show the number of claims in ALJ hearings during the reporting month where the liability of both the beneficiary and provider was limited.
Line 78. Amount Awarded.--For claims included in line 77, show the amount of the submitted charges for services where the liability was limited (including non-covered services where the liability of the beneficiary and provider are limited.) Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.
Section D concerns requests involving limitation of liability determinations in Part A reconsiderations, Part B reviews and Part B hearings. To include a claim in lines 79-82, you must have originally denied it or reduced it for medical necessity or custodial care reasons.
Lines 80-82 are mutually exclusive; i.e., a claim meeting the above conditions may be counted on only one of three lines. Therefore, ensure that the sum of the number of the claims recorded on each of these lines equals the total number of claims considered for limitation of liability during the period as reported on line 79.
The counts in lines 79-82 reflect counts of claims. Report cases corresponding to the claims counted in Section A, as appropriate. If a claim is considered for limitation of liability at the initial claim level, do not count it at the review or hearing level unless you change the limitation of liability decision.
Categorize claims for the columns shown in Section D according to the adjudication level at which limitation of liability is considered or granted.
If you make several different limitation of liability decisions on the same claim, use the highest numbered line (out of 80-82) on the report that applies to that claim. Count the claim only once.
For example, if you waive both the beneficiary and provider liability on any part of the claim, count the claim on line 82.
Line 79. Total Number Considered.--Show, under the appropriate columns, the number of claims, meeting the conditions above, for which limitation of liability was considered during the month.
Line 80. No. Considered - Not Waived.--Show, under the appropriate columns the number of claims that meet the conditions above, on which limitation of liability was considered, but was not granted to the beneficiary. This also includes cases where only provider liability is waived.
Line 81. No. Waived - Ben. Only.--Show, under the appropriate columns, the numbers of claims that meet the conditions above, where the liability of only the beneficiary was limited.
Line 82. No. Waived - Ben. and Prov.--Show, under the appropriate columns, the numbers of claims where the liability of both the beneficiary and provider was limited.
Line 83. Amount Awarded.--For cases included in line 82, show the amount of the submitted charges for services where liability was limited (including noncovered services where liability of the beneficiary and provider are limited). Show charges prior to application of the deductible and coinsurance. Round results to nearest dollar.
Report the number of Part A and Part B claims involved in reopenings completed during the month. See §3795 for discussion of what constitutes a reopening. Include reopenings which do not result in revisions. Claims review, reconsideration, Part B hearings, and ALJ hearings undertaken as part of the appeal process are not reopenings.
Column (1) Total.--All reopenings completed.
Column (2) Pre-Recon.--All reopenings of initial claim determinations. If a claim has been through a reconsideration, do not count it here.
Column (3) Post-Recon.--All reopenings of reconsideration determinations. If a claim has been through any type of hearing, do not count it here.
Column (4) Post-ALJ Hearing.--All reopenings of ALJ hearing determinations. Once a claim has been through an ALJ hearing, count it here if it is reopened.
Line 84. Total Number.--Show the number of claims in which the reopening of a claim, reconsideration, or hearing determination was completed, whether or not the determination was revised.
Line 85. Unfavorable to Claimant.--Of the claims shown in line 84, show the number which resulted in a revision of a previously favorable decision.
Line 86. No Change.--Of the claims shown in line 84, show the number of claims that you reopened, but on which you did not change the initial determination.
Line 87. Favorable to Claimant.--Of the claims shown in line 84, show the number which resulted in a favorable revision of a previously unfavorable decision.
Line 88. Amount Awarded.--For cases included in line 87, show the amount of the submitted charges for services which involved a revision of a previously unfavorable decision. Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.
Column (1) Total.--All reopenings completed.
Column (2) Pre-Review.--All reopenings of initial claim determinations. If a claim has been through a review, or any type of hearing, do not count it here.
Column (3) Post-Review.--All reopenings of review determinations. If a claim has been through any type of hearing, do not count it here.
Column (4) Post-Hearing.--All reopenings of hearing determinations, regardless of the type of hearing; e.g., intermediary HO or ALJ. Once a claim has been through a hearing, count it here if it is reopened.
Line 89. Total Number.--Show the number of claims in which the reopening of a claim, review or hearing determination was completed, whether or not the determination was revised.
Line 90. Unfavorable to Claimant.--Of the claims shown in lines 89, show the number which resulted in an unfavorable revision of a previously favorable decision.
Line 91. No Change.--Of the claims shown in line 89, show the number of claims that you reopened, but on which you did not change the initial determination.
Line 92. Favorable to Claimant.--Of the claims shown in line 89, show the number which resulted in a favorable revision of a previously unfavorable decision.
Line 93. Amount Awarded.--For cases included in line 92, show the amount of the submitted charges for services that involved a revision of a previously unfavorable decision. Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.
Before you send the report to CMS, check for completeness and arithmetical accuracy. Use the following checklist for an arithmetical check for each column:
o Line 50 (column 4) must be less than or equal to the sum of line 50 (column 2) + line 50 (column 3).
o Line 51 (column 4) must be less than or equal to the sum of line 51 (column 2) + line 51 (column 3).
Public reporting burden for this collection of information is estimated to average 2 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to Office of Financial Management, CMS, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project Washington, DC 20503.
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 1.
| INTERMEDIARY ID | REPORTING PERIOD | |||||
|---|---|---|---|---|---|---|
| PART A RECONSIDERATIONS | PART B | |||||
| TOT AL (1) | SNF (2) | HHA/ HOSPICE (3) | OTHER (4) | REVIEWS (5) | HEARINGS (6) | |
| A. INTERMEDIARY APPEAL REQUESTS | ||||||
| 1. OPENING PENDING | ||||||
| 2. ADJUSTMENTS TO PENDING | ||||||
| 3. ADJUSTED PENDING | ||||||
| 4. REQUESTS RECEIVED | ||||||
| 4A. MED. NEC. DOC. DENIALS | ||||||
| 5. REQUESTS TRANSFERRED | ||||||
| 6. REQUESTS CLEARED | ||||||
| 7. NO. OF CLAIMS INVOLVED | ||||||
| 8. AMOUNT IN CONTROVERSY | ||||||
| 9. AFFIRMATIONS | ||||||
| 10. DISMISSAL/WITHDRAWALS | ||||||
| 11. REVERSALS (FULL OR PART) | ||||||
| 12. AMOUNT AWARDED |
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 2.
| INTERMEDIARY ID | REPORTING PERIOD | |||
|---|---|---|---|---|
| A. INTERMEDIARY APPEAL REQUESTS | PART A RECONSIDERATIONS | |||
| TOTAL | SNF | HHA/HOSPICE | OTHER | |
| (1) | (2) | (3) | (4) | |
| PROCESSING TIMES | ||||
| 13. AVERAGE | ||||
| 14. NO. COMPLETED 1-45 DAYS | ||||
| 15. NO. COMPLETED 46-60 DAYS | ||||
| 16. NO. COMPLETED 61-90 DAYS | ||||
| 17. NO. COMPLETED 91-120 DAYS | ||||
| 18. NO. COMPLETED OVER 120 DAYS | ||||
| PENDING TIMES | ||||
| 19. CLOSING PENDING | ||||
| 20. NO. PENDING 1-45 DAYS | ||||
| 21. NO. PENDING 46-60 DAYS | ||||
| 22. NO. PENDING 61-90 DAYS | ||||
| 23. NO. PENDING 91-120 DAYS |
24. NO. PENDING OVER 120 DAYS
Form CMS-2591 Screen 2
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 3
| INTERMEDIARY ID | REPORTING PERIOD | ||
|---|---|---|---|
| A. INTERMEDIARY APPEAL REQUESTS REVIEWS | PART B APPEALS | ||
| Reviews | Hearings | ||
| (1) | HEARINGS | (2) | |
| PROCESSING TIMES | PROCESSING TIMES | ||
| 25. AVERAGE | 35. AVERAGE | ||
| 26. NO. 1-30 DAYS | 36. NO. 1-60 DAYS | ||
| 27. NO. 31-45 DAYS | 37. NO. 61-90 DAYS | ||
| 28. NO. 46-60 DAYS | 38. NO. 91-120 DAYS | ||
| 29. NO. OVER 60 DAYS | 39. NO. OVER 120 DAYS | ||
| PENDING TIMES | PENDING TIMES | ||
| 30. CLOSING PENDING | 40. AVERAGE | ||
| 31. NO. 1-30 DAYS | 41. NO. 1-60 DAYS | ||
| 32. NO. 31-45 DAYS | 42. NO. 61-90 DAYS | ||
| 33. NO. 46-60 DAYS | 43. NO. 91-120 DAYS | ||
| 34. NO. OVER 60 DAYS | 44. NO. OVER 120 DAYS | ||
| B. PART B | OTR | All | All |
| HEARING RESULTS | With No Subsequent (1) | Telephone Hearings (2) | In-Person Hearings (3) | Number In 120 Days (4) |
|---|---|---|---|---|
| 45. REVERSALS | ||||
| 46. AFFIRMATIONS | ||||
| 47. TOTAL DECISIONS | ||||
| 48. NBR IN 120 DAYS | ||||
| 49. NO PREV. OTR HELD | ||||
| 50. PREV. OTR COUNTED | ||||
| 51. PREV. OTR NOT CNTD |
Form CMS-2591 Screen 3
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 4
| INTERMEDIARY ID | REPORT PERIOD | ||||
|---|---|---|---|---|---|
| C. PART A AND B ALJ HEARINGS | PART A | Part B (5) | |||
| Total (1) | SNF (2) | HHA/Hospice (3) | Other (4) | ||
| 52. OPENING PENDING | |||||
| 53. ADJUSTMENTS TO PENDING | |||||
| 54. ADJUSTED OPENING PENDING | |||||
| 55. REQUESTS RECEIVED |
| 56. REQUESTS FRWD. TO ALJ | |||||
|---|---|---|---|---|---|
| 57. NO. OF CLAIMS INVOLVED | |||||
| 58. NO. IN 7 CALENDAR DAYS | |||||
| 59. NO. IN 14 CALENDR DAYS | |||||
| 60. AVG. TIME TO FORWARD | |||||
| 61. COMPLETED | |||||
| 62. AMT. IN CONTROVERSY | |||||
| 63. AFFIRMATIONS | |||||
| 64. DISMISSALS/WITHDRAWALS | |||||
| 65. REVERSALS (FULL/PART) | |||||
| 66. AMOUNT AWARDED | |||||
| 67. CLOSING PENDING |
Form CMS-2591 Screen 4
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 5
| INTERMEDIARY ID | REPORT PERIOD | ||||
|---|---|---|---|---|---|
| PART A | PART B (5) | ||||
| Total (1) | SNF (2) | HHA/Hospice (3) | Other (4) | ||
| C. PART A AND B ALJ HEARINGS |
| DISPOSITIONS | ||||||
|---|---|---|---|---|---|---|
| 68. NUMBER OF DISPOSITIONS | ||||||
| 69. AFFIRMATIONS | ||||||
| 70. DISMISSALS/WITHDRAWALS | ||||||
| 71. REVERSALS (FULL OR PART) | ||||||
| EFFECTUATIONS | ||||||
| 72. TOTAL EFFECTUATIONS | ||||||
| 73. NO. 1-7 DAYS | ||||||
| 74. NO. 8-15 DAYS | ||||||
| 75. NO. 16-30 DAYS | ||||||
| 76. NO. OVER 30 DAYS | ||||||
| LIMITATION OF LIABILITY | ||||||
| 77. WAIVED - BEN & PROV. | ||||||
| 78. AMOUNT AWARDED | ||||||
| D. LIMITATION OF LIABILITY (CLAIM COUNTS) | PART A RECONSIDERATIONS | PART B | ||||
| Total (1) | SNF (2) | HHA/ Hospice (3) | Other (4) | Reviews (5) | Hearings (6) | |
| 79. TOTAL NUMBER CONSIDERED | ||||||
| 80. CONSIDERED - NOT WAIVED | ||||||
| 81. WAIVED - BEN. ONLY | ||||||
| 82. WAIVED - BEN. & PROV. |
83. AMOUNT AWARDED
Form CMS-2591 Screen 5
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 6
| INTERMEDIARY ID | REPORT PERIOD | |||
|---|---|---|---|---|
| E. REOPENINGS (Claims Count) PART A | TOTAL (1) | PRE- Recon (2) | Post- Recon (3) | Post-ALJ Hearing (4) |
| 84. TOTAL | ||||
| 85. UNFAVORABLE TO CLAIMANT | ||||
| 86. NO CHANGE | ||||
| 87. FAVORABLE TO CLAIMANT | ||||
| 88. AMOUNT AWARDED | ||||
| PART B | TOTAL | Pre- Review | Post- Review | Post- Hearing |
| 89. TOTAL | ||||
| 90. UNFAVORABLE TO CLAIMANT | ||||
| 91. NO CHANGE | ||||
| 92. FAVORABLE TO CLAIMANT | ||||
| 93. AMOUNT AWARDED |
(Rev. 6, 08-30-02)
B3-13301
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
All claims data entered on page one of the performance report must represent counts of claims (real and replicate) as defined in the Medicare Claims Processing, Chapter 1, General Billing Requirements. The carrier includes in column (i) the following types of claims: CMS-1500s, CMS-1490s, and CMS-1491s. Of these claims forms, it reports the assigned in column (ii) and the unassigned in column (iii).
It includes any claims where processing has been suspended due to CMS directives since they are still part of its claims workload.
NOTE: It does not count assigned claims received from physicians/suppliers if they are incomplete, incorrect, or inconsistent and consequently returned for clarification. It does not have to control such claims.
Throughout its process, it includes the date material is received on all claims (real and replicate). It shows identifying numbers or codes on all replicate claims through the processing system so that they can be counted and reported separately in Part A.
The carrier reports claims as received in the month the claim is received in its mailroom with the following exceptions:
Split and replicate claims, although carrying the dates the materials were originally received, are to be counted as receipts for the month in which they are recognized by the carrier's system as created (i.e., split or identified as replicate) for purposes of this report.
EXAMPLE: The carrier splits a claim received in the reporting month into two claims because the total number of line items exceeds its system's line item limitation. If it can recognize this split when it occurs, it reports two claims in 'Total Claims Received During Month' and in 'Net Number of Claims Received' (lines 4 and 6, respectively) in Part A of the report. It reports both claims in Part A. After processing the split (replicate) claim, it reports it in Part A under 'Replicate Claims Processed' (line 16), as well as under 'Total Claims Processed' (line 15). If its system does not indicate when the split occurs, it counts the new claim as a receipt for the month in which the system allows it to be recognized, although the date claims materials were originally received must be carried forward and remain unchanged.
The carrier counts claims received near the end of the reporting month but placed under computer control in the following month as received in the reporting month. It obtains this count by a physical inventory or by computer count.
(Rev. 6, 08-30-02)
B3-13302
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13302.1
This report is referenced as Form B for CROWD. The carrier submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI. It reports the number of working days scheduled for the reporting period, less any days where no claims were processed as a result of a strike, snowstorm, etc. It does not count Saturdays, Sundays, or holidays.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
This part of the report presents data on carrier claims processing activity during the reporting period. Counts of claims (real and replicate) processed, total claims (real and replicate) pending, or pending from prior months must reflect the actual status of claims (real or replicate) workloads as of the last day of the reporting calendar month. Data shown must be based on reliable counts of all claims (real or replicate) processing activity and the entire "in-house" pending workload. This data may not be derived from estimates.
If a single claim is split into two or more real claims, or into one real claim and one or more replicate claims, the carrier considers each split (real and replicate) as a separate, distinct claim for purposes of counting claims. The original real claim is a receipt for the month in which it was received. It counts a claim split from the original, or identified as a replicate, as a receipt for the month in which it is actually created or in which its system recognizes it as a separate claim. To determine the age of pending claims, the carrier considers the receipt date as the date the original claim was received and not the date it was split from another claim.
It reports, in Part A, only data relating to initial claims (real and replicate) actions. It does not report data on requests for, or dispositions of, reviews, hearings, or reopenings of initial claim actions.
Line 1. Claims Pending End of Last Month - The system will pre-fill the number pending from line 17 on the previous month's report. Line 2. Adjustments - If it is necessary to revise the pending figure for the close of the previous month, the carrier reports the adjustment, preceded by a minus sign for negative adjustments, as appropriate. Adjustments normally result from:
The carrier reports claims received near the end of the reporting month, and placed under computer control sometime after the reporting month, as claims received in the reporting month. It does not count them as claims received in the following month. If some claims have not been counted in the proper month's receipts, it counts them as adjustments to the opening pending in the subsequent month.
Line 3. Adjusted Opening Pending - The system will sum line 1 + line 2 to calculate the adjusted opening pending.
Line 4. Total Claims Received During Month - The carrier reports all real claims received during the month and all split and replicate claims generated (recognized) during the month. (See the Medicare Claims Processing Manual for a discussion of what constitutes a claim.) Claims received include all claims received in its mailroom during the reporting month even though some of them were placed under computer control in the following month. (See §120.1 for counting receipts.)
The carrier counts claims submitted electronically after they have passed its consistency edits. Prior to that time, it may return these bills or the entire tape (where magnetic tape is the medium of submission), as necessary, without counting them as received. However, once the claims or tapes have passed consistency edits and are counted as received, it uses the actual receipt date, not the date the edits are passed, in calculating pending and processing times.
Line 5. Transferred to Other Carriers - The carrier reports the number of claims received, but transferred to other carriers or Part A intermediaries, during the month because the claimant submitted the claim to the wrong contractor. It includes claims transferred in their entirety or split off from other claims because they contained services from physicians/suppliers outside of their carrier jurisdiction.
Line 6. Net Number of Claims Received - The carrier shows the net number of claims (real and replicate) received after subtracting those transferred.
Line 7. Electronic Media Claims Received - The carrier reports the net number of claims included in line 6 which were received in paperless form via electronic media from providers or their billing agencies and read directly into its claims processing system. It does not count on this line claims that it received in hardcopy and entered using an Optical Character Recognition (OCR) device. It does not count any claims received in hardcopy and transformed into electronic media by any entity working for it directly or under subcontract.
It counts claims which are split automatically by computer, without manual intervention, as electronic media claims. This includes "required" splits
only. (See the Medicare Claims Processing Manual. It excludes replicate claims).
Line 8. Total CWF Claims - The carrier reports the number of initial claims (described in lines 9, 10 and 11 below) processed through Common Working File (CWF) and posted to CWF history. It does not include claims sent to CWF and rejected, unless they were resubmitted and posted to CWF history in the reporting month. The counts entered in lines 9, 10 and 11 are exclusive of each other and represent the total number of CWF claims (real or replicate) processed during the month. On page 1, it reports these claims in the month it move the claim to a processed location in its system after receipt of the host's response to pay, apply entirely toward the deductible or deny in full. For pages 2-9, it reports these claims as processed in the month during which the scheduled payment date falls, which may be in a subsequent reporting period.
Line 9. Claims Paid - The carrier reports the number of initial CWF claims (real or replicate) that it approved for payment and for which the CWF host responded by accepting its determination during the month. It reports only claims which are completely processed. If payment is made on part of a claim and the remainder of the claim requires no payment or is denied for any reason, it reports the claim as paid. It reports claims that have been fully adjudicated, with a response having been received from the CWF host, and that are being held only due to the payment floor.
Line 10. Claims Applied Towards Deductible - The carrier reports the number of CWF claims (real or replicate) for which no payment was made because the deductible had not been met. It includes claims for which all charges were applied toward the deductible, as well as those for which some charges were denied.
Line 11 Claims Denied - The carrier reports the number of CWF claims (real or replicate) for which all services were denied because, for example, the beneficiary was not eligible for Part B benefits, the filing limitation was exceeded, or services were not covered.
Line 12. Total Non-CWF Claims - The carrier reports the number of initial claims (real or replicate) processed outside CWF. Non-CWF claims are those either rejected by or not submitted to CWF which it finally adjudicates outside of CWF and are, therefore, not posted to its history in the reporting month. It reports these claims as non-CWF, even if it plans to submit an informational record in the future. Also, it reports these claims in the month in which it made the determination as to their final disposition.
Line 13. Claims Approved - Of those claims reported on line 12 as not processed through CWF, the carrier reports the number approved for payment or with all charges applied toward the deductible.
Line 14. Claims Denied - Of those claims reported on line 12, the carrier reports the number on which all services were denied.
Line 15. Total Claims Processed - The carrier reports the sum of lines 8 and 12.
Line 16. Replicate Claims Processed - The carrier reports the number of replicate claims included under Total Claims Processed, line 15, column (1).
Replicate claims are those claims split off from original (real) claim. Replicate claims are generally created because of computer line item limitations, the carrier is making partial payments, or it is carving out individual specialty types of services. (See the Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 70.2.).
Line 17. Claims Pending at End of Month - The system calculates the number of bills pending at the end of the month by adding line 3 (adjusted opening pending) to line 6 (net receipts) and subtracting line 15 (total processed). It does not report as pending those bills that the carrier has moved to a processed location after being accepted by the host and are holding only due to the payment floor. It reports such bills as processed on line 17.
Line 18. 1-15 Days - The carrier reports the number of claims, by type, included in line 17 which are 1-15 days old. Line 19. 16-30 Days - The carrier reports the number of claims, by type, included in line 17 which are 16-30 days old. Line 20. 31-60 Days - The carrier reports the number of claims, by type, included in line 17 which are 31-60 days old. Line 21. 61-90 Days - The carrier reports the number of claims, by type, included in line 17 which are 61-90 days old. Line 22. Over 90 Days - The carrier reports the number of claims, by type, included in line 17 which are over 90 days old.
Line 23. Number of Claims Investigated During Month - The carrier reports the number of claims (real and replicate) that required contact during the month by telephone, correspondence, or automatic inquiry with physician, beneficiary, supplier, or social security office, or other entities outside the carrier for missing, incorrect, or inconsistent information. It counts only the number of claims investigated, not the number of contacts made.
(Rev. 248, Issued: 12-19-14, Effective: 01-23-15, Implementation: 01-23-15)
The carrier reports the number of responses it processed as a result of inquiries from, or on behalf of, Medicare beneficiaries or providers during the reporting month. It reports only inquiries processed related to the Medicare program. It excludes inquiries addressing its private line of business. It bases the data on actual counts, not on estimates or samples.
The carrier counts inquiries as follows:
Beneficiary - It counts one inquiry per contact (telephone, written, walk-in), regardless of how many claims the beneficiary inquires about. For example, if a beneficiary writes it about the status of two claims, it counts the response as one beneficiary written inquiry. It counts responses to re-contacts made by that beneficiary as an additional inquiry. It counts any inquiry made by a beneficiary, or by anyone on behalf of the beneficiary, except a provider.
Provider - It counts one inquiry per contact. For example, if a provider calls or writes it regarding the status of 10 claims, it counts the response as one provider-written or phone inquiry. It counts any inquiry made by a provider, or anyone on behalf of the provider, except a beneficiary. It counts inquiries regardless of whether they relate to assigned or unassigned claims.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
Medicaid Crossover Claims - This part of the report represents data on the volume of Medicaid crossover claims.
Line 28 Number Transferred to State Agencies - The carrier reports the total number of Medicaid crossover claims transferred to State agencies or their fiscal agents in the reporting month.
Line 29 Number Transferred Electronically - The carrier reports the total number of Medicaid crossover claims reported in line 28 which were transferred in the reporting month to State agencies, or their fiscal agents, via electronic media.
Line 30 Total Claims - The carrier reports the number of claims received in hardcopy and entered using an OCR device. It does not count these claims as EMC claims on line 7, page 1, or in column 6, pages 2-9.
Line 31 Total MSNs Mailed - The carrier reports the number of MSNs mailed to beneficiaries during the reporting month.
(Rev. 6, 08-30-02)
B3-13305
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13305.1
These pages are referenced as Form T (pages 2-9) and Form E (pages 10-11) for CROWD. It submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 12456; Issued:01-11-24; Effective: 07-01-24; Implementation:07-01-24)
Pages 2-9 of the CMS-1565 include data on its activity in processing all claims to completion during the reporting period. A claim is counted as processed to completion on the scheduled payment date, which is the date the check is mailed, deposited in the provider's account, or transferred electronically. For non-paid claims, the date of completion is the date the MSN or other notice of final action on the claim is mailed. Data shown must be based on reliable counts of all claims (real and replicate) processing activity. The A/B MAC (B) does not estimate claim
counts. It reports only data relating to initial claims (real and replicate) actions. It does not report data on requests for, or dispositions of, reviews, hearings, or reopenings of initial claim actions.
"Clean" claims are defined as those that do not require investigation or development external to the A/B MAC (B)'s operation on a prepayment basis. Claims which do not meet the definition of "clean" are "other" claims. Claims paid are those for which some payment was made (i.e., payment greater than zero). Claims not paid are those for which no payment was made (i.e., claim charges applied completely toward deductible or fully denied).
On pages 2-9, the A/B MAC (B) reports:
The data in lines 1 through 37 of pages 2 through 9 represent the number of claims processed in the number of days shown on that line, counting from the date of receipt. Line 38 represents the sum of lines 1-37. The date of receipt is defined for hard-copy and magnetic tape claims as the date of receipt in the mailroom. For EMC billed via terminal or equivalent, it is the date the claim passes all front-end edits. For split claims, whether required or replicate, the date of receipt is the date of receipt of the original claim material, not the date of the split.
To calculate the processing time for a claim, the A/B MAC (B) subtracts the Julian receipt date from the processed to completion Julian date. When the processed to completion date falls in the year following the year of receipt, it adds 365 to the Julian date of completion (or 366 if the year of receipt is a leap year). If a claim is processed to completion on the same day it is received, the processing time is 1 day. This definition applies to all lines of the report, including line 39.
On line 39, the A/B MAC (B) reports the mean processing time (PT) to one decimal place for each column. To calculate the mean PT, it adds the processing times for the claims shown in line 38 of that column, and divides by the number in line 38. It does not use the categories on the report to calculate the mean PT. Because of the aggregation of claims in lines 34-37, it uses the processing times for individual claims, as explained below, to make this calculation.
Mean PT Calculation for All Claims - To determine the mean PT for all claims:
Accumulate the result to cell counter for number of days for all claims.
Divide this result by the total number of claims.
EXAMPLE:
| Claim | Julian Date Receipt | Paid | Counter by Days | Counter by Claims |
|---|---|---|---|---|
| A | 87103 | 87133 | 30 | 1 |
| B | 87105 | 87206 | 101 | 2 |
| C | 87115 | 87177 | 62 | 3 |
| D | 87120 | 87213 | 93 | 4 |
| E | 87122 | 87215 | 93 | 5 |
| F | 87130 | 87223 | 93 | 6 |
Total Days = 30 + 101 + 62 + 93 + 93 + 93 = 472
Mean = 472/6 = 78.6666 = 78.7
The A/B MAC (B) completes the report for each of the following claim types:
Page 2. Assigned Physician - It shows the number of assigned claims included on page 9 which involved services billed by physicians. Physicians are identified by specialty codes 01-14, 16-30, 33-41, 44, 46, 48, 66, 70, 72, 76-79, 81-86, 90-94, 98, 99, C0, or C3, C5, C6, C7, C8, C9, D3 D4, D7, D8, E1, E2, E3, E4, E5, E6, E7, E9, F1, F2, F3, F4, F5, F6. Page 3. Assigned DME - It shows the number of assigned claims included on page 9 which involved services billed by DME suppliers. Page 4. Assigned Lab - It shows the number of assigned claims included on page 9 which involved services billed by an independent laboratory. Independent laboratories are identified by specialty code 69. Page 5. Assigned Ambulance - It shows the number of assigned claims included on page 9 which involved services billed by ambulance service suppliers. Ambulance service suppliers are identified by specialty code 59. Page 6. Assigned Other - It shows the number of assigned non-physician claims included on page 9 but not represented on pages 3, 4, or 5. Page 7. Unassigned - It shows the number of unassigned claims (real and replicate) included on page 9. Page 8. Participating Physician - It shows the number of claims included on page 9 involving services rendered by physicians enrolled in the Medicare Physician/Supplier Participation Program. Page 9. All Claims - It shows the total number of claims (real and replicate) processed during the month.
(Rev. 6, 08-30-02)
B3-13307
Pages 10-11 of the CMS-1565 include data bills paid or denied during the month that were received via electronic media. The basic instructions and definitions that apply to pages 2-9 (see §150) also apply to pages 10-11. The carrier reports the following information for Participating Physician EMC claims (page 10) and all EMC claims (page 11):
For each claim type (PAR and TOT), the carrier reports the following adjustments for CPEP CPT calculations:
CWF - Claims which were beyond carrier control due to CWF.
A. The number of EMC clean claims processed beyond the EMC ceiling. B. The number of paper clean claims processed beyond the paper ceiling. C. The number of all claims processed beyond 60 days.
WAIVER - Claims paid under the floor for which the carrier had a waiver from CMS.
D. The number of EMC clean claims paid under the EMC floor. E. The number of paper clean claims paid under the paper floor. F. The number of all EMC claims paid under the EMC floor plus the number of all paper claims paid under the paper floor.
(Rev. 6, 08-30-02)
B3-13308
(Rev. 6, 08-30-02)
B3-13308.1
Claims data entered on page 12 of the performance report represent counts of claims (real and replicate) as defined in Ref.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13308.2
This page is referenced as Form V for CROWD. The carrier submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 12456; Issued:01-11-24; Effective: 07-01-24; Implementation:07-01-24)
The A/B MAC (B) reports on Page 12 of the CMS-1565 data on the claims on which it paid interest because it paid the claims after the required payment date per §9311 of the Omnibus Reconciliation Act of 1986 (OBRA 1986). It bases data shown on reliable counts of all claims processing activity, not on estimates. It reports data on initial claims only. It includes in the report all claims requiring interest payments in the month. It reports claims in the month the date of payment falls. (For a discussion of interest payments refer to the Medicare Claims Processing Manual, Publication 100-04, chapter 1, sections 80.2.2 and 80.2.2.1).
The A/B MAC (B) completes the report for each column as follows:
On line 1, the A/B MAC (B) shows the number of claims on which it paid interest in the reporting month. It reports on line 2 the number of claims included in line 1 for which it made payment 1 day after the required payment date (e.g., the required payment date is 17 days after receipt for participating physician claims received in FY 1992.) (See §9311 of OBRA 1986.) Data for lines 3-10 are similar to those for line 2.
The A/B MAC (B) calculates the number of days late by subtracting the Julian date of the required payment date from the Julian date of payment.
On line 11, it shows the amount paid in interest for claims reported in line 1. On lines 12-20, it shows the amount paid in interest for claims reported in lines 2-10, respectively. It shows dollar amounts on lines 11-20 to the nearest penny, and includes the decimal point.
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
Each month the carrier prepares and submits to CMS Central Office (CO) page 13 of the Carrier Performance Report - ATB. This report contains the monthly data for ATB, for both local and toll free calls, the number of beneficiary calls answered in 120 seconds, and the total number of beneficiary calls received.
It reports these statistics electronically by the 15th of the month following the reporting month using the Medicare Contractor Reporting of Operational and Workload Data (CROWD) System at the CMS Data Center (CDC). It enters data on the ATB report screen for each office that has been assigned a separate carrier number.
(Rev. 6, 08-30-02) B3-13309.2
This page is referenced as Form R in the CROWD system.
The carrier completes the ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the reporting format to its screen.
(Rev. 6, 08-30-02) B3-13309.3
The carrier completes the report for each line as follows:
Line 1, column 1 - percent, rounded to the nearest tenth, of all trunks busy (ATB) for local calls.
Line 1, column 2 - percent, rounded to the nearest tenth, of all trunks busy (ATB) for toll free calls.
Line 2, column 1 - number of local beneficiary calls answered in 120 seconds.
Line 2, column 2 - number of toll free beneficiary calls answered in 120 seconds.
Line 3, column 1 - number of local beneficiary calls received.
Line 3, column 2 - number of toll free beneficiary calls received.
Line 4, column 1 - percent, rounded to the nearest tenth, of local beneficiary calls answered in 120 seconds.
Line 4, column 2 -, rounded to the nearest tenth, of toll free beneficiary calls answered in 120 seconds.
EXPLANATION OF FAILURES: When the carrier fails the ATB level percentage standard or the timeliness standard for responding to telephone inquiries, it enters an explanation in this section. It makes the narrative as brief as possible. Refer to MCM-2, §5261.7 regarding the standards.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13310
Prior to transmitting performance reports to CMS the carrier checks for the following:
It uses the following checklists to assure accuracy and consistency:
For each of lines 1-38 on pages 10 and 11, column 1 must be less than or equal to column 2 on pages 8 and 9, respectively;
For each of lines 1-38 on pages 10 and 11, column 2 must be less than or equal to column 3 on pages 8 and 9, respectively; and
C. Page Twelve (CROWD Form V) -
D. Page Thirteen (CROWD Form R) (Inactive)
(Line 2 divided by line 3) times 100 = line 4 for all columns.
200 - Exhibits
(Rev. 126; Issued: 07-13-07; Effective: 01-01-08; Implementation: 01-07-08)
Exhibit 1 - Medicare Program Carrier Performance Report- Page 1
| MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 | |||
|---|---|---|---|
| Carrier | Number | Report Period ( Month/Yr) | Working Days |
| Number and Type of Claim | |||
| Reporting Item | Total (1) | Assigned (2) | Unassigned (3) |
| A. Monthly Workload Operations | |||
| OPENING PENDING | |||
| 1. Claims Pndg End of Last Mo. | |||
| 2. Adjustments (Show + or -) | |||
| 3. Adjusted Opening Pending | |||
| RECEIPTS | |||
| 4. Tot. Clms. Rcvd. During Mo. | |||
| 5. Transferred to Other Carrier | |||
| 6. Net Number of Claims Received | |||
| 7. Electronic Media Claims Recvd. | |||
| CLAIMS PROCESSED |
| 8. Total CWF Claims | |||
|---|---|---|---|
| 9. Claims Paid | |||
| 10. Claims Applied To Deductible | |||
| 11. Claims Denied | |||
| 12. Total Non-CWF Claims | |||
| 13. Claims Approved | |||
| 14. Claims Denied | |||
| 15. Total Claims Processed | |||
| 16. Replicate Claims Processed |
Exhibit 1 (Cont.)
| MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 (cont) | |||
|---|---|---|---|
| Carrier | Number | Report Period ( Month/Yr) | Working Days |
| Number and Type of Claim | |||
| Reporting Item | Total (1) | Assigned (2) | Unassigned (3) |
| CLOSING PENDING | |||
| 17. Claims Pending at End of Month | |||
| DISTRIBUTION OF DAYS ELAPSED SINCE RECEIPT | |||
| 18. 1 - 15 Days | |||
| 19. 16 - 30 Days | |||
| 20. 31 - 60 Days | |||
| 21. 61 - 90 Days | |||
| 22. Over 90 Days | |||
| CLAIMS INVESTIGATIONS | |||
| 23. No. of Clms. Invest. During Mo. | |||
| B. INQUIRIES | TOTAL | BENEFICIARY | PROVIDER |
| 24. Tot. No. Processed During Mo. | |||
|---|---|---|---|
| 25. Telephone | |||
| 26. Walk-In Contact | |||
| 27. Written | |||
| C. MISCELLANEOUS CLAIMS DATA | |||
| MEDICAID CROSSOVER CLAIMS | |||
| 28. No. Transferred to St. Agencies | |||
| 29. No. Transferred Electronically |
Exhibit 1 (Cont.)
| MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 (cont) | |||
|---|---|---|---|
| Carrier | Number | Report Period ( Month/Yr) | Working Days |
| Number and Type of Claim | |||
| Reporting Item | Total (1) | Assigned (2) | Unassigned (3) |
| OPTICAL CHARACTER RECOGNITION CLMS. | |||
| 30. Total Claims | |||
| MEDICARE SUMMARY NOTICES | |||
| 31. Total MSNs Mailed |
Form CMS-1565
FORM CMS-1565, Pages 2-9
CARRIER WORKLOAD REPORT - PAGE __* ___
PART - D (1) CLAIMS PROCESSING TIMELINESS - ALL CLAIMS
CARRIER ID _____ TYPE OF CLAIM _____ * _____ REPORT MO. _____
| LINE NO./DAYS | TOTAL (1) | PAID | NOT PAID | EMC (6) | ||
|---|---|---|---|---|---|---|
| CLEAN (2) | OTHER (3) | CLEAN (4) | OTHER (5) | |||
| 1 1 | ||||||
| 2 2 | ||||||
| 3 3 | ||||||
| 4 4 | ||||||
| 5 5 | ||||||
| 6 6 | ||||||
| 7 7 | ||||||
| 8 8 | ||||||
| 9 9 | ||||||
| 10 10 | ||||||
| 11 11 | ||||||
| 12 12 | ||||||
| 13 13 | ||||||
| 14 14 | ||||||
| 15 15 | ||||||
| 16 16 | ||||||
| 17 17 | ||||||
| 18 18 | ||||||
| 19 19 |
| 20 | 20 | ||||||
|---|---|---|---|---|---|---|---|
| 21 | 21 | ||||||
| 22 | 22 | ||||||
| 23 | 23 | ||||||
| 24 | 24 | ||||||
| 25 | 25 | ||||||
| 26 | 26 | ||||||
| 27 | 27 | ||||||
| 28 | 28 | ||||||
| 29 | 29 |
| LINE NO./DAYS | TOTAL (1) | PAID | NOT PAID | EMC (6) | ||
|---|---|---|---|---|---|---|
| CLEAN (2) | OTHER (3) | CLEAN (4) | OTHER (5) | |||
| 30 30 | ||||||
| 31 31 | ||||||
| 32 32 | ||||||
| 33 33 | ||||||
| 34 34-45 | ||||||
| 35 46-60 | ||||||
| 36 61-90 | ||||||
| 37 91+ | ||||||
| 38 Tot 1-37 | ||||||
| 39 Mean Pt |
CMS-1565 Page __
* PAGE NUMBER AND TYPE OF CLAIM ARE TO BE REPORTED AS FOLLOWS:
| EMC PAID | EMC NOT PAID | ||||
|---|---|---|---|---|---|
| ADJUSTMENTS FOR CPEP CPT | |||||
| LINE NO./DAYS | CLEAN (1) | OTHER (2) | CLEAN (3) | CALCULATIONS: | |
| 1 | 1 | CWF Claims which were beyond carrier control due to CWF. | |||
| 2 | 2 | ||||
| 3 | 3 | ||||
| 4 | 4 | ||||
| 5 | 5 | A. EMC clean claims Processed beyond EMC | |||
| 6 | 6 | ||||
| 7 | 7 | ||||
| 8 | 8 | B. Paper clean claims Processed beyond Paper ceiling | |||
| 9 | 9 | ||||
| 10 | 10 | ||||
| 11 | 11 | C. All claims processed Beyond 60 days _____ | |||
| 12 | 12 | ||||
| 13 | 13 | WAIVER Claims paid under the floor For which the carrier had a waiver from CMS. | |||
| 14 | 14 | ||||
| 15 | 15 | ||||
| 16 | 16 | ||||
| 17 | 17 | D. EMC clean claims Paid under EMC floor _____ | |||
| 18 | 18 | ||||
| 19 | 19 | ||||
| 20 | 20 | E. Paper clean claims Paid under paper floor _____ | |||
| 21 | 21 | ||||
| 22 | 22 | ||||
| 23 | 23 | F. All EMC claims paid under EMC floor and all paper claims paid under paper floor _____ | |||
| 24 | 24 | ||||
| 25 | 25 | ||||
| 26 | 26 | ||||
| 27 | 27 | ||||
| 28 | 28 | ||||
| 29 | 29 | ||||
| 30 | 30 | ||||
| 31 | 31 | ||||
| 32 | 32 | ||||
| 33 | 33 |
| EMC PAID | EMC NOT PAID | ||||
|---|---|---|---|---|---|
| LINE NO./DAYS | CLEAN (1) | OTHER (2) | CLEAN (3) | CALCULATIONS: | |
| 34 | 34-45 | ||||
| 35 | 46-60 | ||||
| 36 | 61-90 | ||||
| 37 | 91+ | ||||
| 38 | Tot 1-37 | ||||
| 39 | Mean Pt | ||||
CMS-1565 Page _*
* PAGE NUMBER AND TYPE OF CLAIM ARE TO BE REPORTED AS FOLLOWS:
Page 10-Participating Physician (PAR)
Page 11-Total (TOT)
CARRIER WORKLOAD REPORT - PAGE __*__ PART-E - INTEREST PAYMENT DATA
REPORT MONTH
| LINE NO CLAIM/PAYMENT LATE DAYS | TOTAL (1) | ASTD PHYS (2) | ASTD DME (3) | ASTD LAB (4) | ASTD AMB (5) | ASTD OTHER (6) | UNASTD (7) | PARTIC. PHYS (8) |
|---|---|---|---|---|---|---|---|---|
| 1. No. of Claims | ||||||||
| 2. 1 Day late | ||||||||
| 3. 2 Days Late | ||||||||
| 4. 3 Days Late | ||||||||
| 5. 4 Days Late | ||||||||
| 6. 5 Days Late | ||||||||
| 7. 6-15 A Late | ||||||||
| 8. 16-30 A Late | ||||||||
| 9. 31-60 A Late | ||||||||
| 10. 61+ A Late | ||||||||
| 11. Amount paid | ||||||||
| 12. 1 Day late | ||||||||
| 13. 2 Days Late | ||||||||
| 14. 3 Days Late | ||||||||
| 15. 4 Days Late | ||||||||
| 16. 5 Days Late | ||||||||
| 17. 6-15 A Late | ||||||||
| 18. 16-30 A Late | ||||||||
| 19. 31-60 A Late | ||||||||
| 20. 61+ A Late |
PART F - ALL TRUNKS BUSY (ATB)
CARRIER ID_ REPORT MONTH_
| LOCAL CALLS (1) | TOLL FREE CALLS (2) | |
|---|---|---|
| 1. PERCENT OF ATB | ||
| 2. NUMBER OF BENEFICIARY CALLS ANSWERED IN 120 SECONDS | ||
| 3. TOTAL NUMBER OF BENEFICIARY CALLS RECEIVED | ||
| 4. % OF BENEFICIARY CALLS ANSWERED IN 120 SECONDS | ||
| EXPLANATION FOR FAILURES: |
If the carrier is a Durable Medical Equipment Regional Carrier (DMERC), it prepares and submits a report each month for its region (either A, B, C, or D - see §210.3 for exhibits) to CMS summarizing its performance in processing DMEPOS claims. It transmits the DMEPOS report as soon as possible after the end of the reporting month, but no later than the 10th day of the following month using the instructions contained in the CROWD User's Guide. It is also required to submit all pages of the CMS-1565 report for its total DMEPOS workload. It must also submit data on forms CMS-2174, CMS-2590, CMS-1564, CMS-1565A, and CMS-1565C via CROWD for its total DMEPOS workload.
Heading - The carrier enters its assigned carrier number in the indicated space. In the space labeled, 'Reporting Period', it enters the numerical month and year for which the report is prepared, e.g., it shows 1001 for the month October 2001. For each of the 8 pages of the report, the 'Type' of claim is pre-entered by the CROWD system. Page 1 will be labeled 'PEN' and be used to report PEN claims (HCPCS codes B0000-B9999; J0000-J9999). The remaining pages (2 thru 8) will be labeled and defined as follows:
| PAGE | TYPE | HCPCS Codes |
|---|---|---|
| 2 | OXY (oxygen) | E0400-E0499; E1351-E1499 |
| 3 | NOE (non-oxygen equipment) | E0000-E0399; E0500-E1350 |
| 4 | DIA (dialysis supplies) | A4650-A4927; E1500-E1649 |
| 5 | NDS (non-dialysis supplies) | A4200-A4640; A5051-A9999 |
| 6 | PRO (prosthetics and orthotics) | L0000-L9999; V0000-V9999 |
| 7 | OTH (other than the previous types above) | An example would be regional-wide code |
| 8 | TOT (total DMEPOS claims) |
If a claim contains more than one category type, the carrier reports the claim under each type identified. For example, it reports a claim including services for oxygen (OXY), non-oxygen equipment (NOE), and dialysis supplies (DIA) under page 2 (OXY), under page 3 (NOE), and under page 4 (DIA). As a result, this claim will end up being counted as 3 claims under page 8 (TOT).
For each of these types (pages 1 through 8), it enters data for lines and columns as follows:
Lines - data reflecting the total of all States and territories in its jurisdiction (region). On subsequent lines (2 and greater), enter data for each State and territory in its region.
Column 1, State Code - A code for the total of all States and an alpha code for each State and territory is pre-entered by the CROWD system.
Column 2, Number - total number of DMEPOS claims processed for type indicated during the month for all States and territories in its region.
The carrier reports claims in the month the payment date or other final adjudication occurs. See MCM-2, §5240, functional standard 11, for definition of payment date for all claims, including those fully denied or having charges applied completely towards the deductible. The total number of claims for all States (line 1) must be equal to or greater than the number reported on page 9, line 38, column 1 of the CMS-1565 that the carrier submits for the same month.
Column 3, In 1-60 Days - total number of DMEPOS claims in type indicated processed within 60 days during the month for all States and territories in its region. To calculate the processing time for a claim, the carrier subtracts the Julian receipt date from the processed to completion Julian date. The total number of claims processed for all States must be equal to or greater than the number reported on page 9, lines 1-35, of column 1 of the CMS-1565 submitted by the carrier for the same month.
Column 4, In 61-90 Days - total number of DMEPOS claims in type indicated processed in 61-90 days during the month for all States and territories in its region. The total number of claims processed for all States (line 1) must be equal to or greater than the number reported on page 9, line 36, column 1 of the CMS-1565 submitted by the carrier for the same month.
Column 5, Mean Processing Time - mean processing time for number of DMEPOS claims for type indicated processed during the month for all States and territories in its region. See §140.2 for an explanation on calculating the mean processing time. The carrier enters data to one decimal place.
Column 6, EMC - number of DMEPOS claims for type indicated processed to completion that were received via electronic media for all States and territories in its region. It does not include claims that the carrier receives in hardcopy and transfers to electronic media via character recognition devices. The total number of claims processed for all States (line 1) must be equal to or greater than the number reported on page 9, line 38, column 6 of the CMS-1565 that the carrier submits for the same month.
Column 7, Number - total number of clean DMEPOS claims for type indicated processed during the month for all States and territories in its region. 'Clean' claims are those that do not require an investigation or development external to the carrier operation on a prepayment basis. See MCM-2, §5240, functional standard 11, for definition of clean claims. The total number of 'clean' claims processed for all States (line 1) must be equal to or greater than the number reported on page 9, line 38, column 2 + 4 of the CMS-1565, the carrier submits for the same month.
Column 8, In 1-30 Days - number of clean DMEPOS claims for type indicated processed 1-30 days for all States and territories in its region.
(Rev. 6, 08-30-02)
B3-13312.2
Before transmitting the report to CMS CO, the carrier checks it for completeness and arithmetical accuracy. It uses the following checklist:
B3-13312.3
DMEPOS State Report - REGION A
Carrier No._ Report Period_ Type_
| State Code (1) | Total Claims Processed for Type Indicated | Clean Claims Processed for Type Indicated | |||||
|---|---|---|---|---|---|---|---|
| Number (2) | In 1-60 Days (3) | In 61-90 Days (4) | Mean Proc. Time (5) | EMC (6) | Number (7) | In 1-30 Days (8) | |
| 1-Tot. All States | |||||||
| 02 CT | |||||||
| 03 DE | |||||||
| 04 MA | |||||||
| 05 ME | |||||||
| 06 NH | |||||||
| 07 NJ | |||||||
| 08 NY | |||||||
| 09 PA | |||||||
| 10 RI | |||||||
| 11 VT | |||||||
| 12 | |||||||
| 13 | |||||||
| 14 | |||||||
| 15 | |||||||
| 16 | |||||||
| 17 | |||||||
| 18 | |||||||
| 19 | |||||||
| 20 |
Page 2-Oxygen
Page 3-Non-Oxygen Equipment
Page 4-Dialysis Supplies
Page 5-Non-Dialysis Supplies
Page 6-Prosthetics and Orthotics Page 7-Other Page 8-Total
DMEPOS State Report - REGION B
Carrier No._ Report Period_ Type_
| State Code (1) | Total Claims Processed for Type Indicated | Clean Claims Processed for Type Indicated | |||||
|---|---|---|---|---|---|---|---|
| Number (2) | In 1-60 Days (3) | In 61-90 Days (4) | Mean Proc. Time (5) | EMC (6) | Number (7) | In 1-30 Days (8) | |
| 1-Tot. All States | |||||||
| 02 DC | |||||||
| 03 IL | |||||||
| 04 IN | |||||||
| 05 MD | |||||||
| 06 MI | |||||||
| 07 MN | |||||||
| 08 OH | |||||||
| 09 VA | |||||||
| 10 WI | |||||||
| 11 WV | |||||||
| 12 | |||||||
| 13 | |||||||
| 14 | |||||||
| 15 | |||||||
| 16 | |||||||
| 17 | |||||||
| 18 | |||||||
| 19 | |||||||
| 20 |
Page 2-Oxygen
Page 3-Non-Oxygen Equipment
Page 4-Dialysis Supplies
Page 5-Non-Dialysis Supplies
Page 6-Prosthetics and Orthotics
Page 7-Other
Page 8-Total
DMEPOS State Report - REGION C
Carrier No._ Report Period_ Type_
| State Code (1) | Total Claims Processed for Type Indicated | Clean Claims Processed for Type Indicated | |||||
|---|---|---|---|---|---|---|---|
| Number (2) | In 1-60 Days (3) | In 61-90 Days (4) | Mean Proc. Time (5) | EMC (6) | Number (7) | In 1-30 Days (8) | |
| 1-Tot. All States | |||||||
| 02 AL | |||||||
| 03 AR | |||||||
| 04 CO | |||||||
| 05 FL | |||||||
| 06 GA | |||||||
| 07 KY | |||||||
| 08 LA | |||||||
| 09 MS | |||||||
| 10 NC | |||||||
| 11 NM | |||||||
| 12 OK2 | |||||||
| 13 PR2 | |||||||
| 14 SC2 | |||||||
| 15 TN2 | |||||||
| 16 TX2 | |||||||
| 17 VI2 | |||||||
| 18 | |||||||
| 19 | |||||||
| 20 | |||||||
Page 2-Oxygen
Page 3-Non-Oxygen Equipment
Page 4-Dialysis Supplies
Page 5-Non-Dialysis Supplies
Page 6-Prosthetics and Orthotics
Page 7-Other
Page 8-Total
Carrier No._ Report Period_ Type_
| State Code (1) | Total Claims Processed for Type Indicated | Clean Claims Processed for Type Indicated | |||||
|---|---|---|---|---|---|---|---|
| Number (2) | In 1-60 Days (3) | In 61-90 Days (4) | Mean Proc. Time (5) | EMC (6) | Number (7) | In 1-30 Days (8) | |
| 1-Tot. All States | |||||||
| 02 AK | |||||||
| 03 AZ | |||||||
| 04 CA | |||||||
| 05 CM | |||||||
| 06 GU | |||||||
| 07 HI | |||||||
| 08 IA | |||||||
| 09 ID | |||||||
| 10 KS | |||||||
| 11 MO | |||||||
| 12 MT | |||||||
| 13 ND | |||||||
| 14 NE | |||||||
| 15 NV | |||||||
| 16 OR | |||||||
| 17 SD | |||||||
| 18 UT | |||||||
| 19 WA | |||||||
| 20 WY |
Page 2-Oxygen Page 3-Non-Oxygen Equipment Page 4-Dialysis Supplies Page 5-Non-Dialysis Supplies Page 6-Prosthetics and Orthotics Page 7-Other Page 8-Total
(Rev. 6, 08-30-02) B3-13320
In addition to the monthly workload report, the carrier prepares and transmits to CMS a Quarterly Supplement to the Carrier Performance Report showing the status and disposition of selected workloads. It prepares a separate report for each office/State that has been assigned a separate carrier number.
(Rev. 6, 08-30-02) B3-13320.1
The Quarterly Supplements to the Carrier Performance Report (Forms CMS-1565A, CMS-1565B, CMS-1565C, CMS-1565D, and CMS-1565E) are the sources of current information on key aspects of carrier Medicare operations. The data, together with information from other sources, are used by CMS for:
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24) B3-13320.2
The carrier transmits Forms CMS-1565A, CMS-1565B, CMS-1565C, and CMS-1565D to CO via PC or terminal as soon as possible after the end of the reporting quarter, but no later than the 15th of the following month, using instructions in the CROWD User Guide available via the CMS Enterprise Portal. With the exception of the due date, it applies these same instructions to Form CMS-1565E. The due date for the CMS-1565E is 75 days following the reporting quarter.
The carrier does not submit hardcopies of the reports.
(Rev. 6, 08-30-02)
B3-13321
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
Claims data entered on the performance report represent counts of claims (real and replicate). (See the Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 70.8.2, for a definition of replicate claims). It includes in column (1) both assigned and unassigned claims. The carrier reports assigned claims in column (2) and unassigned claims in column (3).
(Rev. 6, 08-30-02)
B3-13322
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13322.1
This report is referenced as Form A for CROWD. The carrier submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 6, 08-30-02)
B3-13322.2
This part of the report provides CMS with:
The carrier reports only data relating to initial claims (real and replicate) actions in Part A of the report. It does not report data on disposition of informal reviews, hearings, or reopenings of an initial claim action in Part A. In order to be included in lines 1-7, the allowed amount on a service must be greater than $0. A claim must be reflected on more than one of lines 2-6 if appropriate. For example, if one service on a claim is reduced due to a fee schedule, and two services are reduced due to medical necessity, the carrier counts the claim once on line 2 and once on line 4. It reports the appropriate dollar amounts on lines 3 and 5.
Line 1. Total Covered Charges for All Claims - total amount (rounded to the nearest dollar) of billed charges for covered services on all claims (real and replicate) paid or applied toward the
deductible during the quarter. Claims paid or applied toward deductible are those reported in lines 9, 10, and 13 of the monthly CMS-1565 (CROWD Form B). For those claims in which reasonable charge/fee schedule reductions are made, the carrier reports the total covered charges prior to such reductions.
It does not include charges for otherwise covered services that are duplicates of previously submitted services, or should have been included in previously submitted services (e.g., global fee/rebundling situations).
Line 2. Number of Claims With Reasonable Charge/Fee Schedule Reductions - number of claims (real and replicate) reported as paid (claims included under line 9 of the monthly Form B, applied toward the deductible (claims included under line 10 of the monthly Form B), or approved outside of Common Working File (CWF) (claims included under line 13 of the monthly Form B) in which the charges were reduced as a result of reasonable charge determinations or comparisons to fee schedules.
For provider-based physician claims, the separation of charges for physicians' services and charges for provider component (institutional) services according to some schedule of charges is not a reasonable charge reduction. The carrier counts a claim of this type as a reduced claim only if the submitted charge exceeds the provider billing agreement.
Line 3. Amount of Reduction (in dollars) - total amount (rounded to the nearest whole dollar) by which the claims (real and replicate) reported in line 2 were reduced as a result of reasonable charge determinations or fee schedules.
Line 4. Number of Claims with Medical Necessity Reductions - number of claims (real or replicate) where the carrier reduced the billed charges because of a determination that the level of service was not medically necessary (i.e., a lower level of service would have sufficed). It includes cases where the service was reduced because medical review determined that a lesser service was actually performed.
Line 5. Amount of Reduction (in dollars) - the difference (rounded to the nearest dollar) between the billed and allowed charges for those covered services included on line 4.
Line 6. Number of Claims with Global Fee/Rebundling Reductions - the number of claims (real or replicate) where the charges were reduced because one or more of the services in a global fee was previously paid. It does not include claims with services denied because they should have been included in a previously submitted global fee. The carrier reports such claims in line 17. (See MCM-3, §4630.)
Line 7. Amount of Reduction (in dollars) - the difference (rounded to the nearest dollar) between the billed and allowed charges for those covered services included on line 6.
In this section, the carrier reports data for claims (real and replicate) totally or partially denied. Claims totally denied are claims where it determines the allowed amount to be $0 for all services billed. Claims partially denied are claims where it determines the allowed amount to be $0 for some, but not all services.
The carrier does not report transfers of claims to other carriers or Part A intermediaries since these are not denials. It does not include claims returned to physicians or suppliers because they were lacking necessary information. (Returns are cases where no attempt was made to develop the claim.)
It does not report reductions in billed charges where the fee is deemed to have been included in a global fee, such as postsurgical care. It includes such services only if the allowed amount is $0 (i.e., the service is denied). It reports data for such services reduced to an amount greater than $0 on lines 6 and 7 above.
Line 8. Claims Denied in Full or in Part - the sum of (1) those claims (real and replicate) reported as denied in full on lines 11 and 14 of the Form B submitted for the three months of the reporting calendar quarter, plus (2) those claims (real and replicate) reported as paid or applied toward the deductible in which some charges, but not all, were denied. Claims paid or applied toward deductible are those reported on lines 9, 10 and 13 of the monthly Form B.
Line 9. Amount Disallowed (in dollars) - the total amount (rounded to the nearest dollar) of charges disallowed (billed charges for denied services) on the claims (real and replicate) reported on line 8.
Reason for Denial - On lines 10-18 the carrier enters the number of items denied (column 1), the amount (rounded to the nearest dollar) disallowed (column 2), and the number of claims disallowed (column 3).
The items reported in column 1 of this section represent the number of separate items coded by the carrier which were denied. These items usually relate to a single service, but may also represent more than one service when multiple occasions of the same type of service are coded as a single item. Line 19 for column 1 should contain the total number of items denied. Since more than one item on a claim may be denied, the total on line 19 for items denied (column 1) will usually be larger than the total number of claims denied in full or in part shown on line 8, column 1. However, the total money shown in column 2 on line 19 for amount disallowed must equal the total amount disallowed shown on line 9, column 1.
The carrier shows a claim that contains multiple services, but is denied for only one reason, only once in column 3 under that reason for denial. However, if a claim is denied for more than one reason, it shows it under each reason for denial. Therefore, line 19, for the total number of claims disallowed (column 3), will usually be larger than the number of claims denied in part or full on line 8 (column 1).
Line 10. Claimant Ineligible - the number of items denied, the related amount (in rounded dollars) of total charges disallowed, and the number of claims denied because the recipient of
services was ineligible for Part B benefits, or because the services billed were rendered before the beneficiary's coverage for Part B benefits began, or after coverage was terminated.
Line 11. Filing Limitation Exceeded - the number of items denied, the related amounts (in rounded dollars) of total charges disallowed, and the number of claims denied because the claim was filed later than the time limitation on filing claims. (See MCM-3, §3004.)
Line 12. Duplicate Claim - the number of items denied, the related amount (in rounded dollars) of total charges disallowed, and the number of claims denied because the services billed duplicated those from previously filed claims. The only denials reported on line 12 are actual duplicate charges for the same item or service. The carrier does not report denials for duplicate medical equipment (see line 14) or charges for services which are deemed to be included in a global fee (see line 17).
Line 13. Services Not Covered - the number of items denied, the related amount (in rounded dollars) of charges disallowed and the number of claims denied because the services billed are determined to be excluded from coverage under the SMI program for reasons other than a finding that the services were not medically necessary. Some examples of services not covered are:
• Service date is before provider's participation effective date or after provider's termination date;
Services, supplies, or rental of equipment not needed during a period when the beneficiary was hospitalized; or
Line 14. Services Not Medically Necessary - the number of items denied, the related amount (in rounded dollars) of charges disallowed and the number of claims denied because it was determined that the services billed were not medically necessary. Some examples are:
Line 15. MSP - the number of items denied, the amount (in rounded dollars) of charges disallowed, and the number of claims denied because it was determined that Medicare should have been secondary to another payer. (See MCM-3, §§3330-3340.)
Line 16. Missing Information - the number of items denied, the amount (in rounded dollars) of charges disallowed, and the number of claims denied because the claimant failed to provide information necessary to process the claim.
Line 17. Global Fee/Rebundling - the number of items denied, the amount (in rounded dollars) of charges disallowed, and the number of claims denied because the fee was deemed to have been included in a previously allowed global fee, or a charge for a rebundled set of codes.
Line 18. Other - the number of items denied, the related amount (in rounded dollars) of charges disallowed, and the number of claims denied for reasons other than those specified on lines 10-16. Some examples of items to be reported here are:
Line 19. Total - the total number of items denied, the related amount (in rounded dollars) disallowed and the number of denied claims reported on lines 10-18.
(Rev. 6, 08-30-02)
B3-13322.3
Prior to submitting Form A to CMS, the carrier checks for completeness, accuracy, and internal consistency.
It uses the following checklist to assure accuracy and consistency:
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13323
The carrier prepares and submits to CMS each quarter a report on the number of fraud workload items handled by its Medicare fraud unit. This information is required by CMS to budget for fraud and abuse activities, as well as to monitor the flow of work through the fraud units. It submits this form via CROWD no later than the fifteenth day following the close of the reporting quarter.
(Rev. 6, 08-30-02)
B3-13323.1
This report is referenced as Form M in the CROWD system. The carrier completes the ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the reporting format to its screen.
(Rev. 6, 08-30-02)
B3-13323.2
Before submitting Form M to CMS, the carrier checks for completeness and arithmetical accuracy. It uses the following checklist:
(Rev. 6, 08-30-02)
B3-13323.3
The carrier reports fraud workload items in the following columns for all lines of Form M:
Column (1) - Total - All fraud workload items.
Column (2) - Beneficiary Complaints - The number of complaints received from, or on behalf of, beneficiaries alleging fraud. The carrier does not include complaints filed with the Office of the Inspector General (OIG) Hotline.
Column (3) - OIG Hotline - The number of complaints received via the OIG Hotline.
Column (4) - Referrals and Other - Referrals and any other workload received by the fraud unit (e.g., provider complaints, internally generated referrals from medical review, special requests from OIG or CMS).
(Rev. 6, 08-30-02)
B3-13323.4
Line 1. Opening Pending - The system will pre-fill the number pending from line 8 of the previous quarter's report.
Line 2. Adjustments - If it is necessary to revise the pending figure for the close of the previous quarter because of inventories, reporting errors, etc., the carrier enters the adjustment on this line. It precedes negative adjustments with a minus sign.
Line 3. Adjusted Pending - The system will sum line 1 + line 2 to calculate the adjusted opening pending.
Line 4. Workload Received - The number of complaints and referrals received in the fraud unit during the reporting period.
Line 5. Total Cleared - The system will sum line 6 + line 7 to calculate the total number of complaints and referrals cleared by the fraud unit during the reporting period.
Line 6. Cleared by Contractor - The number of complaints and referrals cleared by the fraud unit by means other than referral to the OIG or designated agency. The carrier includes those that were:
Line 7. Cleared by Referral - The number of complaints and referrals that were incorporated into cases referred formally to the OIG or designated agency for action (e.g., sanctions or prosecution).
Line 8. Closing Pending - The system will calculate the closing pending for the quarter by adding line 3 to line 4, and subtracting line 5.
(Rev. 6, 08-30-02)
B3-13324
(Rev. 12456; Issued:01-11-24; Effective: 07-01-24; Implementation:07-01-24)
The A/B MAC (B) reports on Page 12 of the CMS-1565 data on the claims on which it paid interest because it paid the claims after the required payment date per §9311 of the Omnibus Reconciliation Act of 1986 (OBRA 1986). It bases data shown on reliable counts of all claims processing activity, not on estimates. It reports data on initial claims only. It includes in the report all claims requiring interest payments in the month. It reports claims in the month the date of payment falls. (For a discussion of interest payments refer to the Medicare Claims Processing Manual, Publication 100-04, chapter 1, sections 80.2.2 and 80.2.2.1).
The A/B MAC (B) completes the report for each column as follows:
Column 1. Total - Data for all claims (real and replicate) for which interest payments were made during the month.
Column 2. Assigned Physician - Data for the assigned claims included in column 1 which involved services billed by physicians. Physicians are identified by specialty codes 01-14, 16-30, 33-41, 44, 46, 48, 66, 70, 72, 76-79, 81-86, 90-94, 98, 99, C0, C3, C5, C6, C7, C8, C9, D3, D4, D7, D8, E1, E2, E3, E4, E5, E6, E7, E9, F1, F2, F3, F4, F5, F6. Column 3. Assigned DME - Data for the assigned claims included in column 1 that involved services billed by DME suppliers. Column 4. Assigned Lab - Data for the assigned claims included in column 1 that involved services billed by an independent laboratory. Independent laboratories are identified by specialty code 69. Column 5. Assigned Ambulance - Data for the assigned claims included in column 1 that involved services billed by ambulance service suppliers. Ambulance service suppliers are identified by specialty code 59. Column 6. Assigned Other - Data for the assigned non-physician claims included in column 1 but not represented in columns 3, 4, or 5. Column 7. Unassigned - Data for the unassigned claims included in column 1. Column 8. Participating Physician - Data for claims involving services rendered by physicians enrolled in the Medicare Physician/Supplier Participation Program.
On line 1, the A/B MAC (B) shows the number of claims on which it paid interest in the reporting month. It reports on line 2 the number of claims included in line 1 for which it made payment 1 day after the required payment date (e.g., the required payment date is 17 days after receipt for participating physician claims received in FY 1992.) (See §9311 of OBRA 1986.) Data for lines 3-10 are similar to those for line 2.
The A/B MAC (B) calculates the number of days late by subtracting the Julian date of the required payment date from the Julian date of payment.
On line 11, it shows the amount paid in interest for claims reported in line 1. On lines 12-20, it shows the amount paid in interest for claims reported in lines 2-10, respectively. It shows dollar amounts on lines 11-20 to the nearest penny, and includes the decimal point.
(Rev. 6, 08-30-02)
B3-13325
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13325.1
This report is referenced as Form G for CROWD. The carrier submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI. It must submit Form A for the reporting quarter before the system will allow it to submit Form G for the same quarter.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
This part provides CMS with current quarterly workload data on the results of carrier activity in processing claims for physician and non-physician services according to the participation status of the physician/supplier. It also provides important related information on reasonable charge determinations, the extent to which claims for such services are being denied, and the amount of charges disallowed.
The carrier reports only data relating to initial claims (real and replicate) actions. It does not report data on the disposition of reviews, hearings, or reopenings of initial claim actions.
It reports data for lines 1-34 for each column (participation/assignment status) as defined in the Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 30, unless otherwise stated. Specialty codes for physicians and non-physicians are listed in the Medicare Claims Processing Manual, Chapter 26, Sections 10.8.2 and 10.8.3.
Line 1. Number of Claims Approved - total number of claims, processed to completion during the quarter, which were paid or applied to the deductible. Claims paid or applied toward the deductible are those reported in lines 9, 10, and 13 of Form B. The system will pre-fill columns 1 and 3 based on the total of these lines from the monthly reports.
Line 2. Physician Only - number of claims included in line 1 involving physician services only.
Line 3. Physician and Non-Physician - number of claims included in line 1 involving both physician and non-physician services on the same claim. The carrier shows all claims in this category under the 'Non-Participant-Unassigned' column 3. Therefore, the numbers for columns 1 and 3 should be equal.
Line 4. Non-Physician Only - number of claims included in line 1 involving non-physician services only.
Line 5. Number of Covered Services - total number of covered services on the claims approved as shown on line 1. The carrier does not include services for which charges were completely disallowed.
Line 6. Physician - number of physician services included in line 5. The carrier includes in this count the covered services from the claims shown in line 2 plus the covered physician services from the claims shown in line 3.
Line 7. Non-Physician - number of non-physician services included in line 5. The carrier includes in this count the covered services from the claims shown in line 4 plus the covered non-physician services from the claims shown in line 3.
Line 8. Amount of Covered Charges - total amount (rounded to the nearest dollar) of billed charges for the covered services shown in line 5. For those services in which any charges were reduced as a result of reasonable charge, medical necessity, or global fee/rebundling determinations, the carrier reports the total covered charges prior to such reductions. The system will pre-fill columns 1 and 3 with the data reported in the respective columns on line 1 of Form A for the same quarter.
Line 9. Physician - total amount (rounded to the nearest dollar) of billed charges for the covered physician services shown in line 6. For those services in which any charges were reduced as a result of reasonable charge, medical necessity, or global fee/rebundling determinations, the carrier reports the total covered charges prior to such reductions.
Line 10. Non-Physician - total amount (rounded to the nearest dollar) of billed charges for the covered non-physician services shown in line 7. For those services in which any charges were reduced as a result of reasonable charge, medical necessity, or global fee/rebundling determinations, the carrier reports the total covered charges prior to such reductions.
Line 11. Number of Claims Where Billed Charges Were Reduced - number of claims (real and replicate) reported on line 1 as approved in which any charges were reduced as a result of reasonable charge/fee schedule, medical necessity, or global fee/rebundling determinations. The carrier counts a claim only once, regardless of the number of services reduced or the different categories of reductions that apply. Some examples of such reductions are:
a. Charges over allowed rental limits b. Tests included in a battery of tests, c. Fee covered in basic allowance or surgical allowance, d. Service included in office charge or surgery fee.
Line 12. Physician Only - number of claims included in line 11 involving physician services only.
Line 13. Physician and Non-Physician - number of claims included in line 11 involving both physician and non-physician services on the same claim. The carrier shows all claims in this category under the "Non-Participant-Unassigned" column 3. Therefore, the numbers for columns 1 and 3 should be equal.
Line 14. Non-Physician Only - number of claims included in line 11 involving non-physician services only.
Line 15. Number of Covered Services Where Charges Were Reduced - From the claims shown in line 11, the carrier reports the number of covered services in which any charges were reduced as a result of reasonable charge determinations, medical necessity reductions, or global fee/rebundling reductions. It includes services where a fee is deemed to have been included in a global fee, such as postsurgical care. (See examples given for line 11.)
Line 16. Physician - number of covered physician services included in line 15. This count includes those services where charges were reduced on the claims shown in line 12, plus the physician services where charges were reduced on the claims shown in line 13.
Line 17. Non-Physician - number of covered non-physician services included in line 15. This count includes those services where charges were reduced on the claims shown in line 14, plus the non-physician services where charges were reduced on the claims shown in line 13.
Line 18. Total Amount of Reduction - total amount (rounded to the nearest dollar) by which the services reported in line 15 were reduced as a result of reasonable charge, medical necessity, or
global fee/rebundling determinations. The system will pre-fill columns 1 and 3 with the sum of the data reported in the respective columns on lines 3, 5, and 7 of Form A for the same quarter.
Line 19. Physician - total amount (rounded to the nearest dollar) by which charges for physician services reported in line 16 were reduced as a result of reasonable charge, medical necessity, or global fee/rebundling determinations.
Line 20. Non-Physician - total amount (rounded to the nearest dollar) by which charges for non-physician services reported in line 17 were reduced as a result of reasonable charges, medical necessity, or global fee/rebundling determinations.
Line 21. Number of Claims Denied in Full - total number of claims, processed to completion during the quarter, in which charges for all services were completely disallowed. This number must equal the sum of the numbers reported in lines 11 and 14 of Form B for the three months of the quarter. The system will pre-fill columns 1 and 3 based on the total of these lines from the monthly reports.
Line 22. Physician Only - number of claims included in line 21 involving physician services only.
Line 23. Physician and Non-Physician - number of claims included in line 21 involving both physician and non-physician services on the same claim. The carrier shows all claims in this category under the 'Non-Participant- Unassigned' column 3. Therefore, the numbers for columns 1 and 3 should be equal.
Line 24. Non-Physician Only - number of claims included in line 21 involving non-physician services only.
Line 25. Number of Claims Denied in Full or in Part - sum of (1) those claims (real and replicate) reported as denied in full in line 21, plus (2) those claims (real and replicate) reported as approved on line 1 in which some services, but not all, were denied. The system will pre-fill columns 1 and 3 with the data reported in the respective columns on line 8 of Form A for the same quarter.
Line 26. Physician Only - number of claims included in line 25 involving physician services only.
Line 27. Physician and Non-Physician - number of claims included in line 25 involving both physician and non-physician services on the same claim. The carrier shows all claims in this category under the 'Non-Participant-Unassigned' column 3. Therefore, the numbers for columns 1 and 3 should be equal.
Line 28. Non-Physician Only - number of claims included in line 25 involving non-physician services only.
Line 29. Number of Denied Services - number of services for which charges were fully or partially denied on the claims shown in line 25.
Line 30. Physician - number of denied physician services included in line 29. The carrier includes in this count the denied services from the claims shown in line 26 plus the denied physician services from the claims shown in line 27.
Line 31. Non-Physician - number of denied non-physician services included in line 29. The carrier includes in this count the denied services from the claims shown in line 28, plus the denied non-physician services from the claims shown in line 27.
Line 32. Amount Disallowed - total amount (rounded to the nearest dollar) of charges disallowed on the services shown in line 29. The system will pre-fill columns 1 and 3 with the data reported in the respective columns on line 9 of Form A for the same quarter.
Line 33. Physician - total amount (rounded to the nearest dollar) included in line 32 as disallowed which represented physician services as reported in line 30.
Line 34. Non-Physician - total amount (rounded to the nearest dollar) included in line 32 as disallowed which represented non-physician services as reported in line 31.
(Rev. 6, 08-30-02)
B3-13325.3
Prior to submitting Form G to CMS, the carrier checks for completeness, accuracy and internal consistency. It uses the following checklist to assure accuracy and consistency:
1. For all lines, column 1 must equal the sum of columns 2 through 4,
2. Line 1 should equal the sum of lines 2 through 4 for all columns,
3. Line 5 should be greater than or equal to line 1 for all columns,
4. Line 5 should equal the sum of lines 6 and 7 for all columns,
5. Line 8 should be greater than or equal to line 5 for all columns,
6. Line 8 should equal the sum of lines 9 and 10 for all columns,
7. Line 9 should be greater than or equal to line 6 for all columns,
8. Line 10 should be greater than or equal to line 7 for all columns.
9. Line 11 should be less than or equal to line 1 for all columns,
10. Line 11 should equal the sum of lines 12-14 for all columns,
11. Line 12 should be less than or equal to line 2 for all columns,
12. Line 13 should be less than or equal to line 3 for all columns,
13. Line 14 should be less than or equal to line 4 for all columns,
14. Line 15 should be greater than or equal to line 11 for all columns,
15. Line 15 should equal the sum of lines 16 and 17 for all columns,
16. Line 15 should be less than or equal to line 5 for all columns,
17. Line 16 should be less than or equal to line 6 for all columns,
18. Line 17 should be less than or equal to line 7 for all columns,
19. Line 18 should be less than or equal to line 8 for all columns,
20. Line 18 should equal the sum of lines 19 and 20 for all columns,
21. Line 19 should be less than or equal to line 9 for all columns,
22. Line 20 should be less than or equal to line 10 for all columns,
23. Line 21 should equal the sum of lines 22-24 for all columns,
24. Line 25 should be greater than or equal to line 21 for all columns,
25. Line 25 should be equal to the sum of lines 26-28 for all columns,
26. Line 26 should be greater than or equal to line 22 for all columns,
27. Line 27 should be greater than or equal to line 23 for all columns,
28. Line 28 should be greater than or equal to line 24 for all columns,
29. Line 29 should be greater than or equal to line 25 for all columns,
30. Line 29 should equal the sum of lines 30 and 31 for all columns,
31. Line 32 should equal the sum of lines 33 and 34 for all columns;
32. Column 1 should equal column 3 for lines 3, 13, 23 and 27.
33. The following comparisons should be made between Form G and two other related forms, the CMS-1565 (Form B) and the CMS-1565A (Form A):
a. Line 1, column 1, of Form G must equal the sum of lines 9, 10, + 13, column 1 of Form B for the reporting months. b. Line 1, sum of columns 2 + 4 of Form G must equal the sum of lines 9, 10, + 13, column 2 of Form B for the reporting months. c. Line 1, column 3 of Form G must equal sum of lines 9, 10, + 13, column 3 of Form B for the reporting months. d. Line 21, column 1 of Form G must equal sum of lines 11 + 14, column 1 of the CMS-1565 for the reporting months. e. Line 21 sum of columns 2 + 4 of Form G must equal sum of lines 11 + 14, column 2 of Form B for the reporting months. f. Line 21, column 3 of Form G must equal sum of lines 11 + 14, column 3 of the Form B for the reporting months. g. Line 8, column 1 of Form G must equal line 1 column 1 of Form A for the same quarter. h. Line 8, sum of columns 2 + 4 of Form G must equal line 1 column 2 of the Form A for the same quarter. i. Line 8, column 3 of Form G must equal line 1 column 3 of Form A for the same quarter. j. Line 11, column 1 of Form G must be less than or equal to the sum of lines 2, 4 + 6, column 1 of Form A for the same quarter.
(Rev. 6, 08-30-02)
B3-13326
The carrier prepares and submits to CMS each quarter, a report on carrier CLCCP activity including such items as the number of Limiting Charge Exception Reports (LCERs), Limiting Charge Monitoring Reports (LCMRs), and Sanction Referral Letters (SRLs) sent during the quarter. It prepares its quarterly report based on the data captured in its cycle management reports in accordance with MCM, §7555.6ff.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13326.1
This report is referenced as Form N for CROWD. The carrier submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 6, 08-30-02)
B3-13326.2
Before submitting Form N to CMS, the carrier checks for completeness and arithmetical accuracy. It uses the following checklist:
(Rev. 6, 08-30-02)
B3-13326.3
The carrier reports in items 1-4 numbers of LCERs sent, not the number of providers receiving LCERs. Each of these items, therefore, will be the sum of the numbers shown on its cycle reports for the period.
Line 1 - LCERs Sent to Individual Physicians - The carrier reports the total number of LCERs sent to individual physicians during the period.
Line 2 - LCERs Sent to Group Practices - The carrier reports the total number of LCERs sent to group practices of physicians during the period.
Line 3 - LCERs Sent to All Other Providers - The carrier reports the total number of LCERs sent to all providers other than individual physicians, or group practices of physicians.
Line 4 - Total LCERs Sent for Period - The system will sum lines 1, 2, and 3 to calculate this field.
Line 5 - Total Claims on LCERs Sent - The carrier reports the total number of claims included on all of the LCERs sent for the period.
Line 6 - Claims Selected for Verification - The carrier reports the total number of claims selected for verification of refund/adjustment during the reporting period.
Line 7 - Beneficiaries with Claims on LCERs - The carrier reports the sum of the number of individual beneficiaries counted on its cycle reports for the period. Although an individual is to be counted only once on any particular cycle report, if the individual has claims on more than one cycle report, that individual will be counted more than once on the quarterly report.
(Rev. 6, 08-30-02)
The carrier reports all dollar amounts to two decimal places on lines 8-13. It reports the sum of the net figures for all of the cycles in the reporting period. It calculates and includes changes because of adjustments to claims in a cycle, or from a previous cycle, so that these figures accurately reflect the relationship between allowed dollars and excess dollars. Adjustments which leave overcharges of less than $1.00 may affect the total dollar value reported on line 13, thus it may not always equal the amount reported on line 9.
Line 8 - Total Dollars Allowed - The carrier reports the total dollars allowed from the sum of the cycle reports for the period.
Line 9 - Dollars in Excess of Limiting Charge - The carrier reports the total dollars in excess of the limiting charge from the sum of the cycle reports for the period.
Lines 10-13 - Procedures with Related Excess Charges - The carrier reports on lines 10-13 the total number of procedures (column 1), and related total dollar value of excess charges (column 2) that fall within each of the dollar ranges of excess charges on the respective lines: Line 10 is $1.00 - 4.99, line 11 is $5.00 -499.99, and line 12 is $500.00 + . The carrier need not complete line 11, as the system will calculate it by subtracting lines 10 and 12 from line 13 (Total).
(Rev. 6, 08-30-02)
B3-13326.5
Line 14 - Verifications Posted to the Limiting Charge Exception File (LCEF) - The carrier reports the total number of acceptable verifications posted to the LCEF.
Line 15 - Not Requested on LCER - The carrier reports the number of acceptable verifications included on line 14 that were not requested on an LCER.
Line 16 - Unacceptable Verifications - The carrier reports the number of verifications received, either because of an LCER or unsolicited, that were unacceptable, (i.e., posted as unacceptable to the LCEF or could not be associated with an LCEF record).
(Rev. 6, 08-30-02)
B3-13326.6
Line 17 - LCMRs Sent to Individual Physicians - The carrier reports the total number of LCMRs sent to individual physicians during the reporting period.
Line 18 - LCMRs Sent to Group Practices - The carrier reports the total number of LCMRs sent to group practices of physicians during the reporting period.
Line 19 - LCMRs Sent to All Other Providers - The carrier reports the total number of LCMRs sent to all providers other than individual physicians or group practices of physicians.
Line 20 - Total LCMRs Sent for Period - The system will sum lines 17, 18, and 19 to calculate the total number of LCMRs sent.
(Rev. 6, 08-30-02)
B3-13326.7
Line 21 - SRLs Sent to Individual Physicians - The carrier reports the number of sanction referral letters sent to individual physicians during the reporting period.
Line 22 - SRLs Sent to Group Practices - The carrier reports the number of sanction referral letters sent to group practices of physicians during the reporting period.
Line 23 - All Other Providers - The carrier reports the number of sanction referral letters sent to all providers other than individual physicians or group practices of physicians.
Line 24 - Total SRLs Sent for Period - The system will sum lines 21, 22, and 23 to calculate the total number of sanction referral letters sent.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The carriers/Part B MACs prepare and submit to CMS each quarter a report on information regarding incentive payments made to physicians who render covered Medicare services in HPSAs (see Pub. 100-04, Chapter 12, §§90.4 – 90.4.7) on the results of its review of sample claims for HPSA incentive payments processed during the reporting quarter. It submits this report via CROWD no later than the 75th day following the close of the reporting quarter.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
This report is referenced as Form S for CROWD. The carrier/Part B MAC submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10)
Before submitting Form S to CMS, the carrier/Part B MAC checks for completeness and arithmetical accuracy. It uses the following checklist:
Line 2 plus line 3 must equal line 1. Effective with the first quarterly report of 2005, that is due no later than 75 days after the close of the first calendar quarter of 2005, this will no longer be applicable.
Line 5 plus line 6 must equal line 4. Line 2 plus line 3 must equal line 1. Effective with the first quarterly report of 2005, that is due no later than 75 days after the close of the first calendar quarter of 2005, this will no longer be applicable.
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10)
The carrier/Part B MAC reports in lines 1-3 the number of physicians receiving incentive payment checks during the current reporting quarter and in lines 4-6 the respective amounts of payment issued.
Note: For data reporting purposes for this report, “physicians” will be defined as NPI/PIN combinations as provided to the carriers/Part B MACs by the Shared System.
Line 1. Total Physicians - total number of physicians receiving incentive payments.
Line 2. Urban HPSAs - number of physicians receiving incentive payments classified as providing services in a HPSA urban setting. Effective with the first quarterly report of 2005, that is due no later than 75 days after the close of the first calendar quarter of 2005, this line must no longer be entered.
Line 3. Rural HPSAs - number of physicians receiving incentive payments classified as providing services in a HPSA rural setting. Effective with the first quarterly report of 2005, that is due no later than 75 days after the close of the first calendar quarter of 2005, this line must no longer be entered.
Line 4. Total Incentive Payments - total amount of incentive payments issued to physicians.
Line 5. Urban HPSAs - amount of incentive payments issued to physicians for services provided in a HPSA urban setting. Effective with the first quarterly report of 2005, that is due no later than 75 days after the close of the first calendar quarter of 2005, this line must no longer be entered.
Line 6. Rural HPSAs - amount of incentive payments issued to physicians for services provided in a HPSA rural setting. Effective with the first quarterly report of 2005, that is due no later than 75 days after the close of the first calendar quarter of 2005, this line must no longer be entered.
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10)
The carrier/Part B MAC reports in lines 7-11 information on physicians identified for review based on data for the current reporting quarter excluding those physicians reviewed because they were noncompliant in the previous quarter.
Note: For data reporting purposes for this report, “physicians” will be defined as NPI/PIN combinations as provided to the carriers/Part B MACs by the Shared System.
Line 7. Physicians Reviewed - number of physicians identified for review based on data for the current reporting quarter. The carrier/Part B MAC excludes those physicians reviewed because of noncompliance in the previous quarter.
Line 8. Physicians Paid Incorrectly - number of physicians reviewed on line 7 that incorrectly received an incentive bonus on at least one claim.
Line 9. Claims Reviewed - number of total claims reviewed for physicians reported on line 7.
Line 10. Claims Paid Incorrectly - number of claims included on line 9 where the physician incorrectly received incentive payments.
Line 11. Incentive Amount Paid Incorrectly - total incentive amount incorrectly paid on claims identified on line 10.
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10)
The carrier/Part B MAC reports in lines 12-18 information on physicians reviewed because they were noncompliant in the previous quarter(s).
Note: For data reporting purposes for this report, “physicians” will be defined as NPI/PIN combinations as provided to the carriers/Part B MACs by the Shared System.
Line 12. Physicians Reviewed - number of physicians who were identified in lines 8, 13, 14, or 15 on the previous quarter report as noncompliant.
Line 13. Physicians Noncompliant Two Quarters - number of physicians identified in line 12 that were noncompliant in the current and previous quarters, but no quarters prior.
Line 14. Physicians Noncompliant Three Quarters - number of physicians identified in line 12 that were included in line 13 in the previous quarter's report and still noncompliant in the current quarter.
Line 15. Physicians Noncompliant Four or More Quarters - number of physicians identified in line 12 that were included in line 14 in the previous quarter's report and still noncompliant in the current quarter.
Line 16. Claims Reviewed - number of claims reviewed for the physicians identified in line 12.
Line 17. Claims Paid Incorrectly - number of claims in line 16 that were paid incorrectly.
Line 18. Incentive Amount Paid Incorrectly - total incentive amount paid on those claims identified in line 17.
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10)
This report breaks down the number of claims found to be paid incorrectly by selected error categories for 'Current Quarter Reviews' and 'Prior Quarter(s) Reviews'. Claims counts reported in lines 19-30 under the 'Number of Claims Current Quarter' column should total to the number reported in line 10. Similarly, claims counts reported in lines 19-30 under the 'Number of Claims Prior Quarter(s)' column should total to the number reported in line 17. In a case where the claim could fall into more than one category, the carrier/Part B MAC makes a determination as to which category to put the claim in. Each claim incorrectly receiving a HPSA incentive payment should be counted only once under the 'Error Descriptions' section.
Line 19. Office In, Service Outside HPSA - number of claims where the provider's office is located in a HPSA, but the provider travels to a non-HPSA to provide services.
Line 20. Office Outside, Service Outside HPSA - number of claims where neither the provider's office nor the place of service is located in a HPSA.
Line 21. Multiple Offices, Service Non-HPSA Office - number of claims when the physicians with multiple offices (some of which may be in a HPSA, and some of which are not) bill for services provided in their non-HPSA office.
Line 22. Beneficiary in HPSA, Services Outside HPSA - number of claims where the provider used the beneficiary's address for HPSA incentive eligibility instead of the place of service.
Line 23. Provider Codes Prior to Effective Date HPSA - number of claims where the services were provided before the effective date the area was designated as a HPSA. The effective date providers can begin coding claims for HPSA incentive payments is the first day of the second month following the date CMS is notified by PHS. CMS will transmit the effective date to the carrier/Part B MAC. Effective January 1, 2005, the effective date of a HPSA designation will be the date of the HRSA designation letter which will be reflected on the HRSA Web site.
Line 24. Service Area No Longer HPSA - number of claims requesting HPSA payment after the area is no longer classified as a HPSA. CMS will transmit the termination date to the carrier/Part B MAC.
Line 25. Non-Physician Practitioner - number of claims coded for HPSA incentives, but the services were provided by someone other than a physician. An example is a claim submitted with the HPSA modifier, and the service was provided by a nurse practitioner.
Line 26. Non-Physician Service - number of claims coded for HPSA incentives which were for services other than physician professional services. Examples of services furnished by a physician, but not subject to the HPSA incentive, are technical components of diagnostic tests, drugs, and separately payable supplies.
Line 27. Carrier/Part B MAC Provided Incorrect Information - number of claims that were incorrectly coded by the provider for HPSA incentives as a result of incorrect information the carrier/Part B MAC provided.
Line 28. Carrier/Part B MAC Published Incorrect Notice - number of claims where the provider code for HPSA incentives was based on a population group (noncovered) HPSA notice the carrier/Part B MAC incorrectly published.
Line 29. Carrier Keying/Processing Error - number of claims paid for the HPSA incentives inappropriately due to keying or processing errors made by carrier/Part B MAC staff.
Line 30. Other - number of claims that do not fit into any of the other categories. Although not routinely required, carriers/Part B MACs may be asked to expand on the reason for error on these types of claims.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13329
Exhibit 1 - Medicare Program Quarterly Supplement To The Carrier Performance Report CMS-1565a (Crowd Form A)
| CARRIER | REPORTING PERIOD (QUARTER AND YEAR) | ||
|---|---|---|---|
| NUMBER AND TYPE OF CLAIM | |||
| REPORTING ITEM | TOTAL - 1 | ASSIGNED - 2 | UNASSIGNED - 3 |
| A. CLAIMS REDUCED OR DENIED COVERED CHARGES 1. Tot. Cvrd. Charges For All Claims | |||
|---|---|---|---|
| REAS. CHG./FEE SCHED. REDUCTIONS 2. No. of Clms w/Reas Chg/Fee Sched Red | |||
| 3. Amount of Reduction (in $) | |||
| MEDICAL NECESSITY REDUCTIONS 4. Number of Claims w/ Med. Nec. Red. | |||
| 5. Amount of Reduction (in $) | |||
| GLOBAL FEE/REBUNDLING REDUCTIONS 6. No. of Claims w/ Glo. Fee/Rebun Red. | |||
| 7. Amount of Reduction (in $) | |||
| DENIALS 8. Claims Denied in Full or in Part 9. Amount Disallowed (in $) | |||
| REASONS FOR DENIAL | NUMBER OF ITEMS DENIED (1) | AMOUNT DISALLOWED (2) | NUMBER OF CLMS DENIED (3) |
| 10. Claimant Ineligible | |||
| 11. Filing Limitation Exceeded | |||
| 12. Duplicate Claim | |||
| 13. Services Not Covered | |||
| 14. Services Not Medically Necessary | |||
| 15. MSP | |||
| 16. Missing Information | |||
| 17. Global Fee/Rebundling | |||
| 18. Other | |||
| 19. Total |
CMS-1565B (CROWD FORM M)
CARRIER NUMBER ___
REPORT PERIOD ___
| FRAUD WORKLOAD ITEM | TOTAL 1 | BENEFICIARY COMPLAINT 2 | OIG HOTLINE 3 | REFERRAL & OTHERS 4 |
|---|---|---|---|---|
| 1. OPENING PENDING | ||||
| 2. ADJUSTMENTS | ||||
| 3. ADJUSTED PENDING | ||||
| 4. WORKLOAD RECEIVED | ||||
| 5. TOTAL CLEARED | ||||
| 6. BY CONTRACTOR | ||||
| 7. BY REFERRAL | ||||
| 8. CLOSING PENDING |
FORM-CMS 1565B
| REPORTING ITEM | TOTAL 1 | NON-PAR ASSIGNED 2 | NON-PAR UNASSGNED 3 | PARTICI- PANTS 4 |
|---|---|---|---|---|
| 1. CLAIMS APPROVED: TOTAL | ||||
| 2. PHYS ONLY | ||||
| 3. PHYS AND NONPHYS | ||||
| 4. NONPHYS ONLY | ||||
| 5. COVRD SERVICES: NUMBER | ||||
| 6. PHYS | ||||
| 7. NONPHYS | ||||
| 8. AMT COVRD CHRGS: TOTAL | ||||
| 9. PHYS | ||||
| 10. NONPHYS | ||||
| 11. CLAIMS REDUCED: TOTAL | ||||
| 12. PHYS ONLY | ||||
| 13. PHYS AND NONPHYS | ||||
| 14. NONPHYS ONLY | ||||
| 15. COVRD SRVCS RED: NUM | ||||
| 16. PHYS | ||||
| 17. NONPHYS | ||||
| 18. AMOUNT REDUCED: TOTAL | ||||
| 19. PHYS | ||||
| 20. NONPHYS | ||||
| 21. FULL DENIALS: NUMBER | ||||
| 22. PHYS ONLY | ||||
| 23. PHYS AND NONPHYS | ||||
| 24. NONPHYS ONLY | ||||
| 25. FULL/PART DENIALS: NUM | ||||
| 26. PHYS ONLY | ||||
| 27. PHYS AND NONPHYS | ||||
| 28. NONPHYS ONLY | ||||
| 29. DENIED SERVICES: NUM | ||||
| 30. PHYS | ||||
| 31. NONPHYS | ||||
| 32. AMT DISALLOWED: TOTAL |
| 33. | PHYS | ||||
|---|---|---|---|---|---|
| 34. | NONPHYS |
FORM-CMS 1565C
CARRIER NUMBER __ REPORT PERIOD __
| COLUMN 1 | COLUMN 2 | |
|---|---|---|
| 1. LCERs SENT TO IND PHYSICIANS 2. LCERs SENT TO GROUP PRACTICES 3. LCERs SENT TO ALL OTHER PROVIDERS 4. TOTAL LCERs SENT FOR PERIOD 5. TOTAL CLAIMS ON LCERs SENT 6. CLAIMS SELECTED FOR VERIFICATION 7. BENEFICIARIES W/CLAIMS ON LCERS 8. TOTAL DOLLARS ALLOWED 9. DOLLARS IN ECESS OF LMTNG CHARGE | ||
| 10. $1.00-$4.99 11. $5.00-$499.99 12. $500+ 13. TOTAL | # OF PROCEDURES | TOTAL $ VALUE |
| 14. VERIFICATIONS POSTED TO LCEF 15. NOT REQUESTED ON LCER 16. UNACCEPTABLE VERIFICATIONS | ||
| 17. LCMRs SENT TO IND PHYSICIANS 18. LCMRs SENT TO GROUP PRACTICES 19. LCMRs SENT TO ALL OTHER PROVIDERS 20. TOTAL LCMRs SENT FOR PERIOD 21. SRLs SENT TO IND PHYSICIANS 22. SRLs SENT TO GROUP PRACTICES 23. SRLs SENT TO ALL OTHER PROVIDERS 24. TOTAL SRLs SENT FOR PERIOD |
FORM-CMS 1565D
Screen 1
CARRIER NAME_______
CARRIER NUMBER_______
CMS-1565E REPORT PERIOD_______
CURRENT QUARTER PAYMENTS
PHYSICIANS RECEIVING CHECKS:
1. TOTAL
2. URBAN HPSA'S
3. RURAL HPSA'S
AMOUNT OF INCENTIVE PAYMENTS:
4. TOTAL
5. URBAN HPSA'S
6. RURAL HPSA'S
(Carriers Only - Crowd Form S)
1565E (CARRIERS ONLY - CROWD FORM S)
Screen 2
CARRIER NAME
CMS-1565E
CARRIER NUMBER
REPORT PERIOD
7. PHYSICIANS REVIEWED
8. PHYSICIANS PAID INCORRECTLY
9. CLAIMS REVIEWED
10. CLAIMS PAID INCORRECTLY
11. INCENTIVE AMOUNT PAID INCORRECTLY
12. PHYSICIANS REVIEWED
13. PHYSICIANS NONCOMPLIANT 2 QRTS.
14. PHYSICIANS NONCOMPLIANT 3 QRTS.
15. PHYSICIANS NONCOMPLIANT 4+ QRTS.
16. CLAIMS REVIEWED
17. CLAIMS PAID INCORRECTLY
18. INCENTIVE AMOUNT PAID INCORRECTLY
Exhibit 7 - Health Professional Shortage Area (HPSA) Quarterly Report
HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) QUARTERLY REPORT - CMS-1565E (CARRIERS ONLY - CROWD FORM S)
Screen 3
CARRIER NAME __ CMS-1565E CARRIER NUMBER __ REPORT PERIOD ____
| ERROR DESCRIPTIONS | # OF CLAIMS CURRENT QUARTER | # OF CLAIMS PRIOR QUARTER |
|---|---|---|
| 19. OFFICE IN, SERVICE OUTSIDE HPSA | ||
| 20. OFFICE OUTSIDE, SERV. OUTSIDE HPSA | ||
| 21. MULTI-OFFICE, SERVICE NON-HPSA OFF. | ||
| 22. BENE. IN HPSA, SERVICE OUTSIDE HPSA | ||
| 23. PROV. CODE PRIOR TO EFF. DATE HPSA | ||
| 24. SERVICE AREA NO LONGER HPSA | ||
| 25. NON-PHYSICIAN PRACTITIONER | ||
| 26. NON-PHYSICIAN SERVICE | ||
| 27. CARRIER PROVIDED INCORRECT INFO. | ||
| 28. CARRIER PUBLISHED INCORRECT NOTICE | ||
| 29. CARRIER KEYING/PROCESSING ERROR | ||
| 30. OTHER |
(Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13350
At the end of each calendar quarter (i.e., December, March, June, September) the carrier prepares and submits to CMS a report summarizing beneficiary overpayment activity completed during the reporting quarter. It completes a separate report for each carrier office that has been assigned a separate carrier number.
(Rev. 6, 08-30-02)
B3-13350.1
This report provides CMS with current data on beneficiary overpayments - nationally as well as for each carrier. The report enables CMS to tabulate for administrative and statistical purposes data on beneficiary overpayments:
(Rev. 6, 08-30-02)
B3-13350.2
The carrier transmits the CMS-2174 to CO via PC or terminal as soon as possible after the end of the reporting quarter, but no later than the 15th day of the month following the end of the reporting quarter, e.g., the October-December report is due on January 15. Non-receipt of the report by the due date will result in CMS contacting it to obtain the required information.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13351
(Rev. 6, 08-30-02)
B3-13351.1
Data on the CMS-2174 reflects counts of claims for which the carrier has made a determination that a beneficiary-recoverable overpayment exists. The overpayment must have been made to a beneficiary or to a without-fault physician/supplier on behalf of a beneficiary. The carrier should not confuse this with an assignee overpayment (i.e., one made to an assignee who is at fault and therefore liable). (See Chapter 3, §§200-202.) It counts claims only once regardless of the number of separate instances of overpayments found on them.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24) B3-13360
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24) B3-13360.1
This report is referenced as Form O for CROWD. The carrier enters its ID number in the number box. In the space labeled 'Reporting Period' it enters the fiscal quarter and year (e.g., 0190 for October-December 1989) for which the report is prepared.
(Rev. 6, 08-30-02) B3-13360.2
The carrier reports the number of claims and the dollar amounts for which a determination was made during the reporting quarter or a previous quarter that a beneficiary-recoverable overpayment had been made. It does not count potential overpayment claims under investigation. It includes individual overpayments discovered as part of CMS's Carrier Quality Control Program (QA) end-of-line review sample. It does not include projections of overpayments from QA samples. It includes overpayments discovered where Medicare is secondary to prime insurers (Department of Labor - BL, WC, VA, auto medical or no fault, liability, EGHP under the working aged or ESRD provisions or LGHP under the disabled provision) that also paid the beneficiary. Round amounts to the nearest whole dollar.
Line 1. Pending Start of Quarter - The number of claims and dollar amount of beneficiary overpayments reported in line 13 as the closing pending on the previous quarter's report.
Line 2. Adjustments to Opening Pending - Any adjustments to the previous quarter's closing pending amount due to errors, decisions resulting from reviews and hearings, reopenings, etc. Show as a plus or a minus, as appropriate.
Line 3. Adjusted Opening Pending - The result of line 1 + line 2, as appropriate.
Line 4. Discovered During Reporting Quarter - The number of claims and the dollar amount for which a determination was made during the reporting quarter that a beneficiary-recoverable overpayment had been made. This does not include potential overpayments under investigation. It includes claims where the payee returned or never negotiated the check(s).
Claim counts are treated differently from money amounts in lines 5-9 below. A claim is counted in these lines only when it has been fully disposed. This line does not include partial dispositions in the claim counts for lines 5-9. It does not include any money amounts partially disposed in lines 5-9 as appropriate.
Line 5. Dispositions - The number of claims for which: Recovery of a beneficiary-recoverable overpayment by offset or refund was completed during the quarter (see NOTE 3); or
A determination was made during the quarter that the overpayment is uncollectible or is to be abandoned in accordance with Chapter 3, §§190 ff.
This includes any amount recouped by offset or refund, or determined to be uncollectible or abandoned in accordance with Chapter 3, §§190 ff. during the quarter, regardless of whether it was a full or partial determination.
NOTES:
1. If part of an overpayment is recouped and the remainder is determined to be uncollectible or abandoned, the disposition of the overpayment is considered to be completed.
2. If the disposition of the overpayment is completed and it falls into more than one line of lines 7, 8, 10-12, it is counted once under the "number of claims" in the line category accounting for the greatest dollar amount. The carrier reports the money amount in each appropriate line, however. (It does not report any money amounts reported in previous quarters.)
3. If part of the overpayment has been recouped and part is still outstanding at the end of the quarter, the carrier includes the amount recouped. It does not include the claim count. It includes the portion of the overpayment which is still outstanding in the claim count and amount for line 10.
Line 6. Collected - The carrier enters the number of overpayments recouped by offset or refund during the reporting quarter. Under the money column, it reports any amount recovered by offset or refund.
Line 7. Recouped by Offset - The carrier enters the number of beneficiary-recoverable overpayment claims for which it completed disposition during the reporting quarter and for which most or all of the dollar amounts were recouped by offsetting payment on subsequent requests for payment. (This includes cases where a letter has been written to the payee requesting a refund, but before the refund is received a request for payment is received which completes repayment of the overpayment.) Under the money amount column, it reports any amount recovered by this method, whether a full or partial recovery.
Line 8. Recouped by Refund - The carrier enters the number of beneficiary-recoverable overpayment claims for which it completed disposition during the reporting quarter and the final disposition was made by a refund. (It includes cases where the payees returned the checks.) Under the money amount column, it reports any amount recovered by refund, whether a full or partial recovery.
Line 9. Uncollectibles - The carrier reports the number of beneficiary-recoverable overpayment claims for which it completed disposition during the reporting quarter by determining for most or all of the dollar amount, to be uncollectible and have either referred to the RO, waived, or abandoned them. Under the money column, it reports the amount involved.
Line 10. Referred to RO - The carrier enters the number of beneficiary-recoverable overpayment claims for which it completed disposition during the reporting quarter and where, for most or all of the dollar amount, it terminated recovery efforts and referred the claim to the RO. (See Chapter 3, §§190 ff.) Under the money amount column, it reports the amount referred to RO.
Line 11. Waived by Contractor - The carrier enters the number of beneficiary-recoverable overpayment claims for which it completed disposition during the reporting quarter and where it waived most or all of the dollar amounts. (See Chapter 3, §§190 ff). Under the recovery amount column, it reports any amount waived in this way during the quarter.
NOTE: A waiver is a case in which the beneficiary is liable and the criteria in Chapter 4, §100B for waiver recovery is met; i.e., it appears from the circumstances of the overpayment that the beneficiary was without fault and that the recovery would be against equity and good conscience or would defeat the purpose of the Medicare Program (i.e., cause the individual financial hardship).
Line 12. Abandoned in Accordance with Manual Instructions - The carrier enters the number of beneficiary-recoverable overpayment claims for which it completed disposition during the reporting quarter and which it abandoned for most or all of the dollar amount in accordance with Chapter 4, §70. Under the money amount column, it reports any amount abandoned.
A claim is abandoned when recovery has been terminated because:
Line 13. Pending End of Quarter - The carrier enters the number of beneficiary-recoverable overpayments claims with any amount outstanding at the end of the reporting quarter. If part of a claim is recouped and part is outstanding, it reports only the amount outstanding. It does not include any amounts which have been recouped, either in full or in part.
(Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
This solicits the reasons for overpayments in which a determination was made during the quarter that an overpayment had been made to, or on behalf of, the beneficiary. The data include both the number of claims on which beneficiary-recoverable overpayments were discovered and the amount of overpayment (not over-allowance) involved.
Where more than one cause of overpayment exists, the carrier reports the claim and dollar amount of the overpayment on only one of the lines 14 through 23 according to the principal reason for overpayment. The principal reason is that which involves the greatest dollar amount.
The number of claims and amounts of beneficiary overpayments for reasons 14 through 23 combined should equal the number of claims and amount reported in Section A on line 4.
Line 14. Beneficiary Not Entitled - The carrier enters under the appropriate columns the number and dollar amount of overpayments which resulted because payments were made to, or on behalf of, a beneficiary for services rendered during a period of non-entitlement or for claims processed under the wrong Medicare beneficiary identifier. (See Medicare Carrier Quality Assurance Handbook §290.1).
Line 15. Services Not Covered - The carrier enters the number and dollar amount of overpayments which resulted because payments were made for non-covered services other than medically unnecessary services. (See Medicare Carrier Quality Assurance Handbook §290.2).
Line 16. Charge Exceeded Reasonable Charge - The carrier enters under the appropriate columns the number and dollar amount of overpayments which resulted when improper charges, higher than the reasonable charge amount, were allowed. (See Medicare Carrier Quality Assurance Handbook §290.3).
Line 17. Payment Made to Wrong Payee - The carrier enters under the appropriate columns the number and dollar amount of overpayments which resulted when a person other than the proper payee received the payment (e.g., the beneficiary is paid on an assigned claim). It reports duplicate payments made to the wrong payee in line 18 instead of here.
Line 18. Duplicate Payment - The carrier enters under the appropriate columns the number and dollar amount of overpayments which occurred when payment was made to, or on behalf of, the beneficiary more than once for the same service.
Line 19. Medically Unnecessary Services - The carrier enters under the appropriate columns the number and dollar amount of overpayments discovered which arose because of payments for services later determined to be medically unnecessary.
Line 20. Services Not Rendered - The carrier enters under the appropriate columns the number and dollar amount of overpayments discovered which arose because of payments for services not actually rendered. It includes claims which involve forgery or fraudulent billing for noncovered services and other identified program abuses.
Line 21. Medicare Secondary Payor - The carrier enters under the appropriate columns the number and dollar amounts of overpayments which arose because Medicare is secondary to prime insurers (e.g., Department of Labor, BL, WC, VA, auto, medical or no fault, liability, EGHP under the working aged or ESRD provision or LGHP under the disabled provision).
Line 22. Documentation/Coding/Data Entry - The carrier enters under the appropriate columns the number and dollar amount of overpayments which resulted from:
NOTE: If a documentation/coding data entry error results in an overpayment which may be categorized into any of lines 14 - 21, the carrier uses one of lines 14 - 21 instead of using line 22.
Line 23. Other - The carrier enters under the appropriate columns the number and dollar amount of overpayments discovered which are not specifically provided for in lines 14-22 above.
(Rev. 6, 08-30-02)
B3-13360.4
This shows data on beneficiary-recoverable overpayments according to how they were discovered. Where more than one method of discovery exists, the carrier reports the claim and dollar amount of overpayment on only one of lines 24 - 28 according to the principal method of discovery. The principal method is that which involves the greatest dollar amount.
Line 24. Reported by Beneficiary or Provider - The carrier enters under the appropriate columns the number of overpayments and that part of the dollar amount reported on line 4 which were discovered when a beneficiary or provider reported a beneficiary-recoverable overpayment. (This includes the situation where the beneficiary was paid instead of the provider.)
Line 25. CMS's Carrier Quality Control Program - The carrier enters under the appropriate columns the number of overpayments and that part of the dollar amount reported on line 4 which were discovered through CMS's Carrier Quality Control Program - including both the carrier sample and the RO sub-sample.
Line 26. Carrier Internal Audit or Review - The carrier enters under the appropriate columns the number of overpayments and that part of the dollar amount reported on line 4 which were discovered through its internal auditing procedures or review of subsequent claims. It excludes cases where the overpayment was discovered through CMS's Carrier Quality Control Program. (See line 25.)
Line 27. Government Agency - The carrier enters under the appropriate columns the number of overpayments and that part of the dollar amount reported on line 4 which were discovered by DHHS, GAO, OIG, or other government agency audit.
Line 28. Other Methods of Discovery - The carrier enters under the appropriate columns the number and dollar amounts involved for overpayments discovered by methods.
The number and amount of beneficiary overpayments reported on lines 24 through 28, when combined, should equal the number and amount reported in Section A on line 4.
(Rev. 6, 08-30-02)
B3-13360.5
Before sending reports to CMS, the carrier checks for completeness and arithmetic accuracy. The following checklist assists in the arithmetic check for both the number of claims and the amount of money involved.
(Rev. 6, 08-30-02) B3-13379
CARRIER NUMBER __ REPORTING PERIOD __
| NUMBER OF CLAIMS | AMOUNT OF MONEY | |
|---|---|---|
| A. BENEFICIARY OVERPAYMENTS | ||
| 1. PENDING START OF QUARTER | ||
| 2. ADJUSTMENTS TO OPENING PENDING | ||
| 3. ADJUSTED OPENING PENDING | ||
| 4. DISCOVERED DURING REPORTING QUARTER | ||
| 5. DISPOSITIONS | ||
| 6. COLLECTED | ||
| 7. RECOUPED BY OFFSET | ||
| 8. RECOUPED BY REFUND | ||
| 9. UNCOLLECTIBLES | ||
| 10. REFERRED TO REGIONAL OFFICE | ||
| 11. WAIVED BY CONTRACTOR | ||
| 12. ABANDONED IN ACCORD WITH MAN. INSTR. | ||
| 13. PENDING END OF QUARTER | ||
| B. CAUSE OF OVERPAYMENTS | ||
| 14. BENEFICIARY NOT ENTITLED | ||
| 15. SERVICES NOT COVERED | ||
| 16. CHARGE EXCEEDED REASONABLE CHARGE | ||
| 17. PAYMENT MADE TO WRONG PAYEE | ||
| 18. DUPLICATE PAYMENT | ||
| 19. MEDICALLY UNNECESSARY SERVICES | ||
| 20. SERVICES NOT RENDERED |
| NUMBER OF CLAIMS | AMOUNT OF MONEY | |
|---|---|---|
| 21. MEDICARE SECONDARY PAYER | ||
| 22. DOCUMENTATION/CODING/DATA ENTRY | ||
| 23. OTHER | ||
| C. HOW OVERPAYMENTS WERE DISCOVERED | ||
| 24. REPORTED BY BENEFICIARY OR SUPPLIER | ||
| 25. CMS's CARRIER QUALITY CONTROL PROGRAM | ||
| 26. CARRIER INTERNAL AUDIT OR REVIEW | ||
| 27. GOVERNMENT AGENCY | ||
| 28. OTHER METHODS OF DISCOVERY |
(Rev. 6, 08-30-02)
B3-13400
At the end of each month the carrier prepares and transmits to CMS a report summarizing its Part B review and hearing activity during the month. The carrier completes a separate report for each office assigned a separate carrier number.
Form CMS-2590 is subject to the Paperwork Reduction Act and requires approval from the Office of Management and Budget (OMB). OMB approval has been requested.
(Rev. 6, 08-30-02)
B3-13400.1
The CMS-2590 (see §300 - Exhibits 1 through 4) provides CMS with the basic data needed on review and hearing (both carrier and ALJ) activity. This report enables CMS to tabulate data for administrative purposes on the following information:
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13400.2
The carrier transmits form CMS-2590 to CO via PC or terminal. It uses instructions in the CROWD User Guide available via the CMS Enterprise Portal.
The report is due as soon as possible after the end of the reporting month but no later than the 15th of the month following the end of the reporting month.
(Rev. 6, 08-30-02)
B3-13410
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13410.1
This report is referenced as Form H for CROWD. The carrier submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13410.2
Section A: Carrier Appeal Requests - This part concerns data from the Part B appeals process. The number of appeals requested (received), completed, and pending reflects the status of the workload as of the last day of the reporting month. The carrier bases data on actual counts of each activity and not on sampling or other estimating techniques.
Column (1) Total Reviews - The first formal level of appeal following denial of a Part B claim. It is a second look by a different employee at the claim and supporting evidence. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals). The carrier does not count duplicate review requests or review requests received before it has made an initial determination on a claim. It counts one review per request received. With the exception of line 7, it does not count the number of claims or beneficiaries involved in the requests. It reports in Column (1) data relating to all types of reviews (both those requested in writing and those conducted by telephone).
Column (2) Telephone Reviews - The carrier reports in this column, data on those reviews included in column 1 that were conducted by telephone. It reports data in this column on lines 6, 7, 9, 10, 11, and 12 only.
Column (3) Carrier Hearings - This column represents independent determinations on claims for which the party has appealed the carrier review decision. Such independent determinations are rendered by Hearing Officers (HO) that the carrier assigns. The amount in controversy must be at least $100. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals)
The carrier counts one hearing per request received (i.e., form CMS-1965 or equivalent written request). It includes hearings requested that do not meet the minimum $100 requirements and are subsequently dismissed. With the exception of line 7, it does not count the number of claims or beneficiaries involved in the requests. (It reports claim counts in line 7.) It does not count hearing requests that qualify for an ALJ hearing (i.e., Part B hearings are those hearings that a hearing officer adjudicates, as opposed to an ALJ). See definition for Section D.
It does not count requests for HO hearings received after it has rendered an OTR decision in lines 1-32 of the report. It counts these cases only in lines 33, 34, 35, 36, and 38 as appropriate.
Line 1. Opening Pending - It reports, under the appropriate columns, the numbers of reviews on line 18 and hearings reported on line 28 as the closing pending on the previous month's report.
Line 2. Adjustments to Pending - If it is necessary to revise the pending figure for the close of the previous month because of inventories or reporting errors, the carrier reports the adjustment. It reports requests received near the end of the reporting month and placed under control sometime after the reporting month as received in the reporting month, not as requests received in the subsequent month. If some cases were not counted in the proper month's receipts, it counts them as adjustments to the opening pending in the subsequent month.
If line 3 of the current month differs from the closing pending of the previous month, there must be an entry in line 2 for the current month. The carrier precedes the entry by a '+' or '–,' as appropriate.
Line 3. Adjusted Pending - It reports the result of line 1 + line 2 (taking into account the '–' sign, if any).
Line 4. Requests Received - It reports, under the appropriate columns, the number of review and hearing requests received during the reporting month. (See definitions for columns 1 and 3 for a discussion of what constitutes a request for a review and hearing.) It includes requests transferred to it by other contractors if it incurs the administrative costs for processing the appeals, and reports the costs on the Interim Expenditure Report (Form CMS-1524).
If one physician submits one request involving several assigned claims (and several beneficiaries), the carrier counts this as one request. If one beneficiary submits a request involving several unassigned bills (from several different physicians), it counts this as one request. If an appellant submits more than one request (for different claims) at different times, the carrier counts each request.
NOTE: See definition of column (3) for instructions on hearings requested subsequent to OTR decisions.
Line 4A. Medical Necessity Documentation Denials - The carrier reports the number of requests included in line 4 that involved initial claim denials for lack of medical documentation.
Line 5. Transferred - The carrier reports, under column 1, the number of review requests it transferred to other carriers because it did not process the original claim(s). It reports, under column 3, the number of hearing requests transferred to other carriers because the claimant is not within the original carrier's geographical area, or the claim was transferred to ROs because the issues are outside the HO's responsibility. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals) For columns 1 and 3, if it reported a review or hearing as transferred, it does not report any information regarding it on lines 6-39. The transfer is the final action.
Line 6. Requests Cleared - The carrier reports, under the appropriate columns, the total number of all reviews, telephone reviews, and hearings completed during the month. It reports all completed reviews and hearings, regardless of the final outcome, i.e., affirmation, reversal, withdrawal, or dismissal. It considers a review cleared when the final determination (EOMB or other notice - including dismissal) is printed or typed, or upon notification of withdrawal by the
appellant. In the case of a reversal, it considers the case cleared when it initiates the adjustment action.
A hearing is cleared when the decision is signed, or one of the following conditions is present:
The carrier does not consider a hearing completed upon release of an OTR decision unless the appellant specifically requested an OTR hearing. It does not count the OTR hearing as completed until it has completed all follow-up actions as required in The Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals. If, as a result of follow-up actions, the appellant requests an in-person or telephone hearing after release of the OTR decision, the OTR hearing and decision are not counted on the report with the exception noted below. If the appellant does not appear for the subsequent hearing, the hearing is dismissed. The dismissal is the final action. However, the decision to record in lines 9-11 is the OTR decision.
NOTE: If the carrier closes a review or hearing after the end of a reporting month, but before the report is due on the fifteenth of the subsequent month, it does not count it until the subsequent month's report.
Line 7. No. of Claims Involved - The carrier reports the total number of claims (as defined in §§3000-3000.2) involved in the appeals reported as cleared during the month on line 6. For example, if it processes decisions for two hearings in the month, one of which involved three claims, and the other involved seven claims, it reports 10 claims under column 3.
Line 8. Amount in Controversy - For the hearings reported as affirmed (line 9) or reversed (line 11), during the month, the carrier shows the total dollar amount in controversy on the initial hearing request. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals on how to determine the amount in controversy.) It shows results rounded to the nearest dollar.
Line 9. Affirmations - Under the appropriate columns, the carrier shows the number of all reviews, telephone reviews, and hearings completed during the month in which the previous determination was completely upheld, e.g., no change was made. All parts of all claims in a case must be upheld in order to be counted as an affirmation. An OTR hearing decision does not count as a previous decision if the appellant subsequently requests an in-person or telephone hearing. If the in-person/telephone hearing is dismissed because the appellant did not appear, or the request was withdrawn, the carrier uses the OTR decision to determine if the case is counted here.
See line 11 for partial affirmations. (They are not included here.)
If the carrier upholds its original determination, but pays under limitation of liability, it counts the review or hearing determination as an affirmation. It reports the appropriate information in Section D.
Line 10. Dism./Withdr - The carrier reports, under the appropriate columns, the number of all reviews, telephone reviews, and hearings that were withdrawn by the appellant or dismissed (before determination) by the carrier or the HO. It reports here and in lines 4 and 6 an appeal that is requested and withdrawn or dismissed within the same month. If the appellant requests an in-person or telephone hearing after receiving an OTR decision and the carrier dismisses the hearing because the appellant failed to appear, the OTR decision is the final decision, not the dismissal. Similarly, for a withdrawal, the OTR decision is used.
A dismissal at the review level is done when written correspondence or a telephone conversation has been identified as a review request, but the claimant does not have the right to an appeal. Misrouted correspondence is not a dismissal. If the carrier has incorrectly counted such correspondence as a review on a previous report, it uses line 2 (adjustments to pending) to correct the count. It does not count a duplicate request for review on the report. Likewise, it does not count on the report a request for review received before an initial claim determination has been rendered. (It considers the request an inquiry.)
Line 11. Reversals (Full or Part) - Under the appropriate columns, the carrier shows the number of all reviews, telephone reviews, and hearings completed during the month in which at least part of the prior determination was reversed (e.g., a change was made and some or all of the new determination was in favor of the appellant). For example, if a review or hearing involves several claims, and the initial determinations for some of the claims are affirmed and some are reversed, the review or hearing decision is a reversal. An OTR hearing decision does not count as a previous decision if the appellant subsequently requests an in-person or telephone hearing. If the in-person/telephone hearing is dismissed because the appellant did not appear, or the request was withdrawn, the carrier uses the OTR decision to determine if the case is counted here.
Line 12. Amount Awarded - For cases included in line 11 where the issue on the appeal was not a reasonable charge determination, the carrier shows the amount of allowed charges for services where the determination was reversed. It shows charges after reasonable charge reductions, but prior to application of deductible and coinsurance amounts. If the issue was a reasonable charge reduction, it shows the additional amount allowed. It rounds results to the nearest dollar.
For lines 13-17, the carrier uses the matrix below to determine the number of days from receipt to completion of all reviews (both written and telephone). The date of receipt in all written review requests is the day the processing carrier received it in its corporate mailroom. The date of receipt in all telephone review requests is the day the processing carrier received the request on the dedicated lines or in the dedicated area.
| Situation | Date Completed |
|---|---|
| The appellant withdraws the request | The date the carrier is notified of the withdrawal |
| Carrier dismisses the request or affirms the original determination | The date of the notice |
Carrier processes the request to reversal
The date the carrier initiates the adjustment request
Line 13. Review Processing Time - Average - The average number of days from receipt of the review request to the date of completion for all review requests (both written and telephone).
To compute the average number of days from request to completion, the carrier divides the total days elapsed for all requests cleared in the month by the number of requests cleared. It rounds results to the nearest day. It calculates the days elapsed for an individual request by subtracting the Julian date of receipt of the request from the Julian date of completion.
If the request is cleared in the year following the year of receipt, the carrier adds 365 or 366 to the result, as appropriate. (Otherwise, it will get a negative number.) If a case is cleared the same day it is received, it considers the case to require one day.
NOTE: The carrier includes all cases cleared regardless of whether they were affirmed, reversed, dismissed, or withdrawn.
Line 14. Reviews Completed in 1-30 Days - The number of reviews that required 1-30 days to complete. If a case is cleared the same day it is received, the carrier considers it to require 1 day.
Line 15. Reviews Completed in 31-45 Days - The number of reviews that required 31-45 days to complete.
Line 16. Reviews Completed in 46-60 Days - The number of reviews that required 46-60 days to complete.
Line 17. Reviews Completed Over 60 Days - The number of reviews that required more than 60 days to complete.
Line 18. Closing Pending-Reviews - The total number of reviews that have not been completed by the end of the reporting month.
Line 19. Reviews Pending 1-30 Days - The number of reviews included in line 18 that have been pending 1-30 days, inclusive, at the end of the reporting month.
Line 20. Reviews Pending 31-45 Days - The number of reviews included in line 18 that have been pending 31-45 days, inclusive, at the end of the reporting month.
Line 21. Reviews Pending 46-60 Days - The number of reviews included in line 18 that have been pending 46-60 days, inclusive, at the end of the reporting month.
Line 22. Reviews Pending Over 60 Days - The number of reviews included in line 18 that have been pending more than 60 days at the end of the reporting month.
Computing Time to Process Carrier Hearings for Lines 23-27
For lines 23-27, the carrier uses the matrix below to determine the number of days from receipt to completion of hearings. The date of receipt in all cases is the day the carrier who is processing the
case received it in its corporate mailroom. In out-of-area cases the receipt date is the date that the second carrier received the request.
| Situation | Date Completed |
|---|---|
| An OTR decision is made and the appellant accepts the decision or decides to go directly to an ALJ hearing. | The date of the OTR decision. |
| An OTR decision is made, and the appellant chooses in a timely fashion, to proceed with the in-person or telephone hearing. | The date of the second decision. If the appellant does not appear, and the carrier dismisses the hearing, it uses the date of the dismissal notice. |
| An in-person or telephone hearing is held without an OTR decision. | The date of the decision. |
| The appellant withdraws the hearing request. | The date the carrier was notified of the withdrawal. |
| The HO dismisses the hearing request. | The date of the dismissal notice. |
Line 23. Hearing Processing Time - Average - The carrier reports the average number of days from the receipt of the hearing request to the date of completion. See methodology under line 13.
Line 24. Hearings Completed in 1-60 Days - The number of hearings that required 1-60 days to complete. If a case is cleared the same day it is received, the carrier considers it to require 1 day.
Line 25. Hearings Completed in 61-90 Days - The number of hearings that required 61-90 days to complete.
Line 26. Hearings Completed in 91-120 Days - The number of hearings that required 91-120 days to complete.
Line 27. Number Completed Over 120 Days - The number of cases that required 121 days or more to complete.
Line 28. Closing Pending-Hearings - The total number of hearings that have not been completed by the end of the reporting month.
Line 29. Hearings Pending 1-60 Days - The number of hearings included in line 28 that were pending 1-60 days, inclusive, at the end of the reporting month.
Line 30. Hearings Pending 61-90 Days - The number of hearings included in line 28 that were pending 61-90 days, inclusive, at the end of the reporting month.
Line 31. Hearings Pending 91-120 Days - The number of hearings included in line 28 that were pending 91-120 days, inclusive, at the end of the reporting month.
Line 32. Hearings Pending Over 120 Days - The number of hearings included in line 28 that were pending more than 120 days at the end of the reporting month.
Hearings fall into the following categories:
Column (1) On-the-Record with No Subsequent Hearings - This column represents hearings where:
Column (2) All Telephone - This column represents hearings where the appellant requested and had a telephone hearing subsequent to an OTR hearing decision, or a telephone hearing was held without a prior OTR decision. The carrier counts all telephone hearings including those where the appellant did not follow-up timely to the OTR notice but later requested a telephone hearing.
Column (3) All In-Person - This column represents hearings where the appellant requested and had an in-person hearing subsequent to an OTR hearing decision, or an in-person hearing was held without a prior OTR decision. The carrier counts all in-person hearings including those where the appellant did not follow-up timely to the OTR notice but later requested an in-person hearing.
Column (4) Number in 120 Days - For the total cases included in line 35, columns 2 and 3, the carrier shows for lines 37-39 the numbers that were completed within 120 days of receipt. It uses the methodology shown for lines 23-27 to determine the completion date. Where an OTR decision is made and the appellant chooses to not follow-up timely and later requests either an in-person or telephone hearing, the carrier measures the completion time for this second reported hearing from the date of receipt of the original request to the date of the second decision. If the appellant does not appear, it dismisses the hearing, and uses the date of notice of dismissal as its date completed.
Line 33. Reversals - Under the appropriate columns, the carrier shows the number of OTR, telephone, and in-person hearings completed in the month in which at least part of the review determination was reversed; i.e. a change was made and some, or all, of the new determination was in favor of the appellant. (See line 11 for a definition of a reversal.)
Line 34. Affirmation - Under the appropriate columns, the carrier shows the number of OTR, telephone, and in-person hearings completed in the month in which the review determination was completely upheld; i.e., no change was made. (See line 9 for a definition of affirmation.)
Line 35. Total Decisions - The carrier reports the total number of hearing decisions completed during the month that resulted in a reversal or affirmation (exclude dismissals and withdrawals). This includes those hearings shown in lines 9 and 11.
Line 36. Number in 120 Days - For cases included in line 35, the carrier shows the number that were completed within 120 days of receipt. It uses the methodology shown in column (4) to determine the completion date.
Line 37. No Previous OTR Held - For cases included in line 35, columns (2) and (3), the carrier reports the number where it held the telephone or in-person hearing without first making an OTR decision (i.e., the OTR hearing was bypassed.) In column (4), it reports the number of cases included in either column (2) or (3) that were completed within 120 days.
Line 38. Previous OTR Counted - For cases included in line 35, columns (2) and (3), the carrier reports the number where it included the OTR count on a previous report. In column (4), it reports the number of cases included in either column (2) or (3) that were completed within 120 days. Cases reported in line 38 are those where an OTR decision was made, and the appellant either accepted the OTR decision, did not respond timely in accordance with The Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals, or decided to go directly from the OTR decision to an ALJ hearing. Then, subsequent to this OTR decision 'acceptance,' the appellant decided that they wanted a telephone or in-person hearing. The carrier does not include these cases in line 6.
Line 39. Previous OTR Not Counted - For cases included in line 35, columns (2) and (3), the carrier reports the number where it did not include the OTR count on a previous report. These are cases where it made the OTR decision first and the appellant indicated in a timely fashion that they wanted a telephone or in-person hearing. In column (4), it reports the number of cases included in either column (2) or (3) that were completed within 120 days.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13410.3
Section B is intended for all requests for ALJ hearings including those expected to be dismissed for failure to meet the $500 amount in controversy requirement or for any other reason (such as a lack of a fair hearing).
The carrier counts ALJ Hearings in Columns 1 and 2 using the following two methodologies:
Column (1) Total - The total of all ALJ hearing requests as originally filed.
Column (2) Dispositions - For lines 49 and 51-53 only, the carrier reports the number of dispositions rendered by the ALJ(s) in cases reported as cleared for the month in Line 49. There will usually be more ALJ dispositions than cases counted in line 49. A case is not counted in line 49 until the ALJ has cleared all of the claims included in the request for hearing.
EXAMPLE: The carrier forwards one request to an ALJ involving 20 claims. The ALJ dismisses 10 claims at once. A month later, the ALJ decides to affirm the original decision on 5 others as one group. The other 5 receive separate determinations. This is counted as 7 dispositions.
Line 40. Opening Pending - The number of ALJ hearings reported on line 57 as closing pending on the previous month's report.
Line 41. Adjustments to Pending - If line 42 of the current month differs from data in line 57 of the previous month, there must be an entry in line 41 for the current month. The carrier precedes the entry by a '+' or '-', as appropriate. See definition for line 2.
Line 42. Adjusted Opening Pending - The result of line 40 + line 41 (taking into account the '-' sign, if any).
Line 43. Requests Received - The number of ALJ hearings requested during the month. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals.)
Line 44. Requests Forwarded to ALJ - The number of ALJ hearing requests forwarded to ALJs during the month. The carrier considers the case forwarded when all necessary material has been mailed to the ALJ.
Line 45. No. of Claims Involved - The number of claims involved in the ALJ hearing requests forwarded to ALJs as reported on line 44. (See MCM-3, §§3000-3000.2 for definition of claim.)
Line 46. No. Forwarded in 1-7 Days - The number of ALJ hearing requests forwarded to ALJs within 7 calendar days from receipt of the request to mailing of the necessary information. The carrier shows data for all cases mailed during the month. The number must be less than, or equal to, the number shown in line 44.
Line 47. No. Forwarded in 1-14 Days - The number of ALJ hearing requests forwarded to ALJs within 14 days from receipt of the request to mailing of the necessary information. The carrier shows data for all cases mailed during the month. The number must be less than, or equal to, the number shown in line 44.
Line 48. Average Time to Forward - The average number of calendar days from receipt of the ALJ request to the mailing date of the necessary information. The carrier the same methodology for counting as discussed in §360.2 for line 13.
Line 49. ALJ Hearings Completed - The number of ALJ hearing requests completed during the month. The carrier considers a case completed when it receives the completed decision from the ALJ for all parts of the case.
Line 50. Amount in Controversy - For ALJ hearings reported as affirmed (line 51) or reversed (line 53), during the month, the carrier shows the total dollar amount remaining in controversy according to the initial ALJ hearing request. This should be the amount remaining after previous appeal decisions. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals on how to determine the amount in controversy.) It rounds results to the nearest dollar.
Line 51. Affirmations - The carrier reports number of completed ALJ hearings in which the previous determination was completely upheld i.e., no change was made. All parts of all claims in a case must be upheld in order for the case to be counted as an affirmation. See line 53 for partial affirmations. (The carrier does not include partial affirmations on this line.)
If the prior determination is upheld, but payment is made under limitation of liability, the carrier counts the ALJ hearing determination as an affirmation. It reports the appropriate information in lines 55 and 56.
Line 52. Dismissals/Withdrawals - The e number of completed ALJ hearings that were withdrawn by the appellant or dismissed (before determination) by the ALJ. The carrier reports an appeal that was requested and withdrawn or dismissed within the same month here and in lines 43, 44, and 49.
Line 53. Reversals (Full or Part) - The total number of completed ALJ hearings in which at least part of the prior determination was reversed i.e., a change was made and some or all of the new determination was in favor of the appellant. For example, if an ALJ hearing involves several claims, and the initial determinations for some of the claims are affirmed and some are reversed, the carrier considers the decision a reversal.
Line 54. Amount Awarded - For cases included in line 53, the carrier shows the amount of allowed charges for services where the determination was reversed. It shows charges after reasonable charge reductions, but prior to application of deductible and coinsurance amounts. (If the appeal involved a reasonable charge reduction, it shows the additional amount allowed.) It rounds results to the nearest dollar.
Line 55. Waived - Ben. and Prov - The number of claims involved in requests for ALJ hearings where limitation of liability was granted to both the beneficiary and provider in an assigned claim (see The Medicare Claims Processing Manual, Chapter X, Limitation on Liability), or where the provider's liability was limited in an unassigned claim(see 3 The Medicare Claims Processing Manual, Chapter X, Limitation on Liability).
Line 56. Amount Awarded - For cases included in line 55, the carrier shows the amount of allowed charges for services (including the noncovered services) where the liability of the beneficiary and provider were limited. It shows charges after reasonable charge reductions, but prior to application of deductible and coinsurance amounts, rounding results to the nearest dollar.
Line 57. Closing Pending - The total number of ALJ hearing requests that were not completed by the end of the reporting month. The carrier considers a case transferred to an ALJ as pending until it has received the complete decision from the ALJ for all parts of the case.
Line 58. Effectuation of ALJ Decisions - The number of ALJ hearing decisions for which it initiated effectuation during the month. The carrier considers effectuation of a decision to be initiated when it completes the following:
Line 59. Number 1-7 Days - The number of cases where the carrier effectuated the decision within 7 days, inclusive, of receipt of the decision in its corporate mailroom.
Line 60. Number 8-15 Days - The number of cases where the carrier effectuated the decision within 8-15 days, inclusive, of receipt of the decision in its corporate mailroom.
Line 61. Number 16-30 Days - The number of cases where the carrier effectuated the decision within 16-30 days, inclusive, of receipt of the decision in its corporate mailroom.
Line 62. Number Over 30 Days - The number of cases where the carrier effectuated the decision in more than 30 days, inclusive, of receipt of the decision in its corporate mailroom.
(Rev. 6, 08-30-02)
B3-13410.4
The carrier reports the number of claims (as defined in §§3000-3000.2) involved in reopenings completed during the month. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals) for discussion of what constitutes a reopening.) Claims review, hearings, and ALJ hearings undertaken as part of the appeal process are not considered reopenings.
Reopenings fall into the following categories:
Column (1) Total - The number of reopenings completed.
Column (2) Pre-Review - The number of reopenings of initial claim determinations. If a claim has been through a review or any type of hearing, the carrier does not count it here.
Column (3) Post-Review - The number of reopenings of review determinations. If a claim has been through any type of hearing, the carrier does not count it here.
Column (4) Post-Hearing - The number of reopenings of hearing determinations regardless of the type of hearing e.g., carrier HO or ALJ. Once a claim has been through a carrier hearing, it is counted here if it is reopened.
Line 63. Total - The number of claims for which the carrier completed the reopening of a claim determination, review determination, or hearing determination, whether or not the determination was revised.
Line 64. Unfavorable to Claimant - Of the claims shown in line 63, this is a count of those that resulted in an unfavorable revision of a previously favorable decision.
Line 65. No Change - Of the claims shown in line 63, these are those that the carrier reopened but did not revise the initial determination.
Line 66. Favorable to Claimant - Of the claims shown in line 63, these are those that resulted in a favorable revision of a previously unfavorable decision.
Line 67. Amount Awarded - For cases included in line 66, the carrier shows the amount of allowed charges for services that involved a revision of a previously unfavorable decision. It
shows charges after reasonable charge reductions but prior to application of the deductible and coinsurance amounts. (If the reopening involved a reasonable charge reduction, it shows the additional amount allowed.) It rounds results to the nearest dollar.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13410.5
To include an assigned claim in lines 68-71, the carrier must have originally denied it or reduced it as 'not reasonable and necessary' under §1862(a)(1) of the Act. (see The Medicare Claims Processing Manual, Chapter X, Limitation on Liability)
Lines 69-71 are mutually exclusive i.e., a claim meeting the above condition may be counted on only one of the three lines. Therefore, the carrier ensures that the sum of the number of claims recorded on each of these lines equals the total number of assigned claims considered for limitation of liability during the period reported on line 68.
The counts in lines 69-71 reflect counts of claims at the initial claim (column 1), review (column 2), and hearing levels (column 3) (as defined in MCM-3, §§3000-3000.2), not review or hearing requests. The carrier reports cases corresponding to the claims counted here in Section A also, as appropriate. If a claim is considered for limitation of liability at the initial claim level, the carrier does not count it at the or hearing level unless it changes the limitation of liability decision.
It categorizes claims for columns shown in Section D according to the adjudication level at which limitation of liability is considered or granted. If it makes several different limitation of liability decisions on the same claim, it uses the highest numbered line on the report that applies to that claim. It counts the claim only once. For instance, if it waives liability for both the beneficiary and provider liability on any part of the claim, it counts the claim only on line 71.
Line 68. Total Number Considered - The carrier reports, under the appropriate columns, the number of assigned claims meeting the conditions above for which limitation of liability was considered during the month.
Line 69. Considered - Not Waived - The carrier reports under the appropriate columns the number of assigned claims meeting the conditions above on which limitation of liability was considered but was not granted to the beneficiary.
Line 70. Waived - Bene. Only - The carrier shows, under the appropriate columns, the number of assigned claims meeting the conditions above on which it granted limitation of liability to only the beneficiary.
Line 71. Waived - Bene. and Prov. - The carrier reports, under the appropriate columns, the numbers of assigned claims where it granted limitation of liability during the reporting month to both the beneficiary and provider.
Line 72. Amount Awarded - For cases included in line 71, the carrier shows the amount of allowed charges for services (including noncovered services) where limitation of liability is
granted to the beneficiary and provider. It shows charges after reasonable charge reductions, but prior to application of deductible and coinsurance amounts, rounding results to the nearest dollar.
This section applies to claims where waiver of a provider's liability to make refund to the beneficiary on unassigned claims for those services found to be not reasonable or necessary is considered under 'Limitation on Liability'. See The Medicare Claims Processing Manual, Chapter X, Limitation on Liability.
Line 73. Total Number Considered - The carrier reports, under the appropriate columns, the number of unassigned claims that meet the conditions of §7330 for which limitation of liability was considered during the month.
Line 74. Phys. Refund Waived - The carrier reports, under the appropriate columns, the number of unassigned claims that meet the requirements of §7330 on which it waived the liability of the provider to refund to the beneficiary the amount disallowed as not reasonable and necessary.
Line 75. Phys. Refund Upheld - The carrier reports, under the appropriate columns, the number of unassigned claims that meet the requirements of The Medicare Claims Processing Manual, Chapter X, Limitation on Liability chapter, on which it required the physician to refund the amount disallowed.
(Rev. 6, 08-30-02)
B3-13415
Before sending the report to CMS, the carrier checks for completeness and arithmetical accuracy. It uses the following checklist for each column:
• Line 35 = line 37 + line 38 + line 39 for columns 2 and 3 only.
Line 36 must be less than or equal to line 35 for columns 1, 2, and 3.
Public reporting burden for this collection of information is estimated to average 2 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden may be sent to the following:
Centers for Medicare & Medicaid Services
Office of Financial Management
P.O. Box 26684
Baltimore, MD 21207
and to the
Office of Management and Budget
Paperwork Reduction Project (0938-0452)
Washington, DC 20503.
(Rev. 6, 08-30-02)
B3-13416
Exhibit 1 - Medicare Program - Carrier Appeal Report - Form CMS-2590
MEDICARE PROGRAM - CARRIER APPEAL REPORT - FORM CMS-2590
CARRIER ID ____ REPORT PERIOD ______
| A. CARRIER APPEAL REQUESTS | TOTAL REVIEWS (1) | TELEPHONE REVIEWS (2) | HEARINGS (3) |
|---|---|---|---|
| 1. OPENING PENDING | |||
| 2. ADJSTMTS TO PNDNG | |||
| 3. ADJUSTED PENDING | |||
| 4. REQUESTS RECEIVED | |||
| 4A. MED. DOC. DENIALS | |||
| 5. REQUESTS TRANSFERRED | |||
| 6. REQUESTS CLEARED | |||
| 7. NO. OF CLAIMS | |||
| 8. AMT IN CONTROVERSY | |||
| 9. AFFIRMATIONS | |||
| 10. DISMISSED/WITHDRAWN | |||
| 11. REVERSALS | |||
| 12. AMOUNT AWARDED |
FORM CMS-2590 SCREEN 1
CARRIER ID __ REPORT PERIOD __
| REVIEW REQUESTS | REVIEWS (1) | HEARING REQUESTS | HEARINGS (2) |
|---|---|---|---|
| PROCESSING TIMES | PROCESSING TIMES | ||
| 13. REVIEWS- AVERAGE | 23. HEARINGS- AVERAGE | ||
| 14. NBR COMP 1-30 DYS | 24. NBR COMP 1-60 DYS | ||
| 15. NBR COMP 31-45 DYS | 25. NBR COMP 61-90 DYS | ||
| 16. NBR COMP 46-60 DYS | 26. NBR COMP 91-120 DYS | ||
| 17. NBR COMP 60 DYS+ | 27. NBR COMP 120 DYS+ | ||
| PENDING TIMES | PENDING TIMES | ||
| 18. CLOSING PENDING | 28. CLOSING PENDING | ||
| 19. NBR COMP 1-30 DYS | 29. NBR COMP 1-60 DYS | ||
| 20. NBR COMP 31-45 DYS | 30. NBR COMP 61-90 DYS | ||
| 21. NBR COMP 46-60 DYS | 31. NBR COMP 91-120 DYS | ||
| 22. NBR COMP 60 DYS+ | 32. NBR COMP 120 DYS+ |
| HEARING RESULTS | OTR WITH NO SUBSEQUENT HEARING (1) | TELEPHONE (2) | IN-PERSON (3) | NBR IN 120 DYS (4) |
|---|---|---|---|---|
| 33. REVERSALS | ||||
| 34. AFFIRMATIONS | ||||
| 35. TOTAL DECISIONS | ||||
| 36. NBR IN 120 DYS | ||||
| 37. NO PREV OTR HELD | ||||
| 38. PREV OTR COUNTED | ||||
| 39. PREV OTR NOT COUNTED |
FORM CMS-2590 SCREEN 2
| CARRIER ID | REPORT PERIOD | |||
|---|---|---|---|---|
| B. PART B ALJ HEARINGS | TOTAL (1) | DISPOSITIONS (2) | B. PART B ALJ HEARINGS | TOTAL (1) |
| 40 OPENING PENDING | 55. WAIVED - BEN & PROV | |||
| 41 ADJUSTMENTS TO PENDING | 56. AMOUNT AWARDED | |||
| 42. ADJUSTED OPENING PENDING | 57. CLOSING PENDING | |||
| 43. REQUESTS RECEIVED | 58. EFFECT. OF ALJ DEC | |||
| 44. REQ. FORWARDED TO ALJ | 59. NO. 1-7 DAYS | |||
| 45. NO. OF CLAIMS INVOLVED | 60. NO. 8-15 DAYS | |||
| 46. NO. IN 1-7 CALNDR DAYS | 61. NO. 16-30 DAYS | |||
| 47. NO. IN 1-14 CLNDR DAYS | 62. NO. OVER 30 DAYS | |||
| 48. AVG TIME TO FORWARD | ||||
| 49. COMPLETED | ||||
| 50. AMOUNT IN CONTROVERSY | ||||
| 51. AFFIRMATIONS | ||||
| 52. DISMISSALS/WITHDRAWALS | ||||
| 53. REVERSALS (FULL/PART) | ||||
| 54. AMOUNT AWARDED |
FORM CMS-2590 SCREEN 3
CARRIER ID __ REPORT PERIOD __
| C. REOPENINGS (CLAIM COUNTS) | TOTAL (1) | PRE-REVIEW (2) | POST- REVIEW (3) | POST- HEARING (4) |
|---|---|---|---|---|
| 63. TOTAL | ||||
| 64. UNFAVORABLE TO CLAIMANT | ||||
| 65. NO CHANGE | ||||
| 66. FAVORABLE TO CLAIMANT | ||||
| 67. AMOUNT AWARDED |
| D. LIMITATION OF LIABILITY (CLAIM COUNTS) | INITIAL CLAIM (1) | REVIEW (2) | HEARING (3) | |
|---|---|---|---|---|
| ASSIGNED CASES | ||||
| 68. TOTAL NUMBER CONSIDERED | ||||
| 69. CONSIDERED - NOT WAIVED | ||||
| 70. WAIVED-BEN. ONLY | ||||
| 71. WAIVED-BEN.& PROV | ||||
| 72. AMT AWARDED | ||||
| UNASSIGNED CASES | ||||
| 73. TOTAL NUMBER CONSIDERED | ||||
| 74. PHYS REFUND WAIVED | ||||
| 75. PHYS REFUND UPHELD |
FORM CMS-2590 SCREEN 4
(Rev. 191, Issued: 07-13-11, Effective: 07-01-11, Implementation: 07-05-11)
Unless otherwise requested, the carrier/A/B MAC prepares and transmits to CMS each year a report updating the number and category of participating physicians and suppliers. It completes a separate report for each office assigned a separate carrier number.
(Rev. 191, Issued: 07-13-11, Effective: 07-01-11, Implementation: 07-05-11)
This report enables CMS to gather data for administrative purposes on the number of physicians, limited license physicians, non-physician practitioners and suppliers, by specialty code, electing to participate in CMS' Participating Physician/Supplier Program.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The carrier/A/B MAC transmits data about the Participating Physician/Supplier Program to CO via PC or terminal. It uses instructions in the CROWD User Guide available via the CMS Enterprise Portal.
The report is due 45 days after the end of the enrollment period. It includes updated data as of the end of the most recent enrollment period.
The carrier/A/B MAC does not submit hard copies of the report.
(Rev. 6, 08-30-02)
B3-13422
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13422.1
This report is referenced as Form F for CROWD. The carrier submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
Column 1 - Participating Physicians/LLPs/NPPs/Suppliers - Prior - A count of the number of physicians, limited license physicians (LLPs), non-physician practitioners (NPPs), and suppliers participating prior to the beginning of the latest enrollment period.
Note: The carrier or A/B MAC adjusts this data if there are changes from the information submitted in column 2 on the previous enrollment period.
Examples of possible reasons for changes to the data include:
Column 2 - Participating Physicians/LLPs/NPPs/Suppliers - Current - The number of physicians, limited license physicians, NPPs, and suppliers who are continuing as participants from the prior participation period into the new participation period and the number who have newly signed participation agreements in the latest enrollment period.
Column 3 - Participating Physicians/LLPs/NPPs/Suppliers - Continuing - Only the number of physicians, limited license physicians, NPPs, and suppliers continuing as participants from the prior participation period into the new participation period, not including those who have newly signed participation agreements in the latest enrollment period or those who have dropped out.
Column 4 - Non-Participating Physicians/LLPs/NPPs/Suppliers - Prior - A count of physicians, limited license physicians, NPPs, and suppliers not participating at the beginning of the latest enrollment period.
Note: The carrier or A/B MAC adjusts this data if the information is different from that submitted in column 5 on the previous enrollment period. (See column 1 for further information.)
Column 5 - Non-Participating Physicians/LLPs/NPPs/Suppliers - Current - A count of physicians, limited license physicians, NPPs, and suppliers not participating after the latest enrollment period, including those who were not participating at the beginning of the latest enrollment period and chose not to enroll and those who disenrolled during the latest period.
Column 6 - Participating Drop-Out - Current – Physicians/LLPs/NPPs, and suppliers who, prior to this enrollment period, were participating in the program and have now decided to drop out.
Column 7 - Non-Participating Sign-Up - Current – Physicians/LLPs/NPPs, and suppliers who were non-participating prior to the latest enrollment period and who enrolled in the program during the latest enrollment period.
Column 8 – Participating Disenrolls - Only the number of participants who disenrolled from the Medicare program during an authorized disenrollment period held during the past 12 months. This is blank unless CMS declares an authorized disenrollment period.
(Rev. 191, Issued: 07-13-11, Effective: 07-01-11, Implementation: 07-05-11)
The contractor counts individual participants by specialty. It does not count an individual more than once, even if the individual practices in more than one setting.
NOTE: Refer to the pre-April 2010 version for DMERC activity (Calendar Years 1993-2007)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The following list of codes and narrative describe the kind of medicine physicians practice.
| Code | Physician/Limited License Physician (LLP) Specialty Codes |
|---|---|
| 01 | General Practice |
| 02 | General Surgery |
| 03 | Allergy/Immunology |
| 04 | Otolaryngology |
| 05 | Anesthesiology |
| 06 | Cardiology |
| 07 | Dermatology |
| 08 | Family Practice |
| 09 | Interventional Pain Management |
| 10 | Gastroenterology |
| 11 | Internal Medicine |
| 12 | Osteopathic Manipulative Medicine |
| 13 | Neurology |
| 14 | Neurosurgery |
| 16 | Obstetrics/Gynecology |
| 17 | Hospice and Palliative Care |
| 18 | Ophthalmology |
| 19 | Oral Surgery (Dentists only) (LLP) |
| 20 | Orthopedic Surgery |
| 21 | Cardiac Electrophysiology |
| 22 | Pathology |
| 23 | Sports Medicine |
| 24 | Plastic and Reconstructive Surgery |
| 25 | Physical Medicine and Rehabilitation |
| 26 | Psychiatry |
| 27 | Geriatric Psychiatry |
| 28 | Colorectal Surgery (formerly Proctology) |
| 29 | Pulmonary Disease |
| 30 | Diagnostic Radiology |
| 33 | Thoracic Surgery |
| 34 | Urology |
| 35 | Chiropractic (LLP) |
| 36 | Nuclear Medicine |
| 37 | Pediatric Medicine |
| 38 | Geriatric Medicine |
| 39 | Nephrology |
| 40 | Hand Surgery |
| 41 | Optometry (LLP) |
| 44 | Infectious Disease |
| 46 | Endocrinology |
| Code | Physician/Limited License Physician (LLP) Specialty Codes |
|---|---|
| 48 | Podiatry (LLP) |
| 66 | Rheumatology |
| 70 | Single or Multispecialty Clinic or Group Practice |
| 72 | Pain Management |
| 76 | Peripheral Vascular Disease |
| 77 | Vascular Surgery |
| 78 | Cardiac Surgery |
| 79 | Addiction Medicine |
| 81 | Critical Care (Intensivist) |
| 82 | Hematology |
| 83 | Hematology/Oncology |
| 84 | Preventive Medicine |
| 85 | Maxillofacial Surgery (LLP) |
| 86 | Neuropsychiatry |
| 90 | Medical Oncology |
| 91 | Surgical Oncology |
| 92 | Radiation Oncology |
| 93 | Emergency Medicine |
| 94 | Interventional Radiology |
| 98 | Gynecological Oncology |
| 99 | Unknown Physician Specialty |
| C0 | Sleep Medicine |
| C3 | Interventional Cardiology |
| C5 | Dentist |
| C6 | Hospitalist |
| C7 | Advanced Heart Failure and Transplant Cardiology |
| C8 | Medical Toxicology |
| C9 | Hematopoietic Cell Transplantation and Cellular Therapy |
| D3 | Medical Genetics and Genomics |
| D4 | Undersea and Hyperbaric Medicine |
| D7 | Micrographic Dermatologic Surgery |
| D8 | Adult Congenital Heart Disease |
| E1 | Marriage and Family Therapist |
| E2 | Mental Health Counselors |
| E3 | Dental Anesthesiology |
| E4 | Dental Public Health |
| E5 | Endodontics |
| E6 | Oral and Maxillofacial Pathology |
| E7 | Oral and Maxillofacial Radiology |
| E9 | Oral Medicine |
| F1 | Orofacial Pain |
| F2 | Orthodontics and Dentofacial Orthopedics |
| F3 | Pediatric Dentistry |
| F4 | Periodontics |
| F5 | Prosthodontics |
| F6 | Epileptologists |
NOTE: Specialty Code Use for Service in an Independent Laboratory. For services performed in an independent laboratory, show the specialty code of the physician ordering the x-rays and requesting payment. If the independent laboratory requests payment, use supplier code '69'.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The following list of codes and narrative describe the kind of medicine non-physician practitioners or other healthcare providers/suppliers practice.
| Code | Non-Physician Practitioner/Supplier Specialty Codes |
|---|---|
| 15 | Speech Language Pathologist in Private Practice |
| 31 | Intensive Cardiac Rehabilitation (ICR) |
| 32 | Anesthesiologist Assistant |
| 42 | Certified Nurse Midwife (effective July 1, 1988) |
| 43 | Certified Registered Nurse Anesthetist (CRNA) |
| 45 | Mammography Screening Center |
| 47 | Independent Diagnostic Testing Facility (IDTF) |
| 49 | Ambulatory Surgical Center |
| 50 | Nurse Practitioner |
| 59 | Ambulance Service Supplier, e.g., private ambulance companies, funeral homes |
| 60 | Public Health or Welfare Agencies (Federal, State, and local) |
| 61 | Voluntary Health or Charitable Agencies (e.g., National Cancer Society, National Heart Association, Catholic Charities) |
| 62 | Psychologist (Billing Independently) |
| 63 | Portable X-Ray Supplier (Billing Independently) |
| 64 | Audiologist (Billing Independently) |
| 65 | Physical Therapist in Private Practice |
| 67 | Occupational Therapist in Private Practice |
| 68 | Clinical Psychologist |
| 69 | Clinical Laboratory (Billing Independently) |
| 71 | Registered Dietician/Nutrition Professional |
| 73 | Mass Immunization Roster Biller (Mass Immunizers have to roster bill assigned claims and can only bill for immunizations) |
| 74 | Radiation Therapy Centers |
| 75 | Slide Preparation Facilities |
| 80 | Licensed Clinical Social Worker |
| 88 | Unknown Provider |
| 89 | Certified Clinical Nurse Specialist |
| 95 | Unknown Supplier |
| 97 | Physician Assistant |
| A5 | Pharmacy |
| C1 | Centralized Flu |
|---|---|
| C2 | Indirect Payment Procedure |
| C4 | Restricted Use |
| D1 | Medicare Diabetes Prevention Program |
| D2 | Restricted Use |
| D5 | Opioid Treatment Program |
| D6 | Home Infusion Therapy Services |
Note: Specialty Code Use for Service in an Independent Laboratory. For services performed in an independent laboratory, show the specialty code of the physician ordering the x-rays and requesting payment. If the independent laboratory requests payment, use supplier code “69”.
(Rev. 191, Issued: 07-13-11, Effective: 07-01-11, Implementation: 07-05-11)
Before submitting Form F, the carrier/A/B MAC checks for completeness and arithmetical accuracy using the following checklist:
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
SPECIALTY CODES
| SPECIALTY CODE/GROUP | Participants | Non-Participants | Par Drop-Out Current (6) | Non-Par Sign-Up Current (7) | Par Disenrolls (8) | |||
|---|---|---|---|---|---|---|---|---|
| Prior (1) | Current (2) | Contin. (3) | Prior (4) | Current (5) | ||||
| 01-PHY | ||||||||
| 02-PHY | ||||||||
| 03-PHY | ||||||||
| 04-PHY | ||||||||
| 05-PHY | ||||||||
| 06-PHY | ||||||||
| 07-PHY | ||||||||
| 08-PHY | ||||||||
| 09-PHY | ||||||||
| 10-PHY | ||||||||
| 11-PHY |
SPECIALTY CODES
| SPECIALTY CODE/GROUP | Participants | Non-Participants | Par Drop-Out Current (6) | Non-Par Sign-Up Current (7) | Par Disenrolls (8) | |||
|---|---|---|---|---|---|---|---|---|
| Prior (1) | Current (2) | Contin. (3) | Prior (4) | Current (5) | ||||
| 12-PHY | ||||||||
| 13-PHY | ||||||||
| 14-PHY | ||||||||
| 15-NPP | ||||||||
| 16-PHY | ||||||||
| 17-PHY | ||||||||
| 18-PHY | ||||||||
| 19-LLP | ||||||||
| 20-PHY | ||||||||
| 21-PHY | ||||||||
| 22-PHY | ||||||||
| 23-PHY | ||||||||
| 24-PHY |
SPECIALTY CODES
| SPECIALTY CODE/GROUP | Participants | Non-Participants | Par Drop-Out Current (6) | Non-Par Sign-Up Current (7) | Par Disenrolls (8) | |||
|---|---|---|---|---|---|---|---|---|
| Prior (1) | Current (2) | Contin. (3) | Prior (4) | Current (5) | ||||
| 25-PHY | ||||||||
| 26-PHY | ||||||||
| 27-PHY | ||||||||
| 28-PHY | ||||||||
| 29-PHY | ||||||||
| 30-PHY | ||||||||
| 31-SUP | ||||||||
| 32-NPP | ||||||||
| 33-PHY | ||||||||
| 34-PHY | ||||||||
| 35-LLP | ||||||||
| 36-PHY | ||||||||
| 37-PHY |
SPECIALTY CODES
| SPECIALTY CODE/GROUP | Participants | Non-Participants | Par Drop-Out Current (6) | Non-Par Sign-Up Current (7) | Par Disenrolls (8) | |||
|---|---|---|---|---|---|---|---|---|
| Prior (1) | Current (2) | Contin. (3) | Prior (4) | Current (5) | ||||
| 38-PHY | ||||||||
| 39-PHY | ||||||||
| 40-PHY | ||||||||
| 41-LLP | ||||||||
| 42-NPP | ||||||||
| 43-NPP | ||||||||
| 44-PHY | ||||||||
| 45-SUP | ||||||||
| 46-PHY | ||||||||
| 47-SUP | ||||||||
| 48-LLP | ||||||||
| 49-SUP | ||||||||
| 50-NPP |
SPECIALTY CODES
| SPECIALTY CODE/GROUP | Participants | Non-Participants | Par Drop-Out Current (6) | Non-Par Sign-Up Current (7) | Par Disenrolls (8) | |||
|---|---|---|---|---|---|---|---|---|
| Prior (1) | Current (2) | Contin. (3) | Prior (4) | Current (5) | ||||
| 59-SUP | ||||||||
| 60-SUP | ||||||||
| 61-SUP | ||||||||
| 62-NPP | ||||||||
| 63-SUP | ||||||||
| 64-NPP | ||||||||
| 65-NPP | ||||||||
| 66-PHY | ||||||||
| 67-NPP | ||||||||
| 68-NPP | ||||||||
| 69-SUP | ||||||||
| 70-PHY | ||||||||
| 71-NPP |
SPECIALTY CODES
| SPECIALTY CODE/GROUP | Participants | Non-Participants | Par Drop-Out Current (6) | Non-Par Sign-Up Current (7) | Par Disenrolls (8) | |||
|---|---|---|---|---|---|---|---|---|
| Prior (1) | Current (2) | Contin. (3) | Prior (4) | Current (5) | ||||
| 72-PHY | ||||||||
| 73-SUP | ||||||||
| 74-SUP | ||||||||
| 75-SUP | ||||||||
| 76-PHY | ||||||||
| 77-PHY | ||||||||
| 78-PHY | ||||||||
| 79-PHY | ||||||||
| 80-NPP | ||||||||
| 81-PHY | ||||||||
| 82-PHY | ||||||||
| 83-PHY | ||||||||
| 84-PHY |
SPECIALTY CODES
| SPECIALTY CODE/GROUP | Participants | Non-Participants | Par Drop-Out Current (6) | Non-Par Sign-Up Current (7) | Par Disenrolls (8) | |||
|---|---|---|---|---|---|---|---|---|
| Prior (1) | Current (2) | Contin. (3) | Prior (4) | Current (5) | ||||
| 85-LLP | ||||||||
| 86-PHY | ||||||||
| 88-NPP | ||||||||
| 89-NPP | ||||||||
| 90-PHY | ||||||||
| 91-PHY | ||||||||
| 92-PHY | ||||||||
| 93-PHY | ||||||||
| 94-PHY | ||||||||
| 95-SUP | ||||||||
| 97-NPP | ||||||||
| 98-PHY | ||||||||
| 99-PHY |
SPECIALTY CODES
| SPECIALTY CODE/GROUP | Participants | Non-Participants | Par Drop-Out Current (6) | Non-Par Sign-Up Current (7) | Par Disenrolls (8) | |||
|---|---|---|---|---|---|---|---|---|
| Prior (1) | Current (2) | Contin. (3) | Prior (4) | Current (5) | ||||
| A5-SUP | ||||||||
| C0-PHY | ||||||||
| C1-NPP |
| C2-NPP | ||||||||
|---|---|---|---|---|---|---|---|---|
| C3-PHY | ||||||||
| C4-RES | ||||||||
| C5-PHY | ||||||||
| C6-PHY | ||||||||
| C7-PHY | ||||||||
| C8-PHY | ||||||||
| C9-PHY | ||||||||
| D1-SUP | ||||||||
| D2-RES | ||||||||
| D3-PHY | ||||||||
| D4-PHY | ||||||||
| D5-SUP | ||||||||
| D6-SUP | ||||||||
| D7-PHY | ||||||||
| D8-PHY | ||||||||
| E1-PHY | ||||||||
| E2-PHY | ||||||||
| E3-PHY | ||||||||
| E4-PHY | ||||||||
| E5-PHY | ||||||||
| E6-PHY | ||||||||
| E7-PHY | ||||||||
| E9-PHY | ||||||||
| F1-PHY | ||||||||
| F2-PHY | ||||||||
| F3-PHY | ||||||||
| F4-PHY | ||||||||
| F5-PHY | ||||||||
| F6-PHY |
SPECIALTY CODES
Total Physicians - The contractor reports in the appropriate column the total of all specialty codes applicable to physicians.
Total LLPs - The contractor reports in the appropriate column the total of all specialty codes applicable to limited license physicians.
Total NPPs - The contractor reports in the appropriate column the total of all specialty codes applicable to non-physician practitioners.
Total Physicians/LLPs/NPPs - The contractor reports in the appropriate column the sum of all physicians, LLPs and NPPs.
Total Suppliers - The contractor reports in the appropriate column the total of all specialty codes applicable to suppliers.
| SPECIALTY CODE/GROUP | Participants | Non-Participants | Par Drop-Out Current (6) | Non-Par Sign-Up Current (7) | Par Disenrolls (8) | |||
|---|---|---|---|---|---|---|---|---|
| Prior (1) | Current (2) | Contin. (3) | Prior (4) | Current (5) | ||||
| TOTALS | ||||||||
| PHYs* | ||||||||
| LLPs* | ||||||||
| NPPs* | ||||||||
| PHYs/LLPs/NPPs* | ||||||||
| SUPs* |
* These lines do not represent specific specialty codes. They are the totals of the specialty sub-groups.
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
Each quarter, the carrier prepares and submits to CMS a report on the number of provider enrollment applications received, processed, and pending during the quarter. It submits this report via the Contractor Reporting of Operational and Workload Data (CROWD) system no later than the fifteenth day following the close of the reporting quarter.
(Rev. 6, 08-30-02)
B3-13430.1
This report is referenced as Form 4 in the CROWD system. The carrier completes the ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the reporting format to its screen.
(Rev. 6, 08-30-02)
B3-13430.2
Before submitting Form 4 to CMS, the carrier checks for completeness and arithmetical accuracy, using the following checklist:
(Rev. 6, 08-30-02)
B3-13430.3
The carrier reports provider enrollment application data in the following columns for all lines on Form 4.
Column (1) - Total - The sum of columns 2-24 for each line.
Column (2) - Physician - Provider applications for specialty codes 1-8, 10-14, 16, 18-20, 22, 24-26, 28-30, 33-41, 44, 46, 48, 66, 76-79, 81-86, 90-94, 98, and 99.
Column (3) - Group - Provider applications for specialty code 70.
Column (4) - Certified Nurse Midwife - Provider applications for specialty code 42.
Column (5) - Certified Registered Nurse Anesthetist - Provider applications for specialty code 43.
Column (6) - Nurse Practitioner - Provider applications for specialty code 50.
Column (7) - Ambulance Service Supplier - Provider applications for specialty code 59.
Column (8) - Independent Audiologist - Provider applications for specialty code 64.
Column (9) - Independent Physical Therapist - Provider applications for specialty code 65.
Column (10) - Independent Occupational Therapist - Provider applications for specialty code 67.
Column (11) - Clinical Psychologist - Provider applications for specialty code 68.
Column (12) - Licensed Clinical Social Worker - Provider applications for specialty code 80.
Column (13) - Certified Nurse Specialist - Provider applications for specialty code 89.
Column (14) - Independent Physiological Laboratory - Provider applications for specialty code 95.
Column (15) - Physician Assistant - Provider applications for specialty code 97.
Column (16) - Mammography Screening Center - Provider applications for specialty code 45.
Column (17) - Ambulatory Surgical Center - Provider applications for specialty code 49.
Column (18) - Public Health/Welfare Agency - Provider applications for specialty code 60.
Column (19) - Voluntary Health/Charitable Agency - Provider applications for specialty code 61.
Column (20) - Independent Psychologist - Provider applications for specialty code 62.
Column (21) - Portable X-Ray - Provider applications for specialty code 63.
Column (22) - Independent Clinical Laboratory - Provider applications for specialty code 69.
Column (23) - Unknown Supplier/Provider - Provider applications for specialty code 88.
Column (24) - Flu Immunization Biller - Providers applications from individuals identified as flu immunization billers.
(Rev. 6, 08-30-02)
B3-13430.4
Line 1 - Pending End of Last Quarter - The CROWD system will automatically enter the value from line 11 on the previous quarter's report.
Line 2 - Adjustments to Pending - If it is necessary to revise the pending figure for the close of the previous quarter because of inventories taken or reporting errors discovered, the carrier enters the adjustment here. Adjustments can be positive or negative values. If entering a negative value, it precedes the number with a minus (-) sign.
Line 3 - Adjusted Opening Pending - The CROWD system will automatically sum the values on lines 1 and 2.
Line 4 - New Applications Received - The number of applications received for the first time during the reporting quarter.
Line 5 - Returned Applications Resubmitted - The number of applications received during the reporting quarter that had previously been received and returned to the applicant for correction/completion.
Line 6 - Total Applications Received - The CROWD system will automatically sum the values on lines 4 and 5.
Line 7 - Applications Approved - The number of applications approved (i.e., Medicare number issued) during the reporting quarter.
Line 8 - Applications Denied - The number of applications denied during the reporting quarter.
Line 9 - Applications Returned - The number of applications returned to the applicant for corrections/completion during the reporting quarter.
Line 10 - Total Applications Processed - The CROWD system will automatically sum the values on lines 7, 8, and 9.
Line 11 - Pending End of Quarter - The CROWD system will automatically compute the number of applications pending at the end of the reporting quarter by adding the value on line 3 to the value on line 6 and then subtracting the value on line 10.
(Rev. 6, 08-30-02) B3-13430.5
Line 12 - Sanctioned From Medicare - The number of applications denied because the applicant is currently excluded/sanctioned from Medicare.
Line 13 - Debarred/Excluded by Other Federal Agency - The number of applications denied because the applicant had been debarred, suspended, or excluded by any other Federal agency.
Line 14 - Not Professionally Licensed - The number of applications denied because the applicant was not professionally licensed.
Line 15 - Business Address Invalid - The number of applications denied because the applicant had an invalid business address.
Line 16 - Business Location Not Licensed - The number of applications denied because the applicant's business location was not properly licensed.
Line 17 - CMS Requirements Not Met - The number of applications denied because the applicant did not meet all CMS requirements.
(Rev. 6, 08-30-02) B3-13430.6
Line 18 - Incomplete - The number of applications returned to the applicant because the application was incomplete.
Line 19 - Unverifiable Information - The number of applications returned to the applicant because the application included unverifiable information.
Line 20 - Not Signed - The number of applications returned to the applicant because the applicant did not sign the certification statement.
Line 21 - Invalid Billing Agreement - The number of applications returned to the applicant because the billing agreement did not meet CMS requirements.
Line 22 - Other - The number of applications returned to the applicant for any reason other than the ones indicated on lines 18 through 21.
(Rev. 6, 08-30-02) B3-13430.7
Line 23 - Number Under 21 Days - The number of applications processed in less than 21 days from the date of receipt.
Line 24 - Number in 21-30 Days - The carrier enters the number of applications processed in 21 through 30 days from the date of receipt.
Line 25 - Number in 31-40 Days - The number of applications processed in 31 through 40 days from the date of receipt.
Line 26 - Number Over 40 Days - The number of applications processed in more than 40 days from the date of receipt.
(Rev. 6, 08-30-02) B3-13430.8
Line 27 - Pending End of Last Quarter - The CROWD system will automatically enter the value from line 34 on the previous quarter's report.
Line 28 - Adjustments - If it is necessary to revise the pending figure for the close of the previous quarter because of inventories taken or reporting errors discovered, the carrier enters the adjustment here. Adjustments can be positive or negative values. If entering a negative value, it precedes the number with a minus (-) sign.
Line 29 - Adjusted Opening Pending - The CROWD system will automatically sum the values on lines 27 and 28.
Line 30 - Appeals Received - The number of appeals of previously denied applications received during the reporting quarter.
Line 31 - Denials Sustained - The number of appeals processed for which the carrier sustained the initial denial.
Line 32 - Denials Overturned - The number of appeals processed for which the carrier overturned the initial denial.
Line 33 - Total Appeals Processed - The CROWD system will automatically sum the values on lines 31 and 32.
Line 34 - Pending End of Quarter - -The CROWD system will automatically compute the number of appeals pending at the end of the reporting quarter by adding the value on line 29 to the value on line 30 and then subtracting the value on line 33.
(Rev. 6, 08-30-02)
B3-13430.9
Exhibit 1 - Screens 1 and 2 of Carrier Provider Enrollment Quarterly Workload Report
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| Total 1 | Physician 2 | Group 3 | Cert Nurse M-W 4 | Cert RNA 5 | |
| Workload Operations | |||||
| 1. Pending End of Last Quarter | ____ | ____ | ____ | ____ | ____ |
| 2. Adjustments | ____ | ____ | ____ | ____ | ____ |
| 3. Adjusted Opening Pending | ____ | ____ | ____ | ____ | ____ |
| 4. New Applications Received | ____ | ____ | ____ | ____ | ____ |
| 5. Returned Apps Resubmitted | ____ | ____ | ____ | ____ | ____ |
| 6. Total Applications Received | ____ | ____ | ____ | ____ | ____ |
| 7. Applications Approved | ____ | ____ | ____ | ____ | ____ |
| 8. Applications Denied | ____ | ____ | ____ | ____ | ____ |
| 9. Applications Returned | ____ | ____ | ____ | ____ | ____ |
| 10. Total Applications Processed | ____ | ____ | ____ | ____ | ____ |
| 11. Pending End of Quarter | ____ | ____ | ____ | ____ | ____ |
SCREEN 1
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| Nurse Prac 6 | Ambulance 7 | Audiologist 8 | Ind Phys Ther 9 | Ind Occ Ther 10 | |
| Workload Operations | |||||
| 1. Pending End of Last Quarter | ____ | ____ | ____ | ____ | ____ |
| 2. Adjustments | ____ | ____ | ____ | ____ | ____ |
| 3. Adjusted Opening Pending | ____ | ____ | ____ | ____ | ____ |
| 4. New Applications Received | ____ | ____ | ____ | ____ | ____ |
| 5. Returned Apps Resubmitted | ____ | ____ | ____ | ____ | ____ |
| 6. Total Applications Received | ____ | ____ | ____ | ____ | ____ |
| 7. Applications Approved | ____ | ____ | ____ | ____ | ____ |
| 8. Applications Denied | ____ | ____ | ____ | ____ | ____ |
| 9. Applications Returned | ____ | ____ | ____ | ____ | ____ |
| 10. Total Applications Processed | ____ | ____ | ____ | ____ | ____ |
| 11. Pending End of Quarter | ____ | ____ | ____ | ____ | ____ |
SCREEN 2
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| Ind Clin Psych 11 | Lic Clin SW 12 | Cert Nurse Sp 13 | Ind Phys Lab 14 | Phys Asst 15 | |
| Workload Operations | |||||
| 1. Pending End of Last Quarter | _____ | _____ | _____ | _____ | _____ |
| 2. Adjustments | _____ | _____ | _____ | _____ | _____ |
| 3. Adjusted Opening Pending | _____ | _____ | _____ | _____ | _____ |
| 4. New Applications Received | _____ | _____ | _____ | _____ | _____ |
| 5. Returned Apps Resubmitted | _____ | _____ | _____ | _____ | _____ |
| 6. Total Applications Received | _____ | _____ | _____ | _____ | _____ |
| 7. Applications Approved | _____ | _____ | _____ | _____ | _____ |
| 8. Applications Denied | _____ | _____ | _____ | _____ | _____ |
| 9. Applications Returned | _____ | _____ | _____ | _____ | _____ |
| 10. Total Applications Processed | _____ | _____ | _____ | _____ | _____ |
| 11. Pending End of Quarter | _____ | _____ | _____ | _____ | _____ |
SCREEN 3
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| MSC 16 | ASC 17 | PH/W Agency 18 | VH/C Agency 19 | Ind Psych 20 | |
| Workload Operations | |||||
| 1. Pending End of Last Quarter | _____ | _____ | _____ | _____ | _____ |
| 2. Adjustments | _____ | _____ | _____ | _____ | _____ |
| 3. Adjusted Opening Pending | _____ | _____ | _____ | _____ | _____ |
| 4. New Applications Received | _____ | _____ | _____ | _____ | _____ |
| 5. Returned Apps Resubmitted | _____ | _____ | _____ | _____ | _____ |
| 6. Total Applications Received | _____ | _____ | _____ | _____ | _____ |
| 7. Applications Approved | _____ | _____ | _____ | _____ | _____ |
| 8. Applications Denied | _____ | _____ | _____ | _____ | _____ |
| 9. Applications Returned | _____ | _____ | _____ | _____ | _____ |
| 10. Total Applications Processed | _____ | _____ | _____ | _____ | _____ |
| 11. Pending End of Quarter | _____ | _____ | _____ | _____ | _____ |
SCREEN 4
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | |||
|---|---|---|---|---|
| Port X-Ray 21 | Ind Clin Lab 22 | Unk Supp/Prov 23 | Flu Imm Biller 24 | |
| Workload Operations | ||||
| 1. Pending End of Last Quarter | _____ | _____ | _____ | _____ |
| 2. Adjustments | _____ | _____ | _____ | _____ |
| 3. Adjusted Opening Pending | _____ | _____ | _____ | _____ |
| 4. New Applications Received | _____ | _____ | _____ | _____ |
| 5. Returned Apps Resubmitted | _____ | _____ | _____ | _____ |
| 6. Total Applications Received | _____ | _____ | _____ | _____ |
| 7. Applications Approved | _____ | _____ | _____ | _____ |
| 8. Applications Denied | _____ | _____ | _____ | _____ |
| 9. Applications Returned | _____ | _____ | _____ | _____ |
| 10. Total Applications Processed | _____ | _____ | _____ | _____ |
| 11. Pending End of Quarter | _____ | _____ | _____ | _____ |
SCREEN 5
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| Total 1 | Physician 2 | Group 3 | Cert Nurse M-W 4 | Cert RNA 5 | |
| Reasons for Denial | |||||
| 12. Sanctioned from Medicare | _____ | _____ | _____ | _____ | _____ |
| 13. Debarred/Excluded by Other Fed | _____ | _____ | _____ | _____ | _____ |
| 14. Not Professionally Licensed | _____ | _____ | _____ | _____ | _____ |
| 15. Business Address Invalid | _____ | _____ | _____ | _____ | _____ |
| 16. Business Location Not Licensed | _____ | _____ | _____ | _____ | _____ |
| 17. HCFA Requirements Not Met | _____ | _____ | _____ | _____ | _____ |
| Reason for Return | |||||
| 18. Incomplete | _____ | _____ | _____ | _____ | _____ |
| 19. Unverifiable Information | _____ | _____ | _____ | _____ | _____ |
| 20. Not Signed | _____ | _____ | _____ | _____ | _____ |
| 21. Invalid Billing Agreement | _____ | _____ | _____ | _____ | _____ |
| 22. Other | _____ | _____ | _____ | _____ | _____ |
SCREEN 6
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| Nurse Prac 6 | Ambulance 7 | Audiologist 8 | Ind Phys Ther 9 | Ind Occ Ther 10 | |
| Reasons for Denial | |||||
| 12. Sanctioned from Medicare | _____ | _____ | _____ | _____ | _____ |
| 13. Debarred/Excluded by Other Fed | _____ | _____ | _____ | _____ | _____ |
| 14. Not Professionally Licensed | _____ | _____ | _____ | _____ | _____ |
| 15. Business Address Invalid | _____ | _____ | _____ | _____ | _____ |
| 16. Business Location Not Licensed | _____ | _____ | _____ | _____ | _____ |
| 17. HCFA Requirements Not Met | _____ | _____ | _____ | _____ | _____ |
| Reason for Return | |||||
| 18. Incomplete | _____ | _____ | _____ | _____ | _____ |
| 19. Unverifiable Information | _____ | _____ | _____ | _____ | _____ |
| 20. Not Signed | _____ | _____ | _____ | _____ | _____ |
| 21. Invalid Billing Agreement | _____ | _____ | _____ | _____ | _____ |
| 22. Other | _____ | _____ | _____ | _____ | _____ |
SCREEN 7
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| Ind Clin Psych 11 | Lic Clin SW 12 | Cert Nurse Sp 13 | Ind Phys Lab 14 | Phys Asst 15 | |
| Reasons for Denial | |||||
| 12. Sanctioned from Medicare | _____ | _____ | _____ | _____ | _____ |
| 13. Debarred/Excluded by Other Fed | _____ | _____ | _____ | _____ | _____ |
| 14. Not Professionally Licensed | _____ | _____ | _____ | _____ | _____ |
| 15. Business Address Invalid | _____ | _____ | _____ | _____ | _____ |
| 16. Business Location Not Licensed | _____ | _____ | _____ | _____ | _____ |
| 17. HCFA Requirements Not Met | _____ | _____ | _____ | _____ | _____ |
| Reason for Return | |||||
| 18. Incomplete | _____ | _____ | _____ | _____ | _____ |
| 19. Unverifiable Information | _____ | _____ | _____ | _____ | _____ |
| 20. Not Signed | _____ | _____ | _____ | _____ | _____ |
| 21. Invalid Billing Agreement | _____ | _____ | _____ | _____ | _____ |
| 22. Other | _____ | _____ | _____ | _____ | _____ |
SCREEN 8
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| MSC 16 | ASC 17 | PH/W Agency 18 | VH/C Agency 19 | Ind Psych 20 | |
| Reasons for Denial | |||||
| 12. Sanctioned from Medicare | _____ | _____ | _____ | _____ | _____ |
| 13. Debarred/Excluded by Other Fed | _____ | _____ | _____ | _____ | _____ |
| 14. Not Professionally Licensed | _____ | _____ | _____ | _____ | _____ |
| 15. Business Address Invalid | _____ | _____ | _____ | _____ | _____ |
| 16. Business Location Not Licensed | _____ | _____ | _____ | _____ | _____ |
| 17. HCFA Requirements Not Met | _____ | _____ | _____ | _____ | _____ |
| Reason for Return | |||||
| 18. Incomplete | _____ | _____ | _____ | _____ | _____ |
| 19. Unverifiable Information | _____ | _____ | _____ | _____ | _____ |
| 20. Not Signed | _____ | _____ | _____ | _____ | _____ |
| 21. Invalid Billing Agreement | _____ | _____ | _____ | _____ | _____ |
| 22. Other | _____ | _____ | _____ | _____ | _____ |
SCREEN 9
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | |||
|---|---|---|---|---|
| Port X-Ray 21 | Ind Clin Lab 22 | Unk Supp/Prov 23 | Flu Imm Biller 24 | |
| Reasons for Denial | ||||
| 12. Sanctioned from Medicare | _____ | _____ | _____ | _____ |
| 13. Debarred/Excluded by Other Fed | _____ | _____ | _____ | _____ |
| 14. Not Professionally Licensed | _____ | _____ | _____ | _____ |
| 15. Business Address Invalid | _____ | _____ | _____ | _____ |
| 16. Business Location Not Licensed | _____ | _____ | _____ | _____ |
| 17. HCFA Requirements Not Met | _____ | _____ | _____ | _____ |
| Reason for Return | ||||
| 18. Incomplete | _____ | _____ | _____ | _____ |
| 19. Unverifiable Information | _____ | _____ | _____ | _____ |
| 20. Not Signed | _____ | _____ | _____ | _____ |
| 21. Invalid Billing Agreement | _____ | _____ | _____ | _____ |
| 22. Other | _____ | _____ | _____ | _____ |
SCREEN 10
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| Total 1 | Physician 2 | Group 3 | Cert Nurse M-W 4 | Cert RNA 5 | |
| Application Processing Times | |||||
| 23. # under 21 Days | _____ | _____ | _____ | _____ | _____ |
| 24. # in 21-30 Days | _____ | _____ | _____ | _____ | _____ |
| 25. # in 31-40 Days | _____ | _____ | _____ | _____ | _____ |
| 26. # over 40 Days | _____ | _____ | _____ | _____ | _____ |
| Denials Appealed | |||||
| 27. Pending End of Last Quarter | _____ | _____ | _____ | _____ | _____ |
| 28. Adjustments | _____ | _____ | _____ | _____ | _____ |
| 29. Adjusted Opening Pending | _____ | _____ | _____ | _____ | _____ |
| 30. Appeals Received | _____ | _____ | _____ | _____ | _____ |
| 31. Denials Sustained | _____ | _____ | _____ | _____ | _____ |
| 32. Denials Overturned | _____ | _____ | _____ | _____ | _____ |
| 33. Total Appeals Processed | _____ | _____ | _____ | _____ | _____ |
| 34. Pending End of Quarter | _____ | _____ | _____ | _____ | _____ |
SCREEN 11
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| Nurse Prac 6 | Ambulance 7 | Audiologist 8 | Ind Phys Ther 9 | Ind Occ Ther 10 | |
| Application Processing Times | |||||
| 23. # under 21 Days | _____ | _____ | _____ | _____ | _____ |
| 24. # in 21-30 Days | _____ | _____ | _____ | _____ | _____ |
| 25. # in 31-40 Days | _____ | _____ | _____ | _____ | _____ |
| 26. # over 40 Days | _____ | _____ | _____ | _____ | _____ |
| Denials Appealed | |||||
| 27. Pending End of Last Quarter | _____ | _____ | _____ | _____ | _____ |
| 28. Adjustments | _____ | _____ | _____ | _____ | _____ |
| 29. Adjusted Opening Pending | _____ | _____ | _____ | _____ | _____ |
| 30. Appeals Received | _____ | _____ | _____ | _____ | _____ |
| 31. Denials Sustained | _____ | _____ | _____ | _____ | _____ |
| 32. Denials Overturned | _____ | _____ | _____ | _____ | _____ |
| 33. Total Appeals Processed | _____ | _____ | _____ | _____ | _____ |
| 34. Pending End of Quarter | _____ | _____ | _____ | _____ | _____ |
SCREEN 12
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| Ind Clin Psych 11 | Lic Clin SW 12 | Cert Nurse Sp 13 | Ind Phys Lab 14 | Phys Asst 15 | |
| Application Processing Times | |||||
| 23. # under 21 Days | _____ | _____ | _____ | _____ | _____ |
| 24. # in 21-30 Days | _____ | _____ | _____ | _____ | _____ |
| 25. # in 31-40 Days | _____ | _____ | _____ | _____ | _____ |
| 26. # over 40 Days | _____ | _____ | _____ | _____ | _____ |
| Denials Appealed | |||||
| 27. Pending End of Last Quarter | _____ | _____ | _____ | _____ | _____ |
| 28. Adjustments | _____ | _____ | _____ | _____ | _____ |
| 29. Adjusted Opening Pending | _____ | _____ | _____ | _____ | _____ |
| 30. Appeals Received | _____ | _____ | _____ | _____ | _____ |
| 31. Denials Sustained | _____ | _____ | _____ | _____ | _____ |
| 32. Denials Overturned | _____ | _____ | _____ | _____ | _____ |
| 33. Total Appeals Processed | _____ | _____ | _____ | _____ | _____ |
| 34. Pending End of Quarter | _____ | _____ | _____ | _____ | _____ |
SCREEN 13
| CARRIER NAME: REPORT PERIOD: | CONTRACTOR NUMBER: CROWD FORM 4 | ||||
|---|---|---|---|---|---|
| MSC 16 | ASC 17 | PH/W Agency 18 | VH/C Agency 19 | Ind Psych 20 | |
| Application Processing Times | |||||
| 23. # under 21 Days | _____ | _____ | _____ | _____ | _____ |
| 24. # in 21-30 Days | _____ | _____ | _____ | _____ | _____ |
| 25. # in 31-40 Days | _____ | _____ | _____ | _____ | _____ |
| 26. # over 40 Days | _____ | _____ | _____ | _____ | _____ |
| Denials Appealed | |||||
| 27. Pending End of Last Quarter | _____ | _____ | _____ | _____ | _____ |
| 28. Adjustments | _____ | _____ | _____ | _____ | _____ |
| 29. Adjusted Opening Pending | _____ | _____ | _____ | _____ | _____ |
| 30. Appeals Received | _____ | _____ | _____ | _____ | _____ |
| 31. Denials Sustained | _____ | _____ | _____ | _____ | _____ |
| 32. Denials Overturned | _____ | _____ | _____ | _____ | _____ |
| 33. Total Appeals Processed | _____ | _____ | _____ | _____ | _____ |
| 34. Pending End of Quarter | _____ | _____ | _____ | _____ | _____ |
SCREEN 14
| CARRIER NAME: REPORT PERIOD: | |
|---|---|
| Application Processing Times | Port X-Ray 21 Ind Clin Lab 22 Unk Supp/Prov 23 Flu Imm Biller 24 |
| 23. # under 21 Days | _____ |
| 24. # in 21-30 Days | _____ |
| 25. # in 31-40 Days | _____ |
| 26. # over 40 Days | _____ |
| Denials Appealed | _____ |
| 27. Pending End of Last Quarter | _____ |
| 28. Adjustments | _____ |
| 29. Adjusted Opening Pending | _____ |
| 30. Appeals Received | _____ |
| 31. Denials Sustained | _____ |
| 32. Denials Overturned | _____ |
| 33. Total Appeals Processed | _____ |
| 34. Pending End of Quarter | _____ |
SCREEN 15
(Rev. 6, 08-30-02)
B3-13450
(Rev. 188, Issued: 04-22-11, Effective: 07-01-11, Implementation: 07-05-11)
NOTE: For MSP reporting effective July 2011 for carriers/Part B MACs and October 2011 for DME MACs, refer to the manual instructions located within Publication 100-05, Chapter 5, Section 60 (MSP Reports).
Each month the carrier electronically transmits to CO a Monthly Report on Medicare Secondary Payer Savings (CMS-1564) via the IBM PC. It continues to use existing dialup instructions and the RLINK software sent to it. (See §440.9). Hard copy reports are not required. It transmits a separate report for each office assigned a separate carrier number. When its service area covers more than one State, however, it transmits a separate report for each State even though it has been assigned only one number. It is not required to complete an individual State report for those States in which it has had no MSP activity during the month (reports that would show zeros in every cell, including pending).
(Rev. 6, 08-30-02)
B3-13450.2
The Monthly Carrier Report on Medicare Secondary Payer Savings supplies CMS with current data on MSP savings and MSP pending workloads.
(Rev. 6, 08-30-02)
B3-13450.3
Form CMS-1564 is due in CMS as soon as possible after the end of the reporting month, but no later than the 15th of the following month. Nonreceipt of the report by the due date will result in a telephone contact with the carrier to obtain the report data.
(Rev. 6, 08-30-02)
B3-13450.4
The carrier enters its name, assigned number and the State in which the provider is located. In the space labeled 'Reporting Period' it enters the numeric designation for month and year for which the report is prepared, e.g., show 01/02 for January 2002.
(Rev. 6, 08-30-02)
B3-13450.5
Reporting Dollar Values - The carrier rounds values to the nearest whole dollar. This includes all amounts shown on lines 2, 4, 6, 8 and 10.
Checking Reports - Before mailing the reports, the carrier checks their completeness and accuracy as follows:
(Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
The carrier controls all claims from which it extracts MSP savings and is able to verify all amounts recorded on the CMS-1564.
MSP Savings File - The carrier retains claims specific key identifying information on each claim counted as savings on the CMS-1564. At a minimum, it records the beneficiary's name, Medicare beneficiary identifier, claim control number, type/dates of service, billed charges and savings amounts reported.
Savings Data from Non-Medicare Sources - If the carrier records savings from data which it has obtained from its "private side" records or any other "outside" source, it must be able to extract the same claims specific information noted above; i.e., it must verify that Medicare covered services are involved and be able to calculate "what Medicare would have paid." In addition, it compares these data with the data contained in its MSP savings file to ensure that savings have not previously been recorded for the same claim. If savings have not previously been taken, it counts them as savings on the CMS-1564 and enters them into its MSP savings file.
(Rev. 6, 08-30-02)
B3-13450.7
The carrier reports data by total and by source as shown below:
Column (i) Total - All MSP savings regardless of source. Column (ii) Worker's Compensation, Black Lung, and VA - Data related to all MSP savings resulting from medical benefits provided by the WC Plans of the 50 States, the District of Columbia, Guam and Puerto Rico. Also included is Federal WC provided under the Federal Employee's Compensation Act, the U. S. Longshoremen's and Harbor Workers' Compensation Act and its extensions, the Federal Coal Mine Health and Safety Act of 1969 as amended (the Federal BL Program), and any fee-for-service medical care paid for by the VA. The carrier keeps separate records for each distinct category (WC, BL or VA) as this may become a reporting requirement in the future. Column (iii) Working Aged - The carrier includes data related to all MSP savings resulting from benefits payable under an EGHP for beneficiaries aged 65 and older who are covered by reason of their own employment or the employment of a spouse of any age. Medicare Claims Processing, Chapter 28, Coordinating With Medicaid and Medigap Insurers further defines the individuals subject to this limitation on payment. Column (iv) ESRD - The carrier includes data related to all MSP savings resulting from benefits payable under an EGHP for individuals who are entitled to Medicare benefits solely on the basis of ESRD during a period of up to 12 months. The period during which Medicare pays benefits is defined in Medicare Claims Processing, Chapter 28, Coordinating With Medicaid and Medigap Insurers. Column (v) Auto Medical, No Fault and Liability Insurance - The carrier includes data related to all MSP savings resulting from both: Automobile Medical or No Fault Insurance - Insurance coverage (including a self-insured plan) that pays for all, or part, of the medical expenses for injuries sustained in the use of, or occupancy of, an automobile, regardless of who may have been responsible for the accident. (This insurance is sometimes called "personal injury protection," "medical payments coverage" or "medical expense coverage.") Liability Insurance - Insurance (including a self-insured plan) that provides payment based on legal liability for injury, illness, or damage to property. It includes, but is not limited to, automobile liability insurance, uninsured motorist insurance, homeowners' liability insurance, malpractice insurance, product liability insurance, and general casualty insurance. It does not include situations where a beneficiary receives medical payment under his or her own homeowner's insurance.
Column (vi) Disabled - The carrier includes data related to all MSP savings resulting from situations where Medicare is the secondary payer for disabled beneficiaries under age 65 (except ESRD beneficiaries) who elect to be covered by a large group health plan (LGHP) as a current employee or family member of such employee. A LGHP is any health plan that covers employees of at least one employer who normally employs 100 or more employees. The disabled provisions apply to items and services furnished on or after January 1, 1987 and before January 1, 1992.
(Rev. 6, 08-30-02)
B3-13450.8
The carrier reports data by type of savings as shown below.
Unpaid (cost avoided) claims are those that the carrier returned without payment because it has strong evidence that another insurer is the primary payer and there is no indication that payment has been requested from that payer. Any information the carrier obtains from a non-Medicare source and uses as the basis for claiming cost avoidance savings must meet the criteria in §440.6B.
Information considered adequate for claiming cost avoidance savings includes statements on the claim noting "automobile accident," "collision", or the name of an automobile insurer. The carrier does not count claims it develops as "possible" MSP situations based on routine edits as cost avoidance savings unless it has previous information that another payer has primary responsibility. For example, "trauma code" edits are not, by themselves, considered strong evidence that Medicare is the secondary payer.
Line 1 - Number - The total number of cost avoided claims from which it is recording savings on the report.
Line 2 - Dollar Value - The total dollar value of the potential Medicare payments calculated for the claims on Line 1 that will be saved if the primary payer makes a payment which relieves Medicare of all payment liability.
The carrier shows as the cost avoided amount what Medicare would have paid. It does not count total charges as cost avoided savings. It reduces the cost avoided amount based upon reasonable charge and coinsurance calculations:
The carrier may assume that the deductible has been met.
Cost avoidance savings may not duplicate savings reported as full or partial recoveries and may not be shown where Medicare ultimately makes primary payment. To prevent duplicate counting, the carrier suspends all claims which it returns unpaid. It sets up a control on the claim when it is returned for development. It maintains this control for 75 days, unless it receives further information before that time allowing it to process the claim. If no further information on the claim is received after 75 days, it denies the claim. It is not required to continue tracking the claim, but retains the key identifying information on the claim, as described in §440.6A.
The CMS prefers the carrier to show cost avoidance savings only after 75 days have elapsed. The carrier does, however, have the option of counting the savings when the claim is initially suspended or at any time during the suspension period. If it chooses the latter alternative, it must adjust its cost avoidance savings if the claim is resubmitted during the suspension period with information showing it is not a legitimate cost avoidance.
NOTE: Nonassigned claims may not be returned to beneficiaries (see §3311), but must be controlled as described above when being developed for MSP involvement and counted as cost avoidance savings.
The following situations require special consideration if cost avoidance savings are counted before the 75 day suspense period has ended:
In these situations the carrier adjusts its cost avoidance savings figures by deducting or "backing out" the applicable amounts. It makes the adjustments in the reporting month in which a final determination is rendered. The following chart outlines the correct reporting of savings in each situation:
| Cost Avoidance | MSP SAVINGS REPORTED | ||
|---|---|---|---|
| Partial Recoveries | Full Recoveries | ||
| I. Partial Recovery Adjustment MSP situation indicated. Medicare's payment calculated to be $50 if Medicare was primary payer. Claim is returned to submitter. Claim is resubmitted showing $30 paid by the other insurer. a Medicare secondary payment of $20 is made. | $ 50 | ||
| $(50) * | $ 30 | ||
| II. 'Other' Payer Denial Adjustment MSP situation indicated - Medicare's 'primary' payment calculated to be $75. Claim is returned to submitter. Other payer denies claim. Medicare found to be primary and Medicare payment of $75 is made. | $ 75 | ||
| $ (75)* | |||
| III. Full Recovery Adjustment MSP situation indicated - Medicare's 'primary' payment calculated to be $80. Claim is returned to submitter Provider or other source informs carrier that full payment was made by the other payer. | $ 80 | ||
| $ (80)* | $ 80 |
*Amounts 'backed out' of cost avoidance savings figures.
Line 3 - Number - The number of full recoveries made during the month.
Line 4 - Dollar Value - The dollar value of full recoveries made during the month.
Full recoveries represent savings from claims where the primary payer made a payment which relieved Medicare of all payment liability. They can be either prepayment or post-payment. The carrier counts full recoveries in the month in which it renders a final determination on the claim. In post payment situations this is when it has recovered the full amount paid by Medicare. In prepayment situations it is when it receives documentation showing that an MSP resource made a payment equal to or greater than what Medicare would have paid.
a. Prepayment Full Recovery - a prepayment full recovery occurs when an MSP resource makes full payment on a charge before Medicare makes any payment.
EXAMPLE: A physician identifies an EGHP as the primary payer, submits the bill to that insurer, and the EGHP pays the charges in full. The beneficiary informs the carrier of this and submits a copy of the EGHP EOB. The carrier determines what it would have paid if the EGHP had not made payment and records that total as full recovery savings.
1. Post payment Full Recovery - a post payment full recovery occurs when an MSP resource makes full payment on a charge after Medicare has paid.
EXAMPLE: Medicare paid a physician's bill for charges incurred as a result of an automobile accident. Subsequently an auto liability insurer reimburses the Medicare beneficiary for the full amount and the beneficiary refunds that amount to the carrier. The carrier counts the amount of initial payment as a post payment full recovery.
It records as savings, that portion of a full recovery paid to an attorney or other agent as Medicare's share of the recovery cost. When it refers a case to the RO for recovery action, however, it does not record any savings at that point. Savings from a compromise or 'subrogation' case may be recorded only after a final determination. The carrier does not count these cases for CPEP credit prior to final settlement.
EXAMPLE: A beneficiary incurs a $1,000 physician's bill and a $5,000 hospital bill as a result of injuries sustained in an automobile accident. Assuming that all deductibles are satisfied, Part B pays $800 toward the physician's charges, and Part A covers the hospital bill in full. After litigation, a liability insurer agrees to pay $6,000 for the beneficiary's medical expenses from which the attorney will take a fee. (If the attorney's fee were 33 percent, the actual dollar recovery would be $4,000.) The carrier records $800 in Full Recovery savings (Part Bs full payment). The intermediary is able to count its payment as a Full Recovery savings even though the actual amount recovered, due to the attorney's fee did not equal what the intermediary paid.
Line 5 - Number - The number of partial recoveries made during the month.
Line 6 - Dollar Value - The dollar value of partial recoveries made during the month.
Partial recoveries are those savings realized when a primary payer makes a payment which covers only a part of the Medicare allowable charge, leaving Medicare with a balance to pay. The carrier uses the following formula in computing the savings from a partial recovery:
It counts partial recoveries in the month when it takes final action on the claim (either making a payment supplemental to that of the primary payer or making a partial recovery from a payment by the primary payer) on the claim. Instructions for processing partial recovery claims are in Medicare Claims Processing, Chapter 28, Coordination with Medicaid and Medigap Insurers.
The carrier records as savings, that portion of a partial recovery paid to an attorney or other agent as Medicare's share of the recovery cost. When it refers a case to the RO for recovery action it does not record any savings at that point. Savings from a compromise or 'subrogation' case may be recorded only after a final determination. These cases may not be counted for CPEP credit prior to reaching final settlement.
In this part of the report (lines 7 and 8), the carrier reports data on the totals of unpaid claims plus full and partial recoveries.
Line 7 - Claims - The total number of MSP claims handled during the month.
Line 8 - Dollar Value - The total dollar value associated with MSP claims during the month.
Line 9 - Number - The number of pending claims/cases as of the close of the month. This includes claims/cases for which 'Full Recovery' is expected but all money due has not been received.
Line 10 - Estimated Value - The gross charges for all claims/cases reported as pending on line 9. Where 'Full Recovery or Partial Recovery' has been determined, but all monies have not been received, the carrier reports the gross charges until it receives the full amount due or it is reasonable to expect no further payments.
A case is defined as one or more claims filed on behalf of an individual and related to one specific occurrence which necessitated medical care. When recording data for column 1 concerning WC and Auto Liability, and No Fault Insurance, the carrier counts only cases. For Working Aged (column iii), ESRD (column iv), and Disabled (column vi), it counts each individual claim.
A case/claim is considered pending only after it has been developed to the point where it is determined to be an MSP claim and no final resolution has been made. A partial or interim
payment is not sufficient to remove a case/claim from the pending rolls. Final resolution occurs when there is no longer a practical expectation of further reimbursement by another resource.
Remarks - The carrier enters any comments relevant to the interpretation and analysis of this report.
Signature - The report should be signed by the individual responsible for its compilation.
Date - Date the report is completed and signed.
(Rev. 6, 08-30-02)
B3-13450.9
(Rev. 6, 08-30-02)
B3-13450.10
DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH CARE FINANCING ADMINISTRATION
MEDICARE SECONDARY PAYER SAVINGS
| CARRIER NAME | NUMBER | STATE | REPORTING PERIOD (MO. / YR.) | ||||
|---|---|---|---|---|---|---|---|
| TOTAL (i) | WORKER'S COMP. BLACK LUNG & VA (ii) | WORKING AGED (iii) | ESRD (iv) | AUTO MED. NO FAULT AND LIABILITY (v) | DISABLISHED (vi) | ||
| Unpaid (Cost Avoided) MSP Claims 1. Number | |||||||
| 2. Dollar Value | |||||||
| Full Recoveries | |||||||
| 3. Number | |||||||
| 4. Dollar Value | |||||||
| Partial Recoveries | |||||||
| 5. Number | |||||||
| 6. Dollar Value | |||||||
| Special Projects | |||||||
| 7. Number | |||||||
| 8. Dollar Value | |||||||
| Totals 9. Number (Lines 1 + 3 + 6 + 7) | |||||||
| 10. Dollar Value (Lines 2 + 4 + 6 + 8) |
REMARKS
| SIGNATURE | TITLE | DATE |
|---|---|---|
Form HCFA-1584 (6-90)
(Rev. 253, 08-06-15, Effective: 01-01-16, Implementation: 01-04-15)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
At the end of each month, the contractor prepares and transmits to CMS a report summarizing monthly activity on redeterminations processed by A/B and DME MACs, as well as those actions associated with reconsiderations, and Administrative Law Judge (ALJ) hearings and Part A and Part B Medicare Appeals Council effectuations that are processed by A/B and DME MACs. Contractors shall complete separate reports for each office where a separate A/B or DME MAC Jurisdictional identification number has been assigned.
NOTE: The report is NOT designed to be completed by the Qualified Independent Contractor (QIC) or the Administrative Qualified Independent Contractor (AdQIC). All data shall be entered by the contractor except for those lines that are indicated as “Not Applicable” (e.g., Medicare Approved Amount). The data in the “Not Applicable” lines are not required. Contractors shall continue to use the CMS-2591 and CMS-2590 reports to capture data on appeal workloads received prior to the implementation date of the CMS-2592 report. The CMS-2591 and 2590 reports will be used to record appeals related data received prior to the implementation of the CMS-2592 report until all pending appeals workloads have been completed. If a case was received prior to the implementation of the CMS-2592, and as such is captured on the CMS-2591 or CMS-2590, tracking for the case remains on the CMS-2591 or CMS-2590 until all levels of appeal for the case have been completed.
Note: The CMS-2591 and 2590 reports will continue to be used to capture reopenings data that is not clerical in nature, and as such, is not captured on the CMS-2592 report.
Form CMS-2592 is subject to the Paperwork Reduction Act and requires approval by the Office of Management and Budget (OMB). OMB approval has been requested.
Purpose and Scope--The CMS-2592 enables CMS to tabulate data for administrative purposes on the following information.
Unless specifically indicated, data on the CMS-2592 Report is captured in cases. Where noted, information is also requested in claims. Information on decisions is also requested, as applicable.
Due Date -Transmit the CMS-2592 to CO via PC or terminal. Use instructions in the CROWD User Guide available via the CMS Enterprise Portal.
The report is due as soon as possible after the end of the reporting month but no later than the 15th of the month following the end of the reporting month.
Heading – This report is referenced as Form 7 for CROWD. It submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI.
Refer to the information below when determining how to count and categorize data for reporting purposes.
Controlling Receipt of Cases - In order to ensure that cases are processed timely, cases shall be date stamped or controlled in some way upon receipt. The date of receipt in all cases is the day the processing contractor received the request in its corporate mailroom. The days elapsed for an individual request are calculated using the number of days starting from the Julian date of case receipt through the Julian date of completion. Include the time required for the response to be mailed to the appellant. For example, a case that is received and processed on January 7 is considered to require 1 day to clear. A case received on January 7 and cleared on January 8 is considered to require 2 days to clear. Consider the day of receipt to be Day 1.
Cases that are not received in the mailroom (for example, requests from the QIC for case files received by fax or telephone) shall be controlled in some way to ensure that timeliness requirements are met.
Counting Cases -- If an appellant submits one request involving several different claims (and several different beneficiaries), count it as one case. If the contractor receives one envelope with multiple request forms and supporting documentation, count 1 case per request received. For example, if the envelope contains 10 separate request forms with supporting documentation, count as 10 cases.
Counting Part A, B of A and Part B Claims - If an appellant submits one request involving 5 different claims, count as 5 claims. If an appellant submits one request involving 1 claim, count as 1 claim. If the appellant submits two cases in the same envelope, of which one case has 3 claims and the other 4 claims, count as 2 cases with 7 claims. If an appellant submits a case containing 7 claims, of which 5 are requests for an appeal and the remaining 2 are determined to be reopenings, count the 5 appeal claims among the appeals workload. The remaining 2 claims shall not be counted among the appeals workload, but shall be counted as reopenings (see Line 1 of the Reopenings Section).
Counting Part A, B of A and Part B Cases Involving Appeals and Reopenings – If you receive a case involving multiple claims and some claims are subject to appeal but others must be handled
as a reopening, count the case as an appeal. Note: Reopenings data is captured by claims only. Because of this, no case count is recorded for reopenings.
Additional Evidence Submitted After Request is Received -- If you receive a case for which additional documentation is submitted for some but not all of the claims, count the case among those recorded on Line 7 (Cleared - Evidence Submitted After Request).
When to Consider a Case Reversed -- Consider a case reversed when the initial determination is changed upon appeal, (e.g., the claim was denied at the initial determination level but is reversed when the case is appealed).
When to Consider a Case Completed – Consider a case to be completed when you complete the action that sets in motion correct payment of the claim and you mail the decision letter to the appellant. All redeterminations shall be processed and mailed by the 60th day (unless additional evidence is submitted by the party after the request is received, in which case the contractor has up to 14 additional days for each submission to process and mail the decision letter to the parties.
See Line 6.1 for additional guidance.
When to Consider a Case Effectuated – Consider effectuation of a decision to be completed when payment is issued to the appellant based on a fully favorable or partially favorable decision. If you enter the adjustment in the month of July, but payment is not issued to the appellant until August, the case is considered to be effectuated in August.
Note: Considering a case to be completed is different from determining when a case is effectuated. Note the distinctions in the previous paragraphs. It is possible for some overlap of completion and effectuation timeframes to occur.
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
This section concerns data from Part A and Part B of A appeals processed by A/B MACs (A) as well as Part B appeals processed by A/B MACs (B) and DME MACs.
Redeterminations. The number of redeterminations requested (received), completed, and pending reflects the status of the workload as of the last day of the reporting month. Base data on actual counts of each activity and not on sampling or other estimating techniques.
A redetermination is the first level of appeal following an initial determination of a Part A claim or Part B claim. It is a re-evaluation of the facts and findings of a claim to determine whether the initial decision was correct. (See the Medicare Claims Processing Manual, Publication 100-04, Chapter 29, Section 310.)
Do not count duplicate redetermination requests or redetermination requests received before you have made an initial determination on a claim. Do not count inquiries. Count one redetermination per request received. With the exception of those lines for which claims counts are specifically requested in the report, count only cases. Do not count a duplicate request for appeal as a processed appeal. Duplicate requests can be reflected in Line 2 (Adjustment to Pending) of the CMS-2592 Report for the subsequent month.
Redeterminations fall into the following categories:
Column (1) Part A Cases- Use Column 1 to report information on Part A services processed by the A/B MAC (A).
Column (2) Part B of A Cases- Use Column 2 to report information on Part B services processed by the A/B MAC (A).
Column (3) Part B Cases- Use Column 3 to report information on Part B services processed by the A/B MAC (B) or DME MAC.
Line 1. Opening Pending - Show under columns 1-3, the number of redetermination cases reported on Line 21 as the closing pending redetermination cases on the previous month's report.
Line 2. Adjustments to Pending - CMS understands that it is often necessary to revise the categorization of data from the original categorization given when a case was initially received at the contractor. Likewise, it is often necessary to move data from one line to another in order to maintain accuracy. Prior to the submission of the monthly 2592 report to CMS, contractors are permitted to make changes to data during the reporting month to ensure that appeal workloads are accurately reflected.
Once the monthly 2592 report has been submitted to CMS, any changes to the closing pending figure of the report must be reflected in the Adjustments to Pending line of the subsequent month's report. If it is necessary to revise the pending figure for the close of the previous month's report because of inventories or reporting errors, enter the adjustment. If some cases were not counted in the proper month's receipts, count them as adjustments to the opening pending count in the subsequent month. Examples include any instances where something originally categorized as an appeal was determined not to be an appeal, or vice-versa. Duplicate requests for redetermination are also reflected here. If the contractor receives a request for appeal near the end of the reporting month but the case arrives too late to be reflected as a receipt in the CMS-2592 report for that month, count the case in the Adjustment to Pending line of the subsequent month's report. The purpose of the Adjustments to Pending line is to allow the contractor to modify Opening Pending counts, thereby correcting errors resulting from inventory or reporting problems that were identified after the submission of the CMS-2592 previous month's report to CMS.
Do not make adjustments to the Pending line or other lines of the 2592 report once the report has been submitted to CMS. If there is an entry for Line 2, it should be preceded by a '+' or '-', as appropriate.
Line 3. Adjusted Pending - Enter the result of Line 1 + Line 2 (taking into account the '-' sign, if any).
Line 4. Requests Received - Show, under the appropriate columns, the number of requests for redeterminations received during the reporting month. Include requests transferred to you by other A/B or DME MACs or remanded by the Qualified Independent Contractor (QIC).
NOTE: See the “Note” under Line 6 (Requests Cleared) regarding the handling of Medicare Secondary Payer (MSP) cases.
Line 4.a. Adjusted Requests Received - As a result of actions taken by the A/B and DME MACs to process appeals during the reporting month, show on this line the number of receipts that have actually been validated by the MAC to be a redetermination. This line should include both RAC and non-RAC redeterminations.
NOTE: See the “Note” under Line 6 (Requests Cleared) regarding the handling of Medicare Secondary Payer (MSP) cases.
Line 4.1. Number of Claims Received – Show the total number of redetermination claims involved in Line 4.a.
Line 4.2. Recovery Audit Contractor (RAC) Requests Received - Of the redetermination requests reported in Line 4.a, show the number that are Recovery Audit related. Line 4.2 is a subset of Line 4.a and should contain only RAC redeterminations.
Line 4.2.1. Number of RAC Claims Received – Show the number of redetermination claims involved in Line 4.2.
Line 5. Misrouted Requests Forwarded to Another Contractor - Show under columns 1 through 3 the number of redetermination requests the contractor forwarded to other contractors, because they were misrouted to you and you did not process the original claim(s). For columns 1-3, if you have reported a redetermination as forwarded, do not report any information regarding it on Lines 6-29. The forwarding of the misrouted request is the final action.
NOTE: This line is not intended for QIC reconsideration requests that were misrouted.
Line 6. Requests Cleared - Show, under the appropriate columns, the total number of redeterminations completed during the month. Report all completed redeterminations, regardless if the final outcome was an affirmation, reversal, withdrawal, or dismissal. Do not count cases that were transferred to another contractor because they were misrouted.
NOTE: A/B MACs (A) should count received and completed MSP redetermination cases in Columns 1 of Lines 4 and 6, as appropriate, regardless of whether claims involved are Part A, Part B or a combination. Do not count or report claims involved in MSP cases. MSP cases should be counted in Lines 4, 6, 7, 8, 9, 10 and 11. Do not count MSP claims on Lines 4.1, 6.1, 7.1, 8.1, 9.1, 10.1 and 11.1.
A/B MACs (B) that handle MSP cases should count them in Column 3.
Line 6.1. Number of Claims Cleared – Show the total number of claims involved in Line 6.
NOTE: For Lines 6.1 through 11.1 (letters a through i), enter the number and type of claim processed. If no claims from a certain claim type are processed, report zero (0). Refer to instructions for the CMS-1565 and 1566, as well as appropriate sections of the Claims Processing Manual for guidance on determining the categories and types of claims processed by A/B MACs and DME MACs.
Line 6.1a – Report the number of SNF claims included in Line 6.1. Line 6.1b – Report the number of Home Health claims included in Line 6.1. Line 6.1c – Report the number of Inpatient Hospital claims included in Line 6.1. Line 6.1d – Report the number of Outpatient claims included in Line 6.1. Line 6.1e – Report the number of Lab claims included in Line 6.1. Line 6.1f – Report the number of Ambulance claims included in Line 6.1. Line 6.1g – Report the number of DME claims included in Line 6.1. Line 6.1h – Report the number of Physician claims reported in Line 6.1. Line 6.1i – Report the number of Other claims or claims where the provider type cannot be determined based on the information on the claim included in Line 6.1.
Consider a redetermination cleared when:
Note that sending a letter to the mailroom does not constitute mailing the letter. Letters must be mailed to the appellant on or before the 60th day in order for the requirement to be met.
NOTE: Considering a case to be completed is different from determining when a case is effectuated. Please note the distinctions in the previous paragraphs.
Line 6.2. Recovery Audit Contractor (RAC) Redeterminations Cleared - Of the cases reported in Line 6, how many are RAC related?
Line 6.2.1. Number of RAC Claims Involved – Show the number of claims involved in Line 6.2.
Line 7. Cleared -- Evidence Submitted After Request - Of the cases reported in Line 6, show under the appropriate columns, the total number of redetermination cases for which additional documentation was submitted by the party on his or her own or when the documentation was requested by the contractor after the request was received.
Line 7.1. Number of Claims Involved – Show the total number of claims involved in Line 6.1 for which evidence was submitted after the request was received.
Lines 7.1a through 7.1i are Not Applicable. Line 7.1a – Report the number of SNF claims included in Line 7.1. Line 7.1b – Report the number of Home Health claims included in Line 7.1. Line 7.1c – Report the number of Inpatient Hospital claims included in Line 7.1. Line 7.1d – Report the number of Outpatient claims included in Line 7.1. Line 7.1e – Report the number of Lab claims included in Line 7.1. Line 7.1f – Report the number of Ambulance claims included in Line 7.1. Line 7.1g – Report the number of DME claims included in Line 7.1. Line 7.1h – Report the number of Physician claims reported in Line 7.1. Line 7.1i - Report the number of Other claims or claims where the provider type cannot be determined based on the information on the claim included in Line 7.1.
Line 7.2. RAC Redeterminations Cleared With Additional Documentation - Of the cases reported in Line 7, how many are RAC related?
Line 7.2.1. Number of RAC Claims Involved – Show the number of claims involved in Line 7.2.
Count the cases in the following manner:
| Full | Partial | Affirmation | Dismissal/ Withdrawal | = | Report As |
|---|---|---|---|---|---|
| X | Full | ||||
|---|---|---|---|---|---|
| X | Partial | ||||
| X | Affirmation | ||||
| X | Dismissal/ Withdrawal | ||||
| X | X | Partial | |||
| X | X | Partial | |||
| X | X | Full | |||
| X | X | X | Partial | ||
| X | X | X | X | Partial | |
| X | X | Partial | |||
| X | X | Partial | |||
| X | X | Affirmation | |||
| X | X | X | Partial |
Line 8. Affirmations - Under the appropriate columns, show the number of completed redeterminations from Line 6 in which the previous determinations were completely upheld; i.e., no change was made. All claims in a case must be upheld in order for the case to be counted as an affirmation. In instances where claims some are affirmed, but all others are dismissed or withdrawn, count the case as an affirmation. (Do not include partial reversals in this line. See Line 9 for partial reversals). Include those instances where the decision was affirmed, but a change in liability was noted.
Line 8a. Waiver of Liability Amount Paid (Not Applicable) - Show the amount paid under waiver of liability, on the basis that the party did not know that the service wasn't payable under Medicare.
Line 8.1. Number of Claims Affirmed – Show the number of claims involved in Line 6.1 for which the decision was affirmed.
NOTE -- The following example is counted as an affirmation: A claim is denied at the initial determination level and a redetermination is requested. At the redetermination level, the denial is upheld but the denial is for a reason other than was determined to be applicable at the initial determination level. Count the claim as an affirmation.
Line 8.1a – Report the number of SNF claims included in Line 8.1. Line 8.1b – Report the number of Home Health claims included in Line 8.1. Line 8.1c – Report the number of Inpatient Hospital claims included in Line 8.1. Line 8.1d – Report the number of Outpatient claims included in Line 8.1. Line 8.1e – Report the number of Lab claims included in Line 8.1. Line 8.1f – Report the number of Ambulance claims included in Line 8.1. Line 8.1g – Report the number of DME claims included in Line 8.1. Line 8.1h – Report the number of Physician claims reported in Line 8.1. Line 8.1i – Report the number of Other claims or claims where the provider type cannot be determined based on the information on the claim included in Line 8.1.
Line 8.2. RAC Redeterminations Affirmed- Of the affirmation cases reported in Line 8, how many are RAC related?
Line 8.2.1. Number of RAC Claims Involved – Show the number of claims involved in Line 8.2.
Line 9. Partial Reversals - Under the appropriate columns, show the number of completed redeterminations, from Line 6 in which part of the prior determination decision of the appealed lines was reversed. That is, a change was made and some part of the new determination was in favor of the appellant. NOTE: Consider a case reversed when the initial determination is changed upon appeal, irrespective of a change in payment.
Line 9.1. Number of Claims Partially Reversed – Show the number of claims involved in Line 6.1 for which the decision is partially reversed. Note: It is possible to have zero claims in Line 9.1, even when cases are recorded in Line 9.
Line 9.1a – Report the number of SNF claims included in Line 9.1. Line 9.1b – Report the number of Home Health claims included in Line 9.1. Line 9.1c – Report the number of Inpatient Hospital claims included in Line 9.1. Line 9.1d – Report the number of Outpatient claims included in Line 9.1. Line 9.1e – Report the number of Lab claims included in Line 9.1. Line 9.1f – Report the number of Ambulance claims included in Line 9.1. Line 9.1g – Report the number of DME claims included in Line 9.1. Line 9.1h – Report the number of Physician claims reported in Line 9.1. Line 9.1i – Report the number of Other claims or claims where the provider type cannot be determined based on the information on the claim included in Line 9.1.
Line 9.2. RAC Redeterminations Partially Reversed– Of the partially reversed cases reported in Line 9, how many are RAC related?
Line 9.2.1 Number of RAC Claims Involved – Show the number of claims involved in Line 9.2.
Line 10. Full Reversals - Under the appropriate columns, show the total number of completed redeterminations from Line 6 in which the previous determination decision of the appealed lines was completely reversed. NOTE: Consider a case reversed when the initial determination is changed upon appeal, irrespective of a change in payment.
Line 10.1. Number of Claims Fully Reversed – Show the number of claims involved in Line 6.1 for which the decision is fully reversed.
Line 10.1a – Report the number of SNF claims included in Line 10.1. Line 10.1b – Report the number of Home Health claims included in Line 10.1. Line 10.1c – Report the number of Inpatient Hospital claims included in Line 10.1. Line 10.1d – Report the number of Outpatient claims included in Line 10.1. Line 10.1e – Report the number of Lab claims included in Line 10.1. Line 10.1f – Report the number of Ambulance claims included in Line 10.1. Line 10.1g – Report the number of DME claims included in Line 10.1. Line 10.1h – Report the number of Physician claims reported in Line 10.1. Line 10.1i – Report the number of Other claims or claims where the provider type cannot be determined based on the information on the claim included in Line 10.1.
Line 10.2 RAC Redeterminations Fully Reversed – Of the fully reversed cases reported in Line 10, how many are RAC related?
Line 10.2.1 Number of RAC Claims Involved – Show the number of claims involved in Line 10.2.
Line 11. Dismissals/Withdrawals - Report, under the appropriate column, the number of cases from Line 6 that were withdrawn by the appellant or dismissed (before determination) by you. In order for a case to be recorded in Line 11, all claims in the case must be dismissed or withdrawn.
NOTE: Do not count cases that were dismissed because they were determined to be incomplete in Line 11. Cases that were dismissed because they were determined to be incomplete should only be counted in Line 12.
Line 11.1. Number of Claims Dismissed or Withdrawn – Show the number of claims involved in Line 6.1 which were dismissed or withdrawn.
Line 11.1a – Report the number of SNF claims included in Line 11.1. Line 11.1b – Report the number of Home Health claims included in Line 11.1. Line 11.1c – Report the number of Inpatient Hospital claims included in Line 11.1. Line 11.1d – Report the number of Outpatient claims included in Line 11.1. Line 11.1e – Report the number of Lab claims included in Line 11.1. Line 11.1f – Report the number of Ambulance claims included in Line 11.1. Line 11.1g – Report the number of DME claims included in Line 11.1. Line 11.1h – Report the number of Physician claims reported in Line 11.1. Line 11.1i – Report the number of Other claims or claims where the provider type cannot be determined based on the information on the claim included in Line 11.1.
Misrouted correspondence and duplicate requests are not dismissals.
Line 11.2. RAC Redeterminations Dismissed or Withdrawn - Of the dismissed or withdrawn cases reported in Line 11, how many are RAC related?
Line 11.2.1. Number of RAC Claims Involved – Show the number of claims involved in Line 11.2.
Line 12. Number of Incomplete Redetermination Requests Dismissed - Enter the number of cases that were dismissed because the request was incomplete. Report incomplete cases in Line 12 only if ALL the claims from the case are incomplete. For information on what constitutes an incomplete request, refer to the Medicare Claims Processing Manual, Publication 100-04; Chapter 29; Section 310.1
NOTE: If one redetermination request contains multiple claims and or line items and is split, report the case according to the overall disposition of the individual claims and/or line items. (In many instances, split cases will be reported as partially reversed).
Example: A supplier submits a redetermination request that contains one request with 50 claims involving different beneficiaries. The request contains a name and signature of the appellant/supplier, and the supporting documentation identifies individual claims of the beneficiaries, pertinent Medicare beneficiary identifier and the dates of service. However, for some of the claims, the supplier does not identify the specific services (among the several line items on the claim) that are disputed. The contractor should not dismiss the
entire redetermination request. Rather, in this situation, the contractor issues dismissals (incomplete requests) with respect to the individual claims for which the requisite information is incomplete, and issues favorable and/or unfavorable decisions for the remaining claims, as appropriate. For the purposes of reporting, the case is reported according to the overall disposition of the individual claims and/or line items. If the case contains some affirmations, reversals and dismissals, count the case as partially reversed in Line 9.
Example: A supplier submits a redetermination request that contains one request with 50 claims involving different beneficiaries. The request is missing the signature of the appellant/supplier, but identifies the individual claims of the beneficiaries, pertinent names and Medicare beneficiary identifiers, dates of service and the items or services disputed. Since the signature is missing, the entire request would be dismissed as incomplete, and counted in Line 12 of the CMS-2592.
Do not count cases that were dismissed for reasons other than being incomplete on Line 12. Only count those instances for which the entire request is dismissed on Line 12.
Line 13. Medicare Approved Amount (Not Applicable) - For cases included in Lines 9 and 10, show the Medicare Approved Amount for services where the initial determination was reversed at the redetermination level, either fully (Line 10) or partially (Line 9). Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.
Processing and Pending Times - This deals with processing and pending times for Part A and Part B appeals.
For Lines 6-25, use the matrix below to determine the number of days from receipt to completion of redeterminations. The date of receipt in all cases is the day the processing contractor received the request in its corporate mailroom. In order to ensure that cases are processed timely, cases should also be date stamped or controlled in some way in the mailroom.
The date the dismissal letter is mailed to the party.
The date the dismissal letter is mailed to the party.
For both full and partial reversals, when the contractor completes the action that sets in motion correct
o
The contractor affirms the initial determination
payment of the claim and the contractor mails the decision letter to the party.
The date the decision letter is mailed to the party.
Line 14. Redetermination Processing Time – Average – Report, under the appropriate columns, the average number of days from receipt of the redetermination in the corporate mailroom to the date of completion. Do not include redeterminations where documentation is submitted after the request (i.e., a redetermination cannot be counted in both Line 14 and Line 17).
To compute the average number of days from request to completion, divide the total days elapsed for all requests (where the documentation was submitted timely) cleared in the month by the number of requests cleared. Round results to the nearest day. The days elapsed for an individual request are calculated using the number of days from the Julian date of case receipt through the Julian date of completion. Include the time required for the response to be mailed to the appellant. If the request is cleared in the year following the year of receipt, add 365 or 366 to the result, as appropriate. (Otherwise, you will get a negative number). If a case is cleared the same day it is received, consider it to require one day. For example, a case that is received and processed on January 7 is considered to require one day to clear. A case received on January 7 and cleared on January 8 is considered to require 2 days to clear.
Include all cases cleared, regardless of whether they were affirmed, reversed, dismissed, or withdrawn.
Line 15. Redeterminations Completed in 1-60 Days - Show the number of redeterminations that required 1-60 calendar days to complete (based on the date of receipt of the request in the corporate mailroom). Do not include redeterminations reported in Lines 18-20.
Line 15a. RAC Redeterminations Completed in 1-60 Days – Of the total number of appeals reported in Line 15, show the number that are RAC related.
Line 16. Redeterminations Completed in over 60 Days - Show the number of redeterminations that required more than 60 calendar days to complete (based on the date of receipt of the request in the corporate mailroom). Do not include redeterminations reported in Lines 18-20.
Line 16a. RAC Redeterminations Completed in Over 60 Days – Of the number of appeals reported in Line 16, show the number that are RAC related.
NOTE: This section captures information in instances where the party submits additional documentation at the redetermination level (including those instances when the contractor requests the additional documentation) after the initial request for redetermination is received. The contractor must receive the documentation before the 60 day timeframe is up in order for data to be entered into Lines 17-20.
Line 17. Redeterminations Processing Time - Average (Documentation Submitted Later) – For redeterminations where documentation/evidence is submitted after the request is received, report under the appropriate columns, the average number of days from receipt of the redetermination to the date of completion. Using redeterminations where documentation was submitted later as the basis, follow instructions in Line 14 to calculate the average processing time.
Line 18. Redeterminations Completed in 1-60 Days (Documentation Submitted Later) - Show the number of redeterminations from Line 6 where documentation/evidence is submitted after the request is received, and 1-60 calendar days were required to complete the case.
Line 18a. RAC Redeterminations Completed in 1-60 Days (Documentation Submitted Later) – Of the number of appeals reported in Line 18, show the number that are RAC related.
Line 19. Redeterminations Completed in 61-74 Days (Documentation Submitted Later) - Show the number of redeterminations from Line 6 where documentation/evidence is submitted after the request is received, and 61-74 calendar days were required to complete the case.
Line 19a. RAC Redeterminations Completed in 61-74 Days (Documentation Submitted Later) – Of the number of appeals reported in Line 19, show the number that are RAC related.
Line 20. Redeterminations Completed in over 74 Days (Documentation Submitted Later) - Show the number of redeterminations from Line 6 where documentation/evidence is submitted after the request is received, and more than 74 calendar days were required to complete the case.
Line 20a. RAC Redeterminations Completed in over 74 Days (Documentation Submitted Later) – Of the number of appeals reported in Line 20, show the number that are RAC related.
Line 21. Closing Pending Redeterminations - Show, under the appropriate columns, the total number of redeterminations that have not been completed by the end of the reporting month. Note: Do not include pending effectuations in this line.
Line 22. Redeterminations Pending 1-30 Days – Show the number of redeterminations included in Line 21 that have been pending for 1-30 days, inclusive, at the end of the reporting month.
Line 23. Redeterminations Pending 31-60 Days - Show the number of redeterminations included in Line 21 that have been pending 31-60 days, inclusive, at the end of the reporting month.
Line 24. Redeterminations Pending 61-74 Days - Show the number of redeterminations included in Line 21 which have been pending 61-74 days, inclusive at the end of the reporting month.
Line 25. Redeterminations Pending Over 74 Days - Show the number of redeterminations included in Line 21 which have been pending more than 74 days at the end of the reporting month.
Line 26. Total Effectuations - Show the number of redetermination cases for which you effectuated a decision during the month. Consider effectuation of a decision to be completed when you issue payment to the appellant based on a fully favorable or partially favorable decision. Include effectuation of affirmations where changes in liability are at issue. Do not include cases for which no effectuation is required.
Notes: Considering a case to be completed is different from determining when a case is effectuated. Please refer to the distinctions in the introductory sections of the 2592 report (“When to Consider a Case Completed” and “When to Consider a Case Effectuated”).
Line 26a. Number of Claims Involved – Show the number of claims involved in Line 26.
Line 27. Number Effectuated 1-30 Days - Show the number of claims from Line 26a where you effectuated the decision within 30 calendar days of the date of the decision.
Line 28. Number Effectuated 31-60 Days - Show the number of claims from Line 26a where you effectuated the decision within 31- 60 calendar days of the date of the decision.
Line 29. Number Effectuated Over 60 Days - Show the number of claims from Line 26a where you effectuated the decision in more than 60 calendar days of the date of the decision.
Reconsiderations, the second level of appeal, are processed by the QIC. This section of the report captures information related to several distinct pieces associated with the reconsideration process. While requests for reconsideration should be sent directly by the appellant to the QIC, it is probable that some requests will be sent to A/B MACs and DME MACs, requiring the need for forwarding the request, and the associated case file, to the QIC. In those instances where the requests for reconsideration are sent directly to the QIC as required, the QICs will have to request case file information from the contractor before the reconsideration can be conducted. In addition, the contractor will effectuate QIC decisions, as appropriate.
Column (1) Part A Cases- Use Column 1 to record information on reconsiderations of redeterminations for Part A services processed by the A/B MAC (A).
Column (2) Part B of A Cases Use Column 2 to record information on reconsiderations of redeterminations for Part B services processed by the A/B MAC (A).
Column (3) Part B Cases- Use Column 3 to record information on reconsiderations of redeterminations for Part B services processed by the A/B MAC (B) or DME MAC.
Line 30. Opening Pending - Show the number of closing pending reconsiderations reported on Line 47 on the previous month's report.
Line 31. Adjustments to Pending - If it is necessary to revise the pending figure for the close of the previous month because of inventories or reporting errors, enter the adjustment. Report requests received near the end of the reporting month and placed under control in the subsequent month as received in the reporting month, not as requests received in the subsequent month. If some cases were not counted in the proper month's receipts, count them as adjustments to the opening pending in the subsequent month.
Line 32. Adjusted Opening Pending - Show the result of Line 30 + Line 31 (taking into account the “-” sign, if any).
Line 33. Requests for QIC Reconsideration Received by the Contractor - Show the number of QIC reconsiderations received by the contractor during the month. Although the requests for reconsideration should be sent directly to the QIC, some requests may be sent directly to the contractor in error, and as such, are considered to be “misrouted”. Enter the number reconsideration requests sent by the appellant or their representative directly to the contractor. The contractor must forward these requests, along with the associated case file, to the QIC.
Line 33a. Misrouted Requests Forwarded to QIC –Show the number of misrouted reconsideration requests that were forwarded to the QIC, along with the associated case file, during the month. Do not include duplicate requests for reconsideration in this line.
Line 33b. Misrouted Requests Forwarded Timely – Of the number reflected in Line 33a, show the number forwarded to the QIC in 1-30 calendar days.
Line 33c. Misrouted Requests Forwarded Untimely – Of the number reflected in Line 33a, show the number forwarded to the QIC in more than 30 calendar days.
Line 34. Requests from QIC for Case Files: Upon receipt of the request for reconsideration, the QIC must contact the contractor to request the case file. Show the number of requests for case files received by the contractor from the QIC during the month. Requests can be received in the corporate mailroom, by telephone or by fax. Consider the date of receipt as the date you receive the QIC request for the case file.
Line 35. Number of Case Files Forwarded to QIC - Show the number of reconsideration case files forwarded to QICs during the month. Consider the case forwarded when all necessary material has been mailed to the QIC.
Line 36. Number Forwarded in 1-5 Days – Show the number of Reconsideration case files forwarded to the QIC in 1-5 calendar days from the date of receipt of the QIC request to mailing of the necessary information to the QIC. Show data for all cases mailed during the month.
Line 36a. Number Forwarded In 6 Days - Show the number of Reconsideration case files forwarded to the QICs in 6 calendar days from the date of receipt of the QIC request to mailing of the necessary information to the QIC. Show data for all cases mailed during the month.
Line 37. Number Forwarded In 7-8 Days - Show the number of Reconsideration case files forwarded to the QICs in 7-8 calendar days from the date of receipt of the QIC request to mailing of the necessary information to the QIC. Show data for all cases mailed during the month.
Line 37a. Number Forwarded In Over 8 Days - Show the number of Reconsideration case files forwarded to QICs in over 8 calendar days from the date of receipt of the QIC request to mailing of the necessary information to the QIC. Show data for all cases mailed during the month.
Line 38. Average Time to Forward - The average number of calendar days from date of the QIC request to the date you mail the necessary information. Refer to instructions contained in Line 14 to determine average time to forward.
Line 39. Pending Case File Requests – Show the number of case files yet to be forwarded to the QIC. This could include requests received from, but not yet sent to the QIC, as well as those reconsideration requests sent to the contractor instead of the QIC.
Line 40. Number of QIC Decisions Received From QIC- Show the number of Reconsideration requests completed by the QIC and returned to the contractor during the month.
Line 41. Number of QIC Decisions That Need Effectuation - Show the number of Reconsideration decisions from Line 40 which must be effectuated.
41a. Number of Claims Involved: Show the number of claims involved in Line 41.
Line 42. Total Effectuations - Show the number of Reconsideration decisions for which you effectuated a decision during the month. Consider effectuation of a decision to be completed when you issue payment to the appellant based on a fully favorable or partially favorable decision. Include effectuation of affirmations where changes in liability are at issue. Do not include cases for which no effectuation is required.
NOTE: Considering a case to be completed is different from determining when a case is effectuated. Please refer to the distinctions in the introductory sections of the 2592 report (“When to Consider a Case Completed,” and “When to Consider a Case Effectuated”).
NOTE: If the QIC’s decision is favorable to the appellant and gives a specific amount to be paid, effectuation must occur within 30 calendar days of the date of the QIC’s decision. If the decision is favorable but the amount to be paid must be computed, effectuation must occur within 30 days
after the amount is computed. The amount must be computed as soon as possible, but no later than 30 calendar days of the date of receipt of the QIC's decision.
Line 42a. Number of Claims Involved – Show the number of claims involved in Line 42.
NOTE: Information captured in Lines 43, 44 and 45 reflects time to compute the amount to be paid as well as the effectuation timeframes. Information provided in Lines 43-45 also assumes that contractors must calculate the amounts to be paid. Even though all appropriate timeframes are not reflected here, contractors are still required to follow applicable manual requirements and timeframes with regard to receipt, calculation and effectuation of decisions. CMS anticipates that effectuation of most decisions for which the amount is provided should fall into Line 43.
Line 43. Number Effectuated in 1-30 Days - Show the number of claims from Line 42a where you effectuated the decision within 30 calendar days. Effectuation days include the day of receipt of the reconsideration effectuation notice in your corporate mailroom or electronic transmission, such as fax or secure e-mail through the day the payment is issued.
43a. Contractor Computed Amount – Of the number reflected on Line 43, show the number where the contractor was required to compute the amount to be paid. An entry of zero indicates that the contractor was not required to compute the amount for any claim.
Line 44. Number Effectuated in 31-60 Days - Show the number of claims from Line 42a where you effectuated the decision within 31-60 calendar days. Effectuation days include the day of receipt of the reconsideration effectuation notice in your corporate mailroom or electronic transmission, such as fax or secure e-mail through the day the payment is issued.
44a. Contractor Computed Amount – Of the number reflected on Line 44, show the number where the contractor was required to compute the amount to be paid. An entry of zero indicates that the contractor was not required to compute the amount for any claim.
Line 45. Number Effectuated in Over 60 Days - Show the number of claims from Line 42a where you effectuated the decision in more than 60 calendar days. Effectuation days include the day of receipt of the reconsideration effectuation notice in your corporate mailroom or electronic transmission, such as fax or secure e-mail through the day the payment is issued.
45a. Contractor Computed Amount – Of the number reflected on Line 45, show the number where the contractor was required to compute the amount to be paid. An entry of zero indicates that the contractor was not required to compute the amount for any claim.
Line 46. Medicare Approved Amount (Not Applicable) - For decisions included in Line 42 show the Medicare approved amount for services at the QIC level where the determination was reversed, either fully or partially. Show the charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.
It is preferable to report the Medicare Approved Amount at the time that cases are reported on line 42. However, CMS will consider it acceptable for contractors to report the Medicare Approved Amount when adjustment claims tied to cases that are reporting or will report to line 42 finalize.
Line 46a. Waiver of Liability Amount Paid (Not Applicable) – Of the amount recorded on Line 46, show the amount applicable to a waiver of liability payment on the basis that the party did not know that the service wasn't payable under Medicare.
Line 47. Closing Pending Reconsiderations - Show the total number of reconsideration requests that were not effectuated by the end of the reporting month. Consider a case pending from the date of receipt of the request at the contractor, or the date of the request for the case file from the QIC, until you have received the completed decision from the QIC for all parts of the case. This number shall also reflect those case files not yet forwarded to the QIC by the contractor as well as those decisions that have been received by the contractor from the QIC that still require effectuation on the part of the contractor. For example, if you receive a case from the QIC, and have initiated the adjustment into the system, but have not issued the payment, the case is reported in Line 47 as pending.
Do not include instances where a misrouted file has been sent to the proper QIC in another jurisdiction. Misrouted files that belong to a QIC in another jurisdiction should be considered closed once they have been forwarded to the appropriate QIC. Files that are forwarded to the QIC servicing the same jurisdiction as the contractor should remain open until the effectuation is complete.
Line 48. Opening Pending - Show the number of ALJ decisions reported on Line 57 as the closing pending on the previous month's report.
Line 49. Number of Appeal Requests for ALJ Hearing Misrouted to Contractor – Report the number of appeal requests for an ALJ hearing that were misrouted to the contractor when they should have been filed with the Office of Medicare Hearings and Appeals instead. These are ALJ requests that were filed with the contractor by mistake.
Line 50. Number of ALJ Decisions Received From Administrative QIC (AdQIC) - Show the number of ALJ hearing decisions returned by the AdQIC to the contractor during the month. Consider the receipt date to be the date the case is received from the AdQIC. Include instances where decisions were received in the previous month, but were not entered into the system until the current month.
Line 51. Number of ALJ Decisions Received that Need Effectuation - Show the number of ALJ decisions from Line 50 which must be effectuated.
Line 51a. Number of Claims Involved – Show the number of claims involved in Line 51.
Line 52. Total Effectuations -Show the number of ALJ decisions effectuated during the month. Consider effectuation of a decision to occur when you issue payment based on a fully favorable or partially favorable decision. Include effectuation of affirmations where changes in liability are at issue. Do not include cases for which no effectuation is required.
Line 52a. Number of Claims Involved – Show the number of claims involved in Line 52.
NOTE: Information captured in Lines 53, 54 and 55 assumes that contractors must calculate the amounts to be paid before effectuation can occur. Contractors are required to follow other applicable timeframes used when specific amounts to be paid have been provided with the information received from the AdQIC. CMS anticipates that effectuation of most decisions for which the amount is provided should fall into Line 53.
Line 53. Number Effectuated in 1 - 30 Days - Show the number of claims from Line 52a where you effectuated the decision within 30 calendar days. Effectuation days include day of receipt of the effectuation notice from the AdQIC in your corporate mailroom or electronic transmission, such as fax or secure e-mail, through the day the payment is issued.
Line 54. Number Effectuated in 31 - 60 Days - Show the number of claims from Line 52a where you effectuated the decision within 31-60 calendar days. Effectuation days include day of receipt of the effectuation notice from the AdQIC in your corporate mailroom or electronic transmission, such as fax or secure e-mail, through the day the payment is issued.
Line 55. Number Effectuated in Over 60 Days - Show the number of claims from Line 52a where you effectuated the decision in more than 60 calendar days. Effectuation days include day of receipt of the effectuation notice from the AdQIC in your corporate mailroom or electronic transmission, such as fax or secure e-mail, through the day the payment is issued.
Line 56. Medicare Approved Amount (Not Applicable) - For decisions included in Line 52, show the Medicare approved amount for services where the reconsideration determination was reversed at the ALJ level, either fully or partially. Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.
It is preferable to report the Medicare approved amount at the time that cases are reported on line 52. However, CMS will consider it acceptable for contractors to report the Amount Paid when adjustment claims tied to cases that are reporting or will report to line 52 finalize.
Line 56a. Waiver of Liability Amount Paid (Not Applicable) – Of the amount recorded on Line 56, show the amount applicable to a waiver of liability payment on the basis that the party did not know that the service wasn't payable under Medicare.
Line 57. Closing Pending ALJ Decisions - Show the total number of ALJ decisions that were received from the AdQIC, but were not completed by the contractor at the end of the reporting month, and as such, are still pending effectuation. All claims associated with the decision must be received from the AdQIC in order for the decision to be considered complete.
Line 58. Medicare Appeals Council Effectuations – Show the total number of cases received from the Medicare Appeals Council which require effectuation by the contractor. While it is acknowledged that contractors will not have responsibility for forwarding these cases to the Medicare Appeals Council, information is requested since the contractor will have ultimate
responsibility to make payment. For reporting purposes, the contractor shall consider the date of receipt as the date the Medicare Appeals Council case is received from the AdQIC.
(Rev. 144; Issued: 11-28-08; Effective Date: 04-01-09; Implementation Date: 04-06-09)
When a determination is made on a claim for services, the beneficiary (and the provider, physician or other supplier of medical services) should be able to rely on the fact that the coverage decision and payment amount are correct. Occasionally, information disclosing an error (on the part of the appellant or the contractor) in the determination comes to light after the payment has been incorrectly processed. Regulations do not permit unrestricted reopening of determinations and decisions, but rather, set specific circumstances under which a determination or decision may be reopened. Refer to 42 Code of Final Regulations (CFR) 405.980-986, Interim Final Rule, dated March 8, 2005. The Clerical Error Reopening section of the 2592 report focuses primarily on those clerical error and minor omission reopenings that occur at the pre and post redetermination level. Data on requests at the QIC level and above are only captured in Lines 13 and 14 of the Clerical Error Reopening section of the report. Requests for a clerical error reopening may be received in writing or by telephone. Contractors shall continue to use the appropriate columns and lines of the CMS-2591 and CMS-2590 reports to capture data on reopenings that are not clerical in nature. Do not capture clerical error reopenings data on the 2590/2591.
NOTE: Clerical Error Reopenings data requested in this section should be reported in claims, not cases.
Line 1. Total Number of Clerical Error Reopenings Received – Show the total number of clerical error reopening requests received during the month. This number includes any requests originally categorized as a reopening at the pre or post-redetermination level, as well as those requests that were originally categorized as an appeal, but were later determined to be a clerical error reopening.
Line 2. Total Number of Clerical Error Reopenings Processed -- Show the total number of clerical error reopenings processed by the contractor during the month.
Line 3. Total Number Processed – Own Motion – Of the number reflected on Line 2, show the number the contractor reopened the claim on their own motion.
Line 4. Total Number Processed – Claimant Initiated – Of the number reflected on Line 2, show the number of reopenings initiated by the claimant.
Line 5. Total Number of Clerical Error Reopenings Resulting From Contractor Error -- Of the reopenings reflected in Line 2, show the total number of claims that were the result of contractor error, whether discovered by the contractor or the claimant.
Line 6. Total Number of Clerical Error Reopenings Resulting From Provider Error -- Of the reopenings reflected in Line 2, show the total number of claims that were the result of provider error, whether discovered by the contractor or the claimant.
NOTE: Particularly with regard to Lines 3 through 6, it is possible for the same claim to be reflected on more than one line.
Line 7: Reserved for Future Use
Line 8: Reserved for Future Use
Line 9. Medicare Approved Amount (Not Applicable) – For cases included on Line 2, show the amount paid for services where the determination was reversed either fully or partially. This is the amount sent after the reopening has been completed – the check amount. Round results to the nearest dollar.
NOTE: Time frames noted in Lines 10, 11 and 11a are for clerical error reopenings initiated by the party only. The time frames do not apply to contractor initiated reopenings or mass adjustments. In addition, no time frames have been established for other types of reopenings.
Line 10. Clerical Error Reopenings Processed in 1-30 Days – Show the number of clerical error reopenings from Line 2 processed in 1-30 calendar days. The processing time frame starts from the date of receipt of the request in the contractor’s mailroom.
Line 11. Clerical Error Reopenings Processed in 31-60 Days - Show the number of clerical error reopenings from Line 2 processed in 31-60 calendar days. The processing time frame starts from the date of receipt of the request in the contractor’s mailroom.
Line 11a. Clerical Error Reopenings Processed in More than 60 Days – Show the number of clerical error reopenings from Line 2 processed in 61 days or more. The processing time frame starts from the date of receipt of the request in the contractor’s mailroom.
Line 12. Total Number of Clerical Error Reopening Requests Pending –Show the number of clerical error reopenings pending at the close of the reporting month.
Line 13. Total Number of Higher Level Reopenings Requiring Adjustment by the Contractor – Show the number of claims that were reopened by the QIC, ALJ or Medicare Appeals Council that require an adjustment by the contractor. These are claims for which the contractor must effectuate the claim as a result of the reopening decision at the higher level.
Line 14. Amount Awarded (Not Applicable) – Show the amount approved for services from Line 13 where the determination was reversed, either fully or partially. Show amounts that are sent to the provider. Round results to the nearest dollar.
It is preferable to report the Medicare Approved Amount at the time that cases are reported on line 13. However, CMS will consider it acceptable for contractors to report the Medicare Approved Amount when adjustment claims tied to cases that are reporting or will report to line 13 finalize.
(Rev. 253, 08-06-15, Effective: 01-01-16, Implementation: 01-04-15)
The SSM shall automatically produce the CMS-2592 A/B MAC (B) appeals validation report and the A/B MAC (B) performance validation report on a daily and monthly basis without specific A/B MAC (B) maintenance or request or without A/B MAC (B) intervention.
Before sending the reports to CMS, check for completeness and arithmetical accuracy. Note that the information provided below is applicable to each separate column. Use the following checklist for an arithmetical check for each column:
NOTE: For contractors handling MSP claims, totals for Lines 6.1 through 11.1 may or may not be equal or greater to Lines 6 through 11, respectively.
Line 33b must not exceed Line 33a.
Line 33c must not exceed Line 33a.
(Rev. 253, 08-06-15, Effective: 01-01-16, Implementation: 01-04-15)
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Part A Services | Part B Services | Part B Services | |
| Processed by A/B MAC (A) | Processed by A/B MAC (A) | Processed by A/B MAC (B) or Durable Medical Equipment (DME) MAC | |
| Section I: Redeterminations | |||
| 1: Opening Pending | |||
| 2: Adjustments to Pending | |||
| 3: Adjusted Pending | |||
| 4: Requests Received | |||
| 4.a Adjusted Requests Received | |||
| 4.1 Number of Claims Received |
| 4.2. Recovery Audit Contractor (RAC) Requests Received | |||
|---|---|---|---|
| 4.2.1 Number of RAC Claims Received | |||
| 5: Misrouted Requests Forwarded to Another Contractor | |||
| 6: Requests Cleared | |||
| 6.1 Number of Claims Cleared | |||
| a. SNF | |||
| b. Home Health | |||
| c Inpatient Hospital | |||
| d. Outpatient | |||
| e. Lab | |||
| f. Ambulance | |||
| g. DME | |||
| h. Physician | |||
| i. Other | |||
| 6.2. Recovery Audit Contractor (RAC) Redeterminations Cleared | |||
| 6.2.1 Number of RAC Claims Involved | |||
| 7: Cleared -- Evidence Submitted after Request | |||
| 7.1: Number of Claims Involved | |||
| a. SNF (Not Applicable) | |||
| b. Home Health (Not Applicable) | |||
| c. Inpatient Hospital (Not Applicable) | |||
| d. Outpatient (Not Applicable) | |||
| e. Lab (Not Applicable) | |||
| f. Ambulance (Not Applicable) | |||
| g. DME (Not Applicable) | |||
| h. Physician (Not Applicable) | |||
| i. Other (Not Applicable) | |||
| 7.2: RAC Redeterminations Cleared With Additional Documentation | |||
| 7.2.1: Number of RAC Claims Involved | |||
| 8: Affirmations |
| 8a. Waiver of Liability Amount Paid (Not Applicable) | |||
|---|---|---|---|
| 8.1: Number of Claims Affirmed | |||
| a. SNF | |||
| b. Home Health | |||
| c. Inpatient Hospital | |||
| d. Outpatient | |||
| e. Lab | |||
| f. Ambulance | |||
| g. DME | |||
| h. Physician | |||
| i. Other | |||
| 8.2 RAC Redeterminations Affirmed | |||
| 8.2.1: Number of RAC Claims Involved | |||
| 9: Partial Reversals | |||
| 9.1: Number of Claims Partially Reversed | |||
| a. SNF | |||
| b. Home Health | |||
| c. Inpatient Hospital | |||
| d. Outpatient | |||
| e. Lab | |||
| f. Ambulance | |||
| g. DME | |||
| h. Physician | |||
| i. Other | |||
| 9.2: RAC Redeterminations Partially Reversed | |||
| 9.2.1: Number of RAC Claims Involved | |||
| 10: Full Reversals | |||
| 10.1 Number of Claims Fully Reversed | |||
| a. SNF | |||
| b. Home Health | |||
| c. Inpatient Hospital | |||
| d. Outpatient | |||
| e. Lab | |||
| f. Ambulance | |||
| g. DME | |||
| h. Physician | |||
| i. Other | |||
| 10.2: RAC Redeterminations Fully Reversed |
| 10.2.1: Number of RAC Claims Involved | |||
|---|---|---|---|
| 11: Dismissals/Withdrawals | |||
| 11.1 Number of Claims Dismissed or Withdrawn | |||
| a. SNF | |||
| b. Home Health | |||
| c Inpatient Hospital | |||
| d. Outpatient | |||
| e. Lab | |||
| f. Ambulance | |||
| g. DME | |||
| h. Physician | |||
| i. Other | |||
| 11.2: RAC Redeterminations Dismissed or Withdrawn | |||
| 11.2.1: Number of RAC Claims Involved | |||
| 12: Number of Incomplete Redeterminations Requests Dismissed | |||
| 13: Medicare Approved Amount (Not Applicable) | |||
| 14: Redeterminations Processing Time –Average | |||
| 15: Redeterminations Completed in 1-60 days | |||
| 15a. RAC Redeterminations Completed in 1-60 days | |||
| 16: Redeterminations Completed in Over 60 days | |||
| 16 a. RAC Redeterminations Completed in Over 60 days | |||
| 17: Redeterminations Processing Time- Average (Documentation Submitted Later) | |||
| 18: Redeterminations Completed in 1-60 days (Documentation Submitted Later) | |||
| 18a. RAC Redeterminations Completed in 1-60 days (Documentation Submitted Later) | |||
| 19: Redeterminations Completed in 61-74 days (Documentation Submitted Later) |
| 19a. RAC Redeterminations Completed in 61-74 days (Documentation Submitted Later) | |||
|---|---|---|---|
| 20: Redeterminations Completed in over 74 days (Documentation Submitted Later) | |||
| 20a. RAC Redeterminations Completed in over 74 days (Documentation Submitted Later) | |||
| 21: Closing Pending Redeterminations | |||
| 22 Redeterminations Pending 1-30 days | |||
| 23: Redeterminations Pending 31-60 days | |||
| 24: Redeterminations Pending 61-74 Days | |||
| 25: Redeterminations Pending Over 74 days | |||
| 26: Total Effectuations | |||
| 26a: Number of Claims Involved | |||
| 27: Number Effectuated 1-30 Days | |||
| 28: Number Effectuated 31-60 Days | |||
| 29: Number Effectuated over 60 Days | |||
| Section II: QIC Reconsiderations | |||
| 30: Opening Pending | |||
| 31: Adjustments to Pending | |||
| 32: Adjusted Opening Pending | |||
| 33: Requests For QIC Reconsideration Received by the Contractor | |||
| 33a. Misrouted Requests Forwarded to QIC | |||
| 33b. Misrouted Requests Forwarded Timely | |||
| 33c. Misrouted Requests Forwarded Untimely | |||
| 34. Requests from QIC for Case Files | |||
| 35: Number of Case Files Forwarded to QIC | |||
| 36: Number Forwarded in 1-5 days |
| 36a: Number Forwarded in 6 Days | |||
|---|---|---|---|
| 37: Number Forwarded in 7-8 Days | |||
| 37a: Number Forwarded in Over 8 Days | |||
| 38: Average Time to Forward | |||
| 39. Pending Case File Requests | |||
| 40: Number of QIC Decisions Received from QIC | |||
| 41: Number of QIC Decisions that Need Effectuation | |||
| 41a. Number of Claims Involved | |||
| 42: Total Effectuations | |||
| 42a. Number of Claims Involved | |||
| 43. Number Effectuated in 1-30 Days | |||
| 43a. Contractor Computed Amount | |||
| 44: Number Effectuated in 31-60 Days | |||
| 44a. Contractor Computed Amount | |||
| 45: Number Effectuated in Over 60 Days | |||
| 45a: Contractor Computed Amount | |||
| 46 Medicare Approved Amount (Not Applicable) | |||
| 46a. Waiver of Liability Amount Paid (Not Applicable) | |||
| 47: Closing Pending Reconsiderations | |||
| Section III: ALJ Results | |||
| 48: Opening Pending | |||
| 49: Number of Appeal Requests for ALJ Hearing Misrouted to Contractor | |||
| 50: Number of ALJ Decisions Received from Administrative QIC | |||
| 51: Number of ALJ Decisions Received that Need Effectuation |
| 51a Number of Claims Involved | |||
|---|---|---|---|
| 52: Total Effectuations | |||
| 52a. Number of Claims Involved | |||
| 53: Number Effectuated in 1-30 Days | |||
| 54: Number Effectuated in 31-60 days | |||
| 55: Number Effectuated in Over 60 Days | |||
| 56: Medicare Approved Amount (Not Applicable) | |||
| 56a. Waiver of Liability Amount Paid (Not Applicable) | |||
| 57: Closing Pending ALJ Decisions | |||
| Section IV: Medicare Appeals Council Effectuations | |||
| 58: Medicare Appeals Council Effectuations |
| 1: Total Number of Clerical Error Reopenings Received | |||
|---|---|---|---|
| 2: Total Number of Clerical Error Reopenings Processed | |||
| 3. Total Number Processed – Own Motion | |||
| 4. Total Number Processed – Claimant Initiated | |||
| 5: Total Number of Clerical Error Reopenings Resulting from Contractor Error | |||
| 6: Total Number of Clerical Error Reopenings Resulting from Provider Error | |||
| 7. Reserved for Future Use | |||
| 8. Reserved for Future Use | |||
| 9. Medicare Approved Amount (Not Applicable) | |||
| 10. Clerical Error Reopenings Processed in 1-30 days | |||
| 11. Clerical Error Reopenings Processed in 31-60 days |
| 11.a Clerical Error Reopenings Processed in More than 60 days | |||
|---|---|---|---|
| 12. Total Number of Clerical Error Reopening Requests Pending | |||
| 13. Total Number of Higher Level Reopenings Requiring Adjustment by the Contractor | |||
| 14. Amount Awarded (Not Applicable) |
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
(Rev. 12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
This report, referenced as Form Y for CROWD, is used only when program requirements compel CMS to collect data on an interim basis before the data elements can be incorporated into one of the regular forms. The Medicare contractor submits the appropriate information for the reporting period for each office assigned a separate contractor number and BSI no later than the 10th day of the following month using instructions in the CROWD User Guide available via the CMS Enterprise Portal.
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11)
Exhibit - Special Purpose Data
| SPECIAL PURPOSE DATA | ||||||
|---|---|---|---|---|---|---|
| CONTRACTOR | NUMBER | |||||
| DESCRIPTION | CODE | COL 1 | COL 2 | COL 3 | COL 4 | COL 5 |
| 0000 | 0 | 0 | 0 | 0 | 0 | |
| 0000 | 0 | 0 | 0 | 0 | 0 | |
| 0000 | 0 | 0 | 0 | 0 | 0 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R12894FM | 10/17/2024 | Migration of the Contractor Reporting of Operational and Workload Data (CROWD) to the Centers for Medicare & Medicaid Services (CMS) Enterprise Portal – Internet-Only Manual (IOM) Updates | 11/01/2024 | 12743 |
| R12456FM | 01/11/2024 | New Physician Specialty Code for Epileptologists | 07/01/2024 | 13425 |
| R10521FM | 12/16/2020 | New Medicare National Uniform Billing Committee (NUBC) Type of Bill (TOB), Condition Code and implementing Billing Codes for Opioid Treatment Programs | 01/04/2021 | 11856 |
| R10374FM | 09/25/2020 | New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services | 10/05/2020 | 11750 |
| R10319FM | 08/28/2020 | Removal of Contractor Requirement to Submit Electronic Data Interchange (EDI) Data into the Contractor Reporting of Operational and Workload Data (CROWD) System (Form 5) | 09/29/2020 | 11909 |
| 08/06/2020 | New Medicare National Uniform Billing Committee (NUBC) Type of Bill (TOB), Condition Code and implementing Billing Codes for Opioid Treatment Programs- Rescinded and replaced by transmittal 10521 SENSITIVE/CONTROVERSIAL | 01/04/2021 | 11856 | |
| R10124FM | 05/08/2020 | New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services- Rescinded and replaced by transmittal 10374 | 10/05/2020 | 11750 |
| 12/05/2019 | New Medicare Provider Specialty Code (D5) and Billing Codes for Opioid Treatment Programs and New Place of Service Code 58 | 01/06/2020 | 11353 | |
| 10/29/2019 | New Medicare Provider Specialty Code (D5) and Billing Codes for Opioid Treatment Programs and New Place of Service Code 58 SENSITIVE/CONTROVERSIAL | 01/06/2020 | 11353 | |
| 09/23/2019 | New Medicare Provider Specialty Code (D5) and Billing Codes for Opioid Treatment Programs and New Place of Service Code 58- Rescinded and replaced by Transmittal 329 SENSITIVE/CONTROVERSIAL | 01/06/2020 | 11353 |
| 08/01/2019 | New Medicare Provider Specialty Code (D5) and Billing Codes for Opioid Treatment Programs and New Place of Service Code 58-Rescinded and replaced by Transmittal 324 SENSITIVE/CONTROVERSIAL | 01/06/2020 | 11353 | |
|---|---|---|---|---|
| R315FM | 05/17/2019 | Update to Publication (Pub.) 100-06 to Provide Language-Only Changes for the New Medicare Card Project | 06/18/2019 | 11211 |
| R309FM | 12/20/2018 | New Physician Specialty Code for Undersea and Hyperbaric Medicine | 01/07/2019 | 10666 |
| R304FM | 04/27/2018 | New Physician Specialty Code for Medical Genetics and Genomics | 10/01/2018 | 10457 |
| R302FM | 03/30/2018 | Removal of Contractor Reporting Requirements for the Physician Scarcity Area (PSA), the Health Professional Shortage Area Surgical Incentive Payment Program (HSIP) and the Primary Care Payment Incentive Program (PCIP) Quarterly Reports | 07/02/2018 | 10406 |
| R298FM | 02/02/2018 | Removal of Contractor Reporting Requirements for the Physician Scarcity Area (PSA), the Health Professional Shortage Area Surgical Incentive Payment Program (HSIP) and the Primary Care Payment Incentive Program (PCIP) Quarterly Reports Rescinded and replaced by Transmittal 302 | 07/02/2018 | 10406 |
| R290FM | 07/14/2017 | New Specialty Code for Pharmacy | 01/02/2018 | 9821 |
| R283FM | 04/28/2017 | New Physician Specialty Code for Advanced Heart Failure and Transplant Cardiology, Medical Toxicology, and Hematopoietic Cell Transplantation and Cellular Therapy | 10/02/2017 | 9957 |
| R276FM | 11/25/2016 | New Physician Specialty Code for Hospitalist | 04/03/2017 | 9716 |
| R274FM | 10/28/2016 | New Physician Specialty Code for Hospitalist – Rescinded and replaced by Transmittal 276 | 04/03/2017 | 9716 |
| R269FM | 06/22/2016 | New Physician Specialty Code for Dentist | 07/05/2016 | 9355 |
| R268FM | 06/15/2016 | New Physician Specialty Code for Dentist – Rescinded and replaced by Transmittal 269 | 07/05/2016 | 9355 |
| R265FM | 03/16/2016 | Contractor Reporting of Operational and Workload Data (CROWD) Form 5 Update with Revisions to Pub. 100-06 Medicare Financial Management Manual, Chapter 6 | 07/05/2016 | 8998 |
| R263FM | 02/05/2016 | Contractor Reporting of Operational and Workload Data (CROWD) Form 5 Update with Revisions to Pub. 100-06 Medicare Financial Management Manual, Chapter 6 – Rescinded and replaced by Transmittal 265 | 07/05/2016 | 8998 |
|---|---|---|---|---|
| R262FM | 01/29/2016 | New Physician Specialty Code for Dentist – Rescinded and replaced by Transmittal 268 | 07/05/2016 | 9355 |
| R253FM | 08/06/2015 | Update the Contractor Reporting of Operational and Workload Data (CROWD) CMS-2592 Report to Indicate Requests Received in Claims and Requests Received That Are Recovery Audit Related | 01/04/2015 | 9157 |
| R248FM | 12/19/2014 | Revision of Pub. 100-06 - Medicare Financial Management Manual, Chapter 6 - Intermediary and Carrier Financial Reports, and Pub. 100-09 - Medicare Contractor Beneficiary and Provider Communications, Chapter 6 - Provider Customer Service Program | 01/23/2015 | 8906 |
| R238FM | 08/22/2014 | New Physician Specialty Code for Interventional Cardiology | 01/05/2015 | 8812 |
| R221FM | 06/12/2013 | New Non-Physician Code for Complimentary Insurer | 10/07/2013 | 8282 |
| R219FM | 05/03/2013 | New Non-Physician Code for Complimentary Insurer – Rescinded and replaced by Transmittal 221 | 10/07/2013 | 8282 |
| R216FM | 12/14/2012 | Modification/Addition of Group Codes/Specialty Codes | 01/15/2013 | 8090 |
| R212FM | 08/10/2012 | New Non-Physician Specialty Code for Centralized Flu | 01/07/2012 | 7884 |
| R209FM | 04/27/2012 | New Physician Specialty Code for Sleep Medicine and Sports Medicine | 10/01/2012 | 7600 |
| R195FM | 09/30/2011 | To Create Form 9 Within the Contractor Reporting of Operational and Workload Data (CROWD) System for the Reporting of Primary Care Incentive Payments (PCIP) and HPSA Surgical Incentive Payments (HSIP) | 07/05/2011 | 7285 |
| R191FM | 07/13/2011 | Add Physician Specialty Codes for Cardiac Electrophysiology (21) and Sports Medicine (23) to CROWD Forms “F” (ParDoc) and “8” (OptOut) – Rescinded and replaced by Transmittal 191 | 07/05/2011 | 7233 |
| R188FM | 04/22/2011 | Modify CROWD Form K to Allow the Submission of Additional Medicare Summary Payer (MSP) Savings Information | 07/05/2011 and 10/03/2011 | 7291 |
| R183FM | 02/04/2011 | To Create Form 9 Within the Contractor Reporting of Operational and Workload Data (CROWD) System for the Reporting of Primary Care Incentive Payments (PCIP) and HPSA Surgical Incentive Payments (HSIP) – Rescinded and replaced by Transmittal 195 | 07/05/2011 | 7285 |
| R181FM | 01/04/2011 | Add Physician Specialty Codes for Cardiac Electrophysiology (21) and Sports Medicine (23) to CROWD Forms “F” (ParDoc) and “8” (OptOut) – Rescinded and replaced by Transmittal 191 | 07/05/2011 | 7233 |
| R178FM | 12/03/2010 | Add Physician Specialty Codes for Cardiac Electrophysiology (21) and Sports Medicine (23) to CROWD Forms “F” (ParDoc) and “8” (OptOut) - Rescinded and replaced by Transmittal 181 | 07/05/2011 | 7233 |
|---|---|---|---|---|
| R177FM | 12/03/2010 | Add Supplier Specialty Code 95 (Advanced Diagnostic Imaging (ADI) Accreditation) to CROWD Form F (Participating Physician/Supplier Report) – Rescinded and not replaced. | 07/05/2011 | 7226 |
| R176FM | 11/12/2010 | Clarification for Data Entry on Health Professional Shortage Area Reports | 12/13/2010 | 7223 |
| R175FM | 10/28/2010 | Change the Name of Physician Specialty Code 12 from Osteopathic Manipulative Therapy to Osteopathic Manipulative Medicine | 04/04/2011 | 7093 |
| R173FM | 10/15/2010 | Update to the Quarterly Opt Out Reporting Form (Form 8) in the Contractor Reporting of Operational Workload Data (CROWD) | 11/16/2010 | 7165 |
| R171FM | 05/28/2010 | Expansion of Form 5 of the Contractor Reporting of Operational and Workload Data (CROWD) | 10/04/2010 | 6969 |
| R170FM | 05/21/2010 | Cardiac Rehabilitation and Intensive Cardiac Rehabilitation | 10/04/2010 | 6850 |
| R163FM | 12/04/2009 | Add Physician Specialty Code 27 (Geriatric Psychiatry) to CROWD Form F (Participating Physicians/Supplier Report) | 04/05/2010 | 6613 |
| R159FM | 10/09/2009 | Add Physician Specialty Code 27 (Geriatric Psychiatry) to CROWD Form F (Participating Physicians/Supplier Report) – Rescinded and replaced by Transmittal 163 | 04/05/2010 | 6613 |
| R157FM | 08/21/2009 | Add Specialty Codes to CROWD Form F (Participating Physicians Data) | 01/04/2010 | 6580 |
| R155FM | 07/31/2009 | New Reporting Requirements for the Quarterly Opt Out Report in Contractor Reporting of Operational Workload Data (CROWD) | 01/04/2010 | 6562 |
| R144FM | 11/28/2008 | Revisions to the Monthly Statistical Report on Intermediary and Carrier Part A and Part B Appeals Activity Form (CMS-2592) to Capture Data on Recovery Audit Contractor (RAC) Redeterminations | 04/06/2009 | 6251 |
| R131FM | 09/21/2007 | Participating Physicians Report – Deletion of Requirement to Forward a Memorandum to CMS Detailing Adjustments for Form F Column 1 (PAR Prior) (from previous enrollment period) | 01/07/2008 | 5697 |
| R130FM | 08/31/2007 | “Revisions” of the CROWD Report | 01/07/2008 | 5555 |
| R126FM | 07/13/2007 | Manual Revision Re: MSN Workload Reporting | 01/07/2008 | 5642 |
| R123FM | 06/08/2007 | Contractor CROWD Form 5 Completion Changes | 10/01/2007 | 4274 |
| R121FM | 05/02/2007 | Contractor CROWD Form 5 Completion Changes – Replaced by Transmittal 123 | 10/01/2007 | 4274 |
| R119FM | 04/20/2007 | Contractor CROWD Form 5 Completion Changes - Replaced by Transmittal 121 | 10/01/2007 | 4274 |
|---|---|---|---|---|
| R98FM | 06/16/2006 | Correction of CROWD Form 5 Reporting for Internet Pilot Carriers | 07/17/2006 | 5120 |
| R96FM | 05/26/2006 | Development of New Report to Capture BIPA and MMA Appeals Data | 07/03/2006 | 5056 |
| R88FM | 01/06/2006 | Clarification to IOM 100-06, Sections 290.7 and 290.8 | 02/06/2006 | 4198 |
| R86FM | 12/02/2005 | Development of New Report to Capture BIPA and MMA Appeals Data – Replaced by Transmittal 96, CR 5056 | 07/03/2006 | 4148 |
| R85FM | 11/17/2005 | Expansion of Form 5 of the Contractor Reporting of Operational and Workload Data (CROWD) – Replaced by Transmittal 85 | 04/03/2006 | 3864 |
| R82FM | 10/31/2005 | Expansion of Form 5 of the Contractor Reporting of Operational and Workload Data (CROWD) – Replaced by Transmittal 85 | 04/03/2006 | 3864 |
| R76FM | 08/12/2005 | Development of New Report to Capture BIPA and MMA Appeals Data – Replaced by Transmittal 86, CR 4148 | 04/03/2006 | 3837 |
| R65FM | 02/25/2005 | Revised Reporting Requirements for Contractor Reporting of Operational and Workload Data (CROWD) Physician Scarcity Area (PSA) Quarterly Report (CMS Form-1565F, CROWD Form 6) | 07/05/2005 | 3673 |
| R57FM | 10/22/2004 | Revised Reporting Requirements for Contractor Reporting of Operational and Workload Data (CROWD) Health Professional Shortage Area (HPSA) Quarterly Report (CMS Form-1565E, CROWD Form S) | 04/04/2005 | 3472 |
| R56FM | 10/22/2004 | Revision to Balancing Requirements on Form 5, Line 10 of the Contractor Reporting of Operational and Workload Data (CROWD) | 11/22/2004 | 3486 |
| R45FM | 05/28/2004 | Workload Reporting | N/A | 3246 |
| R40FM | 04/30/2004 | Medicare Contractor Transaction Report | 10/04/2004 | 3257 |
| R36FM | 03/12/2004 | Medicare Contractor Transaction Report (FormCMS-5) | N/A | 2249 & 2547 |
| R06FM | 08/30/2002 | Initial Publication of Chapter | N/A | N/A |
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