Medicare Financial Management Manual 
Chapter 5 - Financial Reporting 
 
Table of Contents 
(Rev. 315, 05-17-19) 
 
 
Transmittals for Chapter 5 
 
10 - Checks Paid Method - General 
20 - Summary of Procedures 
30 - Establishment of Special Bank Accounts 
30.1 - Execution of Bank Agreement 
30.2 - Collateral Requirement 
30.3 - Changes in Collateral Pledged as Security for Federal Health Insurance 
Accounts 
30.4 - Check Format Specifications 
40 - Signature of Bank Individuals Authorized to Draw on The Letter-of-Credit 
40.1 - Revision of Signature Cards 
40.2 - Request for Additional Cards 
40.3 - Signatures of Contractor Personnel Authorized for Federal Health 
Insurance Time Account 
50 - Withdrawal of Federal Funds 
60 - Use of Payment Vouchers 
70 - Form CMS-1521, Payment Voucher on Letter-of-Credit Transmittal 
70.1 - Instructions for Completion of Form CMS-1521 
80 - Form CMS-1522, Monthly Contractor Financial Report 
80.1 - Instructions for Completion of Form CMS-1522 
80.2 - Medicare Contractor Monthly Cash Collections Worksheet 
90 - Intermediary Benefit Payment Report (Form CMS-456) 
90.1 - Purpose and Scope 
90.2 - Due Dates and Transmittal 
90.3 - Verification of Data 
90.4 - Accuracy of Data Contained on Report and Reconciliation of Data 
Reflected on Monthly Intermediary Financial Report (Form CMS-1522) 
90.5 - General Reporting Instructions 
90.6 - Instructions for Completion of the IBPR 
90.7 - Form CMS-456 - Schedule R 
100 - Issuance of Letter-of-Credit 
100.1 - Monthly Limitation 
100.2 - Amending Letter-of-Credit 
100.3 - Establishment of Accounting Records 
110 - Initial Federal Health Insurance Time Account Deposit 
110.1 - Subsequent Time Account Deposits and Adjustments 
110.2 - Bank Account Analysis  120 - Reviewing Bank Agreements 
120.1 - Terminating Bank Agreements 
120.2 - Terminating Federal Health Insurance Accounts 
120.3 - Phase-out Period for Federal Health Insurance Bank Accounts 
130 - Invitation for Bid (IFB) to Provide Banking Services Under The Checks Paid 
Method of Letter-of-Credit Financing 
140 - Bonding 
150 - Letter-of-Credit Check List 
160 - Electronic Funds Transfer (EFT) 
170 - Electronic Remittance Advice (ERA) 
180 - Exhibits 
190 - General Information About Termination Costs 
200 - General 
210 - Instructions for Completing The Form CMS-750A/B, Contractor Financial Reports 
220 - Due Date 
230 - Certification 
240 - Instructions for Completing Form CMS-751 A/B, Status of Accounts Receivable 
250 - Due Date 
260 - Certification 
270 - Line Item Instructions Form CMS-751A/B 
270.1 - Line 1, Beginning FY Balance (Principal & Interest) 
270.2 - Line 2a, New Receivables (Principal) 
270.3 - Line 2b, Accrued Receivables (Principal) 
270.4 - Line 3, Interest Earned (Interest) 
270.5 - Line 4a, Cash/Check Collections on Receivables (Principal & Interest) 
270.6 - Line 4b, Offset Collections on Receivables (Principal & Interest) 
270.7 - Line 4c, Collections Deposited at Another Location (Principal & Interest) 
270.8 - Line 5, Adjusted/Transferred/Waived Amounts (Principal & Interest) 
270.9 - Line 6, Amounts Written-off Closed (Bad Debts)/Transferred CNC 
(Principal & Interest) 
270.10 - Line 7, Ending Balance (Principal & Interest) 
270.11 - Line 7a, Current Receivables (Principal) 
270.12 - Line 7b, Non-current Receivables (Principal) 
270.13 - Line 8, Allowance for Uncollectible Accounts (Principal & Interest) 
270.14 - Line 9, Total Receivables Net of Allowance 
270.15 - Line 10, Cash/Offsets Received for Receivables at Another Location 
(Principal & Interest). 
270.16 - Line 1, Total Not Delinquent (Principal & Interest) 
270.17 - Line 2, Total Delinquencies (Principal & Interest) 
270.18 - Line 3, Status of Delinquent Receivables, less than or equal to 180 Days 
(Principal & Interest) 
270.19 - Line 4, Status of Delinquent Receivables, greater than 180 Days 
(Principal & Interest) 
270.20 - Line 4c, Collections Deposited at Another Location (Principal & 
Interest)  270.21 - Line 10, Cash/Offsets Received for Receivables at Another Location 
(Principal & Interest) 
270.22 - Collections on Delinquent Debt (Principal & Interest) 
270.23 - Line 5c, Transfers Out to other Medicare Contractors (Principal & 
Interest) 
270.24 - Line 5e, Transfers Out to other CMS Locations, POR/PSOR (Principal & 
Interest) 
270.25 - Line 5g, Transfers Out to other CMS Locations, Not POR (Principal & 
Interest) 
280 - Instructions for Completing the CMS-C751A/B, Status of Debt - Currently Not 
Collectible (CNC), and CMS-MC751A/B, Status of MSP Debt - Currently Not 
Collectible (CNC) 
290 - Due Date 
300 - Certification 
310 - Line Item Instructions CMS-C751A/B - Non-MSP and CMS-MC751A/B - MSP 
310.1 - Line 1, Beginning FY Balance (Principal & Interest) 
310.2 - Line 2, New CNC Debt (Principal & Interest) 
310.3 - Line 3, Interest Earned Since CNC Approval (Interest) 
310.4 - Line 4(a) through (e), Reclassified CNC Debt (Principal & Interest) 
310.5 - Lines 5(a) through (f), Amounts Transferred (Principal & Interest) 
310.6 - Line 6, Ending Balance (Principal & Interest) 
310.7 - Line 1, Total Aged CNC Debt (Principal & Interest) 
310.8 - Collections on CNC Debt (Principal & Interest) 
310.9 - Status of CNC Debt over 181 Days (Principal & Interest) 
400 - Exhibits 
400.1 - Exhibit 1 - Statement of Financial Position and Statement of Operations - 
HI/SMI 
400.2 - Exhibit 2 - Statement of Financial Position and Statement of Operations - 
SMI 
400.3 - Exhibit 3 - Status of Accounts Receivable - HI 
400.4 - Exhibit 4 - Status of Accounts Receivable - SMI 
400.5 - Exhibit 5 - Status of Non-MSP Debt - CNC - HI 
400.6 - Exhibit 6 - Status of Non-MSP Debt - CNC - SMI 
400.7 - Exhibit 7 - Status of MSP Accounts Receivable - HI 
400.8 - Exhibit 8 - Status of MSP Accounts Receivable - SMI 
400.9 - Exhibit 9 - Status of MSP Debt - CNC - HI 
400.10 - Exhibit 10 - Status of MSP Debt - CNC - SMI 
400.11 - Exhibit 11 - Medicare Contractor Account Definitions - Data Element 
Definitions 
400.12 - Exhibit 12 - Accounts Payable - Protocol for Estimating Claims - Form 
CMS-750A/B, Statement of Financial Position 
400.13 - Exhibit 13 - Periodic Interim Payments (PIP) Protocol for Estimating 
Payables/Receivables for the Form CMS-750A/B, Statement of Financial Position 
(Intermediaries Only) 
400.14 - Exhibit 14 - Protocol for Estimating Allowance for Uncollectible 
Accounts Form CMS H/M -751A/B, Status of Accounts Receivable  400.15 - Exhibit 15 - Protocol for Prorating Intermediary Time Account Balances 
Between Form CMS 750A (HI) and Form CMS 750B (SMI) 
400.16 - Exhibit 16 - Electronic Certification 
400.17 - Exhibit 17 - Instructions for the Transfer of Debt Between Reporting 
Entities 
400.18 - Exhibit 18 - Collection Reconciliation/Acknowledgement Form 
400.20 - Exhibit 20 - Procedures for Reporting Currently Not Collectible (CNC) 
Debt 
400.21 - Exhibit 21 - CMS Policy for Recognizing Accounts Receivable 
400.22 - Exhibit 22 - Accounts Receivable Trending Analysis Procedures 
400.23  Exhibit 23  Instructions for the Benefits Payable Survey 
400.24  Exhibit 24  Benefits Payable Trending Analysis Procedures 
410  Unsolicited Voluntary Refunds 
410.1  General Information 
410.2  Office of the Inspector General (OIG) Initiatives 
410.3  Unsolicited/Voluntary Refund Accounts 
410.4 - Receiving and Processing Unsolicited/Voluntary Refund Checks When 
Identify Information is Provided 
410.5  Handling Checks or Associated Correspondence with Conditional 
Endorsements 
410.6 - Receiving and Processing Unsolicited/Voluntary Refund Checks when 
Identifying Information is not Provided 
410.7  CMS Reporting Requirements With the Exception of MSP 
410.8  Exhibit 1 Overpayment Refund 
410.9 - Exhibit 2 Unsolicited/Voluntary Refund Checks  Summary Report 
410.10 - Education 
411  Exhibits 
411.1  Overpayment Refund Form 
411.2  Exhibit 2 - Unsolicited/Voluntary Refund Checks  Summary Report 
411.3  OIG Law Enforcement Demand Letter 
420  Procedures for Re-issuance and Stale Dating of Medicare Checks 
500  Procedures for the Reconciliation of Total Funds Expended for Fiscal Intermediary 
Shared System (FISS) Medicare Contractors Used in the Preparation of Form CMS-1522, 
Monthly Contractor Financial Report 
500.1  Identification and Summarization of Detailed Claims Data Records for 
Use in the Financial Reconciliation of Total Funds Expended to Fiscal 
Intermediary Shared System Reports 
500.2  Using the Electronic Spreadsheet to Complete the Reconciliation of the 
Detailed Claims Data File to Fiscal Intermediary Shared System Reports 
500.3  Electronic Spreadsheet Input Schedule 
500.4  Total Funds Expended (Net Disbursements and Adjustments to Net 
Disbursements) 
500.5  Reconciliation of Detailed Claims Data File to FISS System Reports 
500.6  Reconciliation of Non-PIP Payments on FISS System Reports 
500.7  Reconciliation of Interest Received and Paid on FISS System Reports 
500.8  Categorization of Total Funds Expended by Category   510-Procedures for the Reconciliation of Total Funds Expended for Multi-Carrier System 
(MCS) Medicare Contractors Used in the Preparation of Form CMS-1522, Monthly 
Contractor Financial Report 
510.1 - Reconciliation of Detailed Claims Data File to Multi-Carrier System 
(MCS) Report 
510.2 - List of Primary MCS Reports Used in the Reconciliation of Total Funds 
Expended 
510.3 - Standard MCS 1522 Reconciliation Lead Schedule 
510.4 - Reconciliation of Claim Payments from the Detailed Claims Data 
File/Report to the Month-to-Date Analysis of Payment (MCS Report #2002 or 
HBDR2002) 
510.5 - Proof of Net Disbursements and Total Issues per Detailed Claims Data 
File/Report 
510.6 - Proof of Net Disbursements and Total Issues Per MCS Report #2002 
510.7 - Reconciliation of Net Disbursements and System Issues from the Detailed 
Claims Data File/Report to the Month-to-Date Analysis of Payment (HBDR2002) 
510.8 - Proof of Net Disbursement per MCS Register Summary Report 
(HBDR6000) to the Month-to-Date Analysis of Payments (HBDR2002 Report, 
Line G 
510.9 - Input Sheet for Cash Activity Items 
520  Instructions for Completion of the Contractors Monthly Bank Reconciliation 
Worksheet 
 
NOTE: Throughout this chapter, reference to provider includes institutional providers, 
physicians, and suppliers, i.e., all delivers of health care services that are reimbursed by 
either the intermediary or the carrier. 
 
NOTE: Revision 1, the initial release of this chapter, includes a cross reference to the 
source sections in current manuals. The manual is identified by A1, A2, A3, or A4 for 
Intermediary Manual Parts 1 through 4; or by B1, B2, B3 or B4 for Carriers Manual Parts 
1 through 4. This indicator is followed by a dash and the related section number. 
  10 - Checks Paid Method - General - (Rev. 5, 08-30-02) 
A1-1400, B1-4400 
 
Certified Letter-of-Credit Defined: 
 
A certified letter-of-credit is a legal reservation of funds on deposit in the Federal 
Reserve Bank that covers payments for which the contractor has contracted to pay by 
issuing checks and authorizing electronic funds transfer. 
 
The objective of the letter-of-credit checks paid method of financing is to reduce the level 
of the Federal debt and the interest costs of short-term borrowing. This method provides 
cash availability to meet Medicare program requirements, while at the same time, 
controls the timing of cash withdrawals so that the impact of these withdrawals on the 
public debt level and related financing costs is minimized. Cash flow is controlled by: 
 
  Postponing withdrawal of funds from the U.S. Treasury until Medicare checks are 
presented to the contractor's Medicare servicing bank for payment; 
 
  Limiting the amount withdrawn at any time; and  
 
  Reducing the amount of Federal funds required to offset bank service charges. 
 
The Treasury Department requires all Government agencies that make advance payments 
to utilize the letter-of-credit checks paid method of financing. (See Circular No. 1075, 
revised February 27, 1973, and Chapter 1000 of the Treasury Fiscal Requirements 
Manual.) 
 
20 - Summary of Procedures - (Rev. 5, 08-30-02) 
A1-1401, B1-4401 
 
A contractor shall use the following steps to implement the letter-of-credit checks paid 
method of financing: 
 
  It shall notify the RO 165 days prior to the expiration of the current three-party 
bank agreement when a new bank will be secured under the checks paid method; 
 
  It shall request the latest copy of the Invitation for Bid (IFB) from the Regional 
Office (RO); 
 
  It shall use the IFB package as a guide to prepare its IFB. The language contained 
in the package cannot be materially altered except for "BID FORMS AND 
CONTRACTOR'S REQUIRED MEDICARE BANKING SERVICES." (See 
Attachment A, Section G, of the package.) The contractor shall obtain from its 
RO the implementation package that contains examples of material required for 
the bid process as follows: 
    Letter to Commerce Business Daily requesting IFB advertisement; and  
o
 
  Sample write-ups of contractor's specifications for bank services, 
o
computer requirements, check specifications, and electronic funds transfer 
capability; 
 
  It shall send the completed IFB to its RO for approval prior to its release for bid. 
It shall send an additional copy to: 
 
Centers for Medicare & Medicaid Services 
Office of Financial Management 
7500 Security Boulevard 
Baltimore MD 21244-1850 
 
  Obtain bids from two or more banks; 
 
  Follow the Federal Acquisition Regulations (FAR), Part 14, when securing 
competitive bids; 
 
  Evaluate the bank bids and, with the concurrence of the servicing RO, select the 
commercial bank that meets all of the mandatory requirements and submits the 
lowest required time account balance; 
 
  Select a commercial bank and establish special bank accounts; 
 
  Secure Signature Cards. Use Form SF-1194 to obtain the signatures of those 
individuals authorized by the bank to draw payment vouchers against the letter-
of-credit and the signature of the bank official who has the authority to designate 
the authorized individuals; 
 
NOTE:  CMS executes the three-party bank agreement between the contractor, the bank, 
and the Government (the servicing RO). CMS also issues a letter-of-credit that sets forth 
the monthly limitation. 
 
  Post (Bank) collateral with the Federal Reserve Bank; 
 
  Establish (Bank) both the Benefits Account and the Time Account; 
 
  Submit monthly letter-of-credit transmittals (form CMS-1521) via Contractor 
Administrative Financial Management (CAFM) to the Funds Control Branch, 
Central Office. Distribute Medicare funds withdrawn by bank via FNS-5401 
payment voucher according to type of benefits; and  
 
  Submit the monthly form CMS-1522, TAA-1b and TAA-1C, to CMS via the 
CAFM system. 
  30 - Establishment of Special Bank Accounts - (Rev. 5, 08-30-02) 
A1-1403, B1-4403 
 
Keep all Federal funds withdrawn under the letter-of-credit separate from all other funds. 
Designate the Medicare account for deposit in a special bank account established by you 
in a member bank of the Federal Reserve System. Designate the special demand deposit 
checking account as follows: 
 
(Name of Contractor) 
Federal Health Insurance Benefits Account 
 
Designate the special non-interest bearing time account as follows: 
 
(Name of Contractor) 
Federal Health Insurance Time Account 
 
Restrict withdrawals to transfer of funds to the Federal Health Insurance Benefits 
account.(FHIBA) 
 
30.1 - Execution of Bank Agreement - (Rev. 5, 08-30-02) 
A1-1403.1, B1-4403.1 
 
The contractor shall execute the three-party bank agreement with the selected commercial 
bank. The bank agreement requires that the Federal Government retain a lien on all funds 
held in the special bank account. The bank abides by written instructions of the 
Government with regard to the deposit and withdrawal of funds. The Government also 
has the right to inspect or audit the bank's books and records that pertain to the special 
accounts. (Refer to Attachment C of the IFB package.) 
 
The contractor shall use the following guidelines when it executes a bank agreement; 
 
  It must strictly adhere to the wording and format of the bank agreement. 
 
  It may alter only Covenant 7. The provisions of Covenant 7 may, by agreement of 
all parties, be written to require either a one or two-year period of performance 
following the initial two year period; 
 
  The RO forwards an original and three copies of the completed three-party 
agreement to the bank via the contractor for execution. Each copy of the bank 
agreement must contain original signatures. Facsimile signatures are not 
acceptable; and  
 
  After it is countersigned by CMS, individual copies of the agreement are 
distributed to: 
 
  The contractor; 
o  
  The bank; 
o
 
  The servicing RO; and 
o
 
  Centers for Medicare & Medicaid Services 
o
Office of Financial Management 
7500 Security Boulevard 
Baltimore MD 21244-1850 
 
30.2 - Collateral Requirement - (Rev. 5, 08-30-02) 
A1-1403.2, B1-4403.2 
 
Posted collateral is based on the balance to be maintained in the time account less FDIC 
coverage, if applicable. The RO advises the contractor, upon notification by the Federal 
Reserve Bank, when collateral is posted. (Collateral must be acceptable under the 
guidelines provided to the Federal Reserve by the Department of the Treasury). 
 
The contractor shall place the collateral with the Federal Reserve Bank or Branch of the 
district where its servicing financial institution is located or with a custodian designated 
by the Federal Reserve Bank or Branch. It shall include a letter with the collateral that 
states that the collateral is pledged as security for public money by CMS, agency account 
number 5555-4454-5 under the terms of 31 CFR, Part 202 (Treasury Circular 176). 
 
30.3 - Changes in Collateral Pledged as Security for Federal Health 
Insurance Accounts - (Rev. 5, 08-30-02) 
A1-1403.3, B1-4403.3 
 
The CMS, Division of Contractor Financial Management (DCFM), monitors collateral 
requirements. DCFM continuously reviews the most recent balances maintained in the 
Federal Health Insurance Bank Accounts. 
 
If an increase in pledged collateral appears necessary, DCFM requests the bank to post 
additional collateral with its Federal Reserve Bank. 
 
If a decrease in pledged collateral appears warranted, DCFM advises the Federal Reserve 
Bank of the amount of excess collateral pledged. 
 
The contractor shall direct any request for release of excess bank collateral to the local 
Federal Reserve Bank. 
 
30.4 - Check Format Specifications - (Rev. 5, 08-30-02) 
A1-1403.4, B1-4403.4, B2-5215 
 
The following phrase must appear on all checks or drafts written for purposes of paying 
benefits and related administrative costs authorized under the Medicare program:   
MEDICARE PAYMENT 
 
For Health Insurance - Social Security Act 
 
The contractor shall use the following check format specifications: 
 
Check Front 
 
The contractor shall center the words "Medicare Payment" at the top of the check or draft 
and print these words in at lease 1/4-inch type. Contractor name and address should 
appear on the face of the check. The check may also include the contractor's emblem or a 
picture of a building it occupies. The contractor may not include advertising on the face 
of the check. (Advertising should not appear on the envelope in which the check is 
mailed.) It is expected that the type sizes of the items placed on the check will not detract 
from the required "Medicare Payment" phrase. 
 
Check Back 
 
The contractor shall print on the back of all Medicare checks the following statement: 
 
"This payment is made with Federal funds. Fraud in procuring, forging a signature or 
endorsement, or materially altering this check is punishable under the U. S. Criminal 
Code." 
 
For carriers, assigned claims must also include the following statement: 
 
"As provided by the terms of the law under which this check is issued, the undersigned 
payee, in accepting assignment, agreed that the charge determination by the Medicare 
carrier shall be the full charge for any service which the check is payable. The patient is 
responsible only for the applicable deductible and coinsurance, and for non-covered 
services." 
 
It is not necessary to show the account name on the check. If one is shown, it should read 
"Federal Health Insurance Benefits Account." If both Part A and Part B are shown, it 
should read, "Federal Health Insurance Benefits Account - Part A" and "Federal Health 
Insurance Benefits Account - Part B."  
 
The time limitation for cashing the check (if specified on the check) cannot be less than 6 
months. 
 
The contractor shall clear formats of checks with the servicing RO prior to printing or 
contracting for printing. 
 
40 - Signature of Bank Individuals Authorized to Draw on The Letter-
Of-Credit - (Rev. 5, 08-30-02) 
A1-1405, B1-4405   
Signatures of bank representatives authorized to sign payment vouchers must be on file 
along with the letter-of-credit at the servicing Federal Reserve Bank or branch in order to 
honor payment vouchers (FMS-5401). The contractor shall submit a signature card, Form 
SF-1194, for the person(s) authorized by the bank to sign payment vouchers. 
 
NOTE:  Executed signature card(s) must be received in DCFM no later than 20 calendar 
days prior to the effective date of a new letter-of-credit. 
 
40.1 - Revision of Signature Cards - (Rev. 5, 08-30-02) 
A1-1405.1, B1-4405.1 
 
The contractor shall prepare new card(s) if more than two signatures are no longer valid. 
 
It shall prepare two original cards for every four individuals. If more than one card is 
needed, i.e., more than 4 individuals are authorized, it shall number the cards 1 of 2, 2 of 
2 to ensure that all cards are received. 
 
New signature cards must contain the signatures of all individuals who will sign payment 
vouchers and be certified by an official of the bank. The contractor need not resubmit a 
new signature card if change in position or title of an individual authorized to sign 
payment vouchers is involved. 
 
The contractor shall mark new signature cards "Replaces and Supersedes all Previously 
Submitted Cards" on the top edge of the card. 
 
40.2 - Request for Additional Cards - (Rev. 5, 08-30-02) 
A1-1405.2, B1-4405.2 
 
The contractor shall send requests for additional signature cards to: 
 
Centers for Medicare & Medicaid Services 
Office of Financial Management 
7500 Security Boulevard 
Baltimore, MD 21244-1850 
 
40.3 - Signatures of Contractor Personnel Authorized for Federal 
Health Insurance Time Account - (Rev. 5, 08-30-02) 
A1-1405.3, B1-4405.3 
 
Signatures of two or more individuals designated by the contractor to sign withdrawal 
requests to transfer funds from the Federal Health Insurance Time Account to the Federal 
Health Insurance Benefits Account must be on file with the designated commercial bank. 
 
50 - Withdrawal of Federal Funds - (Rev. 5, 08-30-02) 
A1-1406, B1-4406   
The Federal Government assures that funds are always in the Federal Reserve Bank to 
honor properly drawn payment vouchers within the limits of the letter-of-credit. This 
arrangement is consistent with State banking laws since it eliminates any possibility of 
intent to defraud. 
 
60 - Use of Payment Vouchers - (Rev. 5, 08-30-02) 
A1-1408, B1-4408 
 
To obtain Federal funds, the bank prepares a daily payment voucher, Treasury Form 
FMS-5401, and forwards it to the servicing Federal Reserve Bank or Branch holding the 
letter-of-credit. 
 
When the bank receives the initial letter-of-credit, the bank sequentially numbers 
payment vouchers drawn beginning with the number one (1). Amendments to the letter-
of-credit do not interrupt the sequential numbering of payment vouchers. 
 
Payment vouchers are prepared only in an amount equal to the contractor's total checks, 
bank debit memos, and electronic funds transferred. These vouchers are presented for 
payment each day less any balance in the benefits account representing collected other 
deposits or transfers from the Federal Health Insurance Time Account. 
 
If the bank is not located in a Federal Reserve Bank (FRB) city, CMS requests the 
Treasury Department to implement a telephonic method of receiving funds for the bank. 
The bank calls its FRB and requests a specific funding amount. The FRB prepares the 
payment voucher and a copy is sent to the bank. 
 
The letter-of-credit provides a ceiling on the amount that may be drawn during the month 
and is purposely set high to meet peak cash needs. In no instance is a payment voucher to 
be drawn for less than $5,000 or more than $5,000,000 (unless the letter-of-credit has 
been annotated "Authorized to draw payment vouchers in excess of $5,000,000"). Only 
one payment voucher should be drawn per day. Regardless of the factors considered in 
determining when and in what amount to draw payment vouchers, banks are expected to 
abide by the intent of the letter-of-credit Checks Paid Method of financing system by 
assuring that the total of the daily voucher processed is the minimum required to finance 
current disbursements. 
 
NOTE: The "Name and Address of Drawer" block on the Treasury Form FMS-5401 
must include the name of the bank as it appears on the letter-of-credit sent by CMS and 
the annotation "agent for" (name of contractor). Due to space limitations, the contractor 
does not have to show the address in this block. A supply of payment vouchers is 
provided to each commercial bank. Additional supplies of payment vouchers may be 
ordered from: 
 
Centers for Medicare & Medicaid Services 
Office of Budget and Administration  Distribution Liason Officer 
7500 Security Boulevard 
Baltimore, MD 21244-1850. 
 
70 - Form CMS-1521, Payment Voucher on Letter-Of-Credit 
Transmittal - (Rev. 5, 08-30-02) 
A1-1410, B1-4410 
 
The purpose of form CMS-1521, Payment Voucher on Letter-of-Credit Transmittal, is to 
record daily voucher data that the contractor's bank submits to the Federal Reserve Bank 
for payment of Hospital Insurance (HI) and Supplemental Medical Insurance (SMI) 
benefit payments. Administrative costs paid through the Smartlink System are also 
reported on the form. Administrative costs are allocated to current or prior fiscal years 
and to special projects. 
 
Transmit form CMS-1521 to CMS by the 15th of each month via the CAFM System. 
(See operating instructions for completion that are contained in the CAFM Users Guide.) 
 
70.1 - Instructions for Completion of Form CMS-1521 - (Rev. 5, 08-30-
02) 
A1-1410.1, B1-4410.1 
 
Data comes from Treasury Form FMS-5401 Payment Voucher. 
 
Date drawn - Contractor enters the date funds were drawn. It shall use 2 digits. 
 
Voucher Number - Contractor enters the payment voucher number in 3 digits beginning 
with voucher number 001 to 999. It shall inform the bank to start over when number 999 
is reached. 
 
Serial Number - Contractor enters the serial number of the payment voucher. 
 
Hospital Insurance Benefits - Contractor enters the total amount drawn for HI and SMI. 
The total of HI and SMI benefits should equal the total funds drawn. 
 
NOTE: Part B contractors enter amounts for SMI only. 
 
PMS Smartlink Communication System for Administrative Costs   
 
On pages 1 and 2, the contractor shall continue to report administrative costs drawn via 
the PMS Smartlink Telecommunications System in the same designated "Administrative 
Cost" column 4. However, it shall show these amounts after it reports all benefit payment 
amounts. 
  Contractor shall indicate in the "date drawn" column the date the money was deposited 
into its commercial bank account and not the date it requested the money. This entry 
(entries) may occur on either page 1 or 2 depending on the number of entries. 
 
Contractor shall not make entries in the columns for Voucher Number, Serial Number, 
and Voucher Totals. 
 
Contractor shall reflect the current or prior year administrative costs drawn via Smartlink. 
It shall report on page 3 any special project(s) amount(s) drawn via Smartlink. 
 
Public reporting burden for collecting this information is estimated to average 1 hour per 
response. This includes time for reviewing instructions, searching existing data sources, 
gathering and maintaining data needed, and completing and reviewing the collection of 
information. Contractor shall send comments regarding this estimated burden or any 
other suggestions for reducing the burden to: 
 
Office of Management and Budget 
Paperwork Reduction Project (0938-0361) 
Washington, D.C. 20503; 
 
and to: 
 
Centers for Medicare & Medicaid Services 
Office of Financial Operations 
7500 Security Boulevard 
Baltimore, Maryland 21244-1850. 
 
80 - Form CMS-1522, Monthly Contractor Financial Report  (Rev. 5, 
08-30-02) 
A1-1412, B1-4412 
 
Form CMS-1522 is designed to provide a reconciliation of Medicare benefit dollars 
between CMS, the contractor, and the bank. The contractor shall transmit this report to 
CMS by the 15th of each month via the CAFM System. 
 
80.1 - Instructions for Completion of Form CMS-1522 - (Rev. 5, 08-30-
02) - (Rev. 5, 08-30-02) 
A1-1412.1, B1-4412.1 
 
  Screen 1 - Section A - Purpose for Which Funds are Drawn: 
 
  Contractor shall reflect the current or prior year administrative costs drawn 
o
via Smartlink. It shall report on page 3 any special project(s) amount(s) 
drawn via Smartlink. 
    Funds Drawn this Month - Contractor enters the total amount of Federal 
o
funds drawn via payment vouchers during the calendar month for use as 
HI benefits, line 1-B, or SMI benefits, line 2-B. Each entry must equal the 
sum of the amounts shown in this category on the Form CMS-1521 dated 
during the calendar month. 
 
  Total Funds Expended This Month - Contractor enters total funds 
o
expended for HI benefits, line 1-D, and SMI benefits, line 2-D during the 
calendar month. Totals should equal the sum of all checks drawn and 
electronic funds transfer payments against the special bank account during 
the calendar month. (It shall include all checks issued and electronic funds 
transferred, i.e. dated during the calendar month.) Any refunds received 
from beneficiaries or their assignees during the calendar month because of 
prior overpayments deposited in the special bank account should serve to 
reduce total funds expended. 
 
  Funds Drawn for Fiscal Year - This is a calculated field. 
o
 
  Funds on Hand End of Month - This is a calculated field. 
o
 
  Line 3, Drugs and Line 4, Regular Administrative Costs - Contractor shall 
o
not use at this time. 
 
  Bills Paid - Lines 7 and 8 - Completed by Part A intermediaries. Part B 
o
carriers complete only line 8. 
 
  Retro-Adjustment - Part A contractors enter credit adjustments on 
o
appropriate lines. Part B contractors do not use lines 9 or 10. 
 
  Benefits Bank Account 
 
  From Bank Statement - The contractor shall take information for lines 15 
o
through 19 from the statement of the special bank account issued by the 
bank at the end of the calendar month. 
 
  Line 15 - Balance Beginning of Month Per Bank - Contractor enters the 
o
balance in the special bank account as of the beginning of the calendar 
month as shown on the bank statement. 
 
  Line 16a - Payment Vouchers Drawn During Month - Contractor enters 
o
the total amount of funds drawn on payment vouchers (FMS-5401) during 
the calendar month and credited to the benefits account as shown on the 
bank statement. Since all checks drawn for deposit in the Time Account 
are cleared through the benefits account, a payment voucher is drawn for 
this transaction and is included in line 16a. The amount shown on this line 
must agree with the totals from the Form CMS-1521 corresponding to the  calendar month and also with Section A, Line 5, column (b). The only 
exception is for vouchers in transit (line 20). 
 
  Line 16b - Other Deposits - Contractor enters all other deposits credited 
o
during the month to the special bank account as shown on the bank 
statement. It shall reduce the next payment voucher by the amount of the 
deposited refunds in the account in order to minimize idle funds in the 
account. It shall Include any credits or adjustments made to the bank 
account during the calendar month in this line. 
 
  Line 16c - Contractor shall include funds withdrawn from the Time 
o
Account and deposited in the Benefits Account. 
 
  Line 16d - Miscellaneous Credit Memo - Contractor enters any 
o
miscellaneous adjustments to the benefits bank account during the 
calendar month. 
 
  Line 17 - This is a calculated field. 
o
 
  Line 18A - Contractor shall subtract: Checks and EFT Payments Honored 
o
by Bank During Month - It enters from the bank statement the total funds 
charged to the special bank account as a result of checks honored and 
electronic funds transferred by the bank during the month. This total must 
include all checks that were drawn for deposit in the time account and 
honored by the bank during the month. 
 
  Lines 18B and C - Miscellaneous Bank Charges - Contractor enters any 
o
miscellaneous charges made to the special bank account that are part of 
the bank statement. 
 
  Line 19 - This is a calculated field. 
o
 
  Line 20 - Add: Deposits in Transit. - Enter payment vouchers drawn and 
o
other deposits made during the calendar month that the bank has not yet 
credited to the special bank account according to the statement. 
 
  Line 21. - This is a calculated field. 
o
 
  Line 22 - Subtract: Outstanding Checks. - Enter the total of all checks 
o
issued during the current month or any previous month that the bank has 
not yet paid as of the end of the calendar month. If during the calendar 
month payment is stopped on any check previously issued, or any 
previously issued check is otherwise voided, subtract the amount of funds 
represented by that check from this total before making an entry on this 
line. 
    Line 23 - This is a calculated field. 
o
 
  Line 24 - Highest Balance During Month Per Bank. Contractor enters the 
o
highest balance in the special bank account during the calendar month as 
reflected on the bank statement. 
 
  Time Account 
 
  Line 15 - Balance Beginning of Month - Contractor enters the balance in 
o
the time account as of the beginning of the calendar month as shown on 
the bank statement. 
 
  Line 16a - Other Deposits - Contractor enters the amount of funds drawn 
o
from the benefits account for deposit in the time account. 
 
  Line 17 - Total. - This is a calculated field. 
o
 
  Line 18a - Contractor enters only amount of funds withdrawn from the 
o
time account and deposited in the benefits account during the month. 
 
  Line 18b - Contractor enters any miscellaneous items. 
o
 
  Line 19 - Balance EOM Per Bank - This is a calculated field. 
o
 
  Screen 4 - Completed by Part A Contractors Only 
 
  Periodic Interim Payments - Contractor enters amounts paid during the 
o
month by category. 
 
  Accelerated Payments - Contractor enters the amount of accelerated 
o
payments paid out and received during the month. 
 
  Suspended Payments - Contractor enters the amount of payments 
o
suspended and released during the month. 
 
  Screen 5 - Bills Paid - Contractor enters the amount of money actually paid during 
the calendar month as follows: 
 
  Amount paid for disabled or disability (identified by Codes 1 and 3 as 
o
contained in S trailer of query reply). 
 
  Amount paid for chronic renal disease (identified by Code 2 as contained 
o
in S trailer of query reply). 
 
  Amount paid for premium paying enrollees (identified by Codes 8 and 9 
o
as contained in S trailer of query reply).   
  Amount paid for aged. Contractor shall complete entries for disabled, 
o
chronic renal disease, and premium paying enrollees prior to completing 
the entry. It shall then subtract the sum of these entries from the calculated 
Total and enter that amount. 
 
  Total - (Bills paid for the month). This is a calculated field. 
o
 
NOTE:  For those Part A intermediaries that transmit bills to CMS from more than one 
point, each processing point should submit to the home office at the end of the calendar 
month all of the data requested in screen 1. (It shall consolidate data related to amounts 
paid in screen 1.) 
 
  Only Part A Intermediaries complete retroactive adjustments. 
 
  Only Part A Intermediaries complete adjustments between trust funds. 
 
  Interest: 
 
  Interest Received From Providers On Overpayments - Separate Check for 
o
Interest Collected - When a check is received for interest on an 
overpayment, the contractor shall deposit the check immediately in the 
Medicare bank account. It shall report this check as an "Other Deposit" 
(line 16b). Also, it shall report the check as "Interest Received" on screen 
5 and use as a reduction to expenditures on screen 1, funds expended 
column. 
 
  Check Includes Both Interest Collected and Overpayment Recoupment - 
o
Contractor shall deposit the check immediately into the Medicare bank 
account. It shall report the entire amount of the check as an "Other 
Deposit" (line 16b) on screen 2. It shall report the interest portion as 
"Interest Recovered" on screen 5. Both the interest recovered and the 
overpayment recoupment are used as a reduction to expenditures on screen 
1, funds expended column. 
 
  Interest Paid to Providers on Underpayments - Separate Check for Interest 
o
Paid - When a check is issued for interest due to a provider on an 
underpayment, the contractor shall report it as a "Check Honored" (line 
18a) on screen 2. Also, it shall report this amount as "Interest Paid" on 
screen 5 and as an increase to expenditures on screen 1, funds expended 
column. 
 
  Screen 6 - No entries are required at this time. 
 
Public reporting burden for this collection of information is estimated to average 16 hours 
per response. This includes time for reviewing instructions, searching existing data  sources, gathering and maintaining data needed, and completing and reviewing the 
collection of information. Contractors may send comments regarding this estimated 
burden or any other suggestions for reducing the burden to: 
 
Centers for Medicare & Medicaid Service 
Office of Financial Management 
Baltimore, Maryland, 21244-1850; 
 
and to:  
 
Office of Management and Budget 
Paperwork Reduction Project (0938-0361) 
Washington, D.C. 20503. 
 
80.2 - Medicare Contractor Monthly Cash Collections Worksheet 
(Rev. 80, Issued: 10-21-05, Effective: 07-01-05, Implementation: 11-21-05) 
 
The Medicare Contractor Monthly Cash Collections Worksheet is to identify cash 
collections deposited in the Medicare Trust Funds related to Provider Overpayments.  
The Medicare contractors are to follow the line by line instructions for completing the 
collections worksheet.  The instructions are to provide uniformity throughout all 
contractors for the calculations of the data used to populate each line item.  Medicare 
contractors are required to maintain supporting documentation for the amounts reported 
on the Medicare Contractor Monthly Cash Collections Worksheet. 
 
Medicare contractors are required to submit the worksheet via email to 
cashcollection@cms.hhs.gov on the 15th day of the following month end.  For year-end, 
Medicare contractors may be required to submit the Monthly Cash Collections 
Worksheet in an accelerated time frame. 
 
A.  Total Monthly Principal Deposit (Using Forms CMS-1522, Forms CMS-751) 
 
Line 1 - Enter the total Other Deposits (Line 16b, Form CMS-1522) for the 
reporting period (e.g., June 30, etc.). 
 
Line 2 - Enter Deposits-In-Transit (Line 20, Form CMS-1522) for the month 
prior to the reporting period (e.g., May 31, etc.). 
 
Line 3 - Enter Deposits-In-Transit (Line 20, Form CMS-1522) for the reporting 
period (e.g., June 30, etc.). 
 
Line 4  Enter the sum of Line 1 minus (-) Line 2 plus (+) Line 3 equal (=) Total 
Monthly Deposits. 
 
Monthly Interest (Cash) Collections 
  Line 5  Enter the total Received-Provider Overpayment (Line 1, page 4, Form 
CMS-1522) for reporting period (e.g., June 30, etc.). 
 
Line 6  Enter the total Interest Offset for the reporting period. Total Interest 
Offset must equal the amount of the offset collections included in the 
amount reported on Line 1, page 4/4, Form CMS-1522 and included in 
the amount of the offset reported on Line 4b, Form CMS 751 for the 
quarter ending June 30, 2005. 
 
Line 7  The sum of Line 5 minus (-) Line 6 equal (=) Monthly Interest Cash 
Collections. 
 
Line 8  Monthly Interest Cash Collections = Line 7. 
 
Line 9  The sum of Line 4 (Total Monthly Deposits) minus (-) Line 8 Monthly 
Interest Cash Collections) = Total Monthly Principal Cash Deposits. 
 
B. Calculate HI/SMI Percentage Split (FI Only)  12 month rolling average 
 
Line 10  Enter the sum of Line 4a (principal), Form CMS-751A (quarter ending 
June 30, 2005). For example, Line 4a (principal) for the period ending 
June 2005 plus (+) [Line 4a (principal), Form CMS-751A (period 
ending September 2004) minus (-) Line 4a (principal), Form CMS-
751A (period ending June 2004)].  The sum of Line 4a (period ending 
September 2004) minus Line 4a (period ending June 2004) must equal 
Cash Collections for the period July 2004  September 2004. 
 
(NOTE:  12 months of most recent HI principal Cash Collections (e.g., July 
2004 - June 2005)) 
 
Line 11 - Enter the sum of Line 4a (principal), Form CMS-751BA (quarter ending 
June 30, 2005). For example, Line 4a (principal) for the period ending 
June 2005 plus (+) [Line 4a (principal), Form CMS-751BA (period 
ending September 2004) minus (-) Line 4a (principal), Form CMS-
751BA (period ending June 2004)].  The sum of Line 4a (period ending 
September 2004) minus Line 4a (period ending June 2004) must equal 
Cash Collections for the period July 2004  September 2004. 
 
(NOTE:  12 months of most recent SMI principal Cash Collections (e.g., July 
2004 - June 2005)) 
 
Line 12  Enter the sum of Line 10 plus (+) Line 11 = Total HI/SMI collections. 
 
Line 13  Enter the HI percentage split.  The result of Line 10 divided by Line 12. 
  Line 14  Enter the SMI percentage split. 1.00 minus the HI percentage split 
(Line 13). 
(NOTE:  Line 14 must equal Line 11 divided by Line 12) 
 
C.  HI Monthly Cash Deposit = HI percentage split (Line 13) multiplied by Total 
Monthly Principal Cash Deposit (Line 9). 
 
D.  SMI Monthly Cash Deposit = HI percentage split (Line 13) multiplied by Total 
Monthly Principal Cash Deposit (Line 9). 
 
E.  The Chief Financial Officer (CFO) is required to certify/sign the Medicare 
contractor Cash Collection Worksheet Attachment I (electronic signature is 
acceptable if the email is sent by the CFO), as an indication of the 
correctness/completeness of the data in accordance with applicable instructions. 
 
(NOTE:  The sum of C and D must equal Total Monthly Principal Cash Deposits 
(Line 9)) 
 
90 - Intermediary Benefit Payment Report (Form CMS-456)  (Rev. 5, 
08-30-02) 
A1-1414 
 
90.1 - Purpose and Scope - (Rev. 5, 08-30-02) 
A1-1414.1 
 
The Intermediary Benefit Payment Report (IBPR) is a report of current monthly 
information that covers the categories of benefits the contractor paid and selected 
statistical data that relates to those payments. CMS uses this data to: 
 
Track benefit payments by type of provider to detect significant shifts in program 
expenditures;  
 
Monitor implementation of new programs, e.g., hospice benefits, and comprehensive 
outpatient rehabilitation benefits; and  
 
Identify operation problem areas for resolution by the contractor or CMS. 
 
90.2 - Due Dates and Transmittal - (Rev. 5, 08-30-02) 
A1-1414.2 
 
Contractor shall input the reports accompanying the reconciliation between IBPR and the 
Monthly Intermediary Financial Report (Form CMS-1522) into the CAFM system 20 
work days following the report month. 
 
90.3 - Verification of Data - (Rev. 5, 08-30-02) 
A1-1414.3   
The various subsidiary records that include the individual provider files must support the 
data entered on the report. 
 
The contractor must have the capability to trace all data entered on the report to the 
individual provider files. 
 
Where applicable, the Provider Statistical and Reimbursement Report and other provider 
reports containing benefits paid data must support the data on the report. 
 
90.4 - Accuracy of Data Contained on Report and Reconciliation of 
Data Reflected on Monthly Intermediary Financial Report (Form CMS-
1522) - (Rev. 5, 08-30-02) 
A1-1414.4 
 
The contractor must ensure that all data reflected on the report is accurate. 
 
Line 36, column (g) of the report, should equal the amount shown on the CMS-1522, 
column (d), lines 1 and 2 in the aggregate. In the event that the amounts do not agree, the 
contractor shall complete a reconciliation report. 
 
90.5 - General Reporting Instructions - (Rev. 5, 08-30-02) 
A1-1414.5 
 
Where money is withheld from payments due the provider (as an offset) for monies due 
the contractor, the contractor shall show the gross amount (less any deductibles, 
coinsurance, interest, or sequestration) as the payment on the appropriate line and 
column. It shall show the offset as a negative amount in its appropriate line and column. 
 
For example, when the contractor reduces a PPS Periodic Interim Payment (PIP) for a 
settlement amount due from the provider, it shall record the gross PIP amount (less any 
deductibles, coinsurance, interest, or sequestration) on line lA in column 1 (a) or 1(b), as 
appropriate. It shall record the offset on line 6B in column 1(a) or 1(b), as appropriate. 
However, it shall record a claim adjustment (e.g., a PRO disallowance or subsequent 
reversal) as a reduction of claims payments on line 2A for a non-PIP/PPS hospital. 
 
Where the contractor makes an accelerated payment and the provider repays a portion of 
the accelerated payment during the same reporting period, the contractor shall show the 
net amount on the appropriate line and column. 
 
For example, when an accelerated payment of $100,000 is made to a provider during the 
period, and the provider repays $30,000 during the same period, the contractor shows 
$70,000 as the net accelerated payment. 
 
In situations where an accelerated payment is made during the period, and the contractor 
recovers a portion of the accelerated payment through reduction of interim payments, it  shall show the gross amount (less any deductibles, coinsurance, interest, or sequestration) 
of interim payments as payment on the appropriate line and column. It shall show the 
offset amount as a negative amount on the appropriate line and column. 
 
For example, when an accelerated payment is made for $100,000 and later in the month 
$30,000 of the accelerated payment is recouped by offset against PPS/PIP amounts of 
$150,000 paid to the provider, the contractor shows the $150,000 gross PPS/ PIP amount 
on line 1A in column 1(a) or 1(b), as appropriate. It shows a net accelerated payment of 
$70,000 ($100,000-$30,000) on line 7 in column 1(a) or 1(b), as appropriate. 
 
90.6 - Instructions for Completion of the IBPR - (Rev. 5, 08-30-02) 
A1-1414.6 
 
A.   Heading 
 
The contractor enters its name and assigned number. Multi-regional intermediaries use 
the number assigned to the home office for administrative budget and cost reporting 
purposes. The contractor shall furnish a consolidated report for all locations. 
 
The contractor enters the calendar month and year as a four-digit entry, e.g., 1000, 1100, 
1200, 0101. 
 
B.   Column Definitions - Page 1 
 
Column (a) - Single Facility - refers to payments to PPS hospitals that do not have 
distinct part facilities, such as SNFs, HHAs, psychiatric units, or rehabilitation units. 
 
  Column (b) - Facility With Distinct Parts - refers to payments to PPS hospitals 
that include distinct parts, such as SNFs, HHAs, psychiatric units, or 
rehabilitation units. 
 
NOTE:  The contractor enters non-PPS payments to the distinct part on the appropriate 
line and column of page 2. 
 
  Column (c) - Non-PPS Payment - refers to payments to the following: 
 
  Hospitals excluded from PPS (e.g., psychiatric, children's, rehabilitation 
o
and long term); 
 
  Hospitals receiving payments via an alternative payment program (waiver 
o
States); 
 
  Hospitals yet to be phased into PPS; and  
o
 
  PPS hospitals for bills or underpayments applicable to pre-PPS fiscal 
o
years.   
  Column (d) - Total - refers to the total of columns (a), (b), and (c). 
 
C.   Line Item Definitions - Page 1: 
 
1.  Hospital Inpatient (PIP) - refers to hospitals paid by the PIP method. The 
contractor shall show these figures less any deductibles, coinsurance, and interest 
for all items on the PIP bills and any sequestration applicable to this line with any 
offsets shown on line 6A or 6B. 
 
A.  Inpatient Operating Payments - refers to the amount of the PIP that covers 
items that would otherwise be paid on a per claim basis plus those items 
paid on a per claim basis in addition to PIP payment. (Such as payments 
for outliers and hemophilia blood clotting factor add-on.) 
 
The contractor enters the PIP amounts paid as follows: 
 
PPS Provider Payments - Payments related to services furnished after 
conversion to PPS in columns 1(a) or 1(b), as applicable. This includes outlier 
payments, hemophilia blood clotting factor add-on payments, disproportionate 
share amounts, indirect medical education, ESRD payments, and phased-in 
capital-related costs during the transition period. Non-PPS Provider Payments 
- column (c) - Payments related to services furnished prior to conversion to 
PPS. Payments to all providers listed in the definitions for column (c). 
 
B.  Pass Through Costs - Contractor enters the PIP payments, including any 
withholdings, but less any sequestration amounts for items paid on a 
reasonable cost basis as follows: 
 
  Capital; 
 
  Direct medical education which includes nursing and paramedical 
health professional (allied health) programs and graduate medical 
education; 
 
  Kidney and other organ acquisitions; 
 
  Bad debts; and  
 
  Nonphysician anesthetists. 
 
NOTE:  This includes that part of capital-related costs not included in line 
1A. 
 
C.  Indirect Medical Education - Contractor enters the PIP payments for the 
indirect medical education adjustment, whether on a PIP or a claim-by- claim basis for PIP providers, less any sequestration (already included in 
line 1A). 
 
NOTE:  Contractor shall make entries on this line for memorandum purposes 
only to identify the amount of indirect medical education for PIP hospitals. 
 
2.  Hospital Inpatient (Non-PIP), refers to hospitals paid based upon bills reviewed 
and approved. Contractor shall show total payments less any reductions on line 
6A or line 6B. 
 
A.  DRG Bills Paid/Non-DRG Bills Paid - Contractor enters the calculated 
payment less any deductibles, coinsurance, and interest for all items on the 
bill and any sequestration applicable to this line. It shall include payments 
for outliers, disproportionate share, indirect medical education, high 
percentage of end-stage renal disease beneficiary discharges, and 
hemophilia blood clotting factor add-on payments on a claim-by-claim 
basis. Also, it shall include phased-in capital-related costs during the 
transition period. 
 
For DRG bills, it shall use columns (a) and (b). For non-DRG bills paid, it 
shall use column (c). 
 
It shall report all retroactive adjustments pertaining to hospitals on line 6A or 
6B. 
 
B.  Pass Through Costs - The contractor enters the interim payments, less any 
sequestration, for items paid on a reasonable cost basis as follows: 
 
  Capital; 
 
  Direct medical education which includes nursing and paramedical 
health professional (allied health) programs and graduate medical 
education; 
 
  Kidney and other organ acquisitions; 
 
  Bad debts; and  
 
  Nonphysician anesthetists. NOTE: This includes that part of the 
capital-related costs that are not included in line 2A. 
 
C.  Indirect Medical Education - Contractor enters the interim payments for 
the indirect medical education adjustment (already included in line 2A). 
  NOTE:  Contractor shall make entries on this line for memorandum purposes only to 
identify the amount of indirect medical education for non-PIP hospitals. It shall not 
adjust these amounts for MSP or sequestration. 
 
3.  Outlier Payments - Contractor enters additional amounts paid for outlier cases. 
 
NOTE: Contractor shall make entries on this line for memorandum purposes only to 
identify the total outlier payments that are found in the UB82 billing form in Locator 46-
49 in Value Code 17. These amounts are already included in the amounts recorded on 
lines lA and 2A. 
 
A.  Days - The contractor enters additional payments made as a result of the 
length of stay exceeding the day outlier threshold criteria. It shall make 
entries on this line for memorandum purposes only. These are non-add 
items. 
 
NOTE:  After FY 1997, outlier days no longer exist. 
 
B.  Cost - The contractor enters additional payments made for claims where 
extraordinary costs were approved. It shall make entries on this line for 
memorandum purposes only. These are non-add items. 
 
4.  Subtotal - Contractor enters the total of the amounts on lines 1A, 1B, 2A, and 2B. 
 
NOTE:  The amounts included in lines 1C, 2C, 3A and 3B are memo entries only and 
have been included in lines 1A, 1B, 2A and 2B. 
 
5.  Outpatient Payments - Contractor enters the payment, less deductibles, 
coinsurance and sequestration for outpatient and Part B inpatient services. It shall 
report any offset against these amounts on line 6A or 6B. See line 19 for reporting 
SNF outpatient payments. 
 
6.  Retroactive Adjustments: 
 
  PPS Provider Payments - Contractor enters on lines 6A and 6B (as 
applicable), columns (a) or (b), the net amount of retroactive adjustments 
paid and received as a result of interim rate adjustments, pass through cost 
adjustments, and cost report settlements applicable to current or prior 
provider fiscal years. 
 
Contractor shall show interest on cost report overpayments and late-filed cost 
reports on these lines. An example of a proper recording of a retroactive 
adjustment would be an entry of $500,000 of cash received from the provider 
as the first installment of the final settlement of $1,000,000 due the program 
from the prior year's cost report. 
  Another example would be an entry of $500,000 offset against current PIP 
payments due of $1,000,000. (The $1,000,000 would be shown on line 1A.) 
 
  Non-PPS Provider Payments - Contractor enters on line 6A or 6B (as 
applicable) in column (c) the net amount of retroactive adjustments paid 
and received as a result of interim rate adjustments and cost report 
settlements applicable to current or prior provider fiscal years. 
 
It shall show interest on cost report overpayments and late-filed cost reports 
on these lines. 
 
7.  Accelerated Payments - Contractor enters the net amount of accelerated payments 
made to and collected from hospitals and distinct part units. (See 160.5 for an 
explanation of the appropriate recording of offsets.) 
 
8.  Total - The contractor enters the total of lines 4 through 7. 
 
D.  Statistical Data-Hospitals-Page 1: 
 
9.  PIP: 
 
A.  Contractor enters the total number of bills processed for hospitals paid by 
the PIP method. 
 
B.  Contractor enters the dollar amount that would have been paid if the bills 
processed were not subject to PIP in accordance with the definition of line 
2A. 
 
10. Non-PIP - Contractor enters the total number of bills for hospitals paid on a 
submitted-bill basis. 
 
11. Number of Hospitals - Contractor enters the total number of hospitals 
participating in the Medicare program. 
 
12. Number of Admissions - Contractor enters the total number of admissions the 
Common Working File (CWF) has approved for payment. 
 
13. Number of Discharges - Contractor enters the number of discharge bills processed 
during the reporting month. 
 
14. Number of Readmissions - Contractor enters the total number of readmissions to a 
hospital within 7 calendar days of discharge from an acute care facility. 
 
15. Number of Transfers - Contractor enters in column (a) and column (b) the total 
number of transfers to a PPS hospital. It enters in column (c) the total number of 
transfers to a non-PPS hospital.   
16. Outlier Bills: 
 
A.  Days - Contractor enters the total number of day outlier bills paid that 
relate to the dollar amounts shown in line 3A. 
 
NOTE:  Outlier days have been obsolete since the end of FY 1997. 
 
B.  Costs - Contractor enters the total number of cost outlier bills paid that 
relate to the dollar amounts shown in line 3B. 
 
17. Outpatient - Contractor enters the total number of outpatient bills and Part B 
inpatient bills paid that relate to the dollar amounts shown in line 5. 
 
E.  Column Definitions - Page 2 
 
  Column (e) - Single Facility - Refers to all providers that are not part of a hospital 
complex. 
 
  Column (f) - Part of Hospital Complex - Refers to providers that are an integral 
part of a hospital and are operated with other departments of the hospital under 
common licensure and governance. 
 
  Column (g) - Total - Refers to total of columns (e) and (f). 
 
F.  Line Item Definitions - Page 2 
 
Skilled Nursing Facilities - Including swing bed payments for SNF care. 
 
18. PIP - Contractor enters all PIP payments made to SNFs. It enters total payments 
(less any deductibles, coinsurance, interest or sequestration) with any withholding 
reductions being shown on line 20. 
 
19. Bills Paid - Contractor enters total payments less any deductibles, coinsurance, 
interest, or sequestration with any withholdings shown on line 20. It enters the 
calculated payment, less any deductibles, coinsurance and interest for all items, 
and any sequestration applicable to SNFs on a submitted-bill basis. It shall 
include Part A and Part B services. 
 
20. Retroactive Adjustments - Contractor enters the net amount of retroactive 
adjustments paid and received as a result of cost report settlements and lump sum 
interim rate adjustments made in prior or current provider fiscal years. 
 
21. It shall show interest on cost report overpayments and late-filed cost reports on 
this line. An example of a proper recording of a retroactive adjustment would be  an entry of $500,000 cash received from the provider as the first installment of the 
final settlement of $1,000,000 due the program from the prior year's cost report. 
 
22. Accelerated Payments - Contractor enters the net amount of accelerated payments 
made to and collected from SNFs. (See 160.5) for an explanation for reporting 
accelerated payments.) 
 
23. Total SNF Payments - Contractor enters the total of lines 18 through 21. 
 
Home Health Agencies: 
 
23. PIP - Contractor enters all PIP payments made to HHAs including SNF-based. 
 
24. It shall show total payments less any deductibles, coinsurance, interest, or 
sequestration with any withholding reductions shown on line 25. 
 
25. Bills Paid - Contractor shall show total payments (less any deductibles, 
coinsurance, interest, or sequestration) with any withholdings shown on line 25. It 
enters the calculated payment, less any deductibles, coinsurance, and interest, for 
all items, and any sequestration applicable to HHAs on a submitted-bill basis. It 
shall include Part A and Part B services and SNF-based HHAs payments. 
 
26. Retroactive Adjustments - Contractor enters the net amount of retroactive 
adjustments paid and received as a result of cost report settlements and lump sum 
interim rate adjustments made in prior current provider fiscal years. 
 
27. It shall show interest on cost report overpayments and late-filed cost reports on 
this line. An example of a proper recording of a retroactive adjustment would be 
an entry of $500,000 cash received from the provider as the first installment of the 
final settlement of $1,000,000 due the program from the prior year's cost report. 
 
28. Accelerated Payments - Contractor enters the net amount of accelerated payments 
made to and collected from HHAs. (See 160.5) for an explanation for reporting 
accelerated payments.) 
 
29. Total HHA Payments - Contractor enters the total of lines 23 through 26. 
 
Additional Providers: 
 
28. ESRD - Contractor shall include in these columns payments to ESRD networks, 
as applicable: 
 
Column (e) - It enters net payments to independent facilities. Column (f) - It enters 
net payments to hospital-based facilities. 
 
29. Hospice - Contractor enters net payments made to hospices.   
30. RHC - Contractor enters net payments made to rural health clinics (RHCs). 
 
31. OPA/HL - Contractor enters net payments made to organ procurement agencies 
and histocompatibility laboratories. 
 
32. CORF - Contractor enters net payments made to comprehensive outpatient 
rehabilitation facilities (CORFs). 
 
33. Distinct Part Units - Contractor enters net payments made to exempt distinct part 
rehabilitation and psychiatric units. 
 
34. All Others - Contractor enters net payments made to other providers not listed in 
lines 28 -33. 
 
NOTE:  Contractor shall make adjustments, pertaining to providers, identified on lines 
28 through 34 directly to the specific line. This includes checks received and offsets or 
withholdings. 
 
35. Total - Contractor enters the total of lines 28 through 34. 
 
36. Grand Total - Contractor enters the total of lines 8(d), 22(g), 27(g) and 35(g). 
 
G.  Statistical Data - Page 2: 
 
37. SNF: 
 
  Number of SNFs - Contractor enters the total number of participating 
SNFs. 
 
  Number of Admissions - Contractor enters the total number of SNF 
admissions. 
 
38. HHA: 
 
  Number of HHAs - Contractor enters the total number of participating 
HHAs. 
 
  Number of Bills - Contractor enters the total number of bills processed. 
(Audit intermediaries should not complete this line.) 
 
39. Number of Transfers to Distinct Part Units - Contractor enters the total number of 
transfers to distinct part units for which payments are shown in line 33. 
 
It shall use edit checks to ensure completeness, arithmetical accuracy, and to discover 
inconsistencies. It shall have an authorized official sign and date the report.   
90.7 - Form CMS-456 - Schedule R - (Rev. 5, 08-30-02) 
A1-1414.7 
 
(Page 3 of 3 of the Monthly Intermediary Benefit Payment Report) Reconciliation 
Between IBPR and CMS-1522. 
 
A.   Purpose and Scope 
 
The contractor shall use the Schedule R to account for any variances between line 36(g), 
Total on the IBPR, and the HI and SMI Benefits reported on lines 1(d) and 2(d) of the 
CMS-1522 Report. 
 
Schedule R is an integral part of the IBPR and must be completed each month whether or 
not a variance exists between the IBPR and the CMS-1522 Report. If there is no variance, 
the contractor shall complete line 36(g) of the IBPR and HI and SMI Benefits for lines 
1(d) and 2(d) of the Form CMS-1522. If there is a variance, it shall reconcile the two 
reports by completing the appropriate lines. 
 
It must have the capability to substantiate all amounts reflected on Schedule R. 
 
Schedule R includes line items that will facilitate the contractor's reconciliation process. 
 
It shall input the Schedule R, along with pages 1 and 2 of the IBPR, into the Contractor 
Administrative Budget and Financial Management System (CAFM) for each report 
month. 
 
B.   Instructions for Completion of Schedule R: 
 
Heading - The contractor enters the report month and year. (See 160.6A) for 
intermediary name and number.) Also, it enters its current letter-of-credit number. 
 
Line Item Definitions - Schedule R: 
 
CMS-456 (IBPR) Column: 
 
Line 36(g) Total - Contractor enters the amount obtained from page 2 of 3 on line 36(g) 
of the IBPR. 
 
Medicare Secondary Payer (Non-Providers Cash Recoveries) - Contractor enters the cash 
receipts and offsets applied to claims payments or other refunds that are received from 
attorneys, beneficiaries, insurance companies or other non-providers. These amounts 
should be negative numbers since they represent cash receipts. 
  Other Recoveries Identify - Contractor enters recovered or offset amounts not included in 
any other line item (lines 1 through 36 or lines 1 and 3 of Schedule R). These amounts 
should be negative numbers since they represent cash receipts. 
 
Other Items Identify (Lines 3A through 3E) - Contractor enters any other benefit 
payments or refunds not included elsewhere on the CMS-456 or on lines 1 and 2. The 
items shown here may be unique to its operation and should be identified accordingly. It 
shall itemize each major category on lines 3A. through 3E. These amounts could be 
positive or negative numbers. 
 
Total - Contractor enters the sum of all line items in this column. It must take care to 
subtract negative amount(s) included on the above lines. The total amount must equal the 
amount in the total adjacent CMS-1522 column. 
 
1.  Remarks - Contractor enters an explanation to clarify any item or amount. 
 
  Line Item Definitions - Schedule R: 
 
CMS-1522 
 
1.  HI Benefits, Line 1 (d) - Contractor enters the HI benefits amount from form 
CMS-1522 in line 1(d). 
 
2.  SMI Benefits, Line 2(d) - Contractor enters the SMI benefits amount from form 
CMS-1522 in line 2(d). 
 
3.  Subtotal - Contractor enters the total HI and SMI benefit amounts. 
 
4.  Other Items Identify - Contractor enters any other benefit payments or refunds 
that may be unique to your operation that are not included on lines 1(d) or 2(d) of 
form CMS-1522. It shall itemize each major category and identify on line 1 
through 6. These amounts could be positive or negative numbers. 
 
5.  Total - Contractor enters the sum of all line items in this column. It must take care 
to subtract negative amounts included in items 1 through 6. The total amount must 
equal the amount in the total adjacent CMS-456 column. 
 
Public reporting burden for this collection of information is estimated to average 30 hours 
per response. This includes 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 estimated burden or any other 
aspect of this collection of information, including suggestions for reducing the burden, to: 
 
Centers for Medicare & Medicaid Services 
Office of Financial Management 
7500 Security Boulevard  Baltimore MD 21244-1850 
 
and to: 
 
Office of Management and Budget 
Paperwork Reduction Project (0938-0361) 
Washington DC 20503 
 
100 - Issuance of Letter-Of-Credit - (Rev. 5, 08-30-02) 
A1-1416, B1-4414 
 
The Letter-of-Credit, Standard Form-1193, authorizes a Federal Reserve Bank or Branch 
to advance funds to a designated commercial bank on behalf of CMS. Under the Checks 
Paid Method of financing, a letter-of-credit is issued to authorize the designated 
commercial bank to withdraw funds for deposit only to the contractor's Benefits Account 
when a bank presents a payment voucher (FMS-5401). 
 
Upon receipt of the properly executed signature cards and notification from the Federal 
Reserve Bank that the required collateral has been posted, CMS prepares and certifies a 
letter-of-credit in favor of the designated commercial bank. The certified letter-of-credit, 
together with the executed signature cards, are sent to the Treasury Department for 
forwarding to the servicing Federal Reserve Bank or Branch. A copy of the certified 
letter-of-credit and signature cards are also sent to the contractor, the RO, and the 
designated commercial bank. 
 
100.1 - Monthly Limitation - (Rev. 5, 08-30-02) 
A1-1416.1, B1-4414.1 
 
The letter-of-credit specifies a maximum amount of funds that the bank may draw during 
each month. The ceiling amount on the letter-of-credit is established at a sufficiently high 
level to provide for fluctuations in monthly disbursement patterns and is based upon 
benefit payments estimated by CMS and the contractor. The unused portion of the letter-
of-credit is revoked at the end of each month, and the full monthly ceiling amount is 
automatically renewed at the beginning of each month. There is no carryover of any 
unused ceiling amount. Each month stands by itself. 
 
100.2 - Amending Letter-of-Credit 
(Rev. 236, Issued: 06-13-14, Effective: 06-02-14, Implementation: 07-15-14) 
 
All requests for new or amended Letters Of Credit, whether considered routine or 
emergency, must be submitted no later than 6 business days prior to the calendar date of 
the actual need.  All requests must be sent via email to DFSE@cms.hhs.gov; the 
appropriate Regional Office (RO) contacts should also be copied on the request.   
 
Conditions requiring new LOCs include but are not limited to: 
    A new MAC joins the Medicare program; 
 
  A MAC assumes a new workload from another MAC; 
 
  A complete or partial change in MACs name; 
 
  A change in the name of the MACs servicing bank; or  
 
  A change in the Federal Reserve Bank or Branch servicing the MACs 
commercial bank. 
 
Conditions requiring amended LOCs include but are not limited to: 
 
  A permanent increase or decrease in the LOC funding limitation due to significant 
change in Medicare workload or expenditure that is expected to affect the MACs 
financial needs; 
 
  A temporary increase in the LOC funding limitation to cover all Medicare checks 
and Electronic Funds Transfer (EFT) payments presented to the bank for payment 
within a given month. 
 
100.3 - Establishment of Accounting Records - (Rev. 5, 08-30-02) 
A1-1416.3, B1-4414.3 
 
The contractor shall establish adequate accounting records to ensure that: 
 
  The total monetary amount on the payment vouchers issued during the month 
does not exceed the monthly limitation established by the letter-of-credit; 
 
  Funds drawn are properly allocated between HI and SMI benefits. The contractor 
shall establish memorandum accounts to separate the respective benefit payments; 
 
  Refunds received from providers or beneficiaries resulting from prior 
overpayments or retroactive adjustments are immediately deposited into the 
FHIBA. The contractor shall credit all such deposits on the day following the date 
of receipt in its mail room or initial point of entry. (It shall credit within 2 days if 
the bank is not located in the same city as the contractor.); and  
 
  Bank charges for services furnished are in accordance with the contractual 
agreement and that the volume by types of service (e.g., checks paid and deposits) 
are in agreement with the contractor's records. 
 
110 - Initial Federal Health Insurance Time Account Deposit - (Rev. 5, 
08-30-02) 
A1-1418, B1-4416 
  To preclude excessive use of Federal funds, the contractor shall delay the initial deposit 
in the Time Account until it has actually started processing checks that are cleared against 
the FHIBA. It shall effect the initial deposit of Federal funds into the Federal Health 
Insurance Time Account by drawing a check on the new FHIBA payable to the Time 
Account. 
 
It shall establish the amount of the initial time deposit check by re-computing the Award 
Schedule (AS) (Page 2 of 2) that the selected bank submits to reflect the effective prime 
rate (i.e., prime minus one percent) in effect on the date the new accounts are 
implementation. 
 
It shall make the check payable to the designated bank with the following directive 
clearly printed on the reverse: 
 
For Deposit Only In (Name of Contractor) 
Federal Health Insurance Time Account 
 
The contractor shall delay use of the Federal Health Insurance Accounts until the Federal 
Reserve Bank has received authorization from the Treasury Department for the 
designated commercial bank to process payment vouchers under the letter-of-credit 
procedure. 
 
110.1 - Subsequent Time Account Deposits and Adjustments  (Rev. 5, 
08-30-02) 
A1-1418.1, B1-4416.1 
 
The quarterly review of bank activity in the Benefits Account may disclose the need for 
an adjustment in the Time Account balance. When an adjustment is indicated, the 
contractor shall make the adjustment within 15 calendar days after the close of the 
quarter. 
 
It shall follow the procedures outlined for the initial Time Account deposit as described 
in 110 to increase the Time Account balance. 
 
To decrease the Time Account balance, it shall prepare a Time Account withdrawal slip 
that instructs the bank to transfer the amount of the required reduction from the Time 
Account to the FHIBA. 
 
NOTE:  The contractor shall report all initial deposits and subsequent adjustments in the 
Time Account balance on form CMS-1522 
 
110.2 - Bank Account Analysis 
(Rev. 158, Issued: 09-25-09, Effective: 10-26-09, Implementation: 10-26-09) 
 
To ensure a continuing evaluation of all bank services and associated charges, the 
contractor shall adhere to the following procedures:   
  Arrange to receive from the bank its account analysis on a regular monthly basis 
no later than the 10th of the following month. Bank analysis must include: 
 
  Bank Processing Charges (Schedule of Itemized Bank Services Provided 
o
Report); and  
 
  A list of daily closing bank balances (Recap of Daily Available Balances). 
o
 
  The contractor shall verify the accuracy of the data presented for the average daily 
bank balance, units of service, and all other computations on the bank's account 
analysis. 
 
  The contractor shall complete and forward, within 15 calendar days after the end 
of each month to CMS electronically (Excel; Banking2009@cms.hhs.gov;), the 
following schedules: 
 
  Monthly account activity of bank processing charges (Schedule of 
o
Itemized Bank Services Provided Report); and  
 
  Recap of Daily Available Balances (Recap of Daily Available Balances). 
o
 
120 - Reviewing Bank Agreements - (Rev. 5, 08-30-02) 
A1-1420, B1-4418 
 
The contractor shall determine if it wants to continue, renegotiate, or terminate the bank 
agreement by reviewing the bank's performance and processing charges for the present 
term. It shall review 165 days prior to the expiration of the three-party bank agreement. 
 
If the bank's performance is acceptable, and the bank does not request a rate increase, the 
contractor shall recommend to the RO, in writing, that it wants to continue with the bank 
agreement and that it be continued for another year or two year period. It shall advise the 
RO as soon as a bank's request for a rate increase is received along with its evaluation of 
the bank's performance and recommendation, to continue or renegotiate the contract. The 
RO develops comparative analysis of three banks' charges with similar volumes to 
support the recommendation to continue the bank agreement at a higher processing 
charge. If the higher processing charge is not justified, the contractor will be advised to 
begin the termination process. 
 
120.1 - Terminating Bank Agreements - (Rev. 5, 08-30-02) 
A1-1420.1, B1-4418.1 
 
The contractor, the Government, or the bank may terminate the bank agreement when the 
party wishing to terminate submits written notification to the other parties 150 days prior 
to the expiration of the current term. In the event of termination, the bank agrees to retain  the contractor's Federal Health Insurance Account(s) for an additional 180-day period 
(phase-out) beyond the current term to allow for clearance of outstanding checks. 
 
120.2 - Terminating Federal Health Insurance Accounts - (Rev. 5, 08-
30-02) 
A1-1420.2, B1-4418.2 
 
  Initial Adjustment to the Federal Health Insurance Time Account - Pending 
receipt of the prior month's bank statement, the contractor shall reduce on the first 
day of the phase-out period the current balance in the Federal Health Insurance 
Time Account by seventy-five percent (75%). It shall prepare a Time Account 
withdrawal slip that instructs the bank to immediately transfer the computed 
amount to the FHIBA. 
 
  Time Account Analysis - Within 7 days of the expiration of the current term, the 
contractor shall complete Schedule TAA in its entirety to determine whether the 
time account should remain open during the phase-out period. It shall include in 
line 4 the total projected service charges for the entire phase-out period. It shall 
modify the 25 percent figure on line 10 to reflect the actual length of the phase-
out period, e.g., 6-month period would show 50 percent. 
 
  If line 13 of Schedule TAA (page 1 of 3) indicates a positive amount, the 
o
contractor shall maintain that amount of money in the time account during 
the phase-out period, and adjust the present time account balance 
accordingly in lines 14-16. 
 
  If line 9 of Schedule TAA (page 1 of 3) indicates a negative amount, the 
o
contractor shall immediately transfer the current time account balance to 
the benefits account, and the contractor should secure from the bank a 
check payable to the benefits account in an amount equal to the negative 
amount reflected on line 9. 
 
  Closing Federal Health Insurance Time Accounts - At the expiration of the phase-
out period, the contractor shall transfer all funds on deposit in the Time Account, 
if applicable, and FHIBA immediately to the new FHIBA. 
 
120.3 - Phase-out Period for Federal Health Insurance Bank Accounts   
(Rev. 5, 08-30-02) 
A1-1420.3, B1-4418.3 
 
In the event of termination of the bank agreement, the bank agrees to retain the 
contractor's Federal Health Insurance Account(s) for up to an additional 180-day period, 
beyond the current term, to allow for clearance of outstanding checks. (See subsection C 
of the IFB.) The letter-of-credit issued to the bank remains in effect to allow the bank to 
draw payment vouchers to cover all outstanding checks as they are presented for 
payment.   
During this phase out period, the current bank agreement continues in effect with the 
exception of the following: 
 
  Letter-of-Credit - Covenant 5; 
 
  The Term of the Bank Agreement - Covenant 7; 
 
  Termination of Agreement - Covenants 8 and 9; and  
 
  Renegotiation of Agreement - Covenant 10. 
 
It is further understood that during the phase out period: 
 
  The bank maintains collateral in an amount sufficient to cover the high balances 
in the account(s) less FDIC coverage on each account; 
 
  All bank service charges and earnings credits are consistent with those amounts 
reflected in the current agreement; 
 
  All terms and conditions of the original bid submitted by the bank, which are not 
inconsistent with this additional term, remain in effect; and  
 
  The contractor continues to complete the CMS-1521, CMS-1522 and the TAA 
Schedules. 
 
130 - Invitation For Bid (IFB) to Provide Banking Services Under The 
Checks Paid Method of Letter-Of-Credit Financing - (Rev. 5, 08-30-02) 
A1-1422, B1-4420 
 
The contractor shall request the most recent copy of the IFB package from the RO to 
prepare its procurement. The IFB is constantly being updated to meet CMS requirements 
in the changing banking environment. 
 
140 - Bonding - (Rev. 5, 08-30-02) 
A1-1424, B1-4422 
 
The contractor is required to have a fidelity bond on, as a minimum, each certification 
and disbursement employee. Blanket bonds are an acceptable alternative. 
 
Bonds must protect against at least the risks contained in the contractor's agreement 
(specified in the article entitled "Certification and Disbursement and Indemnification"). 
 
As a general rule, the amount of the bond should equal 1/10 of the monthly limitation of 
the letter of credit but not exceed $500,000. 
  CMS accepts a bond in excess of $500,000 and assumes an allocated share of its total 
cost if the contractor determines that a larger bond is desirable.  
 
No deductibles are permitted with respect to coverage, risks, and amounts. 
 
150 - Letter-Of-Credit Check List 
(Rev. 158, Issued: 09-25-09, Effective: 10-26-09, Implementation: 10-26-09) 
 
FORM NAME  DUE DATE 
Intermediary Benefit Payment Report,  Monthly - within 20 working days after the 
CMS-456  end of the reporting month. 
Payment voucher on Letter-of-Credit  Monthly - within 15 days after the end of 
Transmittal - CMS-1521  the reporting month. 
Monthly Intermediary Financial Report, 
Same as above 
CMS-1522 
Banking Schedules,   
Schedule of Itemized Bank Services 
Monthly - within 15 days after the end of 
Provided Report and Recap of Daily 
the reporting month 
Available Balances  
 
160 - Electronic Funds Transfer (EFT) - (Rev. 5, 08-30-02) 
A1-1430, B1-4430 
 
The contractor shall pay claims from providers of services according to the following 
criteria. 
 
A.   Requirement 
 
The contractor may transmit payments electronically to each provider who bills 
Medicare, elects to receive payments electronically, and who provides the necessary bank 
account and routing data to enable the contractor to pay electronically. 
 
B.   Notification Requirement 
 
The contractor shall provide its Regional Office (RO) with quarterly data on the number 
of providers paid under EFT, the transmission protocol, such as the ANSI X12 835 used 
for its EFT transmissions, and the benefit payment amount of EFT transactions. It shall 
use Form CMS-588, Authorization Agreement for Electronic Funds Transfer, to maintain 
a record of those physicians and suppliers that authorize Medicare payment under EFT. 
 
C.   Claims Processing Timeliness (CPT) Requirement 
  When transmitting electronic payments to providers, the contractor shall pay claims in a 
timely manner consistent with the payment floor in effect at the time of payment. It shall 
transmit the EFT authorization to its originating bank upon the expiration of claims 
processing timeliness payment floor, as discussed in the Medicare Claims Processing 
Manual, Chapter 1, General Billing Requirements. For example, an EFT payment in 
March 2001 for an electronic claim may not be transmitted to the originating bank earlier 
than 14 days after the date of receipt. An EFT payment in March 2001 for a paper claim 
may not be transmitted to the originating bank earlier than 27 days after the date of 
receipt. Payment settlement, i.e., the date on which funds are posted to the provider's 
account, should not be earlier than 2 business days following transmission of the 
electronic payment data to the originating bank. The contractor shall accomplish this by 
designating an effective payment date on the electronic payment file of no earlier than 2 
business days after the transmission date. 
 
D.   Electronic Transmission Standard 
 
When making direct deposits to the accounts of providers under EFT, the contractor shall 
use a transmission format that is both economical and compatible with its servicing bank 
and the Automated Clearing House. 
 
For Standard Systems Maintainers, the Medicare standard ANSI 835 health care 
payment/advice can be abbreviated and used to generate an ACH-FORMATTED EFT 
file that contains no beneficiary-specific data. In these cases, the bank translates the 
abbreviated ANSI 835 into an ACH-COMPATIBLE payment file. The entire ANSI 835 
Remittance advice record will be sent directly to the provider. In the event these 
abbreviated ANSI data are not acceptable to certain banks for purposes of initiating 
electronic payments through the appropriate ACH, the standard system users should 
consult with their individual banks to determine which electronic payment data format is 
acceptable. The contractor should refer to Part 3, Chapter 24, EDI Support Requirements 
for more information on the abbreviated ANSI-835. 
 
E.   Alternatives to Electronic Payment 
 
When EFT is not used, the contractor shall make payments to providers via hardcopy 
checks drawn on the commercial bank servicing its Medicare account. It shall send the 
hardcopy check by first class U.S. Postal Service only. 
 
NOTE:  The pickup, next-day delivery, express mail or the use of a courier service for 
hardcopy checks is prohibited except in emergency situations, as authorized by the 
contractor's RO. 
 
F.   Modification of Tri-partite Bank Agreement to Include EFT Method of Payment 
 
The contractor shall work with its servicing bank and its RO to ensure that the Tri-partite 
bank agreement is modified to include wording that allows funding of the Letter of Credit 
to include electronic payments as well as hardcopy checks. The Tri-partite bank  agreement needs to clearly state that all references to checks in the original bank 
agreement shall mean checks and/or electronic funds transfer (EFTs). 
 
The contractor shall have its legal department and that of the originating bank review the 
Tri-partite bank agreement to ensure that it meets contractor needs and the requirements 
of the Medicare program. It shall forward any modifications to the Tri-partite bank 
agreement at least 1 month prior to its effective date to the RO and the Chief, Financial 
Management Unit, OCA, BPO in CO for review and approval. See 160.1, Exhibit 2 for 
a sample addendum to the Tri-partite bank agreement that includes general provisions for 
payment under the EFT method. 
 
G.   The Receiving Bank's Role in EFT/Electronic Remittance Advice (ERA) 
 
While providers may wish to consider criteria such as experience with EFT and receipt of 
ANSI-formatted financial data when choosing a bank, these procedures should in no way 
be interpreted as requiring providers to do business with a particular financial institution 
(e.g., receiving bank only). 
 
H.   Electronic Funds Transfer Transaction Costs 
 
Prior to transmitting payments electronically, the originating bank fills in the relevant 
EFT transaction costs on the Schedule AS (Schedule of Bank Processing Charges), and 
submits it to the contractor. The contractor shall transmit this information to both the RO 
and CO. Once electronic payments are initiated, the originating bank shall include all 
payment information on the Monthly Schedule of Bank Processing Charges, (TAA 1-b), 
and transmit this form to the contractor, who enters the data into the Contractor 
Administrative Budget and Financial Management (CAFM) system where it is reviewed 
and approved first by the RO and then CO. 
 
NOTE:  The EFT costs reported on line 8 of the AS Schedule and the Monthly Schedule 
of Bank Processing Charges (TAA 1-b) shall include a breakdown of all costs associated 
with EFT, including the cost per EFT transaction, set-up costs, monthly charges, 
transmission costs, etc. 
 
I.   Contractor Responsibility for EFT/ERA Records Retention 
 
The contractor shall retain records on EFT/ERA in accordance with established CMS and 
Department of Justice procedures for retention of documentation associated with 
electronic claims. 
 
J - Provider Responsibility for the Accuracy of Claims Data 
 
To minimize errors and disruptions to cash flow, providers are responsible for verifying 
the accuracy of claims payment information submitted to their Medicare contractor. 
 
170 - Electronic Remittance Advice (ERA) - (Rev. 5, 08-30-02)  A1-1431, B1-4431 
 
The contractor shall accommodate provider requests to receive hardcopy checks or 
electronic payments with ERAs. Providers have the option to receive remittance 
information on paper or electronically. Providers who elect EFT are not required to 
receive ERAs. The contractor shall furnish ERAs to providers using the following 
criteria: 
 
A.   Standard Format Requirement 
 
In lieu of the traditional method of sending hardcopy remittance advices and checks to 
providers, effective October 1, 1992, the contractor shall transmit, over wire only, the 
ANSI X12.835, Health Care Claim Payment/Advice (ANSI-835) to a requesting provider 
or to a requesting provider's billing service. The ANSI-835 is the only electronic 
remittance option available as of this date. If the contractor has any technical questions 
on formats or electronic remittance transmission requirements, it should contact its RO. 
 
B.   Privacy Act Compliance 
 
Unless otherwise directed by CO, the contractor shall ensure that remittance information 
is transmitted to providers or their authorized billing agents either directly, through a 
Value Added network, or as authorized by a provider, to a bank that is capable of 
receiving ERA data and agrees to safeguard the data. 
 
C.   Reconciliation Requirement 
 
Prior to entering into an electronic payment arrangement with a provider, the contractor 
shall ensure that its providers are able to reconcile their accounting records using the 
ANSI-835 remittance advice. Once this determination is made, it shall provide telephone 
support during normal business hours and allow for an initial reconciliation period of up 
to 30 days during which it will produce both paper and electronic remittances. After this 
30-day phase-in period, it shall eliminate paper remittances for these providers. 
 
D.   Standard Format Reference 
 
See the Claims Processing Manual, Chapter 22 - Remittance Notice to Providers, for 
information and additional requirements concerning the standard remittance advice 
format. 
 
180 - Exhibits - (Rev. 5, 08-30-02) 
A1-1435 
 
Exhibit 1 - Form CMS-1521 - - See CMS Forms page. 
 
Exhibit 2 - Form CMS-1522 - - See CMS Forms page. 
  Exhibit 3 - Intermediary Benefit Payment Report - - See CMS Forms page. 
 
Exhibit 4 -Authorization Agreement for Electronic Funds Transfer 
 
PROVIDER/PHYSICIAN 
PROVIDER/PHYSICIAN 
NAME____________________ 
ID NUMBER___________________   
I hereby authorize (Insert Contractor Name), hereinafter called COMPANY, to initiate 
credit entries and to initiate, if necessary, debit entries and adjustments for any credit 
entries in error to my ( ) Checking ( ) Savings account (select one) indicated below and 
the depository named below, hereinafter called DEPOSITORY, to credit and/or debit 
the same to such account. 
DEPOSITORY 
NAME _____________________  BRANCH _____________________ 
CITY ______________________  STATE ______ ZIP ____________ 
TRANSIT 
NUMBER ____________   ACCOUNT NUMBER ____________ 
This authority is to remain in full force and effect until COMPANY has received 
written notification from me of its termination in such time and in such manner as to 
afford COMPANY and DEPOSITORY a reasonable opportunity to act on said notice of 
termination. 
NAME ________________________  TITLE _____________________ 
(PLEASE PRINT) 
SIGNED X ______________________  DATE _____________ 
 
Exhibit 5 - Addendum to Medicare Bank Agreement 
 
The parties have executed this Agreement for the Medicare A(B) Bank Accounts using 
the Checks Paid Method of Letter of Credit Financing and desire to add changes to the 
existing agreement currently in force. These changes are necessitated by the 
implementation by (Insert Contractor Name) of the Electronic Funds Transfer (EFT) 
method of paying providers effective (Insert Date). This change in payment method is 
under the direction of the Centers for Medicare and Medicaid Services (CMS) as an 
initiative to increase the uniformity and efficiency of the provider payment process. 
 
Also, item number 10 below, although not related to EFT, is incorporated into the bank 
agreement to insure that no excessive earnings credits accumulate during the period of 
the bank agreement. 
 
The parties hereby agree to the following terms and conditions that shall be considered an 
integral part of the bank Agreement:   
1.  The rates as reflected on the Schedule of Bank Processing Charges shall be in 
effect for the term of this Agreement. 
 
2.  This Agreement, with all its provisions and covenants, shall continue in force 
from year to year after the expiration of such term; provided, however, that 
notification to terminate or renegotiate has not been given by any party as 
specified in the Agreement executed on (Insert Date). 
 
3.  All references to checks in the original Agreement shall hereby mean checks 
and/or Electronic Funds Transfers (EFTs). 
 
4.  The Fiscal Intermediary (Carrier) is obligated to obtain, retain, and provide copies 
of provider authorizations, particularly with regard to the rights, liabilities, and 
responsibilities of Medicare contractors and financial institutions under 
Regulation E. 
 
5.  The nature, format and medium of entries, or entry information is to be furnished 
to the originating bank in writing by the Fiscal Intermediary (Carrier) prior to 
entering into an EFT arrangement. 
 
6.  The Fiscal Intermediary (Carrier) and the originating bank shall negotiate the 
level of security to be established for delivering the payment data from the Fiscal 
Intermediary (Carrier) to the originating bank, such as transmittals with 
authorized signatures, and the method used to verify authenticity of 
telecommunicated data, prior to entering into an EFT arrangement. 
 
7.  The Fiscal Intermediary (Carrier) shall specify the time when funds are to be 
provided to the originating bank prior to entering into an EFT arrangement. 
 
8.  The Fiscal Intermediary (Carrier) and the originating bank shall agree to the 
deadline for reversals, corrections, or changes by the Fiscal Intermediary (Carrier) 
of entries or entry information furnished to the originating bank prior to entering 
into an EFT arrangement. 
 
9.  In those cases where the Fiscal Intermediary's (Carrier's) Medicare bank is unable 
to originate EFT transactions, the Medicare bank may subcontract certain 
functions. The Medicare bank agrees that none of the functions to be performed 
under the Tri-partite agreement shall be subcontracted without prior written 
approval of the Fiscal Intermediary (Carrier) and the CMS. Any such approved 
subcontract shall contain the language of the Examination of Records Clause 
contained in the bank agreement (Covenant 3). 
 
10. If Line 7 of Page 1 of the Quarterly Time Account Adjustment Schedule reflects 
any positive balance, the contractor shall immediately forward supporting 
documentation and a check made payable to CMS for that amount to:   
Send a copy of the check and transmittal letter to: 
 
Centers for Medicare & Medicaid Services 
Office of Financial Management 
7500 Security Boulevard 
Baltimore MD 21244-1850 
 
190 - General Information About Termination Costs - (Rev. 5, 08-30-02) 
A1-1800 
 
The contractor shall prepare a shut-down cost budget voucher based on its natural 
expense line items, and submit the budget to both CMS's Central Office (CO) and to the 
contractor's Regional Office (RO). 
 
It shall include the following information on the voucher: 
 
  All incurred shut-down expenses determined by the contractor's natural cost 
items; 
 
  The amount, and a detailed explanation, for each item it claims; and  
 
  An attestation signed by a company official that validates the costs the contractor 
is claiming are correct. 
 
The CMS pays shut-down costs based on the contractor's voucher's information. The 
contractor shall not draw administrative funds, via its letter-of-credit, after the official 
date of either contract close-out or termination. 
 
It shall submit the voucher on official company letterhead. It shall make sure the voucher 
is signed by an authorized company official, and forward a copy to CMS's CO at the 
following address: 
 
Centers for Medicare & Medicaid Services 
Division of Contractor Financial Management, OFO 
7500 Security Boulevard 
Baltimore MD 21244-1850 
 
200 - General - (Rev. 14, 02-03-03) 
A1-1900, B1-4900 
 
The Contractor Financial Reports provide a method of reporting financial activities for 
benefit payments by Medicare contractors according to the Chief Financial Officers 
(CFOs) Act of 1990. The contractor is required to maintain accounting records according 
to government accounting principles and applicable government laws and regulations. 
This requirement complies with the Office of Management and Budget (OMB) Bulletins  about Financial Statements. These policies and procedures are developed by the Federal 
Accounting Standards Advisory Board (FASAB). 
 
The accounting principles and the auditing standards required are not substantially 
different from Generally Accepted Accounting Principles (GAAP) and Generally 
Accepted Auditing Standards (GAAS) as formulated by the accounting profession. 
Government accounting principles which are developed by FASAB, however, require 
maintaining records not only for preparing financial statements, but also to enforce 
applicable laws and regulations. Accounts are maintained to provide control over 
operations as well as to provide financial information. 
 
Medicare contractors are required to use double entry bookkeeping and accrual basis 
accounting. For example, if an accounts receivable is established, accounts receivable 
should be debited and, most likely, operating/program expense should be credited. If an 
accounts payable is established, accounts payable should be credited and, most likely, 
operating/program expense should be debited. In addition, the information reported must 
be supported by the contractor's books and records as of the end of the period requested 
and adequate audit trails must be maintained. To ensure accurate reporting, proper cutoff 
procedures must also be established in order to limit reporting to activities attributable to 
the reporting period. Where actual data is not available, reasonable estimates are 
acceptable. See Exhibits 12 through 15 for protocols for estimating relevant accounts. 
When end of period entries are made to accrue account balances, the contractor shall 
reverse the entries in the following quarter to allow normal processing of accounting 
transactions. 
 
In order to maintain consistent and accurate financial reporting, Medicare contractors 
must have an internal control structure that integrates the accounting and claims 
processing systems. The internal control structure must provide for the following control 
procedures: 
 
1.  Independent review of proper valuation of recorded amounts and performance; 
 
2.  Segregation of duties (separate authorization, record-keeping, and custody); 
 
3.  Safeguards over access to assets and records; 
 
4.  Authorization of transactions and activities; 
 
5.  Documents and records that are adequate to ensure proper recording; and  
 
6.  Quarterly reconciliation of internal systems to the Provider Overpayment Report 
(POR) system for intermediaries and the Physician Supplier Overpayment Report 
(PSOR) system for carriers. 
 
Supporting documentation must be maintained and available for review and audit. This 
must include lead schedules for all amounts used for report preparation and detailed  documentation, such as demand letters for accounts receivable. A very good procedure 
that CMS recommends to ensure the accuracy of reported amounts, is trending and 
comparative analysis. This analysis involves comparing reported amounts to prior 
amounts to identify material errors. 
 
Hardcopy books and records used to prepare the annual financial reports should be 
retained for 6 years unless microfilmed. Then, the hardcopy needs to be retained for 3 
years and the microfilm retained for the balance of the 6-year period. 
 
The Office of the Inspector General (OIG) will conduct audits of contractors according to 
government auditing standards. This requirement complies with OMB Bulletin No. 98-
08, Audit Requirements for Federal Financial Statements. Applicable government laws 
and regulations also supplement the government auditing standards. These standards are 
similar to those contained in the Comptroller General of the United States Standards for 
Audit of Governmental Organizations, Programs, Activities, and Functions (The Yellow 
Book). 
 
The OMB Bulletin No. 01-09, Form and Content of Agency Financial Statements 
requires the preparation of Federal Agency interim financial statements, in addition to 
accelerating the due date of the submission of year-end audited financial statements to 
OMB and Congress. Because of OMB's new requirements, CMS and its Medicare 
contractors must be able to prepare financial statements at the end of any month at the 
request of CMS. 
 
To meet this obligation, all shared systems must be able to produce any system reports 
required by Medicare contractors utilizing those systems to prepare all the Forms CMS-
750 A/B and the Forms CMS-751 A/B on a month-end basis. These reports must be 
cumulative in order to provide Medicare contractors' financial position and status of 
accounts receivable activity from the beginning of the fiscal year through the month 
requested. 
 
Medicare contractors must be able to support all summary amounts reported on any of 
these reports with transaction level detail, and must be able to produce this support upon 
request by CMS or internal/external auditors. 
 
210 - Instructions For Completing The Form CMS-750A/B, Contractor 
Financial Reports - (Rev. 5, 08-30-02) 
A1-1910, B1-4910 
 
There are separate reports and data screens for Part A, Hospital Insurance (HI), and Part 
B, Supplementary Medical Insurance (SMI) in the Contractor Administrative-Budget and 
Financial Management (CAFM) system. The intermediary enters data in both HI and 
SMI data screens (see Exhibits 1 and 2). The carrier enters data in the SMI data screens 
(see Exhibit 2). 
  The data for the report is HI and SMI financial information as defined in the Medicare 
Account Definitions (see Exhibit 11). In order to facilitate reconciliation, balancing and 
error resolution, the contractor shall report all data in dollars and cents. 
 
The data on the report may not equate on a one-to-one basis with data reported to CMS in 
other reports, such as Draws on Letter of Credit, reported on Form CMS-1521. The 
contractor must maintain records that will allow reconciliation of Form CMS-750A/B 
with those other reports. 
 
220 - Due Date - (Rev. 5, 08-30-02) 
A1-1911, B1-4911 
 
This report is due on January 21, April 21, July 21, October 21 (21 days after the end of 
each quarter) via the CAFM system. If that date occurs on a holiday or a weekend, the 
report is due the following Federal workday. 
 
230 - Certification - (Rev. 5, 08-30-02) 
A1-1912, B1-4912 
 
Medicare contractor certification by the Chief Financial Officer (CFO) is required. The 
CFO must input their password on the CAFM system (see Exhibit 16). Failure to record 
the official's password is a serious error that will prevent acceptance of the report by the 
CAFM system. The following statement appears at the end of the Form CMS-750A/B: 
 
I hereby CERTIFY that I have examined the Statement of Financial Position prepared by 
[name of contractor] for the period beginning (first day of FY) and ending (last day of 
quarter), and that to the best of my knowledge and belief, it is a true, correct and 
complete statement prepared from the books and records of the contractor in accordance 
with applicable instructions. 
 
NAME _______________ Date __________ Title ___________ 
 
240 - Instructions for Completing Form CMS-751 A/B, Status of 
Accounts Receivable - (Rev. 5, 08-30-02) 
A1-1920, A1-1940, B1-4920, B1-4960 
 
Forms CMS-H751A/B and CMS-M751A/B are similar data entry screens used to report 
the following receivables. 
 
  Form CMS-H751A to report debt under Part A (HI) by intermediaries 
 
  Form CMS-H751B to report debt under Part B (SMI) by intermediaries and 
carriers 
 
  Form CMS-M751A to report MSP debt under HI by intermediaries; 
    Form CMS-M751B to report MSP debt under SMI by intermediaries and carriers; 
 
MSP accounts receivable data reported on CMS-M751A/B is a subset of total accounts 
receivable data reported on Form CMS-H751A/B (e.g., 751A/B includes the data 
reported on the CMS M751A/B and non-MSP data. 
 
The screen heading indicates whether the report is for the MSP subset. 
 
Samples of the screens are shown in Exhibits 3 - 9. There are separate reports and data 
screens for Part A, HI, and for Part B, SMI in the CAFM system. The intermediary enters 
data in both HI and SMI data screens (Exhibits 3 and 4). The carrier enters data in only 
the SMI data screens (Exhibit 4). 
 
The intermediary or carrier reports the accounts receivable activity for fiscal year-to-date 
(FYTD) for the period of the report. In order to facilitate reconciliation, balancing and 
error resolution, it reports the accounts receivable in dollars and cents. 
 
The reports require information both for the amount and the number of accounts 
receivable. To provide standardization, CMS suggests that contractors use their collection 
process as a guide when reporting the number of accounts receivable. For example, a 
separate, stand alone accounts receivable collected would be reported as a quantity in the 
number column. 
 
EXAMPLES: 
 
1.  (Intermediaries only). A cost report is one receivable. Even though several claims 
are associated with the cost report, the collection activity would be against the 
entire cost report rather than each claim. 
 
2.  A demand letter issued in a Medicare Secondary Payer (MSP) case to one debtor 
with several claims listed on the letter. If the collection is made and posted against 
an individual claim, each claim on the demand letter would be an individual 
receivable. 
 
3.  A demand letter issued to a physician based on adjustments projected from 
sampling claims equals one. Even though many claims are represented by 
projection of the sample. 
 
Once the principal number is established, the contractor shall report the interest 
associated with the principal amount in the same manner. There can be a difference 
between the principal number and the interest number because some receivables are not 
subject to interest. 
 
250 - Due Date - (Rev. 5, 08-30-02) 
A1-1921, A1-1941, B1-4921, B1-4941 
  This report is due on January 21, April 21, July 21, October 21 (21 days after the end of 
each quarter) via the CAFM system. If that date occurs on a holiday or a weekend, the 
report is due the following Federal workday. 
 
260 - Certification - (Rev. 5, 08-30-02) 
A1-1922, A1-1942, B1-4922, B1-4942 
 
Medicare contractor certification by the CFO is required. The CFO must input their 
password on the CAFM system (see Exhibit 16). Failure to record the official's password 
is a serious error that will prevent acceptance of the report by the CAFM system. The 
following statement appears at the end of Form CMS-H751A/B: 
 
I hereby CERTIFY that I have examined the Status of Accounts Receivable 
prepared by (name of contractor) for the period beginning (first day of FY) and 
ending (last day of quarter), and that to the best of my knowledge and belief, it is 
a true, correct and complete statement prepared from the books and records of the 
contractor in accordance with applicable instructions. 
 
For (Status of MSP Accounts Receivable) (Form CMS-M751) the statement includes a 
reference to MSP and reads as follows: 
 
I hereby CERTIFY that I have examined the Status of MSP Accounts Receivable 
prepared by (name of contractor) for the period beginning (first day of FY) and 
ending (last day of quarter), and that to the best of my knowledge and belief, it is 
a true, correct and complete statement prepared from the books and records of the 
contractor in accordance with applicable instructions. 
 
The name, date and title of the person making the certification are on both certifications. 
 
270 - Line Item Instructions Form CMS-H751A/B - (Rev. 5, 08-30-02) 
A1-1923, A1-1943, B1-4923, B1-4943 
 
Medicare contractors must develop and maintain transaction level detail (at a minimum, 
this would include the provider name, provider number, date of determination, 
outstanding balance, and any adjustments or recoupments) by debt to support the 
amounts reported for each line outlined below. 
 
In addition, non-MSP amounts must be reconciled to the POR (intermediary) or PSOR 
(carrier) system as applicable. 
 
Part I, Status of Receivables 
 
For each line in Section A, below, the instruction applies to each the Form CMS-H751 
and Form CMS-M751, and to the intermediary report and to the carrier report unless 
otherwise noted. The instructions are applicable only to MSP amounts for the Form 
CMS-M751 and are applicable to all amounts for the Form CMS-H751.   
Section A - Outstanding Receivables 
 
270.1 - Line 1, Beginning FY Balance (Principal & Interest)   
(Rev. 5, 08-30-02) 
A1-1923.1, A1-1943.1, B1-4923.1, B1-4943.1 
 
The contractor enters the number and amount for all accounts receivable outstanding as 
of the beginning of the FY. These amounts will be pre-filled with the ending balances 
reported on the preceding (9/30/XX) FY Contractor Financial Reports. The contractor 
must make any corrections to the beginning principal and interest FY balance on Line 5a, 
Adjusted Amounts, Internal Adjustments. It shall apply the offsetting entry, on the related 
Form CMS-750A/B report (debit or credit) to Operating/Program Expense for 
transactions that affect principal, or interest revenue if the transaction affects interest. 
 
270.2 - Line 2a, New Receivables (Principal) - (Rev. 5, 08-30-02) 
A1-1923.2, A1-1943.2, B1-4923.2, B1-4943.2 
 
The contractor enters the number and amount for all new receivables established at its 
location during the FY. New receivables for intermediaries include cost report 
settlements and credit balances. For both intermediaries and carriers, overpayments and 
claims accounts receivables for all claim types are included. For carriers only, beneficiary 
debt and under-tolerance accounts receivable are included. 
 
For MSP new receivables includes group health plan data-match, non-data-match, 
liability (including worker's compensation, auto and no fault), etc. 
 
The contractor does not include those receivables transferred from other Medicare 
contractors, other CMS locations, Currently Not Collectible (CNC), or other transferred 
locations in prior fiscal periods. It includes all of these items on Lines 5b, 5d, 5f, or 6b, 
Transferred In Amounts. 
 
NOTE:  MSP accounts receivable are not established until a settlement, judgment or 
award has been reached and a demand letter is sent. 
 
270.3 - Line 2b, Accrued Receivables (Principal) - (Rev. 5, 08-30-02) 
A1-1923.3, A1-1943.3, B1-4923.3, B1-4943.3 
 
Line 2b is not applicable to carriers or to MSP. 
 
The intermediary enters the number and amount of Periodic Interim Payment (PIP) 
accrued receivables, fiscal year-to-date on this line. The only receivables a FI will accrue 
are those that result from comparing PIP payments to claims submitted. For each 
quarterly reporting period, a new accrual is established and the prior quarter's accrual 
must be reversed or zeroed out. Both the establishment and reversal of the PIP accrual 
must be reflected in this line, except for the reversal of the September's quarterly accrual,  which would be reflected in Line 5a, Adjusted Amounts, Internal Adjustments (see 
Exhibit 13, Periodic Interim Payments (PIP) Protocol for Estimating 
Payables/Receivables for the Form CMS-750A/B, Statement of Financial Position). 
 
270.4 - Line 3, Interest Earned (Interest) - (Rev. 5, 08-30-02) 
A1-1923.4, A1-1943.4, B1-4923.4, B1-4943.4 
 
The contractor enters the number and amount of interest earned on: (a) existing or new 
receivables established at its location during the FY; and (b) the interest earned on 
receivables transferred to it, following the date the receivables are established on its 
records. The contractor shall not include the amount of accrued interest earned at other 
locations. It shall report the accrued interest earned at other locations as transferred in on 
Line 5b, 5d, 5f or 6b, Transferred In Amounts. 
 
270.5 - Line 4a, Cash/Check Collections on Receivables (Principal & 
Interest) - (Rev. 5, 08-30-02) 
A1-1923.5, A1-1943.5, B1-4923.5, B1-4943.5 
 
The contractor enters the amount collected by cash or check on receivables during the 
fiscal period. 
 
270.6 - Line 4b, Offset Collections on Receivables (Principal & Interest) 
- (Rev. 5, 08-30-02) 
A1-1923.6, A1-1943.6, B1-4923.6, B1-4943.6 
 
The contractor enters the amount collected by offset on receivables during the fiscal 
period. 
 
270.7 - Line 4c, Collections Deposited at Another Location (Principal & 
Interest) - (Rev. 5, 08-30-02) 
A1-1923.7, A1-1943.7, B1-4923.7, B1-4943.7 
 
The contractor enters the amount collected or offset by CMS Central Office (CO) for 
collections on accounts receivable referred under the Debt Collection Improvement Act 
(DCIA). Do not transfer the case to CO where the deposit or offset of the money is made. 
Upon receipt of the Collection Reconciliation/Acknowledgement form, enter the amount 
collected or offset by cross servicing/TOP and received by CO in this line to reduce the 
outstanding amount of the receivable being reported on Form CMS-751A/B. CO will 
record the actual deposit of cash/check/offset on Line 10, Cash/Offsets Received for 
Receivables at Another Location of its' Form CMS-R751. 
 
The Medicare contractor or CO that records the actual deposit of cash/check/offset will 
record this amount on Line 10, Cash/Offsets Received for Receivables at Another 
Location. (See 270.15 for instructions and Exhibit 18 Collection Reconciliation/ 
Acknowledgement Form).   
270.8 - Line 5, Adjusted/Transferred/Waived Amounts (Principal & 
Interest) - (Rev. 5, 08-30-02) 
A1-1923.8, A1-1943.8, B1-4923.8, B1-4943.8 
 
The contractor enters the amount of receivables it has adjusted, transferred in from or out 
to other locations, or waived. It is required to maintain supporting documentation and 
records for all these receivables transferred in and out. Amounts transferred in from or 
out to other CMS locations or Medicare contractors must be reconciled to the other 
entity's records for the same reporting period prior to submission of the quarterly reports 
to ensure that only approved transfers are being reported. Documentation of the 
reconciliation must be maintained and must indicate that a supervisory review of the 
reconciliation was performed. Refer to Exhibit 17 for instructions for the transfer of debt 
between other reporting entities. 
 
The contractor reports in Lines: 
 
5.   
a.  Adjusted Amounts (Principal & Interest). The contractor enters the 
amount for any adjustments to the beginning balance, or 
corrections/adjustments of receivables previously established during the 
fiscal period. These adjustments can be either positive or negative. It 
separately reports adjustments resulting from Auditor/Consultant 
recommendations, and those determined independently. 
 
b.  Transfers In from other Medicare Contractors (Principal & Interest). The 
contractor enters the amount transferred in from other Medicare 
contractors during the fiscal period. 
 
c.  Transfers Out to other Medicare Contractors (Principal & Interest). The 
contractor enters the amount transferred out to other Medicare contractors 
during the fiscal period. 
 
d.  Transfers In from other CMS Locations, POR/PSOR (Principal & 
Interest). (Carriers report PSOR, and intermediaries report POR). The 
contractor enters the amount transferred in from other CMS locations and 
reported on the POR/PSOR during the fiscal period. (Applies to non-MSP 
debt only.) 
 
e.  Transfers Out to other CMS Locations, POR/PSOR (Principal & Interest). 
Carriers report PSOR, and intermediaries report POR). The contractor 
enters the amount transferred out to other CMS locations and reported on 
the POR/PSOR during the fiscal period. 
 
f.  (Applies to non-MSP debt only) 
  g.  Transfers In from other CMS Locations, Not POR/PSOR (Principal & 
Interest). The contractor enters the amount transferred in from other CMS 
locations and not reported on the POR/PSOR during the fiscal period. 
 
h.  Transfers Out to other CMS Locations, Not POR/PSOR (Principal & 
Interest). The contractor enters the amount transferred out to other CMS 
locations and not reported on the POR/PSOR during the fiscal period. 
 
i.  Waivers (Principal & Interest). The contractor enters the amount of 
accounts receivable waived based on the application of  1862(b) and 
1870(c) of the Social Security Act. 
 
270.9 - Line 6, Amounts Written-off Closed (Bad Debts)/Transferred 
CNC (Principal & Interest) - (Rev. 5, 08-30-02) 
A1-1923.9, A1-1943.9, B1-4923.9, B1-4943.9 
 
The contractor enters the amount which it has written-off as a bad debt, or transferred to 
or from CNC. 
 
The contractor reports in lines: 
 
6.   
a.  Amounts Written-off Closed (Bad Debts)(Principal & Interest). The 
contractor enters the amount for which collection efforts have been 
abandoned. (This would include the remaining balance on accounts 
receivable after the bankruptcy court has ruled on bankruptcy, appeals, 
and other litigated cases). 
 
b.  Transfers In from CNC (Principal & Interest). The contractor enters the 
amount re-established as active debt that was previously classified as CNC 
during the fiscal period. 
 
c.  Transfers Out to CNC (Principal & Interest). The contractor enters the 
amount removed from the ending balance and reclassified as CNC during 
the fiscal period. 
 
270.10 - Line 7, Ending Balance (Principal & Interest) - (Rev. 5, 08-30-
02) 
A1-1923.10, A1-1943.10, B1-4923.10, B1-4943.10 
 
The ending balance is a computed field reporting the number (manual entry) and amount 
for receivables outstanding as of the end of the reporting period. It equals: 
 
  Principal    Interest 
+  Beginning FY balance (Line 1)  +  Beginning FY balance (Line 1)    Principal    Interest 
+  New Receivables (Line 2a)  +  Interest Earned (Line 3) 
+/-  Accrued Receivables (Line 2b)     
Collections on Receivables (Line 4a-
-  -  Collections on Interest (Line 4a-c) 
4c) 
Adjusted/Transferred Amounts (Line  Adjusted/Transferred Amounts (Line 
+/-  +/- 
5a-5g)  5a-5g) 
-  Waivers (line 5h)  -  Waivers (line 5h) 
Amounts Written-off/Transferred  Amounts Written-off/Transferred 
+/-   
CNC(Lines 6 a - c)  CNC (Lines 6 a - c) 
=  Ending Balance (Line 7)  =  Ending Balance (Line 7) 
 
NOTE:  Although Line 7 is a calculated amount, the contractor must be able to provide a 
detailed listing of all outstanding receivable balances that support this line at any given 
period of time. The ending balance must be equal to the accounts receivable and interest 
receivable amounts reported on the form in Statement of Financial Position. 
 
270.11 - Line 7a, Current Receivables (Principal and Interest)   
(Rev. 5, 08-30-02) 
A1-1923.11, A1-1943.11, B1-4923.11, B1-4943.11 
 
The contractor enters the amount of the receivables due within 12 months following the 
reporting period. The definition of current and non-current does not depend on the time a 
debt is outstanding but when the debt is due. A receivable for which the due date is 12 
months or less from the report date is a current receivable. For example, a debt due 
September 30, 2003, within 12 months from the date of a report for September 30, 2002, 
is a current receivable. In addition, all delinquent receivables are to be reported as 
current. The contractor shall assign between current and non-current the appropriate 
amount of those receivables for which it has negotiated extended repayment schedules, 
based on the installment payment dates. 
 
270.12 - Line 7b, Non-current Receivables (Principal) - (Rev. 5, 08-30-
02) 
A1-193.12, A1-1943.12, B1-4923.12, B1-4943.12 
 
The contractor enters the amount of non-current receivables due more than 12 months 
after the reporting period. The definition of non-current receivables includes those 
receivables for which the due date is more than 12 months from the end of the reporting 
period. For example, those receivables for which the due date is October 1, 2003, 1 year 
from the date of a report for September 30, 2002, are non-current receivables. 
  270.13 - Line 8, Allowance for Uncollectible Accounts (Principal & 
Interest) - (Rev. 5, 08-30-02) 
A1-1923. 13, A1-1943.13, B1-4923.13, B1-4943.13 
 
The contractor enters the amount of the ending balance reported in Line 7 for accounts 
receivable it estimates will not be collectible. (See Exhibit 14, Allowance for 
Uncollectible Accounts). 
 
270.14 - Line 9, Total Receivables Net of Allowance - (Rev. 5, 08-30-02) 
A1-1923.14, A1-1943.14, B1-4923.14, B1-4943.14 
 
Total Receivables Net of Allowance is a computed field (Line 7 less Line 8) reporting the 
contractor's estimate of the amount of accounts receivable it reasonably expects to 
collect. 
 
270.15 - Line 10, Cash/Offsets Received for Receivables at Another 
Location (Principal & Interest). - (Rev. 5, 08-30-02) 
A1-1923.15, A1-1943.15, B1-4923.15, B1-4943.15 
 
This line shall be used only be used in the instances where CO receives collection from 
cross servicing/TOP for DCIA debt. 
 
The Medicare contractor who reports the receivable on Form CMS-751A/B will reduce 
the outstanding balance of the receivable for the amount deposited by CO by recording 
the amount of the collection in Line 4c, Collection Deposited at Another Location. (See 
Exhibit 18, Collection Reconciliation/Acknowledgement Form). 
 
Section B - Delinquent Receivables 
 
270.16 - Line 1, Total Not Delinquent (Principal & Interest)   
(Rev. 5, 08-30-02) 
A1-1923.16, A1-1943.16, B1-4923.16, B1-4943.16 
 
The contractor enters the total number and amount of accounts receivable that are not 
delinquent. 
 
270.17 - Line 2, Total Delinquencies (Principal & Interest) - (Rev. 5, 08-
30-02) 
A1-1923.17, A1-1943.17, B1-4923.17, B1-4943.17 
 
The contractor enters the total number and amount of delinquent receivables. It enters the 
amount of the past due payment unless the full amount is normally due and declared 
payable. The debt becomes delinquent the day following the date that the debt is due with 
all extensions recognized. Thus, for non-MSP if the debt is due 30 days after demand, the 
first day of delinquency starts on day 31. For MSP, if the debt is due 60 days after  demand, the first day of delinquency starts on day 61. If any portion of a debt has been 
delinquent more than 180 days, the entire amount is reported as delinquent. The 
contractor enters the amount of receivables that are delinquent for the respective periods 
(a through i) indicated. 
 
270.18 - Line 3, Status of Delinquent Receivables, less than or equal to 
180 Days (Principal & Interest) - (Rev. 5, 08-30-02) 
A1-1923.18, A1-1943.18, B1-4923.18, B1-4943.18 
 
The contractor enters the total number and amount of delinquent receivables 180 days 
delinquent and less, which are in (a) Bankruptcy, (b) Appeal, (c) Department of Justice, 
(d) Referred for Cross Servicing and/or (e) Other Status. 
 
270.19 - Line 4, Status of Delinquent Receivables, greater than 180 Days 
(Principal & Interest) 
(Rev. 111; Issued:  10-27-06; Effective:  04-01-07; Implementation:  04-02-07) 
 
The contractor enters the total number and amount of delinquent receivables 181 days 
delinquent and greater, which are in one of the following categories: 
 
(a)  Referred to the Department of the Treasury for Cross Servicing. For MSP, 
this means debts entered into the DCS. For Non-MSP, this means debts that have 
been transmitted to DCC by CMS Central Office and the Medicare contractor has 
acknowledged and verified the validity and accuracy of the debts transmitted. 
 
(b)  Not Eligible for Referral, the number and dollar amount is equal to the sum of 
lines (1) through (12) of this section. 
 
1)  Bankruptcy; 
2)  Appeal; 
3)  Department of Justice/Litigation; 
4)  Fraud and Abuse Investigation, if the contractor has received specific 
instructions from the investigating unit (i.e., Office of Inspector General or 
Office of General Counsel, etc.) not to attempt collection; 
 
5)  Deceased Debtor, debts where the debtor is deceased and the estate is 
closed; 
 
6)  Debts less than $25; 
 
7)  Federal Entity Debts, MSP only, where the only entity which received 
the last demand letter is the employer and the employer is a Federal 
agency; 
 
8)  Beneficiary Debts, Non-MSP only; 
  9)  Pending Request for Waiver or Compromise; 
 
10)  CMS Identified Exclusions, MSP only, debts where CMS has 
identified a specific debt or group of debtors as excluded from DCIA 
referral. 
 
11)  Other Exclusions, must footnote. 
 
12)  In the Process of Internal Offset (Previously Under Medicare 
Modernization Act, Section 935 Appeal). 
 
(c) Eligible for Referral, debts that are eligible for referral to the Department of the 
Treasury for cross servicing but not yet referred. 
 
270.20 - Line 4c, Collections Deposited at Another Location (Principal 
& Interest) - (Rev. 5, 08-30-02) 
A1-1923.20, A1-1943.20, B1-4923.20, B1-4943.20 
 
The contractor enters the distribution of collections on receivables, by location, for 
amounts offset or received and deposited at another location. The total amounts listed in 
this section must equal the amount reflected in Section A, Line 4c of this report. 
 
270.21 - Line 10, Cash/Offsets Received for Receivables at Another 
Location (Principal & Interest) - (Rev. 5, 08-30-02) 
A1-1923.21, A1-1943.21, B1-4923.21, B1-4943.21 
 
This will not apply to Medicare contractors. 
 
270.22 - Collections on Delinquent Debt (Principal & Interest)   
(Rev. 5, 08-30-02) 
A1-1923.22, A1-1943.22, B1-4923.22, B1-4943.22 
 
The contractor enters the number and amount of collections on receivables that were 
delinquent upon collection. The total amount should be less than total collections for the 
FY. 
 
Section D - Transferred Receivables 
 
The contractor enters the distribution of debts transferred to Medicare contractors or other 
CMS locations. 
 
For Form CMS-H751A/B, the data in this section is also reported in Section A, Status of 
Accounts Receivable Transfers Out to other Medicare contractors or other CMS 
locations, and will be used by the contractor and other CMS locations to reconcile its 
books and records.   
For Form CMS-M751A/B, the data in this section is also reported in Section A 
Outstanding Receivables, Line 5c, Transfers Out to other Medicare Contractors; Line 5e, 
Transfers Out to other CMS locations on the POR/PSOR; and Line 5g, Transfers Out to 
other CMS Locations, Not POR/PSOR. 
 
270.23 - Line 5c, Transfers Out to other Medicare Contractors 
(Principal & Interest) - (Rev. 5, 08-30-02) 
A1-1923.23, A1-1943.23, B1-4923.23, B1-4943.23 
 
The contractor enters the distribution to Medicare contractor locations of the debts, 
entered in Line 5c, Transfers Out to other Medicare Contractors, reflected in Section A of 
this report. 
 
270.24 - Line 5e, Transfers Out to other CMS Locations, POR/PSOR 
(Principal & Interest) - (Rev. 5, 08-30-02) 
A1-1923.24, A1-1943.24, B1-4923.24, B1-4943.24 
 
The contractor enters the distribution to the various regional offices (ROs) or CO of the 
debts on the POR, entered in Line 5e, Transfers Out to other CMS Locations, 
POR/PSOR, reflected in Section A of this report. 
 
270.25 - Line 5g, Transfers Out to other CMS Locations, Not POR 
(Principal & Interest) - (Rev. 5, 08-30-02) 
A1-1923.25, A1-1943.25, B1-4923.25, B1-4943.25 
 
The contractor enters the distribution to the various ROs or CO of the debts not reported 
on the POR/PSOR, entered in Line 5g,Transfers Out to other CMS Locations, Not 
POR/PSOR, reflected in Section A of this report. POR is applicable to FIs. PSOR is 
applicable to carriers. 
 
280 - Instructions for Completing the Form CMS-C751A/B, Status of 
Debt - Currently Not Collectible (CNC), and Form CMS-MC751A/B, 
Status of MSP Debt - Currently Not Collectible (CNC) - (Rev. 5, 08-30-
02) 
A1-1930, A1-1950, B1-4930, B1-4950 
 
Form CMS-C751A/B and Form CMS-M751A/B are similar data entry screens used to 
report the following. 
 
  Form CMS-C751A to report non-MSP debt under Part A (HI) by intermediaries; 
 
  Form CMS-C751B to report non-MSP debt under Part B (SMI) by intermediaries 
and carriers; 
    Form CMS-MC751A to report MSP debt under HI by intermediaries; and  
 
  Form CMS-MC751B to report MSP debt under SMI by intermediaries and 
carriers; 
 
Note that currently not-collectible debt reported by Forms CMS-C751 and CMS-MC751 
is reported separately for non-MSP and MSP accounts receivables. 
The screen heading indicates whether the CNC report is for the non-MSP or MSP subset. 
 
Samples of the screens are shown in Exhibits 5 and 6. Note that intermediaries must 
prepare separate reports for each category by trust find. 
 
There are separate reports and data screens for Part A, HI, and for Part B, SMI in the 
CAFM system. The intermediary enters data in both HI and SMI data screens (Exhibits 5 
and 6). The carrier enters data in only the SMI data screens (Exhibit 6). 
 
The data for each of these reports are essentially the same. 
 
The contractor reports the CNC accounts receivable activity for FYTD for the period of 
the report. In order to facilitate reconciliation, balancing and error resolution, it reports 
the CNC accounts receivable in dollars and cents. 
 
The reports require information both for the amount and the number of accounts 
receivable. To provide standardization, CMS suggests the contractor use its collection 
process as a guide when reporting the number of accounts receivable. For example, a 
separate, stand alone accounts receivable collected would be reported as a quantity in the 
number column. 
 
Once the principal number is established, the contractor reports the interest associated 
with the principal amount in the same manner. There can be a difference between the 
principal number and the interest number because some receivables are not subject to 
interest. 
 
290 - Due Date - (Rev. 5, 08-30-02) 
A1-1931, A1-1951, B1-4931, B1-4951 
 
This report is due on January 21, April 21, July 21, October 21 (21 days after the end of 
each quarter) via the CAFM system. If that date occurs on a holiday or a weekend, the 
report is due the following Federal workday. 
 
300 - Certification - (Rev. 5, 08-30-02) 
A1-1932, A1-1952, B1-4932, B1-4952 
 
Medicare contractor certification by the CFO is required. The CFO must input their 
password on the CAFM system (see Exhibit 16). Failure to record the official's password 
is a serious error that will prevent acceptance of the report by the CAFM system. The  following statement appears at the end of the Form CMS-C751A/B (as well as the Form 
CMS-MC751A/B): 
 
I hereby CERTIFY that I have examined the Status of Non-MSP Debt - CNC prepared by 
name of contractor for the period beginning (first day of FY) and ending (last day of 
quarter), and that to the best of my knowledge and belief, it is a true, correct and 
complete statement prepared from the books and records of the contractor in accordance 
with applicable instructions. 
 
NAME _____________________ DATE _______ TITLE _________ 
 
NOTE:  In the above statement, "MSP" replaces "Non-MSP" for the MSP report. 
 
310 - Line Item Instructions Form CMS-C751A/B - Non-MSP and Form 
CMS-MC751A/B - MSP - (Rev. 5, 08-30-02) 
A1-1933, A1-1953, B1-4933, B1-4953 
 
The following instructions are to be used by Medicare contractors to report the status of 
Non-MSP or MSP, as applicable, CNC debt. Medicare contractors must develop and 
maintain transaction level detail (at a minimum, this would include the provider name, 
provider number, date of determination, outstanding balance, and any adjustments or 
recoupments) by debt to support the amounts reported for each line outlined below (see 
Exhibits 5 and 6). Medicare contractors must reclassify MSP or Non-MSP debt as CNC 
in accordance with CMS policy (see Exhibit 19 and Exhibit 20). 
 
Within this subset of instructions, the designation "MSP" or "Non-MSP" is implied, 
depending on which report is being submitted, MSP or Non-MSP. 
 
Section A - CNC Debt 
 
310.1 - Line 1, Beginning FY Balance (Principal & Interest)   
(Rev. 5, 08-30-02) 
A1-1933.1, A1-1953.1, B1-4933.1, B1-4953.1 
 
The contractor shall report the number and amount for all CNC debts outstanding as of 
the beginning of the FY. These amounts will be pre-filled with the ending balances from 
the prior FY on Form CMS-C751A/B, Status of Non-MSP Debt-CNC Financial Report 
or Form CMS-MC751A/B, Status of MSP Debt-CNC Financial Report. It shall make any 
corrections to the beginning principal and interest FY balance only on Line 4e, 
Reclassified CNC Debt - Other. 
 
310.2 - Line 2, New CNC Debt (Principal & Interest) - (Rev. 5, 08-30-02) 
A1-1933.2, A1-1953.2, B1-4933.2, B1-4953.2 
 
The contractor enters the number and amount of all debt approved by CMS RO and CO 
for CNC during the FY. This line should include the outstanding principal balance and all  outstanding interest associated with the debt that was earned up to the date the debt was 
removed from Form CMS-751A/B or Form CMS-M751A/B reports, as appropriate, and 
included on the current Form CMS-C751A/B report or Form CMS-MC751A/B. This 
amount must equal the principal and interest amounts reported on Line 6c, Transfers Out 
to CNC. 
 
310.3 - Line 3, Interest Earned Since CNC Approval (Interest)   
(Rev. 5, 08-30-02) 
A1-1933.3, A1-1953.3, B1-4933.3, B1-4953.3 
 
The contractor enters the amount of interest earned in this fiscal year on CNC debt since 
the date the debt was reclassified and included in Line 1, Beginning FY Balance and 
interest earned on debts reclassified to CNC during the FY included in Line 2, New CNC 
Debt on the current report. 
 
310.4 - Line 4(a) through (e), Reclassified CNC Debt (Principal & 
Interest) 
(Rev. 91, Issued: 02-17-06, Effective: 03-17-06, Implementation: 03-17-06) 
 
Reclassified CNC debt reported on Line 4a, Re-established as Active Accounts 
Receivable (A/R) Due to Collection of Cash; Line 4b, Re-established as Active A/R Due 
to Collection by Offset; and Line 4c, Re-established as Active A/R Due to Misstatement 
or Misclassification must agree with the total amount reported on Line 6b, Transfers In 
from CNC on Form CMS-H/M 751A/B. Medicare contractors must retain all 
documentation supporting any reclassified amounts. 
 
4.  The contractor reports in Lines: 
 
a.  Re-established as Active Accounts Receivable (A/R) Due to Collection of 
Cash (Principal & Interest). The contractor enters the amount of CNC debt 
that is re-established as active debt because cash/checks have been 
collected on CNC debts during the FY. Simultaneously, the amount of the 
collection shall be reported on Line 6b, Transfers In from CNC and Line 
4a, Cash/Check Collections on Form CMS-H/M751A/B. The effect of this 
transaction will reclassify the debt from an inactive memorandum entry to 
an active receivable that will be reported for financial statement purposes. 
Additionally, if the outstanding balance of the CNC debt was greater than 
the amount collected, the remaining balance of the debt shall remain in 
CNC.  Medicare contractors shall continue to accrue interest for debt that 
has been reclassified as CNC. 
 
b.  Re-established as Active A/R Due to Collection by Offset (Principal and 
Interest.) The contractor enters the amount of CNC debt that is re-
established as active debt because offsets have been made on CNC debt 
during the FY. Simultaneously, the amount of the offset collection shall be 
reported on Line 6b, Transfers In from CNC and Line 4b, Offset  Collections on Form CMS-H/M751A/B. The effect of this transaction will 
reclassify the debt from an inactive memorandum entry to an active 
receivable that will be reported for financial statement purposes. 
Additionally, if the outstanding balance of the CNC debt was greater than 
the amount collected, the remaining balance of the debt shall remain in 
CNC.  Medicare contractors shall continue to accrue interest for debt that 
has been reclassified as CNC. 
 
c.  Re-established as Active A/R Due to Misstatement or Misclassification 
(Principal & Interest).  The contractor enters the amount of the CNC debt 
that has been re-established to be active debt because the CNC debt is now 
determined to be a misstatement or misclassification.  Simultaneously, the 
amount of the misstatement or misclassification shall be reported on Line 
6b, Transfers In from CNC on Form CMS-H/M751A/B.  The effect of this 
transaction will reclassify CNC the debt from an inactive memorandum 
entry to an active receivable that will be reported for financial statement 
purposes. 
 
d.  Written-off Closed (Principal & Interest). The contractor enters the 
number and amount of CNC debt that has been approved for written-off 
closed during the FY. The receivables will be "closed" in its internal 
systems. No further action will be taken on these debts. CNC debts that 
are written-off as closed will not be reported on the financial statements, 
and all collection activity (i.e., future offsets or interest accruals) and 
servicing of the debt will be terminated. The debts will be closed within 
the contractor's records, reports, and accounts receivable systems. These 
debts will be written-off and closed through Form CMS-C/MC751A/B, on 
line 4d. These debts shall not be reactivated on Form CMS-H/M751A/B. 
 
e.  NOTE:  Medicare contractors cannot write-off debt until formal approval 
has been received from the appropriate authorized official in accordance 
with the existing CMS delegations of authority. 
 
Other (Principal & Interest). The contractor shall use line 4e only to make 
corrections to Form CMS-C/MC751A/B beginning principal and interest FY 
balance. Medicare contractors must retain all documentation justifying any 
adjustments made to the beginning balance. 
 
310.5 - Lines 5(a) through (f), Amounts Transferred (Principal & 
Interest - (Rev. 5, 08-30-02) 
A1-1933.5, A1-1953.5, B1-4933.5, B1-4953.5 
 
The contractor enters the amount of CNC debts that have been transferred in from or out 
to Medicare contractors or CMS RO or CO during the FY. It shall not enter an amount on 
these lines until it has received confirmation that the Medicare contractor, CMS RO or  CO, has accepted the debt. (See Exhibit 17, Transfer of Debt Between Reporting 
Entities). 
 
5.  The contractor shall report in lines: 
 
a.  Transfers In from other Medicare Contractors (Principal & Interest). The 
amount of CNC debt transferred in from other Medicare contractors 
during the fiscal period. 
 
b.  Transfers Out to other Medicare Contractors (Principal & Interest). The 
amount of CNC debt transferred out to other Medicare contractors during 
the fiscal period. 
 
c.  Transfers In from CMS RO (Principal & Interest). The amount of CNC 
debt transferred in from RO during the fiscal period. 
 
d.  Transfers Out to CMS RO (Principal & Interest). The amount of CNC 
debt transferred out to RO during the fiscal period. 
 
e.  Transfers In from CMS CO (Principal & Interest). The amount of CNC 
transferred in from CO during the fiscal period. 
 
Transfers Out to CMS CO (Principal & Interest). The amount of CNC transferred out to 
CO during the fiscal period. 
 
Collection efforts do not cease when debt is reclassified to CNC. Medicare contractors 
must recognize that all debts including CNC debt will continue to be referred (if eligible) 
to the Program Support Center (PSC), Department of Health and Human Services 
(DHHS) or the Treasury Offset Program (TOP). 
 
Medicare contractors are expected to follow existing procedures for the routine referral of 
delinquent debt to the Debt Collection Center (DCC) in accordance with the Debt 
Collection Improvement Act (DCIA) of 1996. 
 
Amounts transferred in from or out to other CMS locations or Medicare contractors for 
the reporting period must be reconciled to the other entity's records for the same reporting 
period prior to submission of the quarterly Forms CMS-750/751A/B. Medicare 
contractors and other CMS locations must reconcile the transfers out lines to ensure that 
only approved transfers are being reported. Documentation of the reconciliation must be 
maintained and must indicate that a supervisory review of the reconciliation was 
performed. See Exhibit 17 for instructions for the transfer of debt between other reporting 
entities. 
 
310.6 - Line 6, Ending Balance (Principal & Interest) - (Rev. 5, 08-30-
02) 
A1-1933.6, A1-1953.6, B1-4933.6, B1-4953.6   
The ending balance is a computed field, reporting the number (manual entry) and amount 
of CNC debt outstanding as of the end of the reporting period. It equals: 
 
  Principal    Interest 
+  Beginning FY balance (Line 1)  +  Beginning FY balance (Line 1) 
+  New CNC Debt (Line 2)  +  New CNC Debt (Line 2) 
    +  Interest Earned (Line 3) 
Re-established as Active A/R Due to  Re-established as Active A/R Due to 
-  - 
Collection of Cash (Line 4a)  Collection of Cash (Line 4a) 
Re-established as Active A/R Due to  Re-established as Active A/R Due to 
-  - 
Collection by Offset (Line 4b)  Collection by Offset (Line 4b) 
Re-established as Active A/R Due to  Re-established as Active A/R Due to 
-  Bankruptcy, Fraud & Abuse Litigation  -  Bankruptcy, Fraud & Abuse Litigation 
or Appeal (Line 4c)  or Appeal (Line 4c) 
-  Written-off Closed (Line 4d)  -  Written-off Closed (Line 4d) 
+/-   Other (Line 4e)  +/-  Other (Line 4e) 
Transfers In From Medicare  Transfers In From Medicare 
+  + 
Contractors/ RO/CO (Lines 5a, 5c, 5e)  Contractors/ RO/CO (Lines 5a, 5c, 5e) 
Transfers Out to Medicare  Transfers Out to Medicare 
-  - 
Contractors/ RO/CO (Lines 5b, 5d, 5f)  Contractors/ RO/CO (Lines 5b, 5d, 5f) 
=  Ending Balance (Line 6)  =  Ending Balance (Line 6) 
 
NOTE:  Although Line 6 is a calculated amount, the contractor must be able to provide a 
detailed listing of all Non-MSP (or MSP, as applicable) CNC receivable balances that 
support this line at any given period of time. 
 
Section B - Aging of MSP or Non-MSP CNC Debt 
 
310.7 - Line 1, Total Aged CNC Debt (Principal & Interest)   
(Rev. 5, 08-30-02) 
A1-1933.7, A1-1953.7, B1-4933.7, B1-4953.7 
 
The contractor enters the number and amount of MSP or Non-MSP CNC debt, as 
applicable. The total dollar amount equals the sum of lines (a) through (e), and should 
also equal Line 6, Ending Balance on Form CMS-C751A/B or Form CMS-MC751AB, as 
applicable. 
 
The contractor reports on lines (a) through (e) the dollar amounts of receivables aged 
from the date of determination of the debt for the respective time periods listed. For Non- MSP, it provides an explanation in the remarks section regarding why debts in category 
(d) and (e) were not recommended for written-off closed. 
 
Section C - Collection Information 
 
310.8 - Collections on CNC Debt (Principal & Interest) - (Rev. 5, 08-30-
02) 
A1-1933.8, A1-1953.8, B1-4933.8, B1-4953.8 
 
The contractor enters the number and amounts of cash/checks/offsets actually collected 
on Non-MSP or MSP CNC debt, as applicable that is reported on Line 4a, Re-established 
as Active A/R Due to Collection of Cash, and Line 4b, Re-established as Active A/R Due 
to Collection by Offset. 
 
Section D - Status CNC Debt over 181 Days 
 
310.9 - Status of CNC Debt over 181 Days (Principal & Interest) - (Rev. 
17, 05-02-03) 
 
The contractor enters the total number and amount of delinquent receivables 181 days 
delinquent and greater, which are in one of the following categories: 
 
(a)  Referred to the Department of the Treasury for Cross Servicing. For MSP, 
this means debts entered into the DCS. For Non-MSP, this means debts that have 
been transmitted to DCC by CMS Central Office and the Medicare contractor has 
acknowledged and verified the validity and accuracy of the debts transmitted. 
 
(b)  Not Eligible for Referral, the number and dollar amount is equal to the sum of 
lines (1) through (11) of this section. 
 
1)  Bankruptcy; 
 
2)  Appeal; 
 
3)  Department of Justice/Litigation; 
 
4)  Fraud and Abuse Investigation, if the contractor has received specific 
instructions from the investigating unit (i.e., Office of Inspector General or 
Office of General Counsel, etc.) not to attempt collection; 
 
5)  Deceased Debtor, debts where the debtor is deceased and the estate is 
closed. 
 
6)  Debts less than $25; 
  7)  Federal Entity Debts, MSP only, where the only entity which received 
the last demand letter is the employer and the employer is a Federal 
agency; 
 
8)  Beneficiary Debts, Non-MSP only; 
 
9)  Pending Request for Waiver or Compromise; 
 
10)  CMS Identified Exclusions, MSP only, debts where CMS has 
identified a specific debt or group of debtors as excluded from DCIA 
referral. 
 
11)  Other Exclusions, must footnote. 
 
(c)  Eligible for Referral, debts that are eligible for referral to the Department of 
the Treasury for cross servicing but not yet referred. 
 
400 - Exhibits - (Rev. 5, 08-30-02) 
A1-1960, B1-4960 
 
Exhibit 1 
CMS-750A Contractor Financial Reports, Hospital Insurance (HI) Statement of 
Financial Position/Statement of Operations 
 
Exhibit 2 
CMS-750B Contractor Financial Reports, Supplementary Medical Insurance 
(SMI) Statement of Financial Position/Statement of Operations 
 
Exhibit 3 
CMS-751A Status of Accounts Receivable, Hospital Insurance (HI) 
 
Exhibit 4 
CMS-751B Status of Accounts Receivable, Supplementary Medical Insurance 
(SMI) 
 
Exhibit 5 
Form CMS-C751A Status of Non-MSP Currently Not Collectible (CNC) 
Accounts Receivable, Hospital Insurance (HI) 
 
Exhibit 6 
Form CMS-C751B Status of Non-MSP Currently Not Collectible (CNC) 
Accounts Receivable, Supplementary Medical Insurance (SMI) 
 
Exhibit 7 
Form CMS-M751A Status of Medicare Secondary Payer (MSP) Accounts 
Receivable, Hospital Insurance (HI)   
Exhibit 8 
Form CMS-M751B Status of Medicare Secondary Payer (MSP) Accounts 
Receivable, Supplementary Medical Insurance (SMI) 
 
Exhibit 9 
Form CMS-MC751A Status of MSP Currently Not Collectible (CNC) Accounts 
Receivable, Hospital Insurance (HI) 
 
Exhibit 10 
Form CMS-MC751B Status of MSP Currently Not Collectible (CNC) Accounts 
Receivable, Supplementary Medical Insurance (SMI) 
 
Exhibit 11 
Medicare Contractor Account Definitions, Data Element Definitions 
 
Exhibit 12 
Accounts Payable, Protocol for Estimating Claims 
 
Exhibit 13 
Periodic Interim (PIP) Payments Protocol for Estimating Payables/Receivables on 
the CMS-750A/B, Statement of Financial Position 
 
Exhibit 14 
Protocol for Estimating Allowance for Uncollectible Accounts 
 
Exhibit 15 
Protocol for Prorating Intermediary Time Account Balances Between the CMS 
750A (HI) and the CMS 750B (SMI) 
 
Exhibit 16 
Electronic Certification 
 
Exhibit 17 
Transfer of Debt Between Reporting Entities 
 
Exhibit 18 
Collection Reconciliation/Acknowledgement Form 
 
Exhibit 19 
Procedures for Non-MSP Reclassification as Currently Not Collectible (CNC) 
 
Exhibit 20 
Procedures for MSP Reclassification as Currently Not Collectible (CNC) 
 
Exhibit 21  CMS Policy for Recognizing Accounts Receivable 
 
400.1 - Exhibit 1 - Statement of Financial Position and Statement of 
Operations - HI/SMI - (Rev. 5, 08-30-02) 
A1-1960 Exhibit 1, B1-4960.1 
 
The FI submits the HI report (Form CMS-H750A). Both FI and carrier submit the SMI 
report (Form CMS-H750B). 
 
  The HI report, in applicable line item descriptions, refers to "provider" and the 
SMI report refers to "physicians, provider or supplier". 
 
  For the SMI report (Form CMS-H750B), the FI completes the items dealing with 
cost reports, PIP, and credit balances; but the carrier omits them. Also, the 
intermediary inserts data relating to the Provider Overpayment Report (POR), 
while the carrier inserts data relating to the Physician Supplier Overpayment 
Report (PSOR). 
 
Exhibit 1 (Cont.) 
 
Contractor Financial Reports 
Statement of Financial Position 
Hospital Insurance (HI) 
As of __________________ 
 
Contractor Name  ID Number 
_______________________  __________ 
 
Assets  Balance 
  Cash 
  Benefits Account  _______________ 
  Time Account  _______________ 
  Undeposited Collections  _______________ 
  Total Cash  _______________ 
   
  Accounts Receivable 
  Non-Medicare Secondary Payments (Non-MSP) Overpayments 
  Provider (Carriers Omit)  _______________ 
    Cost Report Settlements (Carriers Omit)  _______________ 
    Claims Accounts Receivable (Carriers Omit)  _______________ 
    PIP Accrual (Carriers Omit)  _______________ 
    Credit Balances (Carriers Omit)  _______________ 
    Other (Carriers Omit)  _______________ 
  Physician/Supplier Overpayments (Intermediaries  _______________ 
Omit) 
  Beneficiaries  _______________    Total Non-MSP   _______________ 
     
  Medicare Secondary Payer (MSP) 
  Group Health Plan   
    Data Match  _______________ 
    Non-Data Match  _______________ 
       MSP Provider/Physician/Supplier/Beneficiary   
  Liability (including WC, Auto, No Fault, MSP   
beneficiary and other MSP) 
       MSP Beneficiary  _______________ 
    _______________ 
       Other MSP  _______________ 
  Total MSP   _______________ 
 
CMS-H750A/B  Exhibit 1 (Cont.) 
 
Contractor Financial Reports 
Statement of Operations 
Hospital Insurance (HI) 
As of  _______________ 
 
Contractor Name  ID Number 
_______________________  __________ 
 
  Other (footnote)  _______________ 
     
  Total Accounts Receivable  _______________ 
   
  Advances to Others   
  Advance Payments   _______________ 
  Accelerated Payments (Not applicable to carriers)  _______________ 
  Total Advances  _______________ 
   
  Interest Receivable  _______________ 
     
  Other Assets (footnote)  _______________ 
     
 
Liabilities  Balance 
 
Accounts Payable 
  Unprocessed Claims   
  Benefits Payable  _________________ 
    Provider   
      PIP Providers A Cost Report Settlements (Carriers  _________________ 
Omit) 
      PIP Providers A Estimated Payable Accrual (Carriers  _________________ 
Omit) 
      Non-PIP Providers A Underpayments (Interim  _________________ 
Reviews) (Carriers Omit) 
      Non-PIP Providers A Underpayments (Cost  _________________ 
Settlements) (Carriers Omit) 
      Claims Withheld for Non-receipt of Cost Reports  _________________ 
(Carriers Omit) 
    Physicians/Suppliers (Intermediaries Omit)  _________________ 
    Beneficiaries  _________________ 
  Claims on the Payment Floor  _________________ 
 
CMS-H750A/B  Exhibit 1 (Cont.) 
 
Contractor Financial Reports 
Statement of Operations 
Hospital Insurance (HI) 
As of  _______________ 
 
Contractor Name  ID Number 
_______________________  __________ 
  Suspended Payments   
    Claims   ________________   
    Common Working File (CWF)  _________________ 
    MR/UR Prepayment Review  _________________ 
    Medicare Secondary Payer (MSP)  _________________ 
Total Accounts Payable  _______________ 
   
Accrued Interest Payable  _______________ 
     
Other Liabilities   
  Unapplied Receipts  _______________ 
  Excess Recoupments  _______________ 
  Due Medicaid  _______________ 
  Other (footnote)  _______________ 
Total Other Liabilities  _______________ 
   
TOTAL LIABILITIES  _______________ 
   
Fund Account Balance   
  Cumulative Results of Operations  _______________ 
   
TOTAL LIABILITIES AND FUND ACCOUNT BALANCE  _______________ 
 
Revenue  Amount 
 
Interest Revenue  Line 3 
Adjustments (Interest)  Line 5a 
Waivers (Interest)  Line 5h 
Write-offs (Bad Debts)(Interest)  Line 6a 
Transfers in from other Medicare Contractors  Line 5b 
Transfers out to other Medicare Contractors  Line 5c 
Transfers in from CNC (Interest)  Line 6b 
Transfers out to CNC (Interest)  Line 6c 
Transfers in from other CMS Locations (POR/PSOR (as  Line 5d 
applicable)) (Interest) 
 
CMS-H750A/B  Exhibit 1 (Cont.) 
 
Contractor Financial Reports 
Statement of Operations 
Hospital Insurance (HI) 
As of  _______________ 
 
Contractor Name  ID Number 
_______________________  __________ 
 
Transfers out to other CMS Locations (POR/PSOR (as  Line 5e 
applicable)) (Interest) 
Transfers in from other CMS Locations (Not POR/PSOR (as  Line 5f 
applicable)) (Interest) 
Transfers out to other CMS Locations (Not POR/PSOR (as  Line 5g 
applicable)) (Interest) 
   
Draws on Letter of Credit  ________________ 
Other Revenue (footnote)  ________________ 
   
TOTAL REVENUE  ________________ 
 
Expense   
   
  Operating/Program Expense  Line 2 + Benefit Expense 
  Adjustments (Principal)  Line 5a (CR or DR) 
  Transfers In from other Medicare Contractors (Contra  Line 5b 
Account) 
  Transfers Out to other Medicare Contractors (Principal)  Line 5c 
  Transfers In from CNC (Contra Account)  Line 6b 
  Transfers Out to CNC (Principal)  Line 6c 
  Transfers In from other CMS Locations (POR and Not  Line 5d&5f 
POR) (Contra Account) 
  Transfers Out to other CMS Locations (POR and Not  Line 5e&5g 
POR) (Principal) 
    Less: Waivers (Principal)  Line 5h 
    Less: Write-offs (Bad debts) (Principal)  Line 6a 
 
 
CMS-H750A/B  Exhibit 1 (Cont.) 
 
Contractor Financial Reports 
Statement of Operations 
Hospital Insurance (HI) 
As of  _______________ 
 
Contractor Name  ID Number 
_______________________  __________ 
 
Total Program Expense  ________________ 
 
  Interest Expense 
    CPT Interest  ________________ 
    Other Interest  ________________ 
    Other Expense (footnote)  ________________ 
       
  Prior Period Adjustments (footnote) 
 
TOTAL EXPENSE  ________________ 
 
NET RESULTS OF OPERATIONS  ________________ 
 
OTHER DATA (Intermediaries)   
  Value of 1st PIP Payment Cycle in ensuing quarter  ________________ 
 
CMS-H750A/B 
 
400.2 - Exhibit 2 - Statement of Financial Position and Statement of 
Operations - SMI - (Rev. 5, 08-30-02) 
 
This report is a duplicate of the above Exhibit 1, Statement of Financial Position and 
Statement of Operations - HI, except: 
 
  The HI report, in the applicable line item descriptions, refers to "provider", and 
the SMI report refers to "provider, physician, and supplier". 
 
  For the SMI report (CMS-750B), the FI completes the items dealing with cost 
reports, PIP, and credit balances; but the carrier omits them. Also, the 
intermediary inserts data relating to the Provider Overpayment Report (POR), 
while the carrier inserts data relating to the Physician Supplier Overpayment 
Report (PSOR). 
 
400.3 - Exhibit 3 - Status of Accounts Receivable - HI 
(Rev. 111; Issued:  10-27-06; Effective:  04-01-07; Implementation:  04-02-07) 
 
This exhibit is the same as Exhibit 4, Status of Accounts Receivable  SMI, with the 
following exceptions:   
Section B, items 5d through 5g and Section D, items 5d and 5e refer to the POR for the 
HI report and refer to the POR/PSOR for the SMI report.  Only intermediaries enter POR 
data on both the HI report and the SMI report.  Only carriers enter the PSOR data on the 
SMI report. 
 
CMS-751A is the CMS Form Number for the HI (Part A) report. 
 
CMS-751B is the CMS Form Number for the SMI (Part B) report. 
 
Exhibit 3 (Cont.) 
 
Status of Accounts Receivable 
Hospital Insurance (HI) 
As of _________________ 
 
Contractor Name  ID Number 
_______________________  __________ 
 
Section A: Outstanding Receivables 
 
  Principal  Principal  Interest  Interest  
  Number  Dollars  Dollars  Number 
 
1.  Beginning FY Balance  _________  __________  _________  _______ 
2a.  New Receivables  _________  __________     
2b.  Accrued Receivables  _________  __________     
3.  Interest Earned      _________  _______ 
4a.  Cash/Check Collections    __________  _________   
4b.  Offset Collections    __________  _________   
4c.  Collections Deposited at Another Location  __________  _________   
5a.  Adjusted Amounts  __________       
    Internal Adjustments  __________  _________   
    Auditor/Consultant Adjustments  __________  _________   
5b.  Transfers In from other Medicare Contractors  __________  _________   
5c.  Transfers Out to other Medicare Contractors  __________  _________   
5d.  Transfers In from other CMS Locations, POR/PSOR  __________  _________   
5e.  Transfers Out to other CMS Locations, POR/PSOR  __________  _________   
5f.  Transfers In from other CMS Locations,   __________  _________   
not POR/PSOR 
5g.  Transfers Out to other CMS Locations,   __________  _________   
not POR/PSOR 
5h.  Waivers  __________  _________   
6a.  Amounts Written-off (Bad Debts)  __________  __________  _________   
6b.  Transfers In from CNC  __________  __________  _________   
6c.  Transfers Out to CNC  __________  __________  _________   
7.  Ending Balance  _________  __________  ___________  _______ 
  a.  Current  __________  ___________   
  b.  Non-current  __________      8.  Allowance for Uncollectible Accounts  __________     
9.  Total Receivables Net of Allowance  __________  ___________   
10.  Cash/Offsets received for Receivables at   
Another Location  __________  ___________ 
 
 
CMS-H751A  Exhibit 3 (Cont.) 
 
Status of Accounts Receivable 
Hospital Insurance (HI) 
As of _________________ 
 
Contractor Name  ID Number 
_______________________  __________ 
 
Section B: Delinquent Receivables 
 
  Principal  Principal  Interest  Interest  
  Number  Dollars  Dollars  Number 
 
1.  Total Not Delinquent  _________  __________  ___________  _______ 
2.  Total Delinquent  _________  __________  ___________  _______ 
  (a)  1 - 30 days  __________  ___________   
  (b)  31 - 60 days  __________  ___________   
  (c)  61 - 90 days  __________  ___________   
  (d)  91 - 180 days  __________  ___________   
  (e)  181 - 365 days  __________  ___________   
  (f)  1 - 2 years  __________  ___________   
  (g)  2 - 6 years  __________  ___________   
  (h)  6 - 10 years  __________  ___________   
  (i)  Over 10 years  __________  ___________   
           
3.  Total Delinquent 1 - 180 days  _________  __________  _________  _______ 
  (a)  In Bankruptcy  __________  _________   
  (b)  In Appeal  __________  _________   
  (c)  At Department of Justice  __________  _________   
  (d)  Referred for Cross Servicing  __________  _________   
  (e)  Other Status  __________  _________   
        (f)    In the Process of Internal Offset (Previously Under 
              MMA Section 935 Appeal) 
4.  Total Delinquent 181 days & over  _____  __________  _________  _______ 
  A)  Referred for Cross Servicing  __________  _________   
  B)  Not Eligible for Referral   
1)  In Bankruptcy  __________  __________ 
  2)  In Appeal  __________  __________   
  3)  At Department of Justice  __________  __________   
  4)  Fraud and Abuse Investigation  __________  __________   
  5)  Deceased Debtor and Estate Closed  __________  __________   
  6)  Debts Less than $25  __________  __________   
  7)  Federal Entity Debts, MSP only, where   
the only entity which received the last 
demand letter is the employer and the 
employer is a Federal agency;  __________  __________    8)  Beneficiary Debts, Non-MSP only;  __________  __________   
  9)  Pending Request for Waiver or   
Compromise  __________  __________ 
  10)  CMS Identified Exclusions, MSP only,   
debts where CMS has identified a 
specific debt or group of debtors as 
excluded from DCIA referral.  __________  __________ 
  11)  Other Exclusions, must footnote.  __________  __________   
  12)  In the Process of Internal Offset.   
(Previously Under Medicare 
Modernization Act (MMA) Section 935 
Appeal)  __________  __________ 
  C)  Eligible for Referral; debts that are   
eligible for referral to the Department of 
the Treasury for cross-servicing but not 
yet referred.  __________  __________  Exhibit 3 (Cont.) 
 
Status of Accounts Receivable 
Hospital Insurance (HI) 
As of _________________ 
 
Contractor Name  ID Number 
_______________________  __________ 
 
Section C: Other Collections 
 
4c.  Collections Deposited at another Location 
   
      Principal  Interest   
Contractor/Region  Dollars  Dollars 
  ____________________    __________  _________   
  ____________________    __________  _________   
  ____________________    __________  _________   
  ____________________    __________  _________   
  ____________________    __________  _________   
   
10.  Cash Offsets Received for Receivables at another Location 
   
      Principal  Interest   
Contractor/Region  Dollars  Dollars 
  ____________________    __________  _________   
  ____________________    __________  _________   
  ____________________    __________  _________   
  ____________________    __________  _________   
  ____________________    __________  _________   
   
Collections on Delinquent Debt           _________  __________  _________  ________ 
 
Section D: Transferred Receivables 
 
5c.  Transfers Out to other Medicare Contractors 
   
      Principal  Interest   
Contractor Number  Dollars  Dollars 
  ____________________    __________  _________   
  ____________________    __________  _________   
  ____________________    __________  _________   
  ____________________    __________  _________   
  ____________________    __________  _________   
   
 
CMS-H751A  Exhibit 3 (Cont.) 
 
  Status of Accounts Receivable 
  Hospital Insurance (HI) 
  As of _________________ 
Contractor Name  ID Number 
_______________________  __________ 
 
5d.  Transfers Out to other CMS Locations, POR 
  1. Boston    __________  _________   
  2. New York    __________  _________   
  3. Philadelphia    __________  _________   
  4. Atlanta    __________  _________   
  5. Chicago    __________  _________   
  6. Dallas    __________  _________   
  7. Kansas City    __________  _________   
  8. Denver    __________  _________   
  9. San Francisco    __________  _________   
  10. Seattle    __________  _________   
  11. Central Office    __________  _________   
   
5e.  Transfers Out to other CMS Locations, Not on POR 
  1. Boston    __________  _________   
  2. New York    __________  _________   
  3. Philadelphia    __________  _________   
  4. Atlanta    __________  _________   
  5. Chicago    __________  _________   
  6. Dallas    __________  _________   
  7. Kansas City    __________  _________   
  8. Denver    __________  _________   
  9. San Francisco    __________  _________   
  10. Seattle    __________  _________   
  11. Central Office    __________  _________   
 
CMS-H751A 
 
400.4 - Exhibit 4 - Status of Accounts Receivable - SMI - (Rev. 5, 08-30-
02) 
 
This exhibit is the same as Exhibit 3, with the following exceptions: 
 
  Section B, items 5d through 5g and Section D, items 5d and 5e refer to the POR 
for the HI report and refer to the POR/PSOR for the SMI report. 
 
  Only intermediaries enter POR data on both the HI report and the SMI report. 
 
  Only carriers enter the PSOR data on the SMI report. 
    Form CMS-H751A is the CMS Form Number for the HI (Part A) report. 
 
  Form CMS-H751B is the CMS Form Number for the SMI (Part B) report. 
 
400.5 - Exhibit 5 - Status of Non-MSP Debt - CNC - HI 
(Rev. 111; Issued:  10-27-06; Effective:  04-01-07; Implementation:  04-02-07) 
 
The screen formats in exhibits 5 and 6 are identical except 5 is for HI non-MSP and 6 is 
for SMI non-MSP. 
 
MSP debt is reported in exhibits 9 and 10. Exhibit 5 (Cont.) 
 
One of: Status of Non-MSP Debt - CNC; or Status of MSP Debt - CNC will be shown. 
One of:  Hospital Insurance (HI); or Supplementary Medical Insurance (SMI) will be shown 
As of ___________________ 
 
Contractor Name  ID Number 
_______________________  __________ 
 
Section A: CNC Debt 
 
  Principal  Principal  Interest  Interest  
  Number  Dollars  Dollars  Number 
 
1.  Beginning FY Balance  ______  __________  ___________  _______ 
2.  New CNC Debt   ______  __________  ___________  _______ 
3.  Interest Earned Since CNC Approval    ___________   
4.  Reclassified CNC Debt       
  a.  Re-established as Active A/R due to collection of cash  ______  __________  ___________  ____ 
  b.  Re-established as Active A/R due to collection by offset  ______  __________  ___________  ____ 
  c.  Re-established as Active A/R due to bankruptcy, fraud &  ______  __________  ___________  ____ 
abuse, litigation and appeal 
  d.  Written-off Closed  ______  __________  ___________  ____ 
  e.  Other  ______  __________  ___________  ____ 
5.  Amounts Transferred       
  a.  Transfers In from Medicare Contractors  ______  __________  ___________  ____ 
  b.  Transfers Out to Medicare Contractors  ______  __________  ___________  ____ 
  c.  Transfers In from CMS RO  ______  __________  ___________  ____ 
  d.  Transfers Out to CMS RO  ______  __________  ___________  ____ 
  e.  Transfers In from CMS CO  ______  __________  ___________  ____ 
  f.  Transfers Out to CMS CO  ______  __________  ___________  ____ 
6.  Ending Balance   ______  __________  ___________  _______ 
         
 
CMS-C751A 
    Exhibit 5 (Cont.) 
Status of Non-MSP Debt - CNC 
Hospital Insurance (HI) 
As of _________________ 
 
Contractor Name  ID Number 
_______________________  __________ 
 
Section B: Aging of CNC Debt (from the determination date) 
 
1.  Total CNC Debt   ______  __________  ___________  _______ 
           
  (a)  181 - 1 year  __________  ___________   
  (b)  1 - 2 years  __________  ___________   
  (c)  2 - 6 years  __________  ___________   
  (d)  6 - 10 years *  __________  ___________   
  (e)  Over 10 years *  __________  ___________   
   
* Provide an explanation why debts in these categories were not recommended for write-off closed 
  
Section C: Collection Information 
 
Collections on CNC Debt  ______  __________  ___________  _______ 
   
Section D: Status CNC Debt over 181 Days 
 
Total Delinquent       
  A)  Referred for Cross Servicing  __________  _________   
  B)  Not Eligible for Referral   
1)  In Bankruptcy  __________  _________ 
  2)  In Appeal  __________  _________   
  3)  At Department of Justice  __________  _________   
  4)  Fraud and Abuse Investigation  __________  _________   
  5)  Deceased Debtor and Estate Closed  __________  _________      6)  Debts Less than $25  __________  _________   
  7)  Federal Entity Debts, MSP only, where the only entity which   
received the last demand letter is the employer and the 
employer is a Federal agency;  __________  _________ 
  8)  Beneficiary Debts, Non-MSP only;  __________  _________   
  9)  Pending Request for Waiver or Compromise  __________  _________   
  10)  CMS Identified Exclusions, MSP only, debts where CMS   
has identified a specific debt or group of debtors as excluded 
from DCIA referral.  __________  _________ 
  11)  Other Exclusions, must footnote.  __________  _________   
  12)  In the Process of Internal Offset (Previously Under MMA,   
Section 935 Appeal)  __________  _________ 
  C)  Eligible for Referral; debts that are eligible for referral to the   
Department of the Treasury for cross-servicing but not yet 
referred.  __________  _________ 
 
CMS-C751A 400.6 - Exhibit 6 - Status of Non-MSP Debt - CNC - SMI - (Rev. 5, 08-
30-02) 
 
See Section 400.5, Exhibit 5  Status of Non-MSP Debt  CNC  HI 
 
The formats in exhibits 5 and 6 are identical except 5 is for HI non-MSP and 6 is for 
SMI. non-MSP. 
 
MSP debt is reported in exhibits 9 and 10. 
 
400.7 - Exhibit 7 - Status of MSP Accounts Receivable - HI  (Rev. 5, 08-
30-02) 
 
This is an exact duplicate of Exhibit 3, except that the data is limited to data involving 
Medicare as secondary payer. 
 
This exhibit, and Exhibit 8, Status of MSP Accounts Receivable - SMI, are identical with 
the following exceptions: 
 
  Section B, items 5d through 5g and Section D, items 5d and 5e refer to the POR 
for HI reports and refer to the POR/PSOR for the SMI report. 
 
  Only carriers enter the PSOR data on the SMI report. 
 
  The CMS Form Number for this report (HI) is CMS-M751A. 
 
  The CMS Form Number for the SMI report is CMS-M751B. 
 
400.8 - Exhibit 8 - Status of MSP Accounts Receivable - SMI   
(Rev. 5, 08-30-02) 
 
See Exhibit 3, above. 
 
400.9 - Exhibit 9 - Status of MSP Debt - CNC - HI - (Rev. 5, 08-30-02) 
 
See Exhibit 5  Status of Non-MSP Debt  CNC  HI. 
 
400.10 - Exhibit 10 - Status of MSP Debt - CNC - SMI - (Rev. 5, 08-30-
02) 
 
See Exhibit 5  Status of Non MSP Debt  CNC SMI. 
 
400.11 - Exhibit 11 - Medicare Contractor Account Definitions - Data 
Element Definitions - (Rev. 5, 08-30-02) 
   
Medicare Contractor Account Definitions 
Data Element Definitions 
Account Number  Title 
1000  Assets 
 
1100  Cash 
1100.01  Part A and Part B 
1100.01.01  Benefit Account 
1100.01.02  Time Account 
1110  Undeposited Collections 
1110.01  Part A and Part B 
1110.01.01  Undeposited Collections 
 
1310  Accounts Receivable 
1310.01  Part A and Part B 
1310.01.01  Non-MSP Overpayments 
1310.01.01.01  Provider 
1310.01.01.01.01  Cost Report Settlements (FI) 
1310.01.01.01.02  Claims Accounts Receivable (FI) 
1310.01.01.01.03  PIP Accrual (FI) 
1310.01.01.01.04  Credit Balance (FI) 
1310.01.01.01.05  Other (FI) 
1310.01.01.02  Beneficiaries 
1310.01.01.03  Physicians/Suppliers 
1310.01.04  Medicare Secondary Payer (MSP) 
1310.01.04.01  Group Health Plan 
1310.01.04.01.01  Data Match 
1310.01.04.01.02  Non-Data Match 
1310.01.04.02  Liability MSP 
1310.01.04.02.01  MSP Beneficiary 
1310.01.04.02.02  MSP Provider/Physician Supplier 
1310.01.04.03  Other MSP 
 
1310.01.99  Other 
 
1311  Advances to Others 
1311.01  Part A and Part B 
1311.01.01  Advance Payments 
1311.01.02  Accelerated Payments 
  Medicare Contractor Account Definitions 
Data Element Definitions 
Account Number  Title 
1330  Interest Receivable 
1330.01  Part A and Part B 
 
1990  Other Assets 
1990.01  Part A and Part B 
 
2000  Liabilities 
 
2110  Accounts Payable 
2110.01  Part A and Part B 
2110.01.01  Unprocessed Claims 
2110.01.02  Benefits Payable 
2110.01.02.01  Provider 
2110.01.02.01.01  -PIP Provider Cost Report Settlements 
2110.01.02.01.02  -PIP Provider Estimated Payable Accrual 
2110.01.02.01.03  -Non-PIP Provider Underpayments  Interim Rate 
2110.01.02.01.04  -Non-PIP Provider Underpayments  (Cost Report Settlement) 
2110.01.02.01.05  Claims Withheld for Non-receipt of Cost Reports 
2110.01.02.02  Beneficiaries 
2110.01.02.03  Physicians/Suppliers 
2110.01.02.04  Claims on the Payment Floor 
2110.01.03  Suspended Payments 
2110.01.03.01  Claims 
2110.01.03.02  Common Working File (CWF) 
2110.01.03.03  MR/UR Prepayment Review 
2110.01.03.0  Medicare Secondary Payer (MSP) 
 
2140  Accrued Interest Payable 
2140.01  Part A and Part B 
 
2990  Other Liabilities 
2990.01  Part A and Part B 
2990.01.01  Unapplied Receipts 
2990.01.02  Excess Recoupments 
2990.01.03  Due Medicaid 
2990.01.04  Other 
 
3010  Fund Account Balance  Medicare Contractor Account Definitions 
Data Element Definitions 
Account Number  Title 
 
3310  Cumulative Results of Operations 
3310.01  Part A and Part B 
 
5000  Revenue 
 
5303  Interest Revenue 
5303.01  Part A and Part B 
 
5303.01.01  Adjustments/Waivers (Contra Account) 
5303.01.02  Write-off Closed/Transfers 
5303.01.02.01  Bad Debt (Contra Account) 
5303.01.02.02  Transfers Out to Other CMS Locations (Contra Account) 
5303.01.02.02.01  Transfers In from Other CMS Locations 
5303.01.02.03  Transfers Out to CNC (Contra Account) 
5303.01.02.03.01  Transfers In from CNC 
5303.01.02.04  Transfers Out to Other Medicare Contractors (Contra Account) 
5303.01.02.04.01  Transfers In from Other Medicare Contractors 
 
5700  Appropriated Capital Used 
5700.01  Part A and Part B, Draws on Letter of Credit 
 
5900  Other Revenue 
 
5900.01  Part A and Part B 
5900.01.01  Other 
 
6000  Expense 
6100  Operating/Program Expense 
6100.01  Part A and Part B 
 
6101  Waivers 
6101.01  Part A and Part B 
6101.01.02  Transfers Out to Other CMS Locations (Contra Account) 
6101.01.02.01  Transfers In from Other CMS Locations 
6101.01.03  Transfers Out to CNC (Contra Account) 
6101.01.03.01  Transfers In from CNC 
6101.01.04  Transfers Out to Other Medicare Contractors (Contra Account)  Medicare Contractor Account Definitions 
Data Element Definitions 
Account Number  Title 
6101.01.04.01  Transfers In from Other Medicare Contractors 
 
6106  Write Offs/Transfers 
6106.01  Part A and Part B 
6106.01.01  Bad Debts 
 
6330  Interest Expense 
6330.01  Part A and Part B 
6330.01.01  CPT Interest 
6330.01.02  Other Interest 
 
6909  Other Expense 
6909.01  Part A and Part B 
 
7400  Prior Period Adjustments 
7400.01  Part A and Part B 
 
Medicare Contractor Account Definitions 
Data Element Definitions 
The account numbers used in this chart are for reference purposes only. They are not 
mandated for use by Medicare contractors. 
 
Account Number  Title 
1000  Assets 
The contractor reports amounts of physical items or rights to 
 
ownership 
 
1100  Cash 
The contractor reports monetary resources on hand or on deposit 
  with banks or other financial institutions. Balances are the end of 
quarter amounts per the contractor's books. 
 
1100.01  Part A and Part B 
The contractor reports cash allocable for Hospital Insurance (HI) 
and Supplementary Medical Insurance (SMI) activities. HI data 
must reconcile to Column E, Line 1, on Form CMS-1522, Monthly 
 
Contractor Financial Report. SMI data must reconcile to Column 
E, Line 2. Prorate the Time Account by the number of checks and 
electronic funds transfers (EFTs) issued for HI or SMI services.  Account Number  Title 
(See Exhibit 15 Protocol for Prorating Intermediary Time Account 
Balances between HI and SMI.) 
 
1100.01.01  Benefits Account 
The contractor reports the Federal Health Insurance Benefits 
 
Account by HI and SMI 
 
1100.01.02  Time Account 
The contractor reports the balance as of the end of the quarter in 
 
the Federal Health Insurance Time Account by HI and SMI. 
 
1110  Undeposited Collections 
 
1110.01  Part A and Part B 
The contractor reports undeposited collections for HI and SMI 
 
activities 
 
1110.01.03  Undeposited Collections 
The contractor reports collections on hand not deposited within the 
accounting period. Undeposited collections include those items 
received by the last day of the quarter that will be deposited during 
the subsequent quarter. The contractor prorates undeposited 
collections on the basis of Column D, Funds Expended, on Form 
CMS-1522, Monthly Contractor Financial Report for Part A (HI) 
 
and Part B (SMI). Report deposits in transit as part of the book 
balance for either 1100.01.01, Benefits Account, or 1100.01.02, 
Time Account. It reports amounts due from others. A receivable is 
the identification of an overpayment for services rendered. CMS 
will only recognize receivables related to Fraud and Abuse once 
they are litigated by the Department of Justice (DOJ) 
 
1310.01.01  Overpayments 
The contractor accounts receivable for overpayments. It includes 
amounts that exceed adjudicated claims processed, cost reports 
settled, or other authorized payments. This includes, but is not 
 
limited to, overpayments resulting from adjustment bills. It 
reclassifies any overpayment when Medicare is deemed as 
secondary payer to 1310.01.04, MSP 
 
1310.01.01.01  Provider 
The intermediary reports overpayments for institutional providers. 
This includes, but is not limited to, those items listed on the 
 
Provider Overpayment Report (POR) and the Credit Balance 
Summary Report. Include periodic interim payments (PIP) in  Account Number  Title 
excess of PIP bills. Include overpayments resulting from the 
receipt of cost reports, tentative settlements or cost settlements 
when the Notices of Provider Reimbursement (NPR) are prepared. 
It includes overpayments from PRRB settlements when the Notices 
of Correction (NOC) are prepared. This is not a carrier function. 
 
1310.01.01.01.01  Cost Report Settlements 
The intermediary reports the accounts receivable as a result of cost 
  report settlements, interim rate reviews and overpayments as a 
result of accelerated payments 
 
1310.01.01.01.02  Claims Accounts Receivable 
The intermediary reports the accounts receivable as a result of 
 
claims accounts receivable. This is not a carrier function. 
 
1310.01.01.01.03  PIP Accrual 
The intermediary reports the amount accrued for the (estimated) 
  accounts receivable PIP. (See Exhibit 13 Protocol for Estimating 
Payables and Receivables for PIP). This is not a carrier function. 
 
1310.01.01.01.04  Credit Balances 
The intermediary reports the accounts receivable as a result of 
 
credit balance reports This is not a carrier function. 
 
1310.01.01.02  Beneficiaries 
The contractor reports overpayments for beneficiaries. This 
  includes, but is not limited to, those items listed on the CMS-2174, 
Carrier Beneficiary Overpayment Activity Report. 
 
1310.01.01.03  Physicians/Suppliers 
The carrier reports overpayments for physicians and suppliers. This 
includes, but is not limited to, those items listed on the 
 
Physician/Supplier Overpayment Report (PSOR) This is not an 
intermediary function. 
 
1310.01.04  Medicare Secondary Payer 
The contractor reports accounts receivable for amounts due as a 
result of MSP activity, and based on documented debts due 
  Medicare for all debtors. Debtors are employers, insurers, 
providers, beneficiaries or other persons to whom a demand letter 
has been issued 
 
1310.01.04.01  Group Health Plan (GHP)  Account Number  Title 
 
1310.01.04.01.01  Data Match (FI) 
The contractor includes the amounts identified (CMS supplied 
receivables via tapes with an identified report ID on MPaRTS) as a 
result of MSP activity for which a demand letter has been issued 
 
for IRS/SSA Data Match cases. Outstanding receivables are the 
amount of debt that has been demanded and payment has not yet 
been received 
 
1310.01.04.01.02  Non-Data Match (FI) 
The contractor includes the amounts identified (debt specific to 
GHP debt, working aged, disability, End-Stage Renal Disease 
  (ESRD) as a result of MSP activity for which a demand letter has 
been issued. Outstanding receivables are the amount of debt that 
has been demanded and payment has not yet been received 
 
1310.01.04.02  Liability MSP  
The contractor includes the amounts (inclusive of all workman's 
compensation, automobile/no fault and liability debt, this includes 
CMS identified cases) due to MSP activity for which a settlement 
  has been reached related to liability cases. Outstanding receivables 
are the amount of debts that have been demanded, subsequent to 
settlement and/or other action, and payment has not yet been 
received. 
 
1310.01.04.02.01  MSP Beneficiaries 
 
MSP Providers/Physicians/Suppliers Outstanding receivables are 
1310.01.04.02.02  the amount of MSP initiated debts that have been demanded and 
payment has not yet been received. 
 
1310.01.04.03  Other MSP 
The contractor includes the amounts due as a result of other MSP 
 
activity for which a valid MSP debt has been recognized. 
 
1310.01.99  Other 
The contractor reports actual or estimated other accounts 
receivable. It includes those receivables not otherwise classified in 
 
the categories presented above. It provides an identifying footnote 
on CAFM of the nature of this receivable 
 
1311  Advances to Others 
The contractor reports payments made to providers, physicians, or 
 
suppliers in anticipation of claims being processed. Advances are  Account Number  Title 
not to be considered as accounts receivable. It does not include 
them on Form CMS-751A/B, Status of Account Receivable report 
 
1311.01  Part A and Part B 
The contractor reports advance payments and accelerated payments 
 
attributable to HI and SMI activities 
 
1311.01.01  Advance Payments 
The contractor the outstanding balance for payments authorized by 
CMS instructions for advanced payments based on actual provider 
 
claims data. If not recovered according to CMS instructions, it 
reclassifies and reports as overpayments 
 
1311.01.02  Accelerated Payments (FI) 
The intermediary reports the outstanding balance for payments 
authorized by CMS instructions for accelerated payments based on 
  actual provider claims data. If not recovered according to CMS 
instructions, it reclassifies and reports as overpayments This is not 
a carrier function. 
 
1330  Interest Receivable 
The contractor reports interest receivable on accounts receivable. It 
 
accrues interest through the last day of the reporting period. 
 
1330.01  Part A and Part B 
The contractor reports HI and SMI interest receivable on accounts 
 
receivable, including extended repayment plans 
 
1990  Other Assets 
The contractor reports assets that are not otherwise classified. It 
  provides an identifying footnote in the remarks section of Form 
CMS-750A/B report. 
 
1990.01  Part A and Part B 
  The contractor reports HI and SMI unclassified assets. 
 
2000  Liabilities 
The contractor reports amounts owed after processing Medicare 
 
claims and related activities 
 
Accounts Payable Report amounts owed after processing Medicare 
2110  claims or other authorized expenditures. This includes, but is not 
limited to, underpayments resulting from adjustment bills  Account Number  Title 
 
2110.01  Part A and Part B 
The contractor reports accounts payable attributable to HI and SMI 
 
activities 
 
2110.01.01  Unprocessed Claims 
The contractor reports the value of the accounts payable for 
unprocessed claims received in-house that have not yet started 
processing. The actual value may be developed after the reporting 
 
period but before the required date for reporting. It uses the 30 day 
rolling average for the number of claims received and not 
processed to determine the number of average unprocessed claims. 
 
2110.01.02  Benefits Payable 
The contractor reports accounts payable for those claims that have 
completed processing checks, but have not yet been issued nor 
offsets applied. This includes, but is not limited to, underpayments 
 
resulting from adjustment bills. It includes claims approved by the 
Common Working File (CWF) and claims not approved by the 
CWF, but approved by the RO for payment outside the CWF. 
 
2110.01.02.01  Provider 
The intermediary reports benefits payable to institutional providers 
of Medicare services. This includes, but is not limited to the 
following: accounts receivable accrual where the periodic interim 
payment (PIP) bills is in excess of periodic interim payments (PIP); 
  underpayments from receipt of accepted cost reports, tentative 
settlements and final cost settlements, when Notices of Provider 
Reimbursement (NPR) are prepared; and underpayments for PRRB 
settlements, when Notices of Correction (NOC) are prepared, etc 
This is not a carrier function. 
 
2110.01.02.01.01  PIP Providers - Cost Report Settlements 
The intermediary reports benefits payable to PIP providers as a 
 
result of Cost Report Settlements This is not a carrier function. 
 
2110.01.02.01.02  PIP Providers - Estimated Payable Accrued 
The intermediary reports the amount accrued for the (estimated) 
  accounts payable PIP. (See Exhibit 13 Protocol for Estimating 
Payables and Receivables for PIP). This is not a carrier function. 
 
2110.01.02.01.03  Non-PIP Providers - Underpayments (Interim Rate) 
The intermediary reports benefits payable to Non-PIP providers as 
 
a result of Interim Rate Reviews This is not a carrier function  Account Number  Title 
 
2110.01.02.01.04  Non-PIP Providers - Underpayments (Cost Report Settlement) 
The intermediary reports benefits payable to Non-PIP providers as 
 
a result of Cost Report Settlements This is not a carrier function. 
 
2110.01.02.01.05  Claims Payments Withheld for Non-receipt of Cost Reports 
The intermediary reports benefits payable for claims withheld for 
  payment for non-receipt of provider cost reports This is not a 
carrier function. 
 
2110.01.02.02  Beneficiaries 
The contractor reports benefits payable to beneficiaries for 
 
reimbursement for Medicare services. 
 
2110.01.02.03  Physicians/Suppliers 
The carrier reports benefits payable to physicians or suppliers of 
Medicare services. This includes, but is not limited to, 
  underpayments of quarterly Health Professional Shortage Area 
(HPSA) bonus amounts for which a check has not been issued. Not 
an intermediary function. 
 
2110.01.02.04  Claims on the Payment Floor Adjudicated claims not yet paid 
 
2110.01.03  Suspended Payments 
The contractor reports actual or estimated benefits payable for 
  claims that were suspended from payment to allow for additional 
processing. 
 
2110.01.03.01  Claims 
The contractor reports estimated benefits payable for claims 
  needing additional information or further development, including 
CWF rejects and adjustments 
 
210.01.03.02  Common Working File (CWF) 
The contractor reports benefits payable for claims that are pending 
 
submission or were submitted to the CWF for approval. 
 
2110.01.03.03  MR/UR Prepayment Review 
The contractor reports estimated benefits payable, based on a 
  developed rate, suspended for MR/UR before payment. The 
payables after MR/UR are in 2110.01.02, Benefits Payable 
 
2110.01.03.04  Medicare as Secondary Payer (MSP)  Account Number  Title 
The contractor reports benefits payable that are suspended for 
 
investigation of third party liability for MSP prior to payment 
 
2140  Accrued Interest Payable 
The contractor reports actual or estimated interest payable on 
Medicare liabilities through the end of the reporting period 
 
including, but not limited to, pending claims, court settlements, 
claims payment timeliness (CPT), etc. 
 
2140.01  Part A and Part B 
The contractor reports HI and SMI interest payable on Medicare 
 
liabilities 
 
2990  Other Liabilities 
The contractor reports liabilities not otherwise classified. It 
  provides an identifying footnote in the remarks section of Form 
CMS-750A/B report. 
 
2990.01  Part A and Part B 
The contractor reports other liabilities attributable to HI and SMI 
 
activities. 
 
2990.01.01  Unapplied Receipts 
The contractor reports amounts deposited and not yet applied to an 
 
accounts receivable. 
 
2990.01.02  Excess Recoupments 
The contractor reports amounts recovered from overpayments or 
from other sources in excess of receivables established and which 
  are eligible for refund. It includes those payables identified as due 
to third party liability payers, e.g., excess recoupment of MSP 
recoveries being returned to the third party. 
 
2990.01.03  Due Medicaid 
The contractor reports Medicare claims reimbursements withheld 
 
based on RO instructions for payment to Medicaid. 
 
2990.01.99  Other 
The contractor reports actual or estimated amounts payable not 
otherwise classified. These include, but are not limited to, claims 
  payments withheld to satisfy Internal Revenue Service liens, court 
liens, unidentified receipts that have not been applied to an account 
receivable. It provides an identifying footnote in CAFM.  Account Number  Title 
 
Fund Balance Fund balance reflects the cumulative results of 
3010  program operations and extraordinary items. It equals the 
difference between assets and liabilities. 
 
3310  Cumulative Results of Operations 
These accounts track the net difference between income and 
expense activity as reported on the Statement of Operations. This 
 
account is updated with the current year-to-date net results of 
operations 
 
3310.01  Part A and Part B 
The contractor reports HI and SMI interest revenue from accounts 
receivable. It includes current fiscal period earned interest, and any 
 
adjustments. It also includes accrued interest in account 1330, 
Interest Receivable 
 
5000  Revenue and Other Financing Sources 
The contractor reports the amount of income from Medicare 
  activities. Typical sources are draws on letter of credit, interest and 
recoveries of amounts expended in prior periods. 
 
5303  Interest Revenue 
  The contractor reports interest earned from accounts receivable. 
 
5303.01  Part A and Part B 
The contractor reports HI and SMI interest revenue from accounts 
receivable. Include current fiscal period earned interest, and any 
 
adjustments. This will also include accrued interest in account 
1330, Interest Receivable. 
 
5303.01.01  Adjustments/Waivers (Interest) 
The contractor reports the reduction of the amounts of interest 
receivable based on Collections on Delinquent Debt in accordance 
  with 1862(b) and 1870(c) of the Social Security Act.  It 
reconciles this with Form CMS-751A/B, Status of Accounts 
Receivable, Line 5h, Waivers (Interest).  
 
5303.01.02  Write-offs Closed/Transfers (Interest) 
The contractor reports interest receivable for which collection 
efforts have been abandoned or that have been transferred to 
  another Medicare contractor or other CMS location. These 
accounts must be reconciled with the receiving Medicare 
contractor or other CMS location.  Account Number  Title 
 
5303.01.02.01  Amounts Written-Off Closed (Bad Debts) (Interest) 
The contractor reports interest receivables for which collection is 
no longer being pursued according to CMS regulations. It 
 
reconciles this with Form CMS-751A/B, Status of Accounts 
Receivable, Line 6a, Amounts Written-off Closed (Bad Debts). 
 
Transfers Out to other CMS Locations (POR/PSOR & Not 
5303.01.02.02 
POR/PSOR) (Interest). POR not applicable to carriers. 
The contractor reports interest receivable transferred to other CMS 
locations. Reconcile with Form CMS-751A/B, Status of Accounts 
Receivable, Line 5e, Transfers Out to Other CMS Locations, 
 
POR/PSOR, (interest) and Line 5g, Transfers Out to Other CMS 
Locations, Not POR/PSOR, (interest). POR not applicable to 
carriers. 
 
Transfers In from other CMS Locations (POR/PSOR & Not 
5303.01.02.02.01 
POR/PSOR) (Interest). POR not applicable to carriers. 
The contractor reports interest receivable that has been transferred 
to your location from other CMS locations in the current period. It 
reconciles this with Form CMS-751 A/B, Status of Accounts 
 
Receivable, Line 5d, Transfers In from Other CMS Locations, 
POR, (interest), and Line 5f, Transfers In from Other CMS 
Locations, Not POR, (interest). POR not applicable to carriers. 
 
5303.01.02.03  Transfers Out to CNC (Interest) 
The contractor reports interest receivable transferred to CNC in 
accordance with CMS regulations. It transfers the full amount of 
  interest due on the debt. It reconciles this with Form CMS-C751, 
Status of Non-MSP Debt - CNC, Line 2, New CNC A/R (interest) 
and Line 6c, Transfers Out to CNC 
 
5303.01.02.03.01  Transfers In from CNC (Interest) 
The contractor reports interest receivable that has been transferred 
 
in to its location from CNC. 
 
5303.01.02.04  Transfers Out to other Medicare Contractors (Interest) 
The contractor reports interest receivable transferred to other 
Medicare contractors. Reconcile with Form CMS-751A/B, Status 
 
of Accounts Receivable, Line 5c, Transfers Out to Other Medicare 
Contractors. 
 
5303.01.02.04.01  Transfers in from other Medicare Contractors (Interest)  Account Number  Title 
The contractor reports interest receivable transferred to your 
location from other Medicare contractors. It reconciles this with 
 
Form CMS-751A/B Status of Accounts Receivable, Line 5b, 
Transfers In from Other Medicare Contractors (Interest) 
 
5700  Appropriated Capital Used 
The contractor reports the amount of Medicare funds drawn to be 
matched against current period expense. This amount must be 
consistent with amounts reported on Form CMS-1521, Contractor 
  Draws on Letter of Credit, and on Form CMS-1522, Monthly 
Contractor Financial Report. The contractor does not include 
administrative draws through the Payment Management System 
(PMS), (Smartlink) 
 
5700.01  Part A and Part B, Draws on Letter-of-Credit 
 
5900  Other Revenue 
The contractor reports revenue not otherwise classified. It provides 
  identifying footnote(s) in the remarks section of Form CMS-750 
A/R report 
 
5900.01  Part A and Part B 
  The contractor reports HI and SMI other revenue 
 
5900.01.01  Other 
  The contractor reports revenue not otherwise classified 
 
6000  Expense 
The contractor reports the outflow of assets or incurrence of 
  liabilities during a period resulting from rendering Medicare 
services. 
 
6100  Operating/Program Expense 
The contractor reports net benefits costs incurred throughout the 
FY. The expense is the adjusted benefits outlay in cash or its 
  equivalent and accrued liabilities incurred in carrying out the 
Medicare program. This includes, but is not limited to, adjustments 
for MSP recoveries, reconsiderations, and pending litigation. 
 
6100.01  Part A and Part B 
  The contractor reports HI and SMI benefit program expense. 
 
6101  Waivers (Principal)  Account Number  Title 
  The contractor reports HI and SMI waiver expense. 
 
6101.01  Part A and Part B 
The contractor reports the reduction of the amounts receivable 
based on application of 1862(b) and 1870(c) of the Social 
 
Security Act. It reconciles this with Form CMS-751A/B, Status of 
Accounts Receivable, Line 5h, Waivers. 
 
6101.01.02  Transfers Out to other CMS Locations (Principal) 
The contractor reports accounts receivable transferred to other 
CMS locations. It reconciles this with Form CMS-751A/B, Status 
  of Accounts Receivable, Line 5e, Transfers Out to Other CMS 
Locations, POR/PSOR and Line 5g, Transfers to Other CMS 
Locations, Not POR/PSOR. POR not applicable to carriers. 
 
6101.01.02.01  Transfers In from other CMS Locations (Principal) 
The contractor reports accounts receivable amounts that have been 
transferred to its location from other CMS locations in the current 
period. It reconciles this with Form CMS-751 A/B, Status of 
  Accounts Receivable, Line 5d, Transfers In from Other CMS 
Locations, POR/PSOR (principal), and Line 5f, Transfers In from 
Other CMS Locations, Not POR/PSOR (principal). POR not 
applicable to carriers. 
 
6101.01.03  Transfers Out to CNC (Principal) 
The contractor reports accounts receivable amounts that have been 
transferred to CNC in accordance with CMS regulations. . It 
reconciles this with Form CMS-C751A/B, Status of Non- MSP 
 
Debt - CNC, Line 2, New CNC A/R, and Line 6c Transfers Out to 
CNC of Form CMS-751A/B, Status of Accounts Receivable report. 
It transfers the full amount of principal due. 
 
6101.01.03.01  Transfers In from CNC (Principal) 
The contractor reports accounts receivable amounts that have been 
re-established as an active accounts receivable. It reconciles this 
 
with Form CMS-751A/B, Status of Accounts Receivable, Line 6b, 
Transfers In from CNC 
 
6101.01.04  Transfers Out to other Medicare Contractors (Principal) 
The contractor reports HI and SMI accounts receivable transferred 
out to a Medicare contractor for collection. It reconciles this with 
 
Form CMS-751A/B, Status of Accounts Receivable, Line 5c, 
Transfers to Other Medicare Contractors. 
  Account Number  Title 
6101.01.04.01  Transfers In from other Medicare Contractors (Principal) 
The contractor reports HI and SMI accounts receivable transferred 
to your location from other Medicare contractors. It reconciles this 
 
with Form CMS-751 A/B, Status of Accounts Receivable, Line 5b, 
Transfers In from Other Medicare Contractors. 
 
6106  Write-offs Closed/Transfers (Principal) 
The contractor reports accounts receivable for which collection 
efforts have been abandoned, or that have been transferred to 
  another Medicare contractor or other CMS location. These 
accounts must be reconciled with the receiving Medicare 
contractor or other CMS location. 
 
6106.01  Part A and Part B 
The contractor reports HI and SMI accounts receivable written off 
 
or transferred. 
 
6106.01.01  Amounts Written-Off Closed (Bad Debts) (Principal) 
The contractor reports receivables for which collection is no longer 
being pursued according to CMS rules. It reconciles this with Form 
 
CMS-751A/B, Status of Accounts Receivable, Line 6a, Amounts 
Written-off Closed (Bad Debts). 
 
6330  Interest Expense 
The contractor reports interest expense incurred for claims for 
 
Medicare benefits or accounts payable. 
 
6330.01  Part A and Part B 
  The contractor reports HI and SMI interest expense. 
 
6330.01.01  Claims Payment Timeliness (CPT) Interest 
The contractor reports interest paid for claims that failed the claims 
  payment timeliness (CPT) requirement. It reconciles this with 
Form CMS-1522, interest paid, claims timeliness. 
 
6330.01.02  Other Interest 
The contractor reports interest for other late payments. It reconciles 
 
this with Form CMS-1522, interest paid, provider underpayments. 
 
6909  Other Expense 
The contractor reports benefit expenses not reported in named 
  categories or otherwise classified. It provides an identifying 
footnote in the remarks section of Form CMS-750A/B report.  Account Number  Title 
 
6909.01  Part A and Part B 
  The contractor reports HI and SMI unclassified benefit expenses. 
 
7400  Prior Period Adjustments 
The contractor reports adjustments for prior period activity to 
  restate assets, liabilities, etc. It provides an identifying footnote in 
the remarks section of Form CMS-750 report. 
 
7400.01  Part A and Part B 
  The contractor reports HI and SMI prior period adjustments. 
 
400.12 - Exhibit 12 - Accounts Payable - Protocol for Estimating Claims 
- Form CMS-H750A/B, Statement of Financial Position - (Rev. 5, 08-30-
02) 
A1-1960.12, B1-4960.12 
 
Accounts Payable Protocol for Estimating Claims 
Form CMS-H750A/B, Statement of Financial Position 
 
The amounts recorded in accounts payable (A/P) may be estimated based on actual 
volumes and historical rates; therefore, the FI or carrier calculates and accrues a new 
estimated liability each reporting period and reverses the accrual for the previous period 
in full. It charges the expense accounts, rather than the A/P, as actual payments are made. 
 
INTERMEDIARY PROCEDURES 
 
Methodology for Calculating Average Reimbursement Amount and Average Interest for 
Pricing Claim Liabilities 
 
To assign an estimated value to claims for which the amount to be paid is unknown, the 
contractor counts claims and multiplies the total by the average reimbursement amount 
(net of interest) and an average interest amount (CPT), if applicable, determined as 
follows: 
 
The intermediary calculates the average reimbursement amount by taking a representative 
sample of the most recent 12 months of paid claims history. It totals the reimbursement 
amount minus interest and divides by the total number of claims processed. It calculates 
the Claims Payment Timelines (CPT) by adding the interest from the same claims and 
divides by the total number of claims (not just those bearing interest). 
 
The intermediary performs these calculations by bill types and will be segregated 
between Part A and Part B. (See Intermediary Manual, Part 3, 3894.3.) 
  GENERAL PROCEDURES 
 
These methods may be used to assign an estimated value to claims in the following 
categories: 
 
1.  In-house, unprocessed claims; and  
 
MR/UR 
PRO 
 
2.  Claims suspended for prepayment review 
 
Claims 
MR/UR 
PRO 
 
400.13 - Exhibit 13 - Periodic Interim Payments (PIP) Protocol for 
Estimating Payables/Receivables for the Forms CMS-H750/751A/B, 
Statement of Financial Position and Status of Accounts Receivable 
Report (Intermediaries Only) - (Rev. 5, 08-30-02) 
A1-1960.13, B1-4960.13 
 
Periodic Interim Payments (PIP) 
Protocol for Estimating Payables/Receivables for the Form CMS-H750/H751A/B, 
Statement of Financial Position and Status of Accounts Receivable Reports 
 
It is necessary to report on Form CMS-H750, a cumulative estimated accounts receivable 
or payable for all fiscal periods since the provider's last accepted cost report period. To 
estimate this amount, the intermediary performs the following steps: 
 
1.  It determines the total amount for PIP bills processed for the fiscal period less 
outlier amounts; 
 
2.  It compares the PIP bills amount to the actual PIP cash payment and lump sum 
payments (checks issued) made during the fiscal period. This does not include any 
outlier payments that may have been issued on the same check with the PIP; 
 
3.  It reports the amount that PIP bills exceed the PIP cash payment as an account 
payable; and  
 
4.  It reports the amount that PIP cash payment exceeds the PIP bills as an account 
receivable. 
 
For example: If the provider's FY ends on December 31, then the cost report should be 
received and accepted before the June 30 reporting period. The following demonstrates 
how the PIP accumulations would be reported for this provider.   
Period Ending  Reporting 
December 31  Assuming all prior year cost reports have been accepted, 
the only entry on the books for this provider would be 
the estimated accounts receivable or accounts payable 
after comparing PIP payments to claims submitted since 
January 1st to current. 
March 31  Given the same assumption regarding prior cost reports, 
the PIP estimate for this provider will include the entire 
prior FY for the provider (January 1 - December 31) 
unless the cost report has been filed and accepted, and 
the current FY for the provider (January 1- March 31). 
June 30  Given the same assumption regarding prior cost reports, 
assuming the latest cost report has now been received 
and accepted and the appropriate accounts receivable or 
accounts payable are booked, the PIP estimated for this 
provider will now include only the current FY for the 
provider (January 1- June 30). 
Sept 30  Given the same assumption regarding prior cost reports, 
assuming the latest cost report has now been received 
and accepted, the PIP estimate for this provider will now 
include only the current FY for the provider (January 1- 
September 30). 
 
400.14 - Exhibit 14 - Protocol for Estimating Allowance for 
Uncollectible Accounts Forms CMS-H/M751A/B, Status of Accounts 
Receivable 
(Rev. 115, Issued:  01-24-07; Effective Date:  04-01-07; Implementation Date:  04-02-
07) 
 
The Federal Accounting Standards Advisory Board (FASAB) recommends through 
Statement of Federal Financial Accounting Standard Number 1 (Paragraphs 44&45) that 
losses on receivables should be recognized when it is more likely than not that the 
receivables will not be totally collected. The phrase "more likely than not" means more 
than a 50 percent chance of loss occurrence. An allowance for estimated uncollectible 
amounts should be recognized to reduce the gross amount of receivables to its net 
realizable value. The allowance for uncollectible amounts should be re-estimated on each 
annual financial reporting date (at a minimum) and when information indicates that the 
latest estimate is no longer correct. These losses should be measured through a systematic 
methodology. The systematic methodology should be based on analysis of both 
individual accounts and a group of accounts as a whole. 
 
Accounts that represent significant amounts, i.e., greater that $1 million, should be 
individually analyzed to determine the loss allowance. Loss estimation for individual 
accounts should be based on (a) the debtor's ability to pay, (b) the debtor's payment  record and willingness to pay, and (c) the probable recovery of amounts from secondary 
sources, including liens, garnishments, cross collections and other applicable collection 
tools. 
 
The entire allowance for losses generally cannot be based solely on the results of 
individual account analysis. In many cases, information may not be available to make a 
reliable assessment of losses on an individual account basis or the nature of the 
receivables may not lend itself to individual account analysis. In these cases, potential 
losses should be assessed on a group basis. 
CMS has implemented FASAB's recommendations and has developed this protocol for 
Medicare contractors to follow for estimating the allowance for uncollectible accounts. 
The following section outlines this methodology. 
 
Protocol for Estimating Allowance for Uncollectible Accounts 
 
Medicare contractors must recognize on Line 8, Allowance for Uncollectible Accounts, 
on Forms CMS-H/M751A/B, an estimated amount for uncollectible debt in order to 
reduce the gross amount of receivables to its net realizable value. Medicare contractors 
must re-estimate the allowance for uncollectible amounts on March 31 and September 30 
of each FY and when information indicates that the latest estimate is no longer correct. 
 
Medicare contractors must measure potential losses due to uncollectible amounts through 
a systematic method. This systematic method must be based on an analysis. The analysis 
requires that receivables be further stratified into sub-groups (i.e., Cost Report Settlement 
Activity, Claims Accounts Receivable, Credit Balances, Group Health Plan (GHP) MSP, 
Liability MSP and Other Accounts Receivables). The subgroups are somewhat different 
for Group 1 - Fiscal Intermediaries, as compared to Group 2 - Carriers. 
Group 1 (Fiscal Intermediaries) 
 
Sub-Group 1 
 
1.  Cost Report Settlements Activity (Non MSP) 
 
2.  Claims Accounts Receivable, Credit Balances & Other Accounts 
Receivables (Non-MSP) 
 
Sub-Group 2 
 
1.  Group Health Plan (Data Match/Non Data Match) MSP 
 
2.  Liability MSP 
 
For Group 1, Subgroup 1, fiscal intermediaries must perform the following steps to 
calculate and validate the allowance for uncollectible accounts. 
  1.  Calculate the allowance based on the historical collection percentage (see detailed 
instructions below) for Non-MSP as a whole. 
 
2.  Individual Account Analyses: For cost report settlement activity only, fiscal 
intermediaries will identify and total those provider debts that meet certain risk 
characteristics (i.e., bankruptcy, terminations, poor collection history, no 
collection activity for 6 months or more). These will be considered risk accounts, 
and the fiscal intermediary should total all risk accounts identified through this 
analysis. 
 
3.  Compute the total delinquencies exceeding 180 days (Section B of Forms CMS 
H/M751A/B "Delinquent Receivables"). 
 
4.  Compare the three estimated amounts calculated in Steps 1, 2 & 3 and identify the 
amount that ensures that the net receivable is reported at its realizable value. 
 
For Group 1, Subgroup 2, the fiscal intermediary must perform the following steps to 
calculate and validate the allowance for uncollectible accounts. 
 
1.   Calculate the allowance based on the historical collection percentage (see 
detailed instructions below) for MSP as a whole. 
 
2.  Compute the total delinquencies exceeding 180 days (Section B of Forms CMS-
H/M751A/B "Delinquent Receivables"). 
 
3.  Compare the two estimated amounts calculated in Steps 1 & 2 and identify the 
amount that ensures that the net receivable is reported at its realizable value. 
 
Historical Collection Percentage Calculation 
 
A - Determine Total Receivables Eligible for Collection. (Using Forms CMS 
H/M751A/B) 
 
Required Formula: 
 
Beginning Balance  (Line 1) 
Plus: New Receivables  (Line 2a) 
Plus/Less: Adjusted Amounts  (Line 5a) 
(plus if positive number less if negative number)   
Plus: Transfers In from other Medicare Contractors  (Line 5b) 
Plus: Transfers In from other CMS locations, POR & 
(Lines 5d & 5f) 
Not POR 
Plus: Transfers In from CNC  (Lines 6b) 
Less:  Transfers Out to other Medicare Contractors  (Line 5c)     
Less: Transfers Out to other CMS locations, POR & Not  (Lines 5e & 5g) 
POR 
Less:  Waivers & Amounts Written Off (Bad Debts)        (Lines 5h & 6a) 
Less:  Transfers Out to CNC 
  (Line 6c) 
Equals: Total Receivables Available to be Collected 
 
B - Determine Rate of Collections 
 
Line 4a, Cash/Check Collections plus Line 4b, Offsets Collection plus Line 4c, 
Collections Deposited At Another Location divided by Total Receivables Available to be 
Collected (number calculated from Step A) multiplied times 100 determines the rate of 
collections percentage. 
 
C - Determine the Allowance Rate 
 
1.00 minus the percentage determined from Step B, equals the allowance rate 
 
D - Average the Percentage Calculated in Step C with a 5-year Historical Allowance Rate 
(if available, if not available, maintain statistical data to develop historical rate, and 
proceed to Step E). 
 
E - Calculate the Allowance 
 
Multiply the allowance rate from Step C or Step D by the sum of Line 7, Ending Balance 
less Line 2b, Accrued Receivables. 
 
Group 2 (Carriers) 
 
Sub-Group 1 
 
1.  Claims Accounts Receivable, Credit Balances & Other Accounts 
Receivables (Non-MSP) 
 
Sub-Group 2 
 
1.  Group Health Plan (Data Match/Non Data Match) MSP 
 
2.  Liability MSP 
 
For Group 2, Subgroup 1, the carrier must perform the following steps to calculate and 
validate the allowance for uncollectible accounts. 
 
1.  Calculate the allowance based on the historical collection percentage (see detailed 
instructions below) for Non-MSP as a whole.   
2.  Compute the total delinquencies exceeding 180 days (Section B of Forms CMS-
H/M751B "Delinquent Receivables"). 
 
3.  Compare the two estimated amounts calculated in Steps 1 & 2 and identify the 
amount that ensures that the net receivable is reported at its realizable value. 
 
For Group 2, Subgroup 2, the carrier must perform the following steps to calculate and 
validate the allowance for uncollectible accounts. 
 
1.  Calculate the allowance based on the historical collection percentage (see detailed 
instructions below) for MSP as a whole. 
 
2.  Compute the total delinquencies exceeding 180 days (Section B of Forms CMS-
H/M751B "Delinquent Receivables"). 
 
3.  Compare the two estimated amounts calculated in Steps 1 & 2 and identify the 
amount that ensures that the net receivable is reported at its realizable value. 
 
Historical Collection Percentage Calculation 
 
A.  Determine Total Receivables Eligible for Collection. (Using Forms CMS-H/M751B) 
 
Required Formula: 
 
Beginning Balance  (Line 1) 
Plus: New Receivables  (Line 2a) 
Plus/Less: Adjusted Amounts  (Line 5a) 
(plus if positive number  less if negative number)   
Plus: Transfers In from other Medicare Contractors  (Line 5b) 
Plus: Transfers In from other CMS locations, POR & 
(Lines 5d & 5f) 
Not POR 
Plus: Transfers In from CNC  (Line 6b) 
Less:  Transfers Out to other Medicare Contractors  (Line 5c) 
   
Less:  Transfers Out to other CMS locations, POR & No( Line 5 e & 5g) 
   
Less: Waivers & Amounts Written Off (Bad Debts)  (Line 5h & 6a) 
   
Less: Transfers Out to CNC  (Line 6c)   
Equals: Total Receivables Available to be Collected 
 
B.  Determine Rate of Collections 
 
Line 4a, Cash/Check Collections plus Line 4b, Offsets Collections plus Line 4c, 
Collections Deposited At Another Location divided by Total Receivables Available to be 
Collected (number calculated from Step A) multiplied times 100 determines the rate of 
collections percentage. 
 
C.  Determine the Allowance Rate. 
 
1.00 minus the percentage determined from Step B, equals the allowance rate 
 
D.  Average the percentage calculated in Step C with a 5-year historical allowance rate (if 
available, if not available, maintain statistical data to develop historical rate, and go 
proceed to Step E). 
 
E.  Calculate the Allowance 
 
Multiply the allowance rate from Step C or Step D (Group 2, Carriers Section) by Line 7, 
Ending Balance. 
 
Medicare contractors are required to compare the results of the estimated allowance 
based on the protocol and report on Line 8, Allowance for Uncollectible Accounts, the 
amount that ensures that the net receivable is reported at its realizable value.  The 
Medicare contactors are required to maintain supporting documentation that includes the 
assumptions used to calculate the allowance amount reported on Forms CMS 
H/M751A/B.  The documentation must be available for review by CMS, OIG, GAO or 
other parties as required. 
 
Note:  Medicare contractors may apply the same method of results of the principal 
comparison (Col. D, Example 400.14.3) to estimate the interest allowance amount (Col. 
E, Example 400.14.3) to be reported on Line 8, Allowance for Uncollectible Accounts, of 
the Forms CMS H/M 751A/B.  For example, the method of results for the Non-MSP 
principal is delinquencies exceeding 180 days.  The Medicare contractor has the option to 
report on the allowance matrix for interest (Sub-Group 1, Col. E) the amount equal to the 
delinquencies exceeding 180 days from the interest column on Form CMS 751.  The 
method of results for the MSP principal is the historical collection percentage.  The 
Medicare contractor has the option to report on the allowance matrix for interest (Sub-
Group 2, Col. E) the amount equal to the same percentage calculated for MSP principal, 
multiplied by Line 7, ending balance from the interest column on Form CMS 751.  The 
method selected by the Medicare contractor used to estimate the interest allowance shall 
ensure that the net interest receivable is reported at its realizable value. 
  Each Medicare contractor must complete the Allowance for Uncollectible Accounts 
Matrix (Attachment I or Attachment II) for the periods ending March 31 and September 
30 of each year.  The accounts matrix is to be mailed to CMS CO.  The March 31 
Allowance for Uncollectible Accounts Matrix is due on April 21 and the September 30 
Allowance for Uncollectible Accounts matrix is due on October 21.  The Medicare 
contractor must submit a separate Allowance for Uncollectible Accounts Matrix for each 
Form CMS 751 (i.e. H751A, H751B of A, H751B and H751B-DMERC). 
 
Please submit your matrix(s) via email to ALLOWMATRIX@cms.hhs.gov as well as a 
hard copy to the following address: 
 
Centers for Medicare & Medicaid Services 
Division of Financial Reporting and Policy 
Attention: Director of DFRP 
Mail Stop:  N3-11-17 
7500 Security Boulevard 
Baltimore, Maryland  21244     
Example 400.14.1
Status of Accounts Receivable
Hospital Insurance (HI)
As of March 31, 2003
H751 Non-MSP M751
Section A: Outstanding Receivables Principal Principal Principal
1. Beginning FY Balance                  329,345,200      188,945,200 140,400,000
2a. New Receivables                    80,050,600        57,500,600 22,550,000
2b. Accrued Receivables                    40,455,000        40,455,000 0
3. Interest Earned                                 -                     -
4a. Cash/Check Collections                 (218,697,200)     (202,697,200) (16,000,000)
4b. Offset Collections                        (424,000)            (424,000) 0
4c. Collections Deposited at another Location                          (50,000)              (50,000) 0
5a. Adjusted Amounts                     -
Internal Adjustments                     (4,409,000)         (2,319,000) (2,090,000)
Auditor/Consultant Adjustments                     (5,617,400)         (5,617,400) 0
5b. Transfers In from other Medicare Contractors                    10,242,000        10,242,000 0
5c. Transfers Out to other Medicare Contractors                        (160,000)                     - (160,000)
5d. Transfers In from other CMS Locations, POR                         304,000             304,000 0
5e. Transfers Out to other CMS locations, POR                        (247,600)            (247,600) 0
5f. Transfers In from other CMS Locations, Not POR                         126,000             126,000 0
5g. Transfers Out to other CMS Locations, Not POR                        (150,000)            (150,000) 0
5h. Waivers                        (292,000)                     - (292,000)
6a. Amounts Written-off (Bad Debts)                        (536,000)                     - (536,000)
6b. Transfers In from CNC                                 -                     - 0
6c. Transfers Out to CNC                 (106,420,000)         (2,089,600) (104,330,400)
7. Ending Balance                  123,519,600        83,978,000 39,541,600
a.  Current                    92,639,700        62,983,500 29,656,200
b.  Non-current                    30,879,900        20,994,500 9,885,400
8. Allowance for Uncollectible Accounts                   (49,745,910)       (29,327,200) (20,418,710)
9. Total Receivables Net of Allowance                    73,773,690        54,650,800           19,122,890
10. Cash/Offsets Received for Receivables at Another Location                                 -
H751 Non-MSP M751
Section B:  Delinquent Receivables Principal Principal Principal
1. Total Not Delinquent                         239,000             186,000                  53,000
2. Total Delinquent                  123,280,600        83,792,000           39,488,600
(a)  1-30 days                      6,150,302          4,182,736 1,967,566
(b)  31-60 days                    20,341,299        13,825,680 6,515,619
(c)  61-90 days                    23,976,069        16,346,304 7,629,765
(d)  91-180 days                    29,511,844        20,110,080 9,401,764
(e)  181-365 days                    12,316,710          8,371,915             3,944,795
(f)   1-2 years                    30,797,413        20,940,700             9,856,713
(g)  2-6 years                           86,850                 7,285                  79,565
(h)  6-10 years                           15,113                 3,200                  11,913
(I)   over 10 years                           85,000                 4,100                  80,900   Example 400.14.2
Allowance for Uncollectible Accounts
Historical Collection Percentage Calculation
H751A Non-MSP M751A
A. Determine Total Receivable Eligible for Collection Principal Principal Principal
1. Beginning FY Balance         329,345,200         188,945,200         140,400,000
2a. New Receivables           80,050,600           57,500,600           22,550,000
5a. Adjusted Amounts
Internal Adjustments            (4,409,000)            (2,319,000)            (2,090,000)
Auditor/Consultant Adjustments            (5,617,400)            (5,617,400)                        -
5b. Transfers In from other Medicare Contractors           10,242,000           10,242,000                        -
5c. Transfers Out to other Medicare Contractors               (160,000)                        -               (160,000)
5d. Transfers In from other HCFA Locations, POR                304,000                304,000                        -
5e. Transfers Out to other HCFA locations, POR               (247,600)               (247,600)                        -
5f. Transfers In from other HCFA Locations, Not POR                126,000                126,000                        -
5g. Transfers Out to other HCFA Locations, Not POR               (150,000)               (150,000)                        -
5h. Waivers               (292,000)                        -               (292,000)
6a. Amounts Written-off (Bad Debts)               (536,000)                        -               (536,000)
6b. Transfers In from CNC                        -                        -                        -
6c. Transfers Out to CNC        (106,420,000)            (2,089,600)        (104,330,400)
Total Receivables Available to be Collected         302,235,800         246,694,200           55,541,600
B.  Determine Rate of Collections
4a. Cash/Check Collections         218,697,200         202,697,200           16,000,000
4b. Offset Collections                424,000                424,000                        -
4c. Collections Deposited at another Location                  50,000                  50,000                        -
Total Collections         219,171,200         203,171,200           16,000,000
Rate of Collections (Total Collections divided by Adjusted
                                   Total Eligible for Collection) N/A 82% 29%
                [ 203,171,200 / 246,694,200 = .82 or 82%]
C.  Determine Allowance Rate
1.00 minus (-) the percentage determined for Step B N/A 18% 71%
[1.00 - Rate of Collections  (1.00 - 0.82 = 0.18 or 18%)]
D.  5-year Average (if available)
(.50+.46+.48+.43+ Allowance Rate from Step C)/5 =  N/A 41% 52%
FY 99 = 50%
FY 00 = 46%
FY 01 = 48%
FY 02 = 43%
FY 3/03 =
E.  Calculate the Allowance
Multiply the ending balance less PIP accrual  (Line 7 - PIP accrual) by the allowance  rate
(Step C or Step D)
7. Ending Balance         123,519,600           83,978,000           39,541,600
2b. (Less) Accrued Receivables-(PIP Accrual Only)           (40,455,000)          (40,455,000)                        -
Adjusted Ending Balance           83,064,600           43,523,000           39,541,600
Allowance for Uncollectible Accounts           38,232,020           17,813,310           20,418,710 Example 400.14.3
Status of Accounts Receivable
Hospital Insurance (HI)
As of March 31, 2003
Systematic Analysis Comparison H751A Non-MSP MSP
Historical Collection  %       3 8,232,020       1 7,813,310         20,418,710
Individual Account Analysis       1 5,000,800       1 5,000,800                      -
Delinquencies Exceeding 180 days       4 3,301,086       2 9,327,200         13,973,886
400.14 - Exhibit 14 - Protocol for Estimating Allowance for Uncollectible Accounts
Attachment I - Fiscal Intermediary
Allowance for Uncollectible Accounts Matrix
Group 1 Col. A Col. B Col. C Col. D Col. E
Historical Individual  Delinquencies Estimated Estimated Allowance
Collection % Account Exceeding 180 Days Allowance for  for Uncollectible A/R Justification for amount
Total Analysis Total Total Uncollectible A/R (Interest Only) reported on Line 8
Sub-Group 1 (Non-MSP)
Cost Report Settlements,
Claims A/R, Credit Balance & See Attached Workpapers
Other Accounts Receivables     17,813,310     15,000,800                29,327,200             29,327,200               4,768,143
Sub-Group 2 (MSP)
Group Health Plan (Data-Match
& Non-Data Match), See Attached Workpapers
Liability     20,418,710                13,973,886             20,418,710               3,319,762   (Amount reported on M751A/B)
Total     38,232,020     15,000,800                43,301,086             49,745,910               8,087,905 Amount Reported on H751A
Each Medicare contractor will be required to complete the allowance for uncollectible account matrix on March 31 and September 30 of each year.
In addition, this matrix is to be mailed to CMS CO.  Supporting documentation must include assumptions used to calculate the allowance for uncollectible
accounts and should be available for review by CMS, OIG, GAO or other parties as required.  The matrix must be submitted to the following address/email
(provided above) on April 21 and October 21.  If these dates occur on a holiday or weekend, the matrix is due the following Federal workday.  
400.14 - Exhibit 14 - Protocol for Estimating Allowance for Uncollectible Accounts
Attachment I - Fiscal Intermediary
Allowance for Uncollectible Accounts Matrix
Group 1 Col. A Col. B Col. C Col. D Col. E
Historical Individual  Delinquencies Estimated Estimated Allowance
Collection % Account Exceeding 180 Days Allowance for  for Uncollectible A/R Justification for amount
Total Analysis Total Total Uncollectible A/R (Interest Only) reported on Line 8
Sub-Group 1 (Non-MSP)
Cost Report Settlements,
Claims A/R, Credit Balance & See Attached Workpapers
Other Accounts Receivables
Sub-Group 2 (MSP)
Group Health Plan (Data-Match
& Non-Data Match), See Attached Workpapers
Liability   (Amount reported on M751A/B)
Total   Amount Reported on H751A/B
Each Medicare contractor will be required to complete the allowance for uncollectible account matrix on March 31 and September 30 of each year.
In addition, this matrix is to be mailed to CMS CO.  Supporting documentation must include assumptions used to calculate the allowance for uncollectible
accounts and should be available for review by CMS, OIG, GAO or other parties as required.  The matrix must be submitted to the following address/email
(provided above) on April 21 and October 21.  If these dates occur on a holiday or weekend, the matrix is due the following Federal workday.
   
400.14 - Exhibit 14 - Protocol for Estimating Allowance for Uncollectible Accounts
Attachment II - Carrier
Allowance for Uncollectible Accounts Matrix
Group 2 Col. A Col. B Col. C Col. D Col. E
Historical Individual  Delinquencies Estimated Estimated Allowance
Collection % Account Exceeding 180 Days Allowance for  for Uncollectible A/R Justification for amount
Total Analysis Total Total Uncollectible A/R (Interest Only) reported on Line 8
Sub-Group 1 (Non-MSP)
Claims A/R, Credit Balance & See Attached Workpapers
Other Accounts Receivables
Sub-Group 2 (MSP)
Group Health Plan (Data-Match
& Non-Data Match), See Attached Workpapers
Liability   (Amount reported on M751A/B)
Total   Amount Reported on H751B
Each Medicare contractor will be required to complete the allowance for uncollectible account matrix on March 31 and September 30 of each year.
In addition, this matrix is to be mailed to CMS CO.  Supporting documentation must include assumptions used to calculate the allowance for uncollectible
accounts and should be available for review by CMS, OIG, GAO or other parties as required.  The matrix must be submitted to the following address/email
(provided above) on April 21 and October 21.  If these dates occur on a holiday or weekend, the matrix is due the following Federal workday. 400.15 - Exhibit 15 - Protocol for Prorating Intermediary Time Account 
Balances Between Form CMS-H750A (HI) and Form CMS-H750B 
(SMI) - (Rev. 5, 08-30-02) 
A1-1960.15, B1-4960.15 
 
Protocol for Prorating Intermediary Time  
Account Balances Between Form CMS-H750A (HI) and Form CMS-H750B (SMI) 
 
The contractor selects a representative sample of checks and EFT payments issued and 
determines the ratio of the number of HI checks/EFT payments to the number of SMI 
checks/EFT payments. Checks or EFT payments for both HI and SMI will be split 50-50. 
It uses this ratio to prorate the time account balance for the financial reports. 
 
400.16 - Exhibit 16 - Electronic Certification - (Rev. 5, 08-30-02) 
A1-1960.16, B1-4960.16 
 
Electronic Certification 
 
The Electronic Certification process requires that the Chief Financial Officer (CFO) enter 
their password in the certifying official's current password field on the remarks page of 
Form CMS-H750A/B and Form CMS-H751A/B. When the password is keyed in, the 
CFO's name and title will appear on the document, and allow the document to be 
submitted electronically through the CAFM. For security purposes, the new password 
field is present to allow the certifying official to change the password assigned by CMS 
to one only the CFO knows. 
 
Two people are required to submit a certified report. The preparer may input the financial 
data, but cannot certify the reports. The CFO may not input data. The preparer must 
retrieve the report in order to allow certification. 
 
1.  From the CAFM Main Menu select option 2 - Data Entry 
 
2.  Select the type of report to certify 
 
3.  From the Data Entry Menu select option 5 - Update Remarks 
 
4.  Select the package (report) to certify 
 
5.  Enter the certifying official's current password 
 
If there are no serious errors (use PF6 SHOW ERRS to show errors), the contractor may 
submit the report (use PF2 SUBMIT to submit the report) and it will be accepted. 
 
If the contractor is working in a worksheet and decides to certify and submit the report, it 
may either use the function keys (PF7 PAGE- and PF8 PAGE+), enter FREM (find  remarks) on the transporter line or use the jump key (PF9 JUMP) to go to the remarks 
page. 
 
The contractor must re-enter its password if it reviews any portion of the report after 
certification and prior to submission even if no changes are made. CAFM will not store 
the contractor's password. 
 
400.17 - Exhibit 17 - Instructions for the Transfer of Debt Between 
Reporting Entities - (Rev. 5, 08-30-02) 
A1-1960.17, B1-4960.10 
 
Instructions for the Transfer of Debt Between Reporting Entities 
 
CMS continues to receive criticism from the OIG and its financial statement auditors for 
being inconsistent in methods of transferring accounts receivable cases to and from 
Medicare contractors, and other CMS locations. This criticism is a direct result of the 
lack of a formalized process and specific instructions for transferring accounts receivable 
cases between reporting entities. 
 
For financial reporting purposes, the term "referred" is used when a case is not physically 
sent to the receiving entity for collection purposes. In a "referral" situation, the receiving 
entity merely "advises and/or assists" the referring entity on what actions to take next 
with respect to the debt. The responsibility to collect and report the accounts receivable 
remains with the referring entity and must be reported as part of the ending accounts 
receivable balance on their Form CMS-H751A/B, Status of Accounts Receivable report. 
 
A "transfer" results when a copy of the up-to-date overpayment case file is physically 
"transferred" to another reporting entity, i.e., the RO, CO or another Medicare contractor. 
Along with the case file, the transferring entity must attach a "Transfer Request and 
Notification of Acceptance" form (see Exhibit 17, Attachment I for intermediaries (parts 
A and B transfers and Attachment II for carriers). This form will serve as both: 1) the 
transferring entity's request to transfer the case(s), and 2) the receiving entity's 
notification of acceptance of the transfer. 
 
The transferring entity must complete the form and sign Line 1. The form summarizes the 
case(s) requiring transfer approval. No entry will be made on Form CMS-751A/B at this 
time. Upon receipt of the form, the entity receiving the request will sign Line 2 of the 
form and forward a copy of the form back to the transferring entity. This will notify the 
transferring entity of the receipt of the request. The receiving entity will process the 
request within 30 days of receipt of the transfer, and will return a copy of the Transfer 
Request and Notification of Acceptance form indicating the case(s) approved for transfer 
by signing Line 3 of the form.  
 
Only upon receipt of the form signed by the receiving entity, will the transferring entity 
update its internal systems to reflect the transfer of the accounts receivable to the 
receiving entity. The transferring entity will reflect the dollar amount of the case(s)  approved for transfer on the appropriate transfers out line of Form CMS-H751A/B (Line 
5c, Transfers Out to Other Medicare Contractors; Line 5e, Transfers Out to Other CMS 
Locations, POR/PSOR; Line 5g, Transfers Out to Other CMS Locations, Not on 
POR/PSOR). Also upon receipt of the form, the transferring entity must sign Line 4 and 
forward a copy to the receiving entity to acknowledge receipt of the formal approval for 
transfer. 
 
The receiving entity will update all internal systems, as well as the POR/PSOR to reflect 
the transfer. The location or Medicare contractor number must also be updated in the 
POR/PSOR system to reflect the transfer. In addition, the receiving entity will reflect the 
dollar amount of the case(s) approved for transfer on the appropriate transfers in line of 
Form CMS-H751A/B (Line 5b, Transfers In from Other Medicare Contractors; Line 5d, 
Transfers In From Other CMS Locations, POR/PSOR; Line 5f, Transfers In from Other 
CMS Locations, Not POR/PSOR). 
 
Prior to submission of the quarterly Form CMS-H750/751A/B, reporting entities must 
reconcile the transfers in and transfers out lines to ensure approved transfers are only 
being reported. In addition to the requirement to maintain detailed transaction level 
documentation to support these lines, reporting entities must also retain copies of the 
signed Transfer Request and Notification of Acceptance forms.  
Exhibit 17, Attachment I 
 
TRANSFER REQUEST AND NOTIFICATION OF ACCEPTANCE FORM 
 
INTERMEDIARY PART A OR PART B - ACCOUNTS RECEIVABLE  (Indicate whether HI or SMI) 
 
                 
Provider  Provider  Cost  Overpayment  Original  Outstanding  Outstanding  Acceptance  Reason for 
Name  Number  Report  Determination  Amount  Principal  Interest  Of Transfer 
Rejection 
Period  Date  Balance  Balance   
Yes/No 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
 
  Line 1:Requesting/Transferring Entity Official:      (Signature required)  Total Dollar Amount Requested for Transfer:  $____________ 
    Title:_____________________ 
    Telephone:_________________  Date Requested:_________ 
 
  Line 2: Acknowledgement of Receipt of      (Signature required)__(Date received)___ 
  Request Form 
 
 
  Line 3: Approving/Receiving Entity Official:      (Signature required)       Total Dollar Amount Approved for Transfer:   $____________ 
    Title:_____________________ 
    Telephone:_________________  Date Approved:_________ 
       
  Line 4: Acknowledgement of Receipt of       (Signature required)___(Date received)___ 
  Approved Form 
     
Exhibit 17 - Attachment II 
 
TRANSFER REQUEST & NOTIFICATION OF ACCEPTANCE FORM 
 
CARRIER ACCOUNTS RECEIVABLE 
 
                   
Provider  Provider  Claim Number  Claim Paid  Overpayment  Original  Outstanding  Outstanding  Acceptance  Reason for 
Name  Number  Date  Determination  Amount  Principal  Interest  Of Transfer  Rejection 
Date  Balance  Balance   
Yes/No 
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
 
  Line 1:Requesting/Transferring Entity Official:      (Signature required)  Total Dollar Amount Requested for Transfer:  $____________ 
    Title:_____________________ 
    Telephone:_________________  Date Requested:_________ 
 
  Line 2: Acknowledgement of Receipt of      (Signature required)__(Date received)___ 
  Request Form 
 
 
  Line 3: Approving/Receiving Entity Official:      (Signature required)       Total Dollar Amount Approved for Transfer:   $____________ 
    Title:_____________________ 
    Telephone:_________________  Date Approved:_________ 
       
  Line 4: Acknowledgement of Receipt of       (Signature required)___(Date received)___ 
  Approved Form  400.18 - Exhibit 18 - Collection Reconciliation/Acknowledgement Form - (Rev. 5, 08-30-
02) 
A1-1960.18, B1-4960.11 
 
Collection Reconciliation/Acknowledgement Form 
 
There are instances where one reporting entity has received and deposited cash/check/offset/electronic funds 
transfers (EFTs) for a receivable that is being reported by another entity. In this situation, accounts 
receivable cases will not be transferred to the location where the deposit of the money is made. To ensure 
proper matching and application of the collection of monies to the outstanding receivable, the "Collection 
Reconciliation/Acknowledgement" form must be completed. This form must be completed by the entity 
(Medicare contractor, CMS RO or CO) receiving a collection for an accounts receivable that is currently 
being reported on the financial reports (Forms CMS-H751A/B-CMS-R751A/B) of another entity. 
 
Medicare contractors are required to ensure that internal controls are in place over the cash/check receipts 
process to ensure adequate accounting, recording and custody of Medicare assets. 
 
Treatment of Collections Made by a Medicare Contractor for an Account Receivable at Another Medicare 
Contractor Location (applies to Non-Medicare Secondary Payer (MSP) accounts receivables and MSP 
accounts receivables) 
 
If a Medicare contractor collects a debt on behalf of another Medicare contractor, whether the receipt was 
solicited or unsolicited, then the collection must be forwarded to the Medicare contractor that has the 
accounts receivable. In these instances, the Medicare contractor receiving the collection would deposit the 
collection and re-issue that amount to the Medicare contractor that is reporting the accounts receivable. The 
Medicare contractor reissuing the check should ensure that proper segregation of duties exist over the check 
re-issuance (e.g., that the preparer is different from the check authorizer).  
 
The re-issued check must be made payable to "Medicare." In addition, the check must be accompanied by a 
completed Collection Reconciliation/Acknowledgement Form (see MIM 1960.18 and MCM 4960.11), 
any correspondence received, and a copy of the original check including the postmark date. The CFO for 
Medicare Operations for the Medicare contractor reporting the accounts receivable should be contacted and 
informed of the pending check. A listing of CFO contacts has been issued to each Medicare contractor CFO. 
The deposit and re-issuance of the collection will only affect the CMS-H750A/B of the Medicare contractor 
that received the collection. The Collection Reconciliation/Acknowledgement Form will allow for tracking 
of the payment.  
 
Upon receipt of the check and Collection Reconciliation/Acknowledgement Form, the Medicare contractor 
reporting the receivable will apply its normal cash receipt procedures. However, a signed copy of the 
Collection Reconciliation/Acknowledgement Form must be returned to the Medicare contractor that sent the 
collection. 
 
MSP additional information: Medicare contractors should follow the deposit and re-issue process whenever 
another Medicare contractor has the account receivable or another Medicare contractor is or should be the 
lead Medicare contractor. If there is no account receivable established but Medicare contractor X is the lead 
and Medicare contractor Y receives payment, Medicare contractor Y should follow the deposit/re-issue 
process. If there is no lead established and Medicare contractor Y receives payment, Medicare contractor Y 
should do an electronic referral via the Electronic Correspondence Referral System (ECRS) and follow the 
deposit/re-issue process if another Medicare contractor is assigned lead. This rule should be followed even if 
the non-lead Medicare contractor has an interest and/or has paid some of the claims at issue. 
 
Treatment of Collections Made by a Medicare Contractor for an Account Receivable at a CMS Regional 
Office Location (applies to Non-MSP accounts receivables and MSP accounts receivables.) 
  If a Medicare contractor collects a debt on behalf of a CMS RO location, whether the receipt was solicited or 
unsolicited, then the account receivable balance must be transferred to the Medicare contractor that received 
the collection. In these instances, the Medicare contractor receiving the collection would initiate the process 
by completing the Collection Reconciliation/Acknowledgement Form and sending it to the CMS RO who is 
reporting the receivable to notify them of the collection. The Medicare contractor that received the collection 
would deposit any cash or checks received into unapplied receipts, which would be reported as a liability 
until the transfer is complete. 
 
In turn, the CMS RO reporting the receivable will complete the Transfer Request and Notification of 
Acceptance Form (TRNA) described in 1960.17 of the MIM and 4960.10 of the MCM. (The use of the 
TRNA is also discussed in question number 68.) Once both parties sign the TRNA, the transfer is considered 
complete and the collection would then be applied to the account receivable. The CMS RO transferring the 
receivable would record the account receivable on Line 5c, Transfer Out to other Medicare Contractors. The 
Medicare contractor receiving the account receivable would record it on Line 5d/5f, Transfers In from other 
CMS Locations POR/PSOR or Not on POR/PSOR and the applicable collection on either Line 4a, 
Cash/Check Collections or Line 4b, Offset Collections. 
 
Only in the instance where a collection is made by offset for an account receivable at a CMS RO location 
can notification of the offset be e-mailed. The e-mail must be retained for audit trail purposes. The e-mail 
notification must be followed-up with the actual Collection Reconciliation/Acknowledgement Form and the 
Transfer Request and Notification of Acceptance form with all the appropriate signatures. Furthermore, 
since offsets may only be identified after being applied, the offset transaction must be moved manually on 
the Forms CMS-751A/B (i.e., the full amount of the accounts receivable prior to the offset must be shown as 
a transfer in and the amount of the offset must be captured on Line 4b, Offset Collection.) To assist in 
accounting for these offset transactions ONLY, Medicare contractors can prepare the Collection 
Reconciliation/Acknowledgement Form(s) on a monthly basis. 
 
Treatment of Collections Made by A Medicare Contractor for an Account Receivable at CO 
Non-MSP: If Medicare contractors receive collections on debt that is at the Debt Collection Center (DCC), 
and that debt is being reported by CO, the Medicare contractor must notify the CO by submitting the 
Collection Reconciliation/Acknowledgement form (refer to 1960.18 of the MIM and 4960.11 of the 
MCM). In addition, the receipt should be deposited into unapplied receipts until the actual account 
receivable is transferred back to the Medicare contractor. 
 
Once CO receives the Collection Reconciliation/Acknowledgement form, it will perform the necessary steps 
to update the collection information in the Debt Collection System (DCS) and the Provider Overpayment 
Reporting (POR) system or the Physician/Supplier Overpayment Reporting (PSOR) system. CO will change 
the accounts receivable location code in DCS from "H," which means CO is reporting the account receivable 
to "C," which means the Medicare contractor is reporting the account receivable. CO will also update the 
POR/PSOR with the appropriate location code of "IDC," which means the fiscal intermediary at debt 
collection or "CDC," which means the carrier at debt collection (i.e., the debt has been forwarded to debt 
collection but the debt is still on the books of the fiscal intermediary or carrier). If a balance is remaining 
after posting the collection, the debt will remain at DCC for cross servicing/TOP. 
 
To allow the Medicare contractors to properly apply the collection in their internal systems, CO will then 
transfer the receivable back to the Medicare contractor using the TRNA (refer to 1960.17 of the MIM and 
4960.10 of the MCM). Upon CO receiving the signed TRNA from the Medicare contractor, CO will cease 
to report the receivable on its Form CMS-R751A/B. Once the TRNA has been signed and the receivable has 
been transferred, the Medicare contractor will record the transfer in of the receivable on Line 5d, Transfers 
In from other CMS Locations, POR/PSOR, or Line 5f, Transfers In from other CMS Locations, Not 
POR/PSOR. The receipt would then be applied to the account receivable and the collection would be 
recorded on Line 4a, Cash/Check Collections or Line 4b, Offset Collection on the appropriate Form CMS-
H751A/B. 
  MSP: If Medicare contractor X has an account receivable other than a debt which has been referred to the 
Department of Health and Human Services (DHHS) Program Support Center (PSC) under the DCIA and the 
CO/RO receives payment, the Medicare contractor should use Line 4c, Collections Deposited at Another 
Location and footnote in the comments section of the Form CMS-M751A/B that the CO/RO received the 
payment. An example of this type of receipt would be coordination of benefits contractor misrouted checks. 
 
Usage of the Collection Reconciliation/Acknowledgement Form 
 
In the instance where a Medicare contractor, RO or CO receives a collection (whether cash, checks, offset or 
EFT) the entity receiving the collection must complete lines 1 through 10 of the form and attach all 
documentation showing the collection and the re-issued check, if applicable. In the instance where a RO 
receives cash/checks and does not maintain a Medicare bank account to deposit the funds received, the RO 
must complete lines 1 through 10 of the form and attach the cash/check. This form should be forwarded to 
the reporting entity no later than (15) fifteen days before the end of the quarter. The entity receiving the form 
and the check must sign the form on line 11 and forward a copy of the form to the official who signed line 
10, no later than (15) fifteen days after receipt of the form. This will acknowledge the receipt of the form 
and the check. 
 
Collection Reconciliation/Acknowledgement Form 
 
1.  Location of A/R_________________________(i.e., Medicare contractor, RO, or CO) 
 
2.  Location of the Collection _________________(i.e., Medicare contractor, RO, or CO. If RO 
Collection, indicate such even though actual deposit is made at Central Office) 
 
3.  Region_________ Medicare contractor Name and Number_________________________ 
 
4.  Non-MSP Accounts Receivable 
 
Provider/Physician/Supplier) Number_______________ 
Provider/Physician/Supplier Name__________________________________ 
Provider/Physician/Supplier Name__________________________________ 
Overpayment Determination Date__________________ 
Claim Number_________________ 
Cost Report Year ___________________ 
MSP Accounts Receivable  
Debtor Name ______________________________________ 
HIC # / Report ID___________________________________ 
Determination Date__________________ 
Beneficiary Name ___________________________________ 
 
5.  Was debt in CNC status prior to this collection:__________________(Yes/No) 
 
6.  Date of Collection (Postmark or Government Collection date)______________ 
 
7.  Type of Collection ____________________ (i.e., cash/check or offset) 
 
Check Number or Government Collection Number _____________________________ 
Amount of Collection $__________________ 
Amount Applied to Principal $__________________ 
Amount Applied to Interest $__________________ 
 
8.  Collection Reported in quarter ending__________________ 
 
9.  A/R Reported in quarter ending_______________________   
_____________________________  _____________________________ 
10. Signature of Official at Location  11. Signature of Official at Location Where 
Where Collection is Reported  Reduction of A/R is Recorded 
Phone #________________________  Phone #________________________ 
Fax #__________________________  Fax #__________________________ 
 
400.20 - Exhibit 20 - Procedures for Reporting Currently Not Collectible (CNC) Debt 
(Rev. 18, 05-02-03) 
(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. 
 
A1-1960.19, A1-1960.20, B1-4960.12, B1-4960.13 
 
As part of its effort to improve financial reporting, CMS has implemented the category of currently not 
collectible (CNC) for delinquent debt that is unlikely to be collected within a reasonable time frame. The 
CMS' CNC policy provides that CNC debt will not be recognized as an active accounts receivable (A/R) for 
financial statement reporting purposes because to do so would overstate the true economic value of the 
assets on the financial statements. While CNC debts are not A/R reported on the financial statements, 
Medicare contractors must continue appropriate recovery efforts for these debts until they are recommended 
and approved by CMS for "write-off - closed" as such, these debts must remain in their internal system for 
interest accrual and offset. The CNC process permits and requires the use of tools of the Debt Collection 
Improvement Act (DCIA) of 1996. By using these tools delinquent debt will be worked until the end of its 
statutory collection life cycle. 
 
Criteria for Selection 
 
All A/R, whether it is classified as Medicare Secondary Payer (MSP) or Non-MSP, that are 180 days 
delinquent must be recommended for CNC reclassification. The A/R must be 180 days delinquent (i.e., 240 
days old if the repayment time frame is 60 days or 210 days old if the repayment time frame is 30 days) as 
of the last day of the quarter prior to the quarter in which the CNC recommendation is submitted for RO 
approval. 
 
All MSP A/R means all demanded debt, without regard to whether the debt is Group Health Plan (GHP) 
based or liability/no-fault/workers' compensation based and without regard to the type of debtor (employer, 
insurer, beneficiary, provider/supplier, etc.). Where the MSP recovery demand letter stated that the debt was 
due and payable 30 days from the date of the demand, the debt is delinquent on day 31 if it has not been paid 
in full or there is no valid documented defense for the unpaid amount. Where the MSP recovery demand 
letter stated that the debt was due and payable 60 days from the date of the demand, the debt is delinquent on 
day 61 if it has not been paid in full or there is no valid documented defense for the unpaid amount. 
 
All Non-MSP A/R means all demanded debt without regard to whether the debt is 
provider/physician/supplier or beneficiary-based. This includes debts that are not normally reported 
(separately or in summary entries) in the POR/PSOR systems, as long as they meet the CNC criteria. These 
debts should be listed separately, must be identified as not on the POR/PSOR, and the type of debt must be 
listed on the CNC request form in the comments section. Debts that are excluded from this definition are as 
follows: 
    Debts with a principal balance of less than $25. Although these debts may satisfy the CNC criteria, 
Medicare contractors should recommend the termination of collection activity and request approval 
by the Regional Office (RO) to write this debt off as "write-off closed" in accordance with Title 42 
of the Code of Federal Regulations, Section 405.376(e)(3), since the cost of further collection action 
is likely to exceed any recovery. 
 
  Debts with a collection within the last 180 days. Hence, the debt must be 180 days delinquent 
without any collection/recoupment activity within the last 180 day time period for CNC 
reclassification. 
 
Additionally, all accounts receivable that meet the CNC criteria will be reclassified as CNC without regard 
to whether or not the debt is in bankruptcy, under fraud and abuse investigation, has an appeal pending at 
any level, is in litigation/negotiation, or is for a deceased debtor. However, if a Medicare contractor believes 
that a particular A/R meets the criteria for both "write-off - closed" and CNC, the A/R should be 
recommended for "write-off - closed." Medicare contractors may not recommend CNC for less than the full 
amount of an outstanding debt. 
 
NOTE:  For GHP-based MSP A/R where the demand was issued to the employer, insurer, or third party 
administrator, GHP, or other plan sponsor, the debt includes all of the claims in a demand to a debtor for a 
particular beneficiary. For GHP Data Match (DM) recoveries, this would be all of the claims associated with 
a particular Mistaken Payment and Recovery Tracking System (MPaRTS) Report ID although a single cover 
letter might have been issued for multiple beneficiaries' Medicare reimbursed claims. For duplicate primary 
payment recovery demands to a provider/supplier (including physician), the debt includes all claims in the 
recovery demand regardless of the number of beneficiaries involved. For liability, no-fault, or workers' 
compensation, the debt includes all claims in the recovery demand. 
 
A debt's eligibility for DCIA referral to a Department of the Treasury designated Debt Collection Center 
(DCC) for further collection efforts, including the Treasury Offset Program (TOP) has no bearing on or 
relationship to whether or not the debt should be reclassified as CNC. As such, debts referred to the DCC 
should also be recommended for CNC reclassification as long as it meets the CNC criteria. 
 
The Department of the Treasury and the Office of Management and Budget require that Agencies submit 
reports to them on financial management and performance data so that debt collection programs and policies 
can be evaluated. Thus, CMS is requiring its Medicare contractors to report and monitor CNC debt on a 
quarterly basis. 
 
Quarterly Review of Debt for CNC Reclassification & Approval 
 
Medicare contractors must continuously review all debt and quarterly request approval to reclassify debts as 
CNC. Recommendations for the approval of MSP and Non-MSP CNC should be sent to your RO MSP 
Coordinator or the RO Debt Collection staff respectively. These reports should be sent by hard copy 
accompanied with a disk no later than the first day of the second month of each quarter (i.e., November 1, 
February 1, May 1, and August 1). The CFO of Medicare Operations must sign the hard copy and include a 
preprinted address label with the hard copy for the return of the approved CNC recommendations. Medicare 
contractors are required to submit negative reports if there are no debts eligible for CNC for a particular 
quarter. 
 
ROs are responsible for approval or denial of all recommendations for CNC based upon the criteria set forth 
in these instructions. RO approval will be by the Assistant Regional Administrator (ARA) for Financial 
Management. ROs will complete their review of the Medicare contractors' recommended CNC and return 
their approval or denial of such reclassifications by the first day of the last month of each quarter (i.e., 
December 1, March 1, June 1, and September 1). ROs may return a hard copy via fax or a soft copy via disk 
annotated to show approval or denial by the RO ARA for Financial Management, in order to meet the 
required time frame for approval, but this must be followed by a hard copy that was signed and dated by the 
ARA for Financial Management. ROs will also send copies of the signed RO approval or denial letter only,  each quarter to CMS CO to the attention of the Director, Division of Financial Oversight, Office of 
Financial Management (for both MSP and Non-MSP approvals). The ROs must maintain the detailed 
reports that support the amounts approved/disapproved. 
 
The CNC action should not be taken nor should any changes be made to the A/R on any internal systems 
(Medicare contractor systems or other systems which Medicare contractors have responsibility for updating) 
for CNC until the recommendation for CNC has been processed by CMS, approved in writing, and returned 
to the Medicare contractor. The listing of approved CNC will be returned to the contractors by the ROs. 
Receipt of this approval authorizes the Medicare contractor to reclassify the A/R, and update the A/R and 
associated case in all appropriate systems. When the A/R is reclassified as CNC, the associated case file 
must be annotated to show that a particular A/R was reclassified as CNC and the date/quarter of the action. 
Reclassification as CNC does not close the associated case. 
 
If a full or partial collection for the A/R is received between request and approval of CNC reclassification, 
then the collection should be applied. The contractor must make the necessary adjustment to the debt to 
reflect the payment and place the remaining amount, if any, in CNC when the RO approval is received. 
However, when the approval is received, the contractor must then notify the RO of the change in the amount 
originally approved for CNC as well as the reason why. If the contractor has this issue with multiple debts 
recommended for CNC, they need to furnish this information to the RO on a debt specific basis, not just on 
an aggregated basis. This must be communicated to the RO contact in writing. In addition, this 
documentation should be maintained for audit/review purposes. 
 
NOTE:  MPaRTS does not need to be updated for Data Match debt when the MSP A/R is reclassified as 
CNC. 
 
The CMS approval of A/R reclassified as CNC must be retained and available upon request (from the Office 
of the Inspector General or any other internal or external review organization) in accordance with retention 
procedures in the Medicare Intermediary and Carrier Manuals. This CMS approval must also be annotated 
by the Medicare contractor to indicate the date/quarter when the A/R was reclassified. 
 
Data Requirements and Format for Recommendations for MSP CNC 
 
MSP A/R recommended for CNC requires the submission of the following information to the Medicare 
contractor's RO MSP coordinator: (see Attachment I for the recommended format) 
 
  Medicare Contractor Name and Number 
 
  Medicare Contractor Mailing Address 
 
  Medicare Contractor Contact Person/Phone/Fax/E-mail 
 
  Type of MSP Debt [GHP or non-GHP (this includes liability, no-fault, and workers' compensation)] 
 
  Beneficiary Medicare beneficiary identifier 
 
  Beneficiary Name 
 
  Name of Debtor or Insurer for GHP-based debts where the current debtor is the 
insurer/employer/third party administrator/GHP/other plan sponsor 
 
  Type of Debtor [A=insurer/employer/third party administrator/GHP/other plan sponsor; 
B=provider/supplier (including physicians); C=beneficiary, D=other (must specify)] 
 
  Date of Initial Recovery Demand Letter to current debtor 
    Delinquency Date 
 
  Original A/R Amount for the current debtor 
 
  Existing A/R Amount (principal and interest listed separately, as well as a total amount for principal 
plus interest; HI/SMI must also be listed and reported separately) 
 
  Date of Last Payment, Collection, Recoupment, Offset, or Adjustment Activity (provide date or 
"none") 
 
  Tax Identification Number (TIN) for debtor. The TIN is the Employer Identification Number (EIN) 
or Social Security Number (SSN) 
 
  DCS Status Code (if applicable). 
 
NOTE:  The debtor is the individual or entity to whom the last recovery demand was issued. Where the 
demand was issued to an individual in their capacity as legal counsel or representative of any type, the 
debtor is the beneficiary, provider/supplier (including physician), or other individual or entity being 
represented. Where recovery is being pursued from the attorney or other representative in their own right, 
the debtor is the attorney or other representative. 
 
The above listed data elements are mandatory for CNC for all MSP A/R established October 1, 2000 or 
later. It is also mandatory for all MSP A/R with a recovery demand date of October 1, 2000, or later, 
regardless of when the MSP A/R was established. For CNC recommendations for MSP A/R established 
prior to October 1, 2000, Medicare contractors may submit recommendations without the following data 
elements if the CNC recommendation certifies that these data elements are not readily available: Beneficiary 
name and Medicare beneficiary identifier where the beneficiary is not the debtor; Insurer name where the 
insurer is not the debtor; and Type of debtor. 
 
If a Medicare contractor has bulk MSP A/R on the GTE system for older Data Match and non-Data Match 
GHP debt, the contractor - for these MSP A/R only - must: 1) Identify the A/R as a bulk receivable on the 
GTE system, 2) Identify the insurer, 3) Identify the date of the demand, and 4) Identify the associated dollar 
amounts for principal and interest. Any contractor who created bulk receivables for GHP-based MSP debt 
using any system other than GTE must contact their RO for assistance. The RO will, in turn, discuss the 
issue with CO. 
 
Data Requirements and Format for Recommendations for Non-MSP CNC 
 
Non-MSP A/R recommended for CNC require the submission of the following information to the Medicare 
contractor's RO Debt Collection contact: (see Attachments II & III for the recommended format) 
 
  Medicare Contractor Name and Number 
 
  Medicare Contractor Mailing Address 
 
  Medicare Contractor Contact Person/Phone/Fax 
 
  Provider/Physician/Supplier/Beneficiary Name and Number (if applicable) 
 
  Claim Number (PSOR) 
 
  Claim Paid Date (PSOR) or Cost Report Date (POR) 
 
  Overpayment Determination Date 
    POR/PSOR Status Code 
 
  Overpayment Type 
 
  Original Amount of Debt 
 
  Balance Outstanding (principal and accrued interest listed separately) 
 
  Date Interest Accrued Through 
 
  Date of Last Payment, Offset or Recoupment 
 
  POR/PSOR Balance (principal and interest listed separately for POR; for PSOR, principal balance 
only) - For Part A, indicate POR balance if Contractor submits request for Part B of A separately 
 
  POR/PSOR Location Code 
 
  DCS Status Code (if applicable) 
 
  For FIs Only - Part B of A debt can be submitted on the same listing (principal and interest) 
 
Each listing must contain a written certification that all of the required criteria for CNC are met. The CFO of 
Medicare Operations must sign CNC recommendations. The CFO's signature constitutes his/her certification 
to all information/statements contained in the recommendation. 
 
Financial Reporting and Reconciliation of CNC Debts 
 
Debts that have received approval for CNC reclassification must be reported in the following manner: 
 
  On Form CMS-751A/B or CMS-M751A/B the amount reclassified as CNC, including principal and 
interest, will be recorded on Line 6c, Transfers Out to CNC with a corresponding entry on Line 2, 
New CNC Debt on Form CMS-C751A/B or CMS-MC751A/B. This will reduce the ending balance 
reflected on the applicable form. 
 
  Debts that are reclassified as CNC may still be collected. If a collection occurs, the following actions 
should take place: (1) On Form CMS-C751A/B or CMS-MC751A/B an adjustment for the amount of 
the collection should be recorded on Line 4a, Reclassified as Active A/R Due to Collection of Cash 
or Line 4b, Reclassified as Active A/R Due to Collection by Offset; (2) The amount of the collection 
should also be included in Section C - Collection Information of Form CMS-C751A/B or CMS-
MC751A/B; and (3) The amount of the collection should be simultaneously recorded on Line 6b, 
Transfers in from CNC and Line 4a, Cash/Check Collections or Line 4b, Offset Collections of Form 
CMS-751A/B or CMS-M751A/B. As such, if a collection takes place, only the collection would be 
reclassified with the collection being applied against interest first, then principal. If the collection 
does not satisfy the entire debt, the remaining balance of that debt would remain in CNC. 
 
Medicare contractors must continue to accrue interest for debt that has been reclassified as CNC. 
Additionally, CMS recognizes that for those systems where interest is updated automatically, the interest 
submitted with a recommendation for CNC may differ from the interest shown in the Medicare contractor's 
system at the time the Medicare contractor receives approval for CNC. The CMS approval of the principal 
and interest recommended for CNC is sufficient support for the subsequent reclassification, including any 
increase in the interest, as long as the principal remains the same. Any additional interest that accrues prior 
to CNC reclassification would be reported on Form CMS-751A/B or CMS-M751A/B on Line 3, Interest 
Earned. Then the debt would be reclassified to the appropriate form. 
  Medicare contractor systems must be able to maintain transaction level detail of debt that has been 
reclassified as CNC to enable future collection activities and to maintain a proper audit trail. 
 
Regional Offices will ensure that amounts approved as CNC are properly reported on contractor Forms 
CMS-751A/B or CMS-M751A/B and CMS-C751A/B or CMS-MC751A/B. 
 
Systems Update - Non-MSP Only 
 
Medicare Contractor Internal Systems and POR/PSOR System: 
 
Contractors are responsible for the timely update of CNC status in the POR/ PSOR systems and internal 
systems. A CNC date field has been added in the POR/PSOR and additional status codes have been 
developed. The date of CNC approval (i.e., the date of the cover letter signed by the ARA) must be entered 
in the CNC date field. The update must be performed within ten calendar days of receiving the CNC 
approval. Do not change the location code of the debt. Regional Offices will monitor the POR/PSOR 
systems to ensure contractor compliance. 
 
Additional Status Codes for POR/PSOR: 
 
POR Codes  PSOR Codes  Code Description 
01  1  CNC 
02  2  Write-off Closed (disabled effective 2/6/02) 
03  3  CNC - DCIA Letter Sent 
04  4  Reactivate - Bankruptcy (will no longer be used) 
05  5  Reactivate - Payment Received 
06  6  Reactivate - Appeal/Litigation/Fraud & Abuse Investigation (will no 
longer be used) 
07  7  Reactivate - Compromise 
08  8  Reactivate - Extended Repayment Agreement 
09  9  CNC Debt - Written-off Closed 
00  0  Reactivate - Other 
 
NOTE:  For debts that are at the DCC location and reclassified to CNC, the "3" (POR) or "03" (PSOR) 
status code would be used. Furthermore, the "9" must be accompanied by a valid closed date. Cases with a 
status code of "09" (POR) or "9" (PSOR) and a valid closed date will be rolled to the history file at the end 
of the quarter. In addition to updating the POR/PSOR with the appropriate status codes for the reactivation, 
the CNC date previously inputted should be removed. Updating the CNC Date field in the PSOR requires 
the user to enter zeroes in the CNC Date field and pressing the enter key. 
 
Debt Collection System (DCS) 
 
The CMS' CO Division of Financial Reporting and Debt Referral staff will continue to update the Debt 
Collection System (DCS) with approved CNC status for debts that have been referred for Cross 
Servicing/TOP. 
 
Additional Considerations for MSP A/R 
 
These instructions only apply to established MSP A/R. They may not be used to close MSP liability/no-
fault/workers' compensation leads where no settlement, judgment or award exists and no recovery demand 
has been issued. 
  Some Medicare contractors may still have old MSP-based provider/supplier (including physician) debt or 
MSP-based beneficiary debt which has not been reported on their Form CMS-M751A/B and which has been 
referred to the RO under non-MSP rules or otherwise treated as a non-MSP receivable. Old MSP-based debt 
that has been treated as non-MSP debt (that is tracked and processed under non-MSP rules) should be 
treated as non-MSP debt for CNC purposes as well. 
 
Medicare contractors may only recommend CNC for a MSP A/R that is being reported as part of their 
ending MSP A/R balance. MSP A/R that have been transferred to the ROs for referral to other agencies or 
entities such as, the Department of Justice or Office of General Counsel will be addressed by the ROs. CO 
will address MSP A/R with CO locations. MSP A/R that have been referred to another location, without 
transfer, remain the responsibility of the Medicare contractor. 
 
Previously some Medicare contractors processed/tracked MSP-based provider/supplier (including physician) 
A/R and/or MSP-based beneficiary A/R as non-MSP A/R and did not include such A/R on their Form CMS-
M751A/B report. Medicare contractors may no longer do this for new MSP A/R. Any pre-existing MSP-
based provider/supplier (including physician) A/R and/or MSP-based beneficiary A/R that are not reflected 
in the Medicare contractor's Form CMS-M751A/B report may not be recommended for MSP CNC. Pre-
existing MSP-based provider/supplier (including physician) A/R and/or MSP- based beneficiary A/R that 
have been tracked/processed, or otherwise treated as non-MSP debt should follow the rules for non-MP 
CNC  
Exhibit 20 - Attachment I 
 
MSP Accounts Receivable: Contractor Recommendation for Reclassification as CNC 
 
Medicare Contractor Name and Number: 
Medicare Contractor Contact Person/Phone/Fax/E-mail Address: 
Medicare Contractor Mailing Address: 
Part A-HI, or Part B-SMI - as applicable (show which) 
Intermediaries report Part A and/or Part B 
Carriers report Part B only 
 
Type of MSP  Bene.  Bene.  Debtor  Debtor Type  Date of  Original  Current  Current  Current  Current  Total  Date of Last  TIN of 
Debt  Medicare  Name  Name  Initial  AR   Principal  Interest  Principal  Interest   Principal  Payment,   Current 
  beneficiary    Demand  Amount  Balance  Balance   Balance  Balance  and   Offset, Recoup.  Debtor 
identifier      (HI)  (HI)  (SMI)  (SMI)  Interest  Or Adjustment   
             
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
 
(Provide totals for each column if applicable)  
 
CFO of Medicare Operations:                                        (signature required) 
(Signature constitutes certification that all CMS specified criteria for CNC reclassification are met.) 
 
Associate Regional Administrator/Division of Financial Management: (signature required)    ___ Concur   ___NonConcur   
 
Date of Referral to RO : ___________ 
Date of RO decision: ___________ 
Date/quarter when approved MSP A/R were reclassified as CNC: ___________  Attachment II 
 
This is an exact duplicate of Attachment 1, "MSP Accounts Receivable: Contractor 
Recommendation for Reclassification as CNC" for Part B Intermediary Claim Activity.  
The heading at the top of the spreadsheet is "Part B of A" - SMI, instead of "Part A - HI."  
Intermediaries report their SMI data on this report. 
 
400.21 - Exhibit 21 - CMS Policy for Recognizing Accounts Receivable - 
(Rev. 5, 08-30-02) 
A1-1960.21, B1-4960.21 
 
CMS Policy for Recognizing Accounts Receivable 
 
Overview 
 
The majority of the Medicare accounts receivable balances reported by CMS in its 
financial statements are comprised of overpayments made to providers, physicians, 
suppliers, beneficiaries, insurers, employers and other entities. The primary responsibility 
for identifying, recording, collecting, and reporting overpayments lies with CMS's 
Medicare contractors. CMS defines an "overpayment" as Medicare funds that a provider, 
physician/supplier, beneficiary, insurer, employer, or other entity has received in excess 
of amounts due and payable under the Medicare statute and regulations. Once a 
determination of an overpayment has been made, the amount so determined is a debt that 
is owed to the Medicare program. For financial reporting purposes, this overpayment or 
debt must be recognized as an accounts receivable and reported as an asset in CMS's 
financial statements. 
 
CMS has adopted the financial reporting definition for the recognition of an accounts 
receivable set forth by the Federal Accounting Standards Advisory Board (FASAB). The 
FASAB recommends generally accepted accounting standards and principles for the 
Federal Government. The FASAB sets these standards and principles so that Federal 
agencies' financial reports include understandable, relevant, and reliable information 
about the financial position, activities, and results of operations of the United States 
government and its component units.  
 
According to the FASAB's Statement on Federal Financial Accounting Standard Number 
1 (SFFAS No.1), Accounting for Selected Assets and Liabilities, 
 
"Accounts receivables are amounts that an entity claims for payment 
from others. They arise from claims to cash or other assets." 
Additionally, the FASAB recommends, "A receivable should be 
recognized when a Federal entity establishes a claim to cash or other 
assets against other entities, either based on legal provisions, such as a 
payment due date (e.g., taxes not received by the date they are due), or 
goods or services provided. If the exact amount is unknown, a 
reasonable estimate should be made."   
For financial reporting purposes, recognition means the process of formally recording an 
item into the financial statements of an entity as an asset, liability, revenue, expense, or 
the like. In the case of Medicare contractors, recognition would equate to recording the 
accounts receivable on Form CMS-H750A/B and Form CMS-H751A/B Contractor 
Financial Reports. 
 
Recognition Policy 
 
CMS and its Medicare contractors will recognize and report an accounts receivable as of 
the date a demand letter is sent to the debtor. Specifically, contractors will recognize and 
record an accounts receivable (Non-Medicare Secondary Payer (MSP) and MSP 
overpayments) as of the date of the demand letter on Line 2a, New Receivables of Form 
CMS-H751A/B Status of Accounts Receivable Report. The act of sending out the 
demand letter is the event that triggers the recognition of an accounts receivable. The 
purpose of the demand letter is to notify the debtor of the existence of the overpayment, 
and to request payment. Chapter 4, Debt Collection, 10 and 130 outline the language 
and information that, at a minimum, a demand letter must contain. A demand letter must 
contain the name and address of the debtor, the amount of the overpayment, terms of how 
interest will be assessed, date when repayment is due, and the debtor's rights to appeal. 
All these items are consistent with the definition recommended by the FASAB as 
outlined above. 
 
It is important for Medicare contractors to ensure that they retain copies of a demand 
letter(s) sent. The demand letter provides documentation or evidence of the actual debt 
and recovery efforts taken. It must be kept in each case file with other associated case 
documents or correspondence if the case is referred to the Department of Justice; referred 
for debt cross-servicing; requested by CMS, Office of Inspector General (OIG) or 
General Accounting Office (GAO) during audits/reviews. This information is necessary 
and needed to support the debt. 
 
Unless otherwise specifically noted, this policy is applicable to both non-MSP and MSP 
overpayments. The following are specific circumstances where application of this policy 
will not apply, i.e., when an accounts receivable would be recognized even though a 
demand letter has not been issued or, vice versa, where sending a demand letter would 
not necessarily require the recognition of an accounts receivable. 
 
  Accounts Receivables Due to Unfiled Cost Reports; and  
 
  Consent Settlement Agreements. 
 
These two circumstances are not all inclusive. If there is a specific situation that is not 
described above, Medicare contractors should consult CMS for further guidance. 
 
Accounts Receivable Due to Unfiled Cost Reports 
  Through analysis of Federal financial accounting standards and regulations, CMS 
believes that recognition of a receivable prior to the filing of a cost report significantly 
overstates net assets and ultimately net position. Furthermore, CMS believes that current 
accounting procedures for recognizing accounts receivables due to a provider's failure to 
file a cost report timely does not adhere to the accounting principles articulated in 
Statement of Federal Financial Accounting Standards Number (SFFAS No.) 1 - 
Accounting for Selected Assets and Liabilities, SFFAS No. 5 - Accounting for Liabilities 
of the Federal Government, and SFFAS No. 7 - Nonexchange Revenue (Measurement & 
Recognition), as well as Generally Accepted Accounting Principles (GAAP) of 
conservatism and matching. Based on this analysis, the failure to file a cost report does 
not complete the earnings process, and accordingly, no accounting event has occurred. As 
such, the recognition of a receivable prior to the completion of the earnings process 
(receipt or filing of a cost report) is poor matching. In addition, SFFAS Nos. 5 and 7 
states that liabilities and nonexchange revenue should only be recognized when a past 
event or exchange transaction has occurred, use of resources (inflow or outflow) are 
probable and can be reasonably estimated or measured. Without the actual submission of 
the cost report, CMS cannot reasonably estimate the amount of the receivable, as required 
by SFFAS No. 1. 
 
Therefore, unfiled cost report receivables will no longer be reported on the Form CMS-
H;750 Contractor Financial Report and Form CMS-H751, Status of Accounts Receivable 
Report. CMS's current financial reporting instructions require Medicare fiscal 
intermediaries to place providers who have not filed a timely cost report on 100 percent 
penalty withhold, and recognize and demand a receivable based on the value of all 
interim payments made to the provider in, and subsequent to, the cost reporting period, 
without considering the value of actual services performed during that period. Federal 
debt collection regulations allow CMS to demand repayment of the full amount paid to a 
provider during a cost reporting period if a provider fails to comply with the requirements 
to file a cost report in a timely manner. However, for financial reporting purposes, CMS 
recognizes that the entire amount being demanded does not truly represent funds owed to 
CMS. Since the provider has performed services, the true economic value of the 
receivable demanded is overstated. In fact, CMS may have a liability upon settlement. 
Cost report receivables should not be accrued until related cost reports are received, and 
CMS can support the existence of a receivable through provider agreement, such as filing 
a cost report, filing a cost report without sufficient payment, or a court ruling in favor of 
CMS. 
 
As a result, for financial reporting purposes, CMS is revising its policy for reporting 
unfiled cost reports as an accounts receivable, unless the fiscal intermediary is aware of a 
unique situation where recording an accounts receivable would be appropriate. Fiscal 
intermediaries will continue to reflect an overpayment on the Provider Overpayment 
Reporting (POR) system based on the value of all interim payments made to the provider 
in, and subsequent to, the cost reporting period. 
 
However, effective for the March 31, 2001 reporting period, accounts receivable for 
unfiled cost reports will no longer be reported on Form CMS-H750 and Form CMS- H751. CMS will continue to monitor and manage the status of unfiled cost reports 
through the POR system, without overstating accounts receivable on the financial 
statements. All other processes related to unfiled cost reports remain unchanged. Fiscal 
intermediaries must continue to: (1) Place the providers on 100 percent penalty withhold, 
(2) Demand the submission of delinquent cost reports from providers based on current 
debt collection regulations, and (3) Refer the debt in accordance with the requirements of 
the Debt Collection Improvement Act of 1996. 
 
Fiscal intermediaries must ensure that Line 7, Ending Balance, of Form CMS-H751 does 
not include any receivables due to unfiled cost reports. If accounts receivables due to 
unfiled cost reports were included in the December 31, 2000 Form CMS-H751, these 
receivables must be zeroed out by recording a downward adjustment for these amounts 
on Line 5a, Reclassified/Adjustments, on Form CMS-H751 and provide a specific 
footnote in the remarks section of the report identifying the nature and amount of the 
adjustment. 
 
Consent Settlement Agreements Resulting from Comprehensive Medical Reviews 
(CMRs) 
 
Typically, postpayment reviews of claims are conducted for a specified 
provider/physician/supplier or group in order to evaluate their billing patterns over a 
selected period of time. CMRs are performed to determine whether a suspected 
provider/physician/supplier or groups are providing noncovered or medically unnecessary 
services. A CMR is a thorough analysis of a sample of processed claims and all pertinent 
data (such as medical record, beneficiary payment history, etc.) for selected 
providers/physicians/suppliers for a specified time period. CMRs are usually targeted to 
providers/physicians/suppliers who have demonstrated aberrant billing and/or practice 
patterns. 
 
If a CMR determines that an incorrect amount of money has been paid to the 
provider/physician/supplier, the contractor must assess an overpayment based on 
instructions outlined in the contractor manuals. Per Chapter 3, Overpayments, there are 
three different types of overpayments that result from a CMR: Actual overpayment, 
projected overpayment, and limited projected overpayment. The type of sample used 
during a CMR determines how Medicare contractors are to assess and demand money 
back from the provider or physician/supplier who was overpaid. 
 
An actual overpayment is, for the actual claims reviewed, the sum of the payments (based 
on the amount paid to the provider/physician/supplier and Medicare approved amounts) 
made to a provider/physician/supplier for services which were determined to be not 
medically necessary or incorrectly billed. If an actual overpayment is assessed, Medicare 
contractors must send a demand letter for the amount of the actual overpayment and 
recognize an accounts receivable on Line 2a, New Receivables, of Form CMS-H751. 
 
A projected overpayment is defined as the numeric overpayment obtained by projecting 
an overpayment from a statistically valid random sample (SVRS) to all similar claims in  the universe under review. Medicare contractors must notify the provider or 
physician/supplier of the overpayment, and refer the case to the Medicare contractor's 
overpayment staff to demand and collect the overpayment. Medicare contractors must 
send a demand letter for the amount of the projected overpayment and recognize an 
accounts receivable on Line 2a, New Receivables, of Form CMS-H751. 
 
A limited projected overpayment is the numeric overpayment obtained by projecting an 
overpayment from a limited sample or limited SVRS subsample to all similar claims in 
the universe under review. If this type of overpayment is assessed, Medicare contractors 
have three overpayment assessment options. The Medicare contractor can assess an 
actual overpayment; a projected overpayment based on a SVRS by performing an 
expanded CMR; or can offer the provider or physician/supplier a consent settlement 
based on the potential projected overpayment amount. Again, if an actual or project 
overpayment is assessed, Medicare contractors must send a demand letter, and recognize 
an accounts receivable on Line 2a, New Receivables, of Form CMS-H751. 
 
If a consent settlement is offered to the debtor, the consent settlement document must 
carefully explain what rights a debtor waives by accepting the consent settlement. It must 
contain a binding statement that a debtor agrees to waive any rights to appeal the decision 
regarding the potential overpayment determination. If this option is used, the Medicare 
contractors must not recognize an account receivable until a consent settlement is signed 
and agreed to by the debtor and CMS. 
 
400.22 - Exhibit 22 - Accounts Receivable Trending Analysis Procedures 
(Rev. 120, Issued:  04-27-07; Effective:  07-01-07; Implementation:  07-02-07) 
 
The Centers for Medicare & Medicaid Services (CMS) utilizes contractors to manage and 
administer the fee-for-service portion of the Medicare program.  Medicare contractor 
financial reports provide a method of reporting financial activities by the contractors as 
required by the Chief Financial Officers (CFO) Act of 1990.  The Medicare contractors 
are required to maintain accounting records in accordance with federal government 
accounting principles and applicable government laws and regulations and are required to 
use double entry bookkeeping and accrual basis accounting.  The due date for Medicare 
contractors using the Healthcare Intergraded General Ledger Accounting System 
(HIGLAS) Financial Statements, is seven calendar days after the close of the period and 
twenty-one calendar days for Medicare contractors using the Contractor Administrative 
and Financial Management (CAFM) system.  If the date occurs on a holiday or a 
weekend, the report is due the following Federal workday.  These dates are subject to 
change during the accelerated reporting periods.  The major financial reports in HIGLAS 
are the Balance Sheet, the Income Statement, Summary 2 Trial Balance, and the CMS 
Report on Receivables Due From the Public (CMS TROR).  The financial reports in 
CAFM consist of the Statement of Financial Position (Form CMS-750) and Status of 
Accounts Receivable (Form CMS-751).  The system accumulates and reports by fund, as 
there are separate reports for Part A Hospital Insurance (HI) trust fund, Part B 
Supplementary Medical Insurance (SMI) trust fund, and the general fund (Interest).  The 
accounts receivable activity is reported for the fiscal year-to-date for the period of the  report.  These reports include Accounts Receivable (AR) activity for Medicare Secondary 
Payer (MSP) and non Medicare Secondary Payer (non-MSP) accounts. 
 
Accounts receivable represent amounts owed by health care providers, insurers, third 
party administrators, beneficiaries, employers, and other government agencies.  Medicare 
accounts receivable is comprised of various components with the balance derived from 
MSP and non-MSP receivables, as well as miscellaneous amounts owed the program 
from various sources.  The Financial Statements include receivable balances consisting 
of, or are due to cost report settlements, claims accounts receivable, periodic interim 
payments (PIP) and other overpayments.  The detailed activity for these components are 
included in the 751 (CAFM) and TROR.  Also, include on The Financial Statements HI 
and SMI balances consisting of receivables specific to Data Match, non-Data Match, 
liability (including workers compensation (WC), auto, no-fault) and MSP beneficiary 
debts.  The detailed activity for the MSP components is included in the M751 and/or 
CMS TROR. 
 
Medicare contractors must maintain and make available lead schedules and detailed 
documentation to support all amounts reported. 
 
Objective 
 
To ensure that accounts receivable balances reported are reasonable, Medicare 
contractors are required to perform trending procedures.  Trending procedures can be 
used as an important tool to identify potential errors, system weaknesses, or inappropriate 
patterns of accounts receivable accumulation, collections, transfers or write-
offs.  Trending procedures involve comparisons of recorded amounts to expectations 
developed by the Medicare contractors.  To properly apply trending procedures, it is 
necessary to take the following steps: 
 
Compare Current Year Amounts with Comparative Financial Data 
 
In comparing current-period financial results with prior-period financial results, there is 
an implied assumption that the volume of activity in the two periods is comparable.  If 
there has been a substantial change in volume, it is necessary to take this change into 
account and to quantify the change, when making the comparisons.  For example, if a 
contractor's Accounts Receivable balance has increased by 10 percent, it is necessary to 
determine and document the reason for the increase.  The increase may be the result of 
transitions of providers, new legislation, etc. 
 
Understand Identified Variances and Document the Results 
 
Medicare contractors must identify and provide an explanation for variances that meets 
the thresholds outlined in these procedures.  Typically, this will be accomplished 
primarily through inquiry of operations personnel in the Audit and Reimbursement, MSP, 
Medical Review, and other areas that report and track accounts receivable balances.  If an 
explanation does not adequately describe the variance, the Medicare contractors must  perform additional procedures such as review of detail transactions to identify the 
underlying cause(s) of any unusual changes. 
 
The causes for the variances should be quantified.  For example, if the change was 
mainly attributable to a contractor transition, then the total amount of receivables 
transitioned should be identified and included in the Medicare contractors' work papers. 
 
Methodology 
 
Trending & Comparative Analysis for Accounts Receivables 
 
The primary emphasis for performing trend analysis is focusing on the change in the 
ending principal accounts receivable balance.  The ending principal accounts receivable 
balance is comprised of non-MSP and MSP accounts receivables.  For FIs, the non-MSP 
overpayment sections consist of four major components (cost report settlements, PIP, 
claims accounts receivable, and credit balances).  For Carriers, the non-MSP 
overpayment section consists of two main areas: 1) amounts owed from beneficiaries and 
2) amounts owed from physicians/suppliers. 
 
These two areas consist of two major components (claims accounts receivable and credit 
balances).  For both FIs and Carriers, the MSP section consists of three major 
components (Data Match, non-Data Match, and liability (including WC, auto, no-fault)).  
In order to properly identify and understand variances, an analysis must be performed at 
the component level.  Although the instructions specify ending principal accounts 
receivable balance, Medicare contractors must have available an explanation of any 
significant change in the ending interest accounts receivable balance and any other 
sections on the CMS-750/751 and the TROR meeting these thresholds.  The 
explanation should be available for review by the CMS, Office of the Inspector 
General, General Accounting Office and /or other related parties. 
 
Prior to the certification of the CMS-750/751 and/or the CMS TROR, Balance Sheet and 
Income Statement, each Medicare contractor must perform the following steps on a 
quarterly basis.  The CFO for Medicare Operations' certification of these reports is 
indicative that trending procedures have been performed. 
 
HIGLAS Financial Reports 
 
HIGLAS Medicare contractor shall use the following HIGLAS reports to perform the 
quarterly accounts receivable trend analysis. 
 
  CMS TROR Reconciliation Worksheet (HIGLAS I) -The HIGLAS Medicare 
contractor prepared excel spreadsheet. 
  CMS Beginning Balance Report  This report identifies the beginning balances 
by MSP/non-MSP category by fund (See Attachment BBrpt). 
  CMS Transaction Register - This report identifies the new established receivables 
by MSP/non-MSP category by fund (See Attachment TALn2rpt).    CMS Transaction Register Report Line 3  This report is the cumulated accrued 
interest for the reporting period (See Attachment TALn3rpt). 
  CMS Adjustment Register - The Line 3 report is the cumulated adjustments for 
interest.  The Line 5 & 6 report is the cumulated adjustments for principal (See 
Attachments AdjLn3rpt and AdjLn5&6rpt). 
  CMS AR Overpayment Report - This report is receivables balance by MSP/non-
MSP components (See Attachment AROvrrpt). 
  CMS Applied Collection Register  This report identifies the cash receipts by 
MSP/non-MSP category by fund (See Attachment AppCollrpt). 
 
CMS TROR Detail Reconciliation (HIGLAS I) 
 
Step (1) 
Use the CMS TROR(s) to populate the Non-Federal and/or Federal sections 
(Columns K and L) of the HIGLAS I worksheet. 
 
Step (2) 
Use the CMS Beginning Balance Report to populate Line 1 (Beginning FY 
Balance) for HI-Fund 050961 (MSP/Non-MSP) Columns (Columns E and F), 
SMI-Fund 050960 (MSP/Non-MSP) Columns (Columns G and H) and Interest-
Fund 050720 (MSP/Non-MSP) Columns (Columns I and J) of the HIGLAS I 
worksheet (Non-Federal and/or Federal sections). 
 
Step (3) 
Use the CMS Transaction Register to populate Line 2 (New Receivables) for HI-
Fund 050961 (MSP/Non-MSP) Columns and SMI-Fund 050960 (MSP/Non-
MSP) Columns of the HIGLAS I worksheet (Non-Federal and/or Federal 
sections). 
 
Step (4) 
Use the CMS Transaction Register (support Line 3) to populate Line 3a (Accruals 
(+) New Interest Receivables) for the Interest-Fund 050720 (MSP/Non-MSP) 
Columns of the HIGLAS I worksheet (Non-Federal and/or Federal sections) 
 
Step (5) 
Use the CMS Adjustment Register (support Line 3) to populate Line 3b (Accruals 
(+) Interest Adjustments) for Interest-Fund 050720 (MSP/Non-MSP) Columns of 
the HIGLAS I worksheet (Non-Federal and/or Federal sections). 
 
Step (6) 
Use the CMS Applied Collections Register to populate (Line 4, Collections On 
Receivables), Line 4A (At Agency-Cash/Checks-Offsets), for HI-Fund 050961 
(MSP/Non-MSP) Columns, SMI-Fund 050960 (MSP/Non-MSP) Columns and 
Interest-Fund 050720 (MSP/Non-MSP) Columns of the HIGLAS I worksheet 
(Non-Federal and/or Federal sections).   
Step (7) 
Use the CMS Adjustment Register to populate Line 5a (Reclassified/Adjusted 
Amounts) for HI-Fund 050961 (MSP/Non-MSP) Columns, SMI-Fund 050960 
(MSP/Non-MSP) Columns and Interest-Fund (MSP/Non-MSP) Columns of the 
HIGLAS I worksheet (Non-Federal and/or Federal sections). 
 
Step (8) 
Use the CMS Adjustment Register to populate (Line 6, Amounts Written-Off)) 
Line 6A (Currently Not Collectible) and Line 6B (Written-Off and Closed) for 
HI-Fund 050961 (MSP/Non-MSP) Columns, SMI-Fund 050960 (MSP/Non-
MSP) Columns and Interest-Fund 050720 (MSP/Non-MSP) Columns of the 
HIGLAS I worksheet (Non-Federal and/or Federal sections).  Note:  Line 6 is the 
sum of Line 6A plus Line 6B. 
 
Step (9) 
Compare the Line by Line activity of the Total Detail Activity Report (Column 
B) to the Line by Line activity of the Total CMS TROR (Column A).  The Total 
Detail Activity Report is the sum of the HI-Fund Columns, SMI-Fund Columns 
and the Interest-Fund Columns (Columns E through J).  The Total CMS TROR 
Column is the sum of the Non-Federal/Federal CMS TROR (Columns K and L).  
The Medicare contractor must provide an explanation for variances identified in 
Column C, when the total variance (Line 7, Column C) is more then +/- 10 
percent of Line 7, Ending Balance of the CMS TROR (Column A). 
 
Step (10) 
Sum the amounts reported in Step 1 through Step 8 for HI-Fund 050961 
(MSP/Non-MSP) Columns, SMI-Fund 050960 (MSP/Non-MSP) Columns and 
Interest-Fund 050720 (MSP/Non-MSP) Columns of the HIGLAS I worksheet.  
The total of the sum of the Columns shall equal the amount reported on Line 7, 
Ending Balance of the CMS TROR (Column A), Detail Activity Report (Column 
B) and the Summary 2 Trial Balance (HI-Fund 050961, SGL 131002, SMI-Fund 
050960, SGL 131002 and Interest-Fund 050720 SGL 134004). 
 
Step (11) 
Use the CMS AR Overpayment Register to populate the AR Overpayments 
Report section (component breakout) of the HIGLAS I worksheet for HI-Fund 
050961 (MSP/Non-MSP) Columns, SMI-Fund 050960 (MSP/Non-MSP) 
Columns and Interest-Fund 050720 (MSP/Non-MSP) Columns. 
 
NOTE:  HIGLAS Medicare contractors reporting Non-Federal/Federal accounts 
receivable amounts shall repeat Step 1 through Step 11 for both types of debtors.  The 
HIGLAS contractor shall sum the Non-Federal/Federal activity and report the sum of the 
amounts in the appropriate comparative Attachment (Attachments I, I-A, II, II-A, IV, IV-
A, V & V-A. 
  Accounts Receivable Trend Analysis Attachments (CAFM and/or HIGLAS) 
 
Step (1) 
Compare the current quarter Non-MSP overpayments section of Form(s) CMS-
H750 and/or CMS AR Overpayments section of the HIGLAS I worksheet 
Columns F and H (FIs/Carriers) component line items to the same component line 
items in the prior quarter (i.e. 06/30/02 versus 03/31/02) and the current quarter to 
the prior year's quarter (i.e. 06/30/02 versus 06/30/01). Calculate the dollar and 
percentage difference for each component line item. (See Attachments I & I-A for 
the required format.) 
 
NOTE:  For FIs, due to the seasonal nature of the cost report settlements, PIP, etc., 
independent quarter activity in the current year should not be the only analysis compared 
to the preceding quarter. Comparisons should always be performed from current period 
year-to-date activity to prior period year-to-date activity for the same period of time (i.e. 
06/30/02 versus 06/30/01). 
 
Step (2) 
Compare the current quarter MSP section of Form(s) CMS-H750 and/or CMS AR 
Overpayments section of the HIGLAS I worksheet Columns E and G 
(FIs/Carriers) component line items to the same component line items in the prior 
quarter and prior year.  Calculate the dollar and percentage difference for each 
component line item. (See Attachments II & II-A for the required format.) 
 
Step (3) 
Verify that the dollar amount for each component line item is supported by lead 
schedules (detailed documentation) and/or HIGLAS activity reports.  Any errors 
or misstatements identified as a result of this analysis must be corrected prior to 
the submission of Forms CMS-750/751 and/or CMS TROR, Balance Sheet and 
Income Statement. 
 
Step (4) 
The sum of the components for the Non-MSP overpayments sections (See 
Attachments I & I-A) plus the sum of the components for the MSP sections (See 
Attachments II & II-A) must equal the ending balances reported on Line 7, of 
Form(s) CMS-H751A/B and/or detail report activity section of the HIGLAS I 
worksheet Columns E, F, G, and H (FIs/Carriers).  The sum of the components for 
the Non-MSP overpayments sections must equal the ending balances reported on 
Line 7, of Attachments IV and IV-A and/or detail report activity report section of 
the HIGLAS I worksheet Columns F and H for the current and prior quarters. The 
sum of the components for the MSP sections must equal the ending balances 
reported on Line 7, of Form(s) CMS-M751 and/or detail report activity section of 
the HIGLAS I worksheet Columns E and G (FIs/Carriers) (See Attachments V & 
V-A) for the current and prior quarters. 
 
Step (5)  Provide explanations for each component line item where the amount changed 
meets the threshold of +/-15 percent and the amount changed is +/- 5 percent of 
the components ending balance. (See Attachments I, I-A, II & II-A) 
 
Supporting Analysis 
 
Step (1) 
Ensure the current year beginning balance is the same amount as the prior year's 
ending balance and the beginning balance for the prior year's quarter is the same 
as the beginning balance of the final quarterly report for that FY (i.e., 06/30/01 
and 09/30/01). Additionally, for the second through fourth quarter periods, ensure 
that the beginning balances are unchanged from the amount reported as the first 
quarter beginning balances. 
 
Note:  In the first quarter following a contractors transition to HIGLAS the 
beginning balance will not equal the previous quarters beginning balance and/or 
the prior year beginning balance.  The differences are related to the prior year PIP 
accrual and/or transition clean up (e.g. approved write-offs of non-supported 
debts, valid documented defense, etc.).  Medicare contractors shall reconcile the 
CAFM and HIGLAS beginning balances and provide an explanation for identified 
variances. 
 
Step (2) 
Compare the current quarter Form(s) CMS-H/M751 and/or detail report section of 
the HIGLAS I worksheet Columns E, F, G and H line items to the same line items 
in the prior quarter and prior year. Calculate the dollar and percentage difference 
for each line item for Section A of Forms CMS-H/M751. and/or detail report 
section of the HIGLAS I worksheet Columns E, F, G and H (See Attachments IV, 
IV-A, V & V-A) 
 
NOTE:  The Medicare contractors are not required to perform trending procedures or 
provide variance explanations on the line items of Forms CMS-H/M751 and/or detail 
report section of the HIGLAS I worksheet Columns E, F, G, and H. However, the above 
steps should be used to assist the Medicare contractor in providing an explanation for the 
variances identified in Attachments I, I-A, II & II-A. 
 
Overall Summary 
 
Step (1) 
Document conclusions in a summary memorandum (See Attachment VI) to be 
included with HIGLAS I worksheet, Attachments I, I-A, II, II-A, IV, IV-A, V & 
V-A and submit to the CFO for Medicare Operations for sign off approval. 
For example, the Medicare contractor must identify any external and/or internal 
factors that attributed to the variances. 
  External factors might include (1) Medicare contractor transitions from the 
Medicare program, (2) seasonal variances such as provider year-ends, (3) new 
legislation impacting reimbursement policies, MSP policies, etc., (4) current 
economic conditions (provider termination, bankruptcy, extended repayment 
schedules, etc.). 
 
Internal factors might include (1) turnover of key personnel, (2) changes in 
accounting guidance or CMS priorities/initiatives, (3) reporting system 
modifications, (4) number of contractor processing sites. 
 
Step (2) 
Medicare contractors shall submit a signed approved copy of the summary memorandum 
(See Attachment VI). In addition, HIGLAS contractors shall submit the HIGLAS 
Financial Reports, Attachments I, I-A, II, II-A, IV, IV-A, V & V-A, the CMS TROR 
Reconciliation Worksheet (HIGLAS I), and the CMS HIGLAS Contractor Trend 
Analysis Checklist (Attachment H-II), to the regional office for final approval. 
 
Note:  The summary memorandum (See Attachment VI) and the analysis schedules 
(HIGLAS I, Attachments I, I-A, II, II-A, IV, IV-A, V & V-A) will be reviewed and 
approved by the CFO for Medicare Operations and the region's Associate Regional 
Administrator (ARA). The ARA will review the trend analysis submitted by the 
Medicare contractor and either approve or request additional explanation and/or 
documentation. The ARA must notify the Medicare contractor by phone, email or fax no 
later than February 15, May 15, August 15, and November 8 as to the 
approval/disapproval. The ARA must allow the Medicare contractor no less than two 
days (upon receipt of the request) to provide the additional documentation needed to 
support their variance. Upon receiving the request, the Medicare contractor has no more 
than four days to provide the additional documentation to the ARA.  If the ARAs request 
for any additional information can not be submitted by the due dates, the ARA must 
notify the CO Division of Financial Reporting and Policy (DFRP) (by phone, email or 
fax) and provide a date when the Medicare contractors trend analysis will be forwarded 
to the CO.  Upon receipt of notification that the CO review process is completed, the 
ARA will submit a signed approved copy of the summary memorandum to the Medicare 
contractors and CO, DFRP. 
 
III. Due Date 
 
The analysis must be submitted to each contractor's respective regional office on 
February 8, May 8, August 8, and November 1 (The third/fourth quarter due dates may 
change due to the accelerated time periods.  Medicare contractors will be notified of these 
changes by a Joint Signature Memorandum (JSM)).  The ARA must review the Medicare 
contractors' submissions and forward them to CO by February 15, May 15, August 15, 
and November 8.  If that date occurs on a holiday or a weekend, the report is due the 
following Federal workday.  The Medicare contractor and the ARA may email or fax the 
analysis by the due dates and immediately follow up with a hard copy. 
  NOTE:  The ARA will submit a copy of the Medicare contractors' summary 
memorandums and the analysis schedules to the CO/DFRP.  The CO will notify the RO 
by email upon receipt of the Medicare contractors trend analysis.  The CO will review 
the Medicare contractors analysis schedules and may request additional documentation.  
The CO is not responsible for approving or denying the Medicare contractors' trend 
analysis.  If additional documentation is needed, the CO will notify the RO by email 
within 14 days upon receipt of the Medicare contractors analysis schedules.  Upon the 
completion of the COs review, CO will notify the RO by email that no additional 
information is needed and the COs review process is completed. The ARA will sign and 
approve the Medicare contractors summary memorandum, and submit a signed approved 
copy to the CO, DFRP and to the Medicare contractors.  CMS HIGLAS TROR Reconciliation Worksheet 
HIGLAS I (Non-Federal/Federal) 
Part I - Status of Receivables HIGLAS I
Section A (Col. A) (Col. B) (Col. C) (Col. D) (Col. E) (Col. F) (Col. G) (Col. H) (Col. I) (Col. J) (Col. K) (Col. L)
(Total Non-Federal/Federal) (Col. K + L) (Col. E+F+G+H+I+J) List of Detailed Reports
Receivables and Collections TROR Total Detail HI - Fund 050961 SMI - Fund 050960 Interest - Fund 050720 CMS TROR
Report  Activity Registers Variance HIGLAS Source MSP Non-MSP MSP Non-MSP MSP Non-MSP Non-Fed Fed
(1) Beginning FY Balance         2 ,888 76,000,000 76,000,000 0 Beginning Balance Rpt 14,000,000 25,000,000 10,000,000 25,000,000 1,000,000 1,000,000 69,750,000 6,250,000
(2) New Receivables (+)       2 4,632 200,000,000 200,000,000 Transaction Register 35,000,000 100,000,000 15,000,000 50,000,000 0 0 187,500,000 12,500,000
(3) Accruals (+) (New Interest Receivables) 1,576,728 1,576,728 76,728 1,500,000 1,557,546 19,182
Transaction Register (support line 3) 500,000 500,000 Transaction Register 0 500,000 500,000 0
CMS Adjustment Register (support line 3) 1,076,728 1,076,728 Adjustment Register 76,728 1,000,000 1,057,546 19,182
(4) Collections on Receivables (-) (120,815,566) (120,815,566) 0 (4,081,254) (94,709,110) (3,000,000) (17,925,202) (100,000) (1,000,000) (119,020,253) (1,795,314)
(A) At Agency-Cash/Checks (9,231,254) (9,231,254) Applied Collections (4,081,254) (1,000,000) (3,000,000) (1,000,000) (100,000) (50,000) (7,435,941) (1,795,314)
                     -Offsets  (111,584,312) (111,584,312) Applied Collections (93,709,110) (16,925,202) (950,000) (111,584,312) 0
(B) At Third Party 0 0
(C) Asset Sales 0 0
(D) Other - Must footnote 0 0
(5) Adjustments         1 ,093 (5,774,224) (5,774,224) 0 Adjustment Register (975,538) (4,042,637) (296,554) (226,534) (59,757) (173,204) (5,441,262) (332,962)
(A) Reclassified/Adjusted Amounts (+ or -)         1 ,093 (5,774,224) (5,774,224) (975,538) (4,042,637) (296,554) (226,534) (59,757) (173,204) (5,441,262) (332,962)
(B) Adjustments Due to Sale of Assets (+ or -) 0 0
(C) Consolidations (+ or -) 0 0
(6) Amounts Written-Off (-)            1 52 (1,940,261) (1,940,261) 0 (220,610) (1,303,694) (50,464) (222,153) (23,149) (120,191) (1,866,706) (73,555)
(A) Currently Not Collectible (-)            1 46 (1,862,750) (1,862,750) Adjustment Register (209,275) (1,252,857) (37,313) (222,153) (22,991) (118,161) (1,795,355) (67,395)
(B) Written-Off and Closed Out (-)                6  (77,511) (77,511) Adjustment Register (11,335) (50,837) (13,151) 0 (158) (2,030) (71,351) (6,161)
(7) Ending Balance (TROR/Activity Registers)         2 ,889 149,046,677 149,046,677 0 (x) 43,722,598 24,944,559 21,652,982 56,626,111 893,822 1,206,605 132,479,326 16,567,351
AR Overpayments Report: HIGLAS Source MSP Non-MSP MSP Non-MSP MSP Non-MSP Total Total
Cost Report Settlements 19,800,000 19,800,000 AR Overpayment Rpt 9,000,000 10,000,000 800,000 19,800,000 0
Claims Accounts Receivable 49,308,754 49,308,754 AR Overpayment Rpt 12,000,000 37,308,754 0 49,308,754 0
Credit Balances 303,621 303,621 AR Overpayment Rpt 303,621 0 0 303,621 0
Other 13,359,902 13,359,902 AR Overpayment Rpt 5,000,000 7,958,297 401,605 13,359,902 0
Physician/Supplier 0 0 0 0
Beneficiary 0 0 0 0
GHP(Data/non-Data Match) 22,322,019 22,322,019 AR Overpayment Rpt 18,822,019 3,000,000 500,000 16,741,514 5,580,505
MSP Prov/Phys/Supp/Bene 0 0 0 0
MSP Beneficiary (Liability) 40,210,579 40,210,579 AR Overpayment Rpt 22,900,000 17,010,579 300,000 30,157,934 10,052,645
Other MSP (Liability) 3,741,803 3,741,803 2,000,000 1,642,982 98,821 2,806,352 935,451
Total Overpayment Reports 149,046,678 149,046,678 43,722,019 26,303,621 21,653,561 55,267,051 898,821 1,201,605 132,478,078 16,568,600
Difference (TROR/Activity Registers vs. Ovrpymnt Rpt) (1) (a) (1)(b) 579 (1,359,062) (579) 1,359,060 (4,999) 5,000 1,248 (1,249)
(x)= variance between the detail activity registers vs. the TROR
(a)= variance between the TROR vs.overpayments reports
(b)= variance between the detail activity registers vs. overpayments reports
 
Note:Contractors are required to provide variance explanations for the amounts reported on the AR Overpayments Report
  CMS Beginning Balance Report 
Attachment BBrpt 
 
                                                                      Beginning Balance Report                             Report Date: 06-JAN-06 01:06 PM 
                                                                      As of Date: 30-SEP-2005                              Page: X of X 
 ORGANIZATION: Contractor ABC                                                                                              User Name: GDH0 
 
                                                                         As of Date: 30-SEP-05 
                                                                       Workload Low: Contractor # 
                                                                      Workload High: Contractor # 
                                                               Transaction Type Low: 
                                                              Transaction Type High: 
                                                                      AR Number Low: 
                                                                     AR Number High: 
                                                                Customer Number Low: 
                                                               Customer Number High: 
                                                         Customer Profile Class Low: 
                                                        Customer Profile Class High: 
                                                Include CNC Receivables/Debit Memos: Y 
                              Show Invoices with Negative Fund Level Balances Only?: 
                                                                   Open/Closed/Both: 
                                                                 Type of Receivable: A 
                                                                     Customer Class: NONFEDERAL 
                                                                       Summary Only: Y 
 
  Totals for all Workloads 
 
 
                                         HI Fund                    SMI Fund                       GEN Fund                        Total                 
                               -------------------------    -------------------------     -------------------------     ------------------------- 
  MSP Balances                       14,000,000.00                  10,000,000.00                 1,000,000.00                      25,000,000.00 
  NonMSP Balances                    25,000,000.00                  25,000,000.00                 1,000,000.00                      56,000,000.00 
                               -------------------------    -------------------------     -------------------------     ------------------------- 
  Total                             39,000,000.00                   35,000,000.00                 2,000,000.00                      76,000,000.00 
  CMS Transaction Register  
Attachment TALn2rpt 
Transaction Register as of     31-DEC-05 
 
                                                                                                                         Current Date 06-JAN-2006 01:08:36 
                                                                                                                         Request ID  123456 
     Support TROR Line2                                  Y 
     Fiscal Year                                         2006 
     Workload Id Low                                     Contractor ABC 
     Workload Id High                                    Contractor ABC 
     Quarter 
     As of Date                                          31-DEC-05 
     Type Of Receivable                                  A 
     Customer Class                                      NONFEDERAL 
     GL Date Low 
     GL Date High 
     Invoice Date Low 
     Invoice Date High 
     Transaction Type Low 
     Transaction Type High 
     Invoice Class 
     Co. Segment Low 
     Co. Segment High 
                  
CMS SET OF BOOKS 
                                                                                            Invoice Currency :         USD 
 
 
 
                                                                                                                                  No. of Lines        24632 
 
 
      Summary Information : 
      ---------------------- 
        FUND                            YEAR                                     MSP                          NON MSP                             Total 
 
       050960                            XXXX                                   0.00                   50,000,000.00                       50,000,000.00 
                                         XXXX                          15,000,000.00                            0.00                       15,000,000.00 
 
                                                          ---------------------------     ----------------------------        ---------------------------- 
        Fund Total                                                     15,000,000.00                   50,000,000.00                       65,000,000.00 
 
       050961                            XXXX                                   0.00                  100,000,000.00                      100,000,000.00 
                                         XXXX                          35,000,000.00                            0.00                       35,000,000.00 
 
                                                          ---------------------------     ----------------------------        ---------------------------- 
        Fund Total                                                     35,000,000.00                  100,000,000.00                      135,000,000.00 
 
                                                         ----------------------------     ---------------------------         --------------------------- 
        Report Total                                                   50,000,000.00                  150,000,000.00                      200,000,000.00 
 
  CMS Transaction Register 
Attachment TALn3rpt 
Transaction Register as of     31-DEC-05 
 
                                                                                                                     Current Date 06-JAN-2006 01:09:15 
                                                                                                                     Request ID 417123 
 
     Support TROR Line2                                  N 
     Fiscal Year                                         2006 
     Workload Id Low                                      
     Workload Id High                                     
     Quarter 
     As of Date                                          31-DEC-05 
     Type Of Receivable                                  A 
     Customer Class                                      NONFEDERAL 
     GL Date Low 
     GL Date High 
     Invoice Date Low 
     Invoice Date High 
     Transaction Type Low                                DM-INTEREST 
     Transaction Type High                               DM-LATE FEE INTEREST 
     Invoice Class 
     Co. Segment Low 
     Co. Segment High 
     
     CMS SET OF BOOKS 
                                                                                            Invoice Currency :         USD 
 
 
 
                                                                                                                                  No. of Lines        375 
 
                                                        
      Summary Information : 
      ---------------------- 
        FUND                            YEAR                                     MSP                          NON MSP                             Total 
 
       050720                            XXXX                                   0.00                      500,000.00                        500,000.00 
 
                                                          ---------------------------     ----------------------------        ---------------------------- 
        Fund Total                                                              0.00                      500,000.00                          500,000.00 
 
                                                         ----------------------------     ---------------------------         --------------------------- 
        Report Total                                                            0.00                      500,000.00                          500,000.00 
  CMS Adjustment Register 
Attachment AdjLn3rpt 
Adjustment Register as of 31-DEC-05 
                                        Report Date:    06-JAN-06 13:09:50 
                                               Page 1 / 2Request ID 734123 
            Summary Report                 Y 
            Fiscal Year                    2006 
            Quarter Number 
            As of Date                     31-DEC-05 
            Type Of Receivable             Administrative Receivables 
            Customer Class                 NONFEDERAL 
            Receivable Activity From 
            Receivable Activity To 
            Include Line 3 Only    Y 
 
    TROR SUMMARY INFORMATION 
   ------------------------------ 
    3 
 
      FUND                                        MSP                    NON MSP                 TOTAL                   COUNT 
      GEN -050720XXXX0D00                            76,727.70           1,000,000.00             1,076,727.70                1414 
                                            --------------------   --------------------    ---------------------      -------------- 
                       REPORT TOTAL                  76,727.70           1,000,000.00             1,076,727.70                1414 
 
  CMS Adjustment Register 
Attachment AdjLn5&6rpt
 
Adjustment Register as of 31-DEC-05 
                                        Report Date:    06-JAN-06 13:09:50 
                                               Page 1 / 2 
                                                                                                                                      Request ID 317123 
            Summary Report                    Y 
            Fiscal Year                       2006 
            Quarter Number 
            As of Date                        31-DEC-05 
            Type Of Receivable                Administrative Receivables 
            Customer Class                    NONFEDERAL 
            Receivable Activity From 
            Receivable Activity To 
            Include Line 3 Only               N 
 
     TROR SUMMARY INFORMATION 
   ------------------------------ 
 
   5A 
 
      FUND                                        MSP                    NON MSP                 TOTAL                   COUNT 
      GEN -050720XXXX0D00                            (59,756.87)           (173,204.12)             (232,960.99)                342 
      HI  -050961XXXX0DC0                           (975,538.15)         (4,042,636.65)           (5,018,174.80)                215 
      SMI -050960XXXX0DC0                           (296,554.15)           (226,533.54)             (523,087.69)                272 
                                            --------------------   --------------------    ---------------------      -------------- 
                       REPORT TOTAL               (1,331,849.17)         (4,442,374.31)           (5,774,223.48)                829 
    6A 
 
      FUND                                        MSP                    NON MSP                 TOTAL                   COUNT 
      GEN -050720XXXX0D00                            (22,990.98)           (118,160.76)             (141,151.74)                 65 
      HI  -050961XXXX0DC0                           (209,274.75)         (1,252,856.76)           (1,462,131.51)                 38 
      SMI -050960XXXX0DC0                            (37,313.17)           (222,153.20)             (259,466.37)                 39 
                                            --------------------   --------------------    ---------------------      -------------- 
                       REPORT TOTAL                 (269,578.90)         (1,593,170.72)           (1,862,749.62)                142 
    6B 
 
      FUND                                        MSP                    NON MSP                 TOTAL                   COUNT 
      GEN -050720XXXX0D00                               (158.36)             (2,030.22)               (2,188.58)                  3 
      HI  -050961XXXX0DC0                            (11,334.88)            (50,837.02)              (62,171.90)                  2 
      SMI -050960XXXX0DC0                            (13,151.05)                  0.25               (13,151.30)                  2 
                                            --------------------   --------------------    ---------------------      -------------- 
                       REPORT TOTAL                  (24,644.29)            (52,867.49)              (77,511.78)                  7 
 
  CMS AR Overpayment Report 
Attachment AROvrrpt
 
AR Overpayment Report as of  31-DEC-05 
                                                                                                                      Report Date:    06-JAN-06 12:30:58 
                                                                                                                      Page 1 / 3 
                                                                                                                      Request ID:     476123 
      Workload Low..................................: 
      Workload High.................................: 
      Comparative Summary(Yes/No)...................:   N 
      As of Date1 Summary Only(Yes/No)..............:   Y 
      As of Date1...................................:   31-DEC-05 
      As of Date2(Comparative)......................: 
      Invoice Class.................................: 
      Customer Class................................:   NONFEDERAL 
      Transaction Type Low..........................: 
      Transaction Type High.........................: 
      Co. Segment Low...............................: 
      Co. Segment High..............................: 
 
SUMMARY OF OVERPAYMENTS AS OF     31-DEC-05 
 
     ------------------------------------------------ 
       MSP        OVERPAYMENT                                   HI -050961              SMI-050960             INT-050720                  TOTAL 
 
      ------------------------------------------------------------------------------------------------------------------------------------------ 
       BENE-LIABILITY                                       22,900,000.00           17,010,579.00             300,000.00          40,210,579.00 
       GROUP HEALTH PLAN                                    18,822,019.00            3,000,000.00             500,000.00          22,322,019.00 
       MSP PROV/PHY/SUPP/BENE                                        0.00                    0.00                   0.00                   0.00 
       OTHER-LIABILITY                                       2,000,000.00            1,642,982.00              98,821.00           3,741,803.00 
                                                  ------------------------  -----------------------  ---------------------- ---------------------- 
                  MSP         TOTAL                         43,722,019.00           21,653,561.00             898,821.00          66,274,401.00 
 
       NON MSP    OVERPAYMENT                                   HI -050961              SMI-050960             INT-050720                  TOTAL 
 
      ------------------------------------------------------------------------------------------------------------------------------------------ 
       BENEFICIARY                                                   0.00                    0.00                   0.00                   0.00 
       CLAIMS ACCOUNT RECEIVABLE                            12,000,000.00           37,308,754.00                   0.00          49,308,754.00 
       COST REPORT SETTLEMENT                                9,000,000.00           10,000,000.00             800,000.00          19,800,000.00 
       CREDIT BALANCES                                         303,621.00                    0.00                   0.00             303,621.00 
       OTHER                                                 5,000,000.00            7,958,297.00             401,605.00          13,359,902.00 
       PIP ACCRUAL                                                   0.00                    0.00                   0.00                   0.00 
                                                  ------------------------  -----------------------  ---------------------- ---------------------- 
                  NON MSP     TOTAL                         26,303,621.00          55,267,051.00           1,201,605.00           82,772,277.00 
 
                                                 -------------------------   ----------------------  ---------------------- ---------------------- 
                  MSP AND NON-MSP TOTAL                     70,025,640.00          76,920,612.00            2,100,426.00        149,046,678.00 
 
                                                     ======================     ====================    ===================    ================== 
 
  CMS Applied Collection Register 
Attachment AppCollrpt
 
CMS APPLIED COLLECTIONS REGISTER As of 31-DEC-05 
                Report Date: 06-JAN-06 01:10 PM 
                                                                                                                       Page 2 of 8 
                                                                                                                       Request ID: 422123 
           REPORT PARAMETERS 
           Show Detail                               :                   N 
           Support TROR                              :                   Y 
           Fiscal Year                               :                   2006 
           As of Date                                :                   31-DEC-2005 
           GL Date From                              : 
           GL Date To                                : 
           Cash Receipt Batch Number From            : 
           Cash Receipt Batch Number To              : 
           Cash Receipt Number From                  : 
           Cash Receipt Number To                    : 
           Credit Memo Number From                   : 
           Credit Memo Number To                     : 
           Invoice/Debit Memo Number From            : 
           Invoice/Debit Memo Number To              : 
           Customer Name From                        : 
           Customer Name To                          : 
           Workload ID From                          :                   Contractor # 
           Workload ID To                            :                   Contractor # 
           Type of Receivable                        :                    A 
           Customer Class                            :                    NONFEDERAL 
 
TRENDING SUMMARY FOR ALL WORKLOADS                                                                    AMOUNT                       SUBTOTAL/TOTAL                           
PRINCIPAL 
    GEN        Non-MSP           OFFSET 
                                                    OTHER                                              8,633.00 
                                                              Subtotal OFFSET                                                         8,633.00 
                                            Total GEN Non-MSP                                                                         8,633.00                
Total GEN Collections                                                                                                                 8,633.00 
    HI         MSP               CASH 
                                                    INSURER                                            31,254.00 
                                                    EMPLOYER                                          150,000.00 
                                                    BENEFICIARY                                     3,900,000.00 
                                                              Subtotal CASH                                                       4,081,254.00 
                                            Total HI MSP                                                                          4,081,254.00                                 
               Non-MSP           4A 
                                                    PROVIDER                                       -3,000,000.00 
                                                              Subtotal 4A                                                        -3,000,000,00 
                                 CASH 
                                                    PROVIDER                                        4,000,000.00 
                                                              Subtotal CASH                                                       4,000,000.00 
                                 OFFSET 
                                                    PROVIDER                                       93,709,110.00 
                                                              Subtotal OFFSET                                                    93,709,110.00 
 
                                            Total HI Non-MSP                                                                     94,709,110.00                                 
  CMS Applied Collection Register 
Attachment AppCollrpt
 
 
 
               Total HI Collections                                                                                             98,790,364.00                                  
     
TRENDING SUMMARY FOR ALL WORKLOADS                                                                    AMOUNT                       SUBTOTAL/TOTAL                            
 
SMI        MSP               CASH 
                                                    EMPLOYER                                          100,000.00 
                                                    BENEFICIARY                                     2,900,000.00 
                                                              Subtotal CASH                                                       3,000,000.00 
                                            Total SMI MSP                                                                         3,000,000.00                                
               Non-MSP           4A 
                                                    PROVIDER                                       -1,000,000.00 
                                                              Subtotal 4A                                                        -1,000,000.00 
                                 CASH 
                                                    PROVIDER                                        2,000,000.00 
                                                              Subtotal CASH                                                       2,000,000.00 
                                 OFFSET 
                                                    PROVIDER                                       16,925,202.00 
                                                              Subtotal OFFSET                                                    16,925,202.00 
                                            Total SMI Non-MSP                                                                    17,925,202.00                                 
              Total SMI Collections                                                                                              20,925,202.00                                
                                            Total Collections - PRINCIPAL                                                      $119,724,199.00                                                                        
                                                                                                                                                   INTEREST 
 
 
    GEN        MSP               CASH 
                                                    OTHER                                             100,000.00 
                                                              Subtotal CASH                                                         100,000.00 
                                            Total GEN MSP                                                                           100,000.00                                 
               Non-MSP           CASH 
                                                    OTHER                                              50,000.00 
                                                              Subtotal CASH                                                          50,000.00 
                                 OFFSET 
                                                    OTHER                                            941,367.00 
                                                              Subtotal OFFSET                                                       941,367.00 
                                            Total GEN Non-MSP                                                                       991,367.00                                 
               Total GEN Collections                                                                                              1,091,367.00                                 
                                           Total Collections - INTEREST                                                          $1,091,367.00                                                                          
                                                                                                                                                     
 
   
  CMS Applied Collection Register 
Attachment AppCollrpt
 
 
 
   TOTAL COLLECTIONS - Principal and Interest By Debtor Type 
                                                                                      
 
 
OTHER                                          708,220.00 
 
INSURER                                         12,003.00 
 
 
EMPLOYER                                       240,073.00 
 
ROVIDER                                    113,794,976.00 
 
 
 
BENEFICIARY                                  6,060,294.00 
                                       -------------------- 
         REPORT TOTAL                    $120,815,566.00 
                                   ======================== 
  CMS Medicare Accounts Receivable Non-MSP (Part A HI) 
Contractor ABC 
Attachment I 
SOURCE:  CMS AR Overpayment Report (HIGLAS I Worksheet)
SCOPE:   If percentage change is greater than +/- 15% and amount change +/- 5 % of the combined component ending balances.
(A-B) (C/B x 100%)
A B C D
12/31/2005 9/30/2005 $ Change % Change Note
Cost Report Settlements $     1 4,000,000 $      1 7,000,000 (3,000,000) -17.65% 1
Claims 12,000,000 13,000,000 (1,000,000) -7.69% NER
PIP 0 0 0 0.00% NER
Credit Balance 303,621 0 303,621 0.00% NER
Other 0 0 0 0.00% NER
Total Non-MSP $     2 6,303,621 $      3 0,000,000 $       ( 3,696,379) -12.32%
Total TROR $     2 4,944,560 $      2 9,025,250
Variance (Over/Under Application) $       1 ,359,061 $           9 74,750
5% of Combined Ending Balance $       1 ,315,181 ($26,303,621 x 5%)
No Explanation Required (NER)
(1) Cost Report Settlements-The total variance for the Non-MSP (HI) balance for the current quarter reflects a decrease
of $3.7 million compared to the prior quarter.  The bulk of this variance is a result of the change in Cost Report Settlements
a decrease of $3 million.   The primary cause of this variance is due to the result of the larger hospitals with the potential
for large overpayments being settled in the last quarter of the year.  
  CMS Medicare Accounts Receivable Non-MSP (Part A HI) 
Contractor ABC 
Attachment I-A 
SOURCE:  CMS AR Overpayment Report (HIGLAS I Worksheet) & H750A
SCOPE:   If percentage change is greater than +/- 15% and amount change +/- 5 % of the combined component ending balances.
(A-B) (C/B x 100%)
A B C D
12/31/2005 12/31/2004 $ Change % Change Note
Cost Report Settlements $     1 4,000,000 $      1 3,000,951 999,049 7.68% NER
Claims 12,000,000 13,000,000 (1,000,000) -7.69% NER
PIP 0 14,000,000 (14,000,000) -100.00% (4)
Credit Balance 303,621 0 303,621 0.00% NER
Other 0 0 0 0.00% NER
Total Non-MSP $     2 6,303,621 $      4 0,000,951 $     ( 13,697,330) -34.24%
Total TROR $     2 4,944,560 $      4 0,000,951
Variance (Over/Under Application) $       1 ,359,061 $                   -
5% of Combined Ending Balance $       1 ,315,181 ($26,303,621 x 5%)
No Explanation Required (NER)
(4)   PIP Accrual - HIGLAS Medicare contractors are no longer required to report an estimate PIP accrual.  
 
 
  CMS Medicare Accounts Receivable MSP (Part A HI) 
Contractor ABC 
Attachment II 
SOURCE:  CMS AR Overpayment Report (HIGLAS I Worksheet)
SCOPE: If percentage change is greater than +/- 15% and amount change +/- 5 % of the combined component ending balances.
(A-B) (C/B x 100%)
A B C D
12/31/2005 9/30/2005 $ Change % Change Note
GHP(Data/non-Data Match)        1 8,822,019         2 3,050,000          ( 4,227,981) -18.34% (2)
MSP Provider/Physician/Supplier                      -                       -  0.00% NER
MSP Beneficiary (Liability)        2 2,900,000         1 9,120,000            3,780,000 19.77% (3)
Other MSP (Liability)          2 ,000,000                      -             2,000,000 0.00% NER
Total MSP $     4 3,722,019 $      4 2,170,000 $         1,552,019 3.68%
Total TROR $     4 3,722,598 $      4 1,317,525
Variance (Over/Under Application) $                (579) $           8 52,475
5% of Combined Ending Balance $       2 ,186,101 ($43,722,019  x  5%)
No Explanation Required (NER)
(2) GHP-HIGLAS does not break down GHP between Data Match and Non-Data Match.  GHP overall has 
decreased by $4.2 million in comparison to the previous quarter.   Non-Data Match receivables decreased by
$3 million, which reflects a significant decrease in the number of demands produced since the implementation of 
ReMas during FY 2005.  
  CMS Medicare Accounts Receivable MSP (Part A HI) 
Contractor ABC 
Attachment II-A 
SOURCE:  CMS AR Overpayment Report (HIGLAS I Worksheet) & H750A
SCOPE: If percentage change is greater than +/- 15% and amount change +/- 5 % of the combined component ending balances.
(A-B) (C/B x 100%)
A B C D
12/31/2005 12/31/2004 $ Change % Change Note
GHP(Data/non-Data Match)        1 8,822,019         2 1,322,019          ( 2,500,000) -11.72% (5)
MSP Provider/Physician/Supplier                      -                       -  0.00% NER
MSP Beneficiary (Liability)        2 2,900,000         2 4,000,000          ( 1,100,000) -4.58% NER
Other MSP (Liability)          2 ,000,000                      -             2,000,000 0.00% NER
Total MSP $     4 3,722,019 $      4 5,322,019 $       ( 1,600,000) -3.53%
Total TROR $     4 3,722,598 $      4 5,322,019
Variance (Over/Under Application) $                (579) $                   -
5% of Combined Ending Balance $       2 ,186,101 ($43,722,019  x  5%)
No Explanation Required (NER)
(5) Currently GHP-HIGLAS does not break out Data Match and Non-Data Match.  GHP overall has 
decreased by $2.5 million in comparison to the previous year.   Since the implementation of ReMAS during 
FY 2005,  the Non-Data Match receivables reflects the significant decrease.  
  CMS Medicare Accounts Receivable Non-MSP (Part A HI) 
Contractor ABC 
Attachment IV 
SOURCE:  Detail Activity Reports (HIGLAS I Worksheet)
Part I - Status of Receivables
Section A
Receivables and Collections
HI - Fund 050961
12/31/2005 9/30/2005 $ Change %Change
(1) Beginning FY Balance 25,000,000 22,613,882 2,386,118 10.55%
(2) New Receivables (+) 100,000,000 91,601,759 8,398,241 9.17%
(3) Accruals (+) (New Interest Receivables)
(4) Collections on Receivables (-) (94,709,110) (81,520,069) (13,189,041) 16.18%
(A) At Agency-Cash/Checks (1,000,000) (42,043,277) 41,043,277 -97.62%
                     -Offsets  (93,709,110) (39,476,792) (54,232,318) 137.38%
(B) At Third Party
(C) Asset Sales
(D) Other - Must footnote
(5) Adjustments (4,042,637) (3,655,694) (386,943) 10.58%
(A) Reclassified/Adjusted Amounts (+ or -) (4,042,637) (3,655,694) (386,943) 10.58%
(B) Adjustments Due to Sale of Assets (+ or -)
(C) Consolidations (+ or -)
(6) Amounts Written-Off (-) (1,303,694) (14,628) (1,289,066) 8812.32%
(A) Currently Not Collectible (-) (1,303,694) (14,628) (1,289,066) 8812.32%
(B) Written-Off and Closed Out (-) 0 0 0 0.00%
(7) Ending Balance (TROR/Activity Registers) 24,944,560 29,025,250 (4,080,690) -14.06%
Total Collections 94,709,110 81,520,069
Total Adjusted Receivables 119,653,670 110,545,319
Collection Percentage 79.15% 73.74%  
  CMS Medicare Accounts Receivable Non-MSP (Part A HI) 
Contractor ABC 
Attachment IV-A 
SOURCE:  Detail Activity Reports (HIGLAS I Worksheet),  H751A & M751A
Part I - Status of Receivables
Section A
Receivables and Collections
HI - Fund 050961
12/31/2005 12/31/2004 $ Change %Change
(1) Beginning FY Balance 25,000,000 22,613,882 2,386,118 10.55%
(2) New Receivables (+) 100,000,000 90,976,509 9,023,491 9.92%
(3) Accruals (+) (New Interest Receivables) 14,000,000 (14,000,000)
(4) Collections on Receivables (-) (94,709,110) (83,384,118) (11,324,992) 13.58%
(A) At Agency-Cash/Checks (1,000,000) (45,067,576) 44,067,576 -97.78%
                     -Offsets  (93,709,110) (38,316,542) (55,392,568) 144.57%
(B) At Third Party
(C) Asset Sales
(D) Other - Must footnote
(5) Adjustments (4,042,637) (4,155,694) 113,057 -2.72%
(A) Reclassified/Adjusted Amounts (+ or -) (4,042,637) (4,155,694) 113,057 -2.72%
(B) Adjustments Due to Sale of Assets (+ or -)
(C) Consolidations (+ or -)
(6) Amounts Written-Off (-) (1,303,694) (49,628) (1,254,066) 2526.93%
(A) Currently Not Collectible (-) (1,303,694) (49,628) (1,254,066) 2526.93%
(B) Written-Off and Closed Out (-) 0 0 0 0.00%
(7) Ending Balance (TROR/Activity Registers) 24,944,560 40,000,951 (1,056,391) -2.64%
Total Collections 94,709,110 83,384,118
Total Adjusted Receivables 119,653,670 109,385,069
Collection Percentage 79.15% 76.23%  
  CMS Medicare Accounts Receivable MSP (Part A HI) 
Contractor ABC 
Attachment V 
SOURCE:  Detail Activity Reports (HIGLAS I Worksheet)
Part I - Status of Receivables
Section A
Receivables and Collections
HI - Fund 050961
12/31/2005 9/30/2005 $ Change %Change
(1) Beginning FY Balance 14,000,000 18,000,000 (4,000,000) -22.22%
(2) New Receivables (+) 35,000,000 34,453,226 546,774 1.59%
(3) Accruals (+) (New Interest Receivables)
(4) Collections on Receivables (-) (4,081,254) (18,589,335) 14,508,081 -78.05%
(A) At Agency-Cash/Checks (4,081,254) (18,589,335) 14,508,081 -78.05%
                     -Offsets  0 0 0 0.00%
(B) At Third Party
(C) Asset Sales
(D) Other - Must footnote
(5) Adjustments (975,538) 12,142,077 (13,117,615) -108.03%
(A) Reclassified/Adjusted Amounts (+ or -) (975,538) 12,142,077 (13,117,615) -108.03%
(B) Adjustments Due to Sale of Assets (+ or -)
(C) Consolidations (+ or -)
(6) Amounts Written-Off (-) (220,610) (4,688,443) 4,467,833 -95.29%
(A) Currently Not Collectible (-) (209,275) (4,685,151) 4,475,876 -95.53%
(B) Written-Off and Closed Out (-) (11,335) (3,292) (8,043) 244.32%
(7) Ending Balance (TROR/Activity Registers) 43,722,598 41,317,525 2,405,073 5.82%
Total Collections 4,081,254 18,589,335
Total Adjusted Receivables 47,803,852 59,906,860
Collection Percentage 8.54% 31.03%  
  CMS Medicare Accounts Receivable MSP (Part A HI) 
Contractor ABC 
Attachment V-A 
SOURCE:  Detail Activity Reports (HIGLAS I Worksheet) & M751A
Part I - Status of Receivables
Section A
Receivables and Collections
HI - Fund 050961
12/31/2005 12/31/2004 $ Change %Change
(1) Beginning FY Balance 14,000,000 18,000,000 (4,000,000) -22.22%
(2) New Receivables (+) 35,000,000 31,074,736 3,925,264 12.63%
(3) Accruals (+) (New Interest Receivables)
(4) Collections on Receivables (-) (4,081,254) (2,598,173) (1,483,081) 57.08%
(A) At Agency-Cash/Checks (4,081,254) (2,598,173) (1,483,081) 57.08%
                     -Offsets  0 0 0 0.00%
(B) At Third Party
(C) Asset Sales
(D) Other - Must footnote
(5) Adjustments (975,538) (685,700) (289,838) 42.27%
(A) Reclassified/Adjusted Amounts (+ or -) (975,538) (685,700) (289,838) 42.27%
(B) Adjustments Due to Sale of Assets (+ or -)
(C) Consolidations (+ or -)
(6) Amounts Written-Off (-) (220,610) (468,844) 248,234 -52.95%
(A) Currently Not Collectible (-) (209,275) (468,515) 259,240 -55.33%
(B) Written-Off and Closed Out (-) (11,335) (329) (11,006) 3345.25%
(7) Ending Balance (TROR/Activity Registers) 43,722,598 45,322,019 (1,599,421) -3.53%
Total Collections 4,081,254 2,598,173
Total Adjusted Receivables 47,803,852 47,920,192
Collection Percentage 8.54% 5.42%  
  CMS Medicare Accounts Receivable (Part A HI) 
Contractor ABC 
AR Summary Memorandum 
Period Ending ___________________________ 
Attachment VI 
The following represents the summary for the changes in the accounts receivable balance for the current quarter. 
(1) Cost Report Settlements-The total variance for the Non-MSP (HI) balance for the current quarter reflects a
decrease of $3.7 million compared to the prior quarter.  The bulk of this variance is a result of the change in
cost report settlement a decrease of $3 million.   The primary cause of this variance is due to the result of 
of the larger hospitals with the potental for large overpayments being settled in the last quarter of the year.
(2) GHP-HIGLAS does not break down GHP between Data Match and Non-Data Match.  GHP overall has 
decreased by $4.2 million in comparison to the previous quarter.   Non-Data Match receivables decreased by
$3 million, which reflects a significant decrease in the number of demands produced since the implementation of 
ReMas during FY 2005.
(3) MSP Beneficiary-increased by $3.7 million and is the result of an increase in workload for total demands.
(4) PIP Accrual - HIGLAS Medicare contractors are no longer required to report an estimate PIP accrual.
(5) Currently GHP-HIGLAS does not break out Data Match and Non-Data Match.  GHP overall has 
decreased by $2.5 million in comparison to the previous year.   Since the implementation of ReMAS during 
FY 2005,  the Non-Data Match receivables reflects the significant decrease.
Prepared by:   Date
Reviewed by:   Date
CFO for Medicare Operations approval: ________________________________   Date
ARA approval:___________________________________________________   Date  
  Attachment H-II 
 
 
CMS HIGLAS Contractor Trend Analysis Checklist 
 
Contractor Number   
Contractor Name   
Period   
 
 
 
 
 
   
   Medicare Contractor has submitted the following HIGLAS reports.     
_____  CMS Report On Receivables Due From the Public (Attachment HIGLAS I). 
_____   CMS Beginning Balance Report (Attachment BBrpt). 
_____  CMS Transaction Register Report Line 2 (Attachment TALn2rpt). 
_____  CMS Transaction Register Report Line 3 (Attachment TALn3rpt). 
_____  CMS Adjustment Register Report for Line 3 (Attachments AdjLn3rpt). 
_____  CMS Adjustment Register Report for Lines 5 and 6 (Attachments AdjLn5&6rpt).    
_____  CMS AR Overpayment Report(Attachment AROvrrpt). 
_____  CMS Applied Collections Report (Attachment AppCollrpt). 
_____  CMS Summary 2 Trail Balance. 
 
     
                         
                  _______________________________________       Date:  _________________________ 
                          Preparer Signature 
 
 
 
   
400.23  Exhibit 23  Instructions for the Benefits Payable Survey 
(Rev. 105, Issued: 08-25-06, Effective/Implementation: 09-30-06) 
 
CMS is required to prepare fiscal year financial statements in accordance the Office of 
Management and Budgets (OMBs) accelerated mandated schedule.  In order to meet the 
accelerated timeframes, CMS requests specific contractor financial data for the 
preparation and audit of CMS annual financial statements. 
 
For inclusion in the year-end CMS financial statements, the Office of the Actuary 
(OACT) prepares the Medicare Incurred But Not Reported (IBNR) estimate which is 
based on actuarial estimates.  Due to the complexity of the actuarial estimate and the 
availability of data, OACT prepares this estimate for yearend statements only.  The 
Medicare IBNR estimate represents the amount of CMS claims incurred but not yet paid 
at the end of the fiscal year (FY) and is a summation of five different components: 
 
(1) the incurred to approval of payment amount  represents Medicare Services 
provided, for which, a corresponding claim has not been approved for payment 
and also is referred to as the incurred to approved amount; 
 
(2) the retroactive settlements on cost reports amount  represents the estimated net 
liability for cost reports awaiting final settlement and is also referred to as the cost 
settlement amount; 
 
(3) the approval to actual payment amount  represents the aggregate claims 
approved for payment, for which, the corresponding reimbursement has not been 
issued and is also referred to as the approved to paid amount; 
 
(4) the paid to cleared amount  represents the aggregate claims for which checks 
have been issued, but have not cleared the Medicare contractors financial 
institution and is also referred to as the outstanding checks amount; and  
 
(5) the advance payments under Periodic Interim Payment (PIP) amount  represents 
the bi-weekly payments for estimated benefit payments for plans under such a 
payment plan and is also referred to as the PIP amount. 
 
The data required for items (3) through (5) is obtained directly from the Medicare 
contractors and is submitted via the Benefits Payable survey (Attachment I, II, and/or III).  
Typically, the survey is sent to the Medicare contractors in May or June of the current 
FY. 
 
Due to the on-going transition to the Healthcare Integrated General Ledger Accounting 
System (HIGLAS) by the Medicare contractors, the data elements on the survey which 
are required for submission have been revised.  Instructions for each data element on the 
attachments are discussed below. 
 
  1)  PIP  value of the first periodic interim payment (PIP) cycle paid in the ensuing 
month for the end of the month being reviewed.  (Fiscal intermediaries 
ONLY) 
 
  CAFM contractors should continue to utilize their shared system to obtain this 
amount.  If the payment cycle has not been run, please provide an estimate of 
this amount.  Do not include pass through costs. 
 
  HIGLAS contractors should obtain this amount from their 810 interface report.  
If the payment cycle has not been run, please provide an estimate of this 
amount.  Do not include pass through costs. 
 
2)  Claims on the payment floor  Adjudicated claims not yet paid for both Health 
Insurance (HI) and Supplemental Medical Insurance (SMI), if applicable. 
 
  CAFM contractors should continue to utilize their shared system to obtain this 
amount.  The amount reported on the survey must agree to the amount reported 
on the year-end Form CMS-750A and/or 750B, Statement of Financial Position. 
 
  HIGLAS contractors should obtain this amount from their Summary 2 Trial 
Balance, GL account 216002, Entitlement Benefit Due/Payable  Adjudicated 
Claims. 
 
3)  Claims on Hold This amount would include claims held resulting from Do Not 
Forward, providers being investigated for fraud, claims payments due to 
bankrupt providers.  This amount does not include the amount for claims 
withheld for non-receipt of cost reports.  Amounts must be provided for both HI 
and SMI, if applicable.  (CAFM Contractors only). 
 
  CAFM contractors should obtain this amount from their shared system.  The 
amount reported on this survey must agree to the applicable portion reported on 
the Other Liabilities (footnote) line of the year end Form CMS-750, Statement 
of Financial Position.  The amount should include claims held in accordance 
with CR 5047, Hold on Medicare Payments. 
 
4)  Outstanding Checks  The amount of checks and EFT payments that have been 
issued, but have not cleared the Medicare contractors banking institution.  
Amounts must be provided for both HI and SMI, if applicable. 
 
  CAFM contractors should obtain this amount from their banking institution or 
internally generated documentation.  The amount reported on the survey must 
agree to outstanding check amount reported on the September 1522, Monthly 
Contractor Financial Report. 
 
  HIGLAS contractors should obtain this amount from their Summary 2 Trial 
Balance, GL account 212001 - Accounts Payable Disbursements in Transit. 
 
  5)  Health Professional Shortage Area payments (HPSA)  the bonus amount paid 
to physicians for eligible services rendered in zip code areas that fall fully 
within a designated HPSA area or are dominant to the area based on a 
determination by the U.S. Postal Service and/or; 
 
  Physician Scarcity Area (PSA)  the bonus amount paid to the primary care and 
specialty physicians providing eligible services in the counties with the lowest 
20% ratio of primary care or specialty physicians to Medicare beneficiaries 
and/or; 
 
Transitional Outpatient Payments (TOPs) - the amount paid to rural hospitals 
having 100 or fewer beds that are not classified as a sole community hospital.  
(Fiscal intermediaries ONLY) 
 
If PSA/HPSA and/or TOPs payments were disbursed on or before the last day 
of the quarter/month, enter amount as zero.  If PSA/HPSA and/or TOPs 
payments are disbursed on or after the first day of the quarter/month, provide 
the amount of the payments.  Contractors must provide these amounts for both 
HI and SMI, if applicable. 
 
CAFM contractors should obtain this information from their shared system, if 
applicable. 
 
HIGLAS contractors should obtain these amounts from their 810H and 810 
files, if applicable.  HIGLAS contractors should also provide a footnote to 
disclose whether the amounts indicated for these payments are included in GL 
account 216002, Entitlement Benefit Due/Payable  Adjudicated Claims. 
 
Time Account Balances (Attachment IV) 
 
The CMS reports the aggregate total Part A and total Part B Time Account balances as 
Medicare trust fund Cash and Other Monetary Assets on the balance sheet in its annual 
CMS Financial Report.  Previously, these account balances were obtained from the Form 
CMS-750 reports; however, the year-end 750 due date is typically extended until after 
annual financial statements must be completed.  Therefore, time account balances as of 
September 30, FY end, must be submitted as part of the attached Benefits Payable Survey 
 Attachment IV.  Fiscal intermediaries should prorate their time account balances 
between HI and SMI. 
 
Due Dates 
 
The annual Joint Signature Memorandum outlining the accelerated financial reporting 
timeframes for FY end Medicare contractor financial reports will provide the due date for 
the Benefits Payable Survey (Attachments I, II and/or III) as well as the Time Account 
Balance information (Attachment IV). 
  Attachment 1 
   
Contractor No. ______  HI BENEFITS PAYABLE SURVEY 
 
 
INTERMEDIARY    For Period Ending:  September 30, 20xx 
 
1.  PIP Providers 
Value of the First PIP Cycle Paid in the ensuing month ___________  
for the end of the month being reviewed.  (If the payment cycle has not been run, 
please provide an estimate of this amount. 
Do not include Pass Through Costs.) 
 
NOTE:  HIGLAS contractors should obtain this amount from their  
810 interface file.   
 
2.  Claims on the Payment Floor (in dollars)                                                 ___________ 
 (CAFM Contractors  Amount must agree to amount reported on the  
 September Form CMS-750) 
 
NOTE:  HIGLAS contractors should obtain this amount from their  
Summary 2 Trial Balance GL account 216002, Entitlement 
Benefit Due/Payable  Adjudicated Claims. 
 
3.  Claims on Hold (in dollars)  CAFM contractors ONLY  ___________ 
  (Amount should be obtained from the Other Liabilities line on the  
  Form CMS-751) 
 
4.  Outstanding Checks (in dollars)   ___________ 
(Amount must include outstanding EFTs and agree to the  
outstanding check amount on the September Form CMS-1522) 
 
NOTE:  HIGLAS contractors should obtain this amount from their  
Summary 2 Trial Balance GL account 212001, Accounts Payable 
Disbursements in Transit. 
 
5.   PSA/HPSA/TOPS payments (in dollars)  ___________ 
(If payments were disbursed on or before the last day of the  
quarter/month, enter amount as zero.  If payments are disbursed  
after the 1st day of the quarter/month, provide the amount of the payments) 
 
NOTE:  HIGLAS contractors should obtain these amounts from their  
810H and 810 files, if applicable. HIGLAS contractors should also provide a 
footnote to disclose whether the amounts indicated for these payments are 
included in GL account 216002, Entitlement Benefit Due/Payable  Adjudicated 
Claims 
    Attachment 2 
 
Contractor No. ______  SMI BENEFITS PAYABLE SURVEY 
 
 
INTERMEDIARY   For Period Ending:  September 30, 20xx 
 
 
1.  Claims on the Payment Floor (in dollars)                                              ___________ 
(CAFM Contractors  Amount must agree to amount reported on the  
September Form CMS-750) 
 
NOTE:  HIGLAS contractors should obtain this amount from their  
Summary 2 Trial Balance GL account 216002, Entitlement 
Benefit Due/Payable  Adjudicated Claims. 
 
2.  Claims on Hold (in dollars)  CAFM contractors ONLY  ___________ 
  (Amount should be obtained from the Other Liabilities line on the  
  Form CMS-751) 
 
3.  Outstanding Checks (in dollars)   ___________ 
(Amount must include outstanding EFTs and agree to the  
outstanding check amount on the September Form CMS-1522) 
 
NOTE:  HIGLAS contractors should obtain this amount from their  
Summary 2 Trial Balance GL account 212001, Accounts Payable 
Disbursements in Transit. 
 
4.  PSA/HPSA/TOPS payments (in dollars)  ___________ 
(If payments were disbursed on or before the last day of the  
quarter/month, enter amount as zero.  If payments are disbursed  
after the 1st day of the quarter/month, provide the amount of the payments) 
 
NOTE:  HIGLAS contractors should obtain these amounts from their  
810H and 810 files, if applicable. HIGLAS contractors should also provide a 
footnote to disclose whether the amounts indicated for these payments are 
included in GL account 216002, Entitlement Benefit Due/Payable  Adjudicated 
Claims 
 
    Attachment 3 
 
Contractor No. ______  BENEFITS PAYABLE SURVEY 
 
 
CARRIER      For Period Ending:  September 30, 20xx 
 
1.  Claims on the Payment Floor (in dollars)                                                  ___________ 
(CAFM Contractors  Amount must agree to amount reported on the  
September Form CMS-750) 
 
NOTE:  HIGLAS contractors should obtain this amount from their  
Summary 2 Trial Balance GL account 216002, Entitlement 
Benefit Due/Payable  Adjudicated Claims. 
 
2.  Claims on Hold (in dollars)  CAFM contractors ONLY  ___________ 
  (Amount should be obtained from the Other Liabilities line on the  
  Form CMS-751) 
 
3. Outstanding Checks (in dollars)   ___________ 
(Amount must include outstanding EFTs and agree to the  
outstanding check amount on the September Form CMS-1522) 
 
NOTE:  HIGLAS contractors should obtain this amount from their  
Summary 2 Trial Balance GL account 212001, Accounts Payable 
Disbursements in Transit. 
 
4.  PSA/HPSA payments (in dollars)  ___________ 
(If payments were disbursed on or before the last day of the quarter, 
enter amount as zero.  If payments are disbursed after the 1st day of the  
quarter, provide the amount of the payments) 
 
NOTE:  HIGLAS contractors should obtain these amounts from their 810H and 
810 files, if applicable. HIGLAS contractors should also provide a footnote to 
disclose whether the amounts indicated for these payments are included in GL 
account 216002, Entitlement Benefit Due/Payable  Adjudicated Claims 
 
  Attachment 4 
 
FEDERAL HEALTH INSURANCE TIME ACCOUNT 
 
Contractor No. ______ 
 
 
 
INTERMEDIARY    For Period Ending:  September 30, 20xx 
 
 
Part A Balance (in dollars)                                                                         ____________ 
 
Part B Balance (in dollars):                              ____________ 
 
 
FEDERAL SUPPLEMENTARY MEDICAL INSURANCE  
TIME ACCOUNT 
 
Contractor No. ______ 
 
 
 
CARRIER      For Period Ending:  September 30, 20xx 
 
 
Part B Balance (in dollars)                                                                         ____________ 
  400.24 - Exhibit 24  Benefits Payable Trending Analysis Procedures 
(Rev. 105, Issued: 08-25-06, Effective/Implementation: 09-30-06) 
 
Objective 
 
To ensure that benefit payable balances reported on the survey are reasonable, Medicare 
contractors are required to perform trending procedures. Trending procedures can be used 
as an important tool to identify potential errors, omissions, system weaknesses, or 
inappropriate patterns of adjustments or accumulation. Trending procedures involve 
comparisons of current fiscal year (FY) benefit payable data to prior year benefit payable 
data submitted on the Benefits Payable surveys. 
 
Compare Current Year Amounts with Comparative Financial Data 
 
In comparing current-period financial results with prior-period financial results, there is 
an implied assumption that the volume of activity in the two periods is comparable. If 
there has been a substantial change in volume, it is necessary to take this change into 
account and to quantify the change, when making the comparisons. For example, if a 
contractor's PIP balance has increased by 10 percent, it is necessary to determine and 
document the reason for the increase. The increase may be the result of new PIP 
providers or increased settlement activity. 
 
Understand Identified Variances and Document the Results 
 
Medicare contractors must identify and provide an explanation for variances that meet the 
thresholds outlined in these procedures.  If an explanation does not adequately describe 
the variance, the Medicare contractors must perform additional procedures such as a 
review of detail transactions to identify the underlying cause(s) of any unusual changes. 
 
The causes for the variances should be quantified.  For example, if the change was 
attributable to a change in the number of claim cycles, then include the number of 
additional claims on the payment floor attributed to the additional cycles as well as the 
reason why additional cycles were added. 
 
Methodology 
 
The primary reason for performing trend analysis is to focus on the change in the ending 
balances of PIP, claims on the payment floor, and outstanding checks. All explanations 
should be available for review by CMS, Office of the Inspector General, Government 
Accountability Office and /or other related parties. 
 
Each Medicare contractor must perform the following steps on a year end basis, 
beginning with FY ending September 30, 2006. The CFO for Medicare Operations' must 
submit the explanations via email as evidence that he/she has reviewed the trending 
explanations.  To properly apply trending procedures, it is necessary to complete the 
following steps: 
   
Benefits Payable Trending Analysis Procedures for FIs and carriers 
 
Step (1) 
 
Compare the value of the first PIP cycle paid in the ensuing month for the end of 
the month being reviewed, the claims on the payment floor amount, and the 
outstanding check amount reported on the current FYs Benefits Payable survey 
to the same line items reported on the prior years Benefits Payable survey (i.e. 
9/30/06 vs. 9/30/05) for all lines of business applicable to each contractor number.  
Calculate the dollar and percentage difference for each item. (See Attachments I, 
II, and III for the required formats). 
 
NOTE:  Trending on the amount of Claims on hold and Physician Scarcity Area 
(PSA) payments, Health Professional Shortage Area (HPSA) payments, and 
Transitional Outpatient Payments (TOPs) will not be required until FY 2007. 
 
Step (2) 
 
Verify that the dollar amount for each item is supported by lead schedules and/or 
detailed documentation. Any errors or misstatements identified as a result of this 
analysis must be corrected prior to the submission of the Form CMS-750 report, 
the Form CMS-1522 report and/or CMS Balance Sheet, CMS Income Statements 
and CMS Summary 2 Trial Balance. 
 
Step (3) 
 
PIP (for FIs only) 
Provide explanations where the dollar amount change is at least +/-$2 million or 
equates to a 100 percentage change. 
 
Claims on the payment floor 
Provide explanations where the dollar amount change is at least +/- $10 million or 
equates to a 100 percentage change. 
 
Outstanding checks 
Provide explanations where the dollar amount change is at least +/- $3 million or 
equates to a 100 percentage change. 
 
Step (4) 
 
Document conclusions in a summary memorandum (See Attachment IV) to be 
included with Attachments I, II, and III and provide to the CFO for Medicare 
Operations for submission to CMS. 
 
Due Date 
   
The analysis must be submitted by the CFO of Medicare Operations via email to the 
Division of Financial Reporting and Policy (DFRP) contact identified in the Joint 
Signature Memorandum outlining the accelerated financial reporting timeframes for 
Medicare contractor financial reports and is due the day following the submission of the 
Benefits Payable Survey by 8:00 pm Eastern Daylight Time.  If a copy of the analysis is 
signed by the CFO, scanned, and attached to the email sent to the DFRP contact, the CFO 
is not required to send the email directly.  If this date occurs on a holiday or a weekend, 
the analysis must still be submitted by this due date.  Please notify the DFRP contact if a 
problem arises. 
 
The DFRP contact will review the summary memorandums and the analysis schedules 
and may request additional explanations and/or documentation to support the Medicare 
contractors' analysis schedules. The DFRP contact will contact the Medicare contractor 
by phone to request any additional documentation needed to support existing variances.  
A response is requested as soon as possible, but no later than two days from the day of 
request. 
 
410  Unsolicited Voluntary Refunds 
 
410.1 - General Information 
(Rev. 50, 07-30-04) 
 
All Medicare contractors receive unsolicited/voluntary refunds (i.e. monies received not 
related to an open accounts receivable).   Following are detailed instructions on how to 
identify, process, track and report unsolicited/voluntary refund checks received from 
providers/physicians/suppliers, and other entities (e.g., beneficiaries, insurers, employers, 
third party administrators (TPAs), etc.).  These instructions shall not supersede other 
CMS guidance provided regarding the recovery and collection action on demanded 
debt, where an accounts receivable has already been established.  If monies are received 
and the results of a contractors investigation identify the existence of an established 
receivable, then the refund shall not be considered an unsolicited/voluntary refund 
within the context of the following instructions, and would not be reported on Exhibit 2 
of these instructions (see section 410.9). 
 
Intermediaries generally receive unsolicited/voluntary refunds from providers in the form 
of an adjustment bill, but may receive some unsolicited/voluntary refunds from providers 
and third party payers as checks.  Carriers generally receive checks from physicians, 
suppliers and third party payers.  Substantial funds are returned to the trust funds each 
year through such unsolicited/voluntary refunds. 
 
Acceptance/deposit of the voluntary refund check in no way limits the rights of the 
Federal Government or any of its agents to pursue any appropriate criminal, civil, or 
administrative remedies arising from or relating to these or any other claims. 
 
410.2 - Office of the Inspector General (OIG) Initiatives 
  (Rev. 50, 07-30-04) 
 
The OIG, working with the Department of Justice and CMS, has initiatives to help 
combat health care fraud and abuse and to encourage health care 
providers/physicians/suppliers, and other entities to comply with the rules and regulations 
of Federal health care programs.  Some of these initiatives include guidance, corporate 
integrity agreements (CIAs), and the OIG Self-Disclosure Protocol.  The OIG Self-
Disclosure Protocol is voluntary while the CIAs are mandatory.  These initiatives are 
designed to ensure that the providers/physicians/suppliers, and other entities refund 
inappropriately received Medicare monies back to the trust funds. 
 
CIAs are entered into between a health care provider/physician/supplier/other entity and 
OIG as part of a global settlement of a fraud investigation.  Under the CIA (which can be 
for a period ranging from 3 to 5 years), the provider/physician/supplier or other entity is 
required to undertake specific compliance obligations, such as designating a compliance 
officer, undergoing training, and auditing.  The provider/physician/supplier or other 
entity must report regarding their compliance activities on an annual basis to the OIG, 
which is responsible for monitoring the agreements. 
 
The OIG Self-Disclosure Protocol was produced by the OIG to provide guidance to 
health care providers/physicians/suppliers and other entities that decide to voluntarily 
disclose irregularities in their dealings with the Federal health care programs.  The 
decision to follow the OIG Self-Disclosure Protocol rests exclusively with the 
provider/physician/supplier and other entity.  The OIG Self-Disclosure Protocol is 
intended to facilitate the resolution of only matters that, in the provider/physician/supplier 
and other entitys reasonable assessment, potentially violates Federal, criminal, civil, or 
administrative laws.  It should be noted that providers/physicians/suppliers and other 
entities who self-disclose to the OIG sign an agreement stating that any refunds submitted 
as part of the self-disclosure process are not subject to appeal. 
 
410.3 - Unsolicited/Voluntary Refund Accounts 
(Rev. 50, 07-30-04) 
 
All Medicare systems shall be able to separately distinguish and track 
unsolicited/voluntary refund checks which result from a 1) provider/physician/supplier 
and other entity under a CIA; 2) Provider/physician/supplier and other entity under the 
OIG Self-Disclosure Protocol; and 3) Straight Refund (a straight refund is a refund from 
a provider/physician/supplier, or other entity who is not under a CIA nor the OIG Self-
Disclosure Protocol).  All Medicare systems shall have the ability to identify and produce 
a report that distinguishes a refund as a CIA, OIG Self-Disclosure Protocol, or straight 
refund at the point of disposition (i.e., after investigation of the origin of the refund). 
 
To assist in identifying providers/physicians/suppliers under a CIA, Medicare contractors 
should access the OIG Web site (http://www.oig.hhs.gov/fraud/cias.html) for a list of all 
providers/physicians/suppliers, and other entities under a CIA.  The OIG Web site will 
also give the effective date of the CIA.  To obtain the termination date of the CIA, click 
  on the CIA agreement.  The time period of the CIA is contained within the agreement.  If 
the Web site does not provide enough information to determine whether a CIA agreement 
is in existence, the contractor shall contact the provider as part of their 
investigation/resolution of the unsolicited/voluntary refund.  Because OIG Self-
Disclosure Protocol agreements are voluntary, contractors may not be aware of this 
agreement unless a provider/physician/suppliers or other entity specifically notifies them. 
 
Providers/physicians/suppliers under an OIG Self-Disclosure Protocol agreement are not 
given on the OIG Web site.  The OIG will send a letter directing the 
provider/physician/supplier to refund money back to the Medicare contractor when the 
OIG has completed the Self-Disclosure matter and determined that an 
unsolicited/voluntary refund should be collected rather than a civil settlement pursued.  A 
copy of the letter is included as Exhibit 3.  The OIG will also send a copy of the letter to 
the attention of the Chief Financial Officer for Medicare Operations at the Medicare 
contractor.  The OIG will direct the provider/physician/supplier to identify that the refund 
check is the result of an OIG Self-Disclosure Protocol agreement.  The 
provider/physician/supplier will have 30 days to refund the contractor.  If the contractor 
does not receive the refund within 30 days, the contractor shall notify the Office of 
Counsel to the Inspector General (OCIG) attorney assigned to the OIG Self-Disclosure 
Protocol matter, as identified in the letter. 
 
410.4 - Receiving and Processing Unsolicited/Voluntary Refund Checks 
When Identifying Information is Provided 
(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 following instructions shall not supersede the present Program Integrity Manual 
(PIM) that references procedures for handling unsolicited refunds where there is a 
voluntary repayment and referral to law enforcement.  The following procedures shall be 
followed when unsolicited/voluntary refund checks are received: 
 
1)  Do not return any check submitted by a provider/physician/supplier and other 
entities that is made payable to the Medicare program. 
 
2)  To ensure that repayment of Medicare funds is handled properly, Medicare 
contractors shall deposit such a check within 24 hours of receipt in accordance 
with Chapter 5, Financial Reporting Manual, section 100.3 and record the check 
in the account entitled Other Liabilities  Unapplied Receipts per Form CMS-
750 instructions found in Chapter 5, Financial Reporting, Section 210. 
 
  3)  If any checks are not deposited within the 24-hour period, contractors shall 
record those undeposited checks in the account entitled Assets/Cash  
Undeposited Collections per Form CMS-750 instructions found in Chapter 5, 
Financial Reporting, Section 210.  Medicare contractors shall implement 
internal controls to ensure the safeguarding of these Medicare checks until 
deposit. 
 
4)  If the specific Patient/Medicare beneficiary identifier information was provided, 
the contractor shall deposit the check and make/initiate the appropriate 
adjustments, depending on the entity making the refund and the purpose of the 
refund, either to the claims and/or to the claim history file within 60 days from 
the checks date of deposit for Non-Medicare Secondary Payer (MSP), or 100 
days from the initial ECRS inquiry for MSP.  For those contractors whose 
checks are received through a locked box, appropriate claims adjustments shall 
be updated within 60 days of receipt of the banks notification of deposit for 
Non-MSP, and 100 days from the initial ECRS inquiry for MSP. 
 
5)  If the provider/physician/supplier, or other entity is not participating in the Self-
Disclosure Protocol, contractors shall ensure that any MSN, or Remittance 
Advice, generated as the result of the claims adjustment contains appeals 
language, where appropriate.  If necessary, contractors should determine the 
proper handling of unsolicited/voluntary refunds on any open or re-openable 
cost report. 
 
6)  No appeal rights shall be afforded, as stated in Exhibit 1, if the 
provider/physician/supplier, or other entity 1) does not submit the specific 
Patient/Medicare beneficiary identifier information, or 2) is participating in a 
Self-Disclosure Protocol agreement. 
 
7)  The Medicare contractor shall establish an accounts receivable in the Medicare 
system that shall be recognized on line 2a, New Accounts Receivable on Form 
CMS-751 report within 60 days after the deposit of the voluntary refund for 
Non-MSP, or 100 days from initial ECRS inquiry for MSP.  In addition, the 
Medicare contractor shall reduce the Other Liabilities account for the same 
amount, and shall apply the refund to the established accounts receivable and 
recognize the collection on line 4a, Cash/Check Collections on Form CMS-751 
report. 
 
8)  The accounts receivable shall be established using the last name of the debtor 
that issued the check or on whose behalf the check was issued, as well as the 
debtors employer/tax identification number and/or provider or beneficiary 
number.  If the debtors employer/tax identification number or provider or 
beneficiary number is unavailable, then the first four letters of the debtors name 
and last four digits of the bank account number on the check shall be used as 
identifying information for setting up the accounts receivable.  All Medicare 
systems shall have the ability to manually complete this procedure. 
   
9)  If the amount of the unsolicited/voluntary refund check exceeds the amount of 
the original claim, Medicare contractors shall check all categories of open 
account(s) receivable for that provider/physician/supplier or other entity 
including those established as a result of medical review, benefit integrity (BI) 
review, cost reports, other overpayment demands, and MSP demands.  If an 
outstanding receivable is identified, the contractor shall apply the remaining 
amount of the unsolicited/voluntary refund to the outstanding receivable 
balance.  If there are multiple outstanding accounts receivables, then the excess 
funds should be applied to the oldest accounts receivable first  interest then 
principal. 
 
10) Medicare contractors shall not automatically refund excess recoupments to the 
provider/physician/supplier, or other entity.  Contractors shall only refund 
excess recoupments when no other outstanding accounts receivable exists, or 
written documentation/evidence clearly supports that Medicare is not entitled to 
the money or was not the intended recipient of the refund check.  Contractors 
shall follow the non-MSP provider/physician/supplier refund process when 
encountering MSP provider/physician/supplier unsolicited/voluntary refunds.  
Monies voluntarily sent in from beneficiaries (or a representative of) and/or 
insurers or other third party payers may be refunded only if COBC determines, 
after 100 days, no issue exists or an issue exists which results in the lead 
contractor identifying Medicares claim to be less than the refunded amount.  
For example, many times an attorney may remit payment for the total 
conditional amount prior to a formal demand. 
 
11) The Medicare contractor shall be responsible for completing Exhibit 1 (or 
facsimile thereof) as appropriate and reporting it on Exhibit 2. 
 
12) Contractors are not required to report the established accounts receivable on the 
Physician Supplier Overpayment Reporting System (PSOR).  (This requirement 
does not preclude the contractor from reporting the receivable on the PSOR for 
non-MSP, if current systems already do so.  The contractor shall not report MSP 
accounts receivable on the PSOR.) 
 
410.5 - Handling Checks or Associated Correspondence with 
Conditional Endorsements 
(Rev. 50, 07-30-04) 
 
Conditional endorsements are statements on the face of the check or associated 
correspondence, which might suggest that the payer has discharged its obligation by 
writing paid in full or like phrases that the payer intends as satisfaction/ extinguishment 
of the debt.  Guidelines from the General Accounting Office (GAO) state that agencies 
must be extremely careful to avoid an unintended accord and satisfaction (i.e., an 
agreement to accept a payment in full for an amount less than the amount claimed). 
 
  The following instruction shall be applied to checks or associated correspondence with a 
conditional endorsement: 
 
1)  Medicare contractors shall deposit such a check within 24 hours of receipt in 
accordance with CMSs Medicare Financial Management Manual, Chapter 5 
Financial Reporting, section 100.3 and record the check in the account entitled 
Other Liabilities  Unapplied Receipts per Form CMS-750 instructions found 
in Chapter 5, Financial Reporting, Section 210. 
 
2)  If any checks are not deposited within a 24-hour period, contractors shall record 
those checks in the account entitled Assets/Cash  Undeposited Collections 
per Form CMS-750 instructions found in Chapter 5, Financial Reporting, 
section 210.  Medicare contractors shall implement internal controls to ensure 
the safeguarding of these Medicare checks until deposit. 
 
3)  Contractors shall immediately notify the debtor and/or the entity on whose 
account the check is drawn, if not the debtor, by certified mail.  The following 
statement is suggested: This is to acknowledge the receipt of the repayment 
in the amount of $XX, check number XX.  The matter is being researched; 
however, the amount of the repayment may be insufficient to discharge the 
obligation and the debt may not be fully extinguished. 
 
4)  The check(s) shall than be processed as outlined under section 410.4 or 410.6 as 
applicable. 
 
The infrequent receipt of checks with conditional endorsements should not negatively 
impact your production process.  The standard letter needed to meet this requirement 
shall be added to your automated letter processing or generated from a personal 
computer. 
 
410.6 - Receiving and Processing Unsolicited/Voluntary Refund Checks 
When Identifying Information is not Provided 
(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. 
 
After depositing unsolicited/voluntary refund checks in accordance with section 410.4 
above, Medicare contractors shall do the following: 
 
For Non-MSP Checks 
 
  1)  If no specific Patient/Medicare beneficiary identifier information was provided 
with the unsolicited/voluntary refund, the contractor shall contact the 
provider/physician/supplier, or other entity sending the refund check for further 
information.  Exhibit 1 (overpayment refund) contains the minimum claim 
specific data necessary to process the refund.  The contractor should use this 
form during phone inquiry or attach it to a letter to the 
provider/physician/supplier requesting further information regarding the 
submitted refund. 
 
2)  When there is no identifying information provided, the contractor shall perform 
the research necessary to obtain the minimum data required to meet the 
reporting requirements in Exhibit 2 (Summary Report).  If the information is 
being collected via a telephone inquiry, the contractor employee conducting the 
inquiry shall inform the provider/physician/supplier, or other entity verbally that 
if the specific Patient/ Medicare beneficiary identifier information is not 
provided, no appeal rights can be afforded. 
 
The minimum reporting data shall include: 
 
a.  Provider/physician/supplier, or other entitys name, number, and Tax ID 
number.  
 
b.  Identification of whether the provider/physician/supplier, or other entity 
has a CIA with the OIG or are under the OIG Self-Disclosure Protocol; 
and whether it is a straight refund (i.e., a provider not under a CIA or OIG 
Self-Disclosure Protocol). 
 
c.  The reason(s) for each refund. 
 
d.  The total number of refund checks (in the case of a check with multiple 
providers/reason codes, each instance shall be counted separately). 
 
e.  The total dollar amount of refunds. 
 
3)  Medicare contractors shall have 60 days from deposit of the check to obtain the 
minimum claim specific data required to apply the check.  The contractor shall 
take at least one documented follow-up action during the 60-day period to 
obtain the data. 
 
4)  If the minimum claim specific data required to apply the refund is obtained 
from the provider/physician/supplier, or other entity within 60 days from the 
checks date of deposit, the contractor shall make/initiate any appropriate 
adjustments to the identified claims and/or the claim history file for the amount 
of the refund.  The contractor shall establish an account(s) receivable and apply 
the balance of the check to the account(s) receivable from the Other 
Liabilities account within 60 days after the deposit of the voluntary refund.  
  The contractor shall ensure that any Remittance Advice or MSN generated as a 
result of the claim adjustment contains the appropriate appeals language, if 
applicable. 
 
5)  If the minimum claim specific data required to apply the refund is not obtained 
from the provider/physician/supplier, or other entity within 60 days from the 
checks date of deposit, the Other Liabilities account shall be reduced and an 
accounts receivable due to a straight refund shall be established for the amount 
of the unapplied unsolicited/voluntary refund.  All Medicare systems shall allow 
contractors the ability to set up accounts receivable using either the 
provider/physician/supplier, or other entity or beneficiary number. 
 
6)  In both instances, the Medicare contractor shall establish an accounts receivable 
in the Medicare system that shall be recognized on line 2a, New Accounts 
Receivable on Form CMS-751 report within 60 days after the deposit of the 
voluntary refund.  In addition, the Medicare contractor shall perform a 
simultaneous transaction to apply the refund to the established accounts 
receivable and recognize the collection on line 4a, Cash/Check Collections on 
Form CMS-751 report. 
 
7)  The accounts receivable shall be established using the last name of the debtor 
identified on the check, as well as the debtors employer/tax identification 
number and/or provider or beneficiary number.  If the debtors employer/tax 
identification number or provider or beneficiary number is unavailable, then the 
first four letters of the debtors name and last four digits of the bank account 
number on the check shall be used as identifying information for setting up the 
accounts receivable.  All Medicare systems shall have the ability to manually 
complete this procedure. 
 
8)  If the amount of the unsolicited/voluntary refund check exceeds the amount of 
the original claim, Medicare contractors shall check all categories of open 
account(s) receivable for that provider/physician/supplier including those 
established as a result of medical review, BI review, cost reports, other 
overpayment demands, and MSP demands.  If an outstanding receivable is 
identified, the contractor shall apply the remaining amount of the 
unsolicited/voluntary refund to the outstanding receivable balance.  If there are 
multiple outstanding accounts receivables, then the excess funds should be 
applied to the oldest accounts receivable first  interest then principal. 
 
9)  Medicare contractors shall not automatically refund excess recoupments to the 
provider/physician/supplier, or other entity.  Contractors shall only refund 
excess recoupments when no other outstanding accounts receivable exists, or 
written documentation/evidence clearly supports that Medicare is not entitled to 
the money or was not the intended recipient of the refund check. 
 
  10) The Medicare contractor shall be responsible for ensuring the completion of 
Exhibit 1 (or facsimile thereof) and reporting it on Exhibit 2 upon final 
disposition of the unsolicited/voluntary refund (i.e., after investigation of the 
origin of the refund). 
 
11) Contractors are not required to report the established accounts receivable on the 
PSOR.  (This requirement does not preclude the contractor from reporting the 
receivable on the PSOR if current systems already do so.) 
 
For MSP Checks 
 
1)  The Medicare contractor shall determine if there is an existing case and/or 
accounts receivable.  If this is an existing case and/or accounts receivable, the 
contractor shall follow normal recovery procedures.  If there is no case and/or 
accounts receivable, and there is indication of MSP involvement, the contractor 
shall send an MSP inquiry via the Electronic Correspondence Referral System 
(ECRS) to the MSP Coordination of Benefits Contractor (COBC) within 20 
days from the checks date of deposit.  The 45-day correspondence timeframe is 
not appropriate for addressing checks either solicited or unsolicited.  
Contractors shall identify checks during the initial mail sort and place a priority 
on their resolution and distribution. When referring information to the COBC 
for MSP investigation, the contractor shall forward all pertinent data.  All 
fields on the ECRS Inquiry screen shall be completed if the data is 
available on the returned check or any accompanying correspondence.  
Information in the informant fields such as telephone numbers, point of 
contact, etc. are critical to COBC development efforts. 
 
2)  Medicare contractors shall only allow 100 days from the date of the ECRS 
inquiry for a response from the COBC before taking action with respect to the 
unapplied receipts.  This time period will also allow for the COBC to develop 
the case.  If additional information is obtained after the initial inquiry that would 
help facilitate the processing and research of information, the COBC Consortia 
Representative shall be contacted and provided the additional information, via 
fax or telephone, to assist in completing the research.  The contractor shall not 
send a second ECRS inquiry.  A total of 120 days from the checks date of 
deposit will be allowed to bring closure to the unapplied receipt. 
 
3)  If the minimum reporting information from the MSP COBC is provided within 
100 days from the initial ECRS inquiry, the contractor shall make/initiate any 
appropriate adjustments to either the identified claims and/or the claim history 
file for the amount of the refund, depending on the entity making the refund and 
the purpose of the refund.  The Medicare contractor shall establish an account(s) 
receivable and apply the balance of the check to the account(s) receivable from 
the Other Liabilities account.  If as a result of applying the voluntary refund 
the contractor identifies additional dollars specific to the issue in CWF, a 
demand letter shall be sent for the remaining amount owed. 
   
4)  If, within 100 days from the initial ECRS inquiry, 1) the minimum reporting 
information is not provided, 2) a response has not been received from the MSP 
COBC, or 3) a response from the COBC indicates they could not obtain a 
response (e.g., CM Code 62), Medicare contractors shall establish an accounts 
receivable and apply the balance of the check to the account(s) receivable from 
the Other Liabilities account.  For COBC no response codes specific to a 
provider/physician/supplier unsolicited/voluntary refund, contractors should do 
the full claim adjustment but use a non-MSP reason (i.e., billed in error), which 
would then not need an MSP record to be established on CWF.  The contractor 
shall report the refund in Exhibit 2 (Unsolicited/Voluntary Refund - Summary 
Report), and annotate with reason code 16.  In addition, Exhibit 1 and/or the 
contractors supporting documentation shall specify the refund as received with 
no reason for refund and/or no MSP response. 
 
5)  The Medicare contractor shall establish an accounts receivable in the Medicare 
system and that shall be recognized on line 2a, New Accounts Receivable on 
Form CMS-M751 report within 100 days after the initial ECRS inquiry.  In 
addition, the Medicare contractor shall perform a simultaneous transaction to 
apply the refund to the established accounts receivable and recognize the 
collection on line 4a, Cash/Check Collections on Form CMS-M751 report.  The 
contractor shall initiate normal MSP recovery action for any remaining 
outstanding balance owed. 
 
6)  The accounts receivable shall be established using the last name of the debtor 
that issued the check or on whose behalf the check was issued, as well as the 
debtors employer/tax identification number and/or provider or beneficiary 
number.  If the debtors employer/tax identification number or provider or 
beneficiary number is unavailable, then the first four letters of the debtors name 
and last four digits of the bank account number on the check shall be used as 
identifying information for setting up the accounts receivable.  All Medicare 
systems shall have the ability to manually complete this procedure. 
 
7)  If the amount of the unsolicited/voluntary refund check exceeds the amount of 
the original claim, Medicare contractors shall check all categories of open 
account(s) receivable for that provider/physician/supplier or other entity 
including those established as a result of medical review, BI review, cost 
reports, other overpayment demands. If an outstanding receivable is identified, 
the contractor shall apply the remaining amount of the unsolicited/voluntary 
refund to the outstanding receivable balance.  If there are multiple outstanding 
accounts receivables, then the excess funds should be applied to the oldest 
accounts receivable first  interest then principal. 
 
8)  Medicare contractors shall not automatically refund excess recoupments to the 
provider/physician/supplier, or other entity.  Contractors shall only refund 
excess recoupments when no other outstanding accounts receivable exists, or 
  written documentation/evidence clearly supports that Medicare is not entitled to 
the money or was not the intended recipient of the refund check.  Contractors 
shall follow the non-MSP provider/physician/supplier refund process when 
encountering MSP provider/physician/supplier unsolicited/voluntary refunds.  
Monies voluntarily sent in from beneficiaries (or a representative of) and/or 
insurers or other third party payers may be refunded only if COBC determines, 
after 100 days, no issue exists or an issue exists which results in the lead 
contractor identifying Medicares claim to be less than the refunded amount.  
For example, many times an attorney may remit payment for the total 
conditional amount prior to a formal demand. 
 
9)  The Medicare contractor shall be responsible for ensuring the completion of 
Exhibit 1 (or facsimile thereof) and reporting it on Exhibit 2 upon final 
disposition of the unsolicited/voluntary refund (i.e., after investigation of the 
origin of the refund). 
 
10) Contractors shall not report the MSP accounts receivable on the PSOR. 
 
410.7 - CMS Reporting Requirements With the Exception of MSP 
(Rev. 122, Issued: 05-25-07, Effective: 06-25-07, Implementation: 06-25-07) 
 
Contractors are exempt from including MSP unsolicited/voluntary refunds in their 
unsolicited/voluntary refund reports.  Contractors shall not make any system changes to 
exclude MSP if the system already includes MSP in the reporting based on compliance 
with the previous instructions. 
 
With the exception noted above contractors shall report, in the provided Exhibit 2 format, 
the receipt of all unsolicited/voluntary refund checks from providers/physicians/suppliers.  
The reports may be run quarterly but contractors shall only submit reports to CMS when 
requested.  All contractors shall be required to submit a negative report, when reports 
are requested, even if they have a $0 dollar reporting. 
 
NOTE: HIGLAS will supply a report upon user request. 
 
410.8 - Overpayment Refund Form 
(Rev. 50, 07-30-04) 
 
Exhibit 1 displays the required information needed to research and document 
unsolicited/voluntary refunds received.  Medicare contractors shall maintain files that 
include copies of all unsolicited/voluntary refunds received and the completed report, 
Exhibit 1.  These documents shall serve as a tracking mechanism for audit trail purposes. 
 
Contractors are not required to use Exhibit 1 verbatim; however, the alternative 
documents used shall contain, at a minimum, all of the elements outlined in Exhibit 1. 
 
410.9 - Unsolicited/Voluntary Refund Checks  Summary Report 
  (Rev. 50, 07-30-04) 
 
Exhibit 2 displays reporting requirements for all CMS unsolicited/voluntary refund 
checks.  The contractor shall report all unsolicited/voluntary refunds from 
providers/physicians/suppliers, and other entities identified on the OIG Web site, in 
addition to those that identify themselves as having a CIA, OIG Self-Disclosure Protocol, 
and/or straight refund.  The following data shall be captured: the 
provider/physician/supplier, or other entitys name(s), provider number(s) Tax ID(s), 
reason code for refund, number of refund checks, and the total dollar amount of refund 
checks.  Reason code #16 shall be used to identify that no reason was provided for the 
refund. 
 
The contractor is not required to list each check received for the quarter individually, but 
may total all the checks on one line for the same provider/physician/supplier.  Therefore, 
multiple checks for the same provider/physician/supplier when totaled shall be grouped 
by like categories for the following: 
 
1.  Same Provider/Physician/Supplier 
2.  Same Reason Code 
3.  CIA category 
4.  Self-Disclosure category 
5.  Straight Refund category 
 
Example 1: Ten checks totaling $100.00 are received from Dr. X for Reason Code 02, but 
5 checks are under a CIA and 5 checks are a straight refund. 
 
Exhibit Columns: 
 
Column 1, Provider/Physician/Supplier or Other Entity Name(s): Dr. X 
Column 2, Provider/Physician/Supplier Number(s): 99999 
Column 3, Tax ID Numbers: 9999999999 
Column 4, Reason Codes: 02 
Column 5, Line 1 CIA, SDP, Straight Refund: CIA 
Column 5, Line 2 CIA, SDP, Straight Refund: Straight Refund 
Column 6, Line 1 Total Number of Refund Checks: 5 
Column 6, Line 2 Total Number of Refund Checks: 5 
Column 7, Line 1 Total Amount of Refunds: $50.00 
Column 7, Line 2 Total Amount of Refunds: $50.00 
 
Example 2: Ten checks totaling $100.00 are received from Dr. Y, 8 checks are for 
Reason Code 02 and 5 of these checks are a CIA and 3 are a straight refund, 2 checks are 
for Reason Code 03 and 1 check is a CIA and 1 check is a straight refund. 
 
Exhibit Columns: 
 
Column 1, Provider/Physician/Supplier or Other Entity Name(s): Dr. Y 
  Column 2, Provider/Physician Supplier Number9s): 99999 
Column 3, Tax ID Numbers: 9999999999 
Column 4, Line 1 Reason Codes: 02 
Column 4, Line 2 Reason Codes: 02 
Column 4, Line 3 Reason Codes: 03 
Column 4, Line 4 Reason Codes: 03 
Column 5, Line 1 CIA, SDP, Straight Refund: CIA 
Column 5, Line 2 CIA, SDP, Straight Refund: Straight Refund 
Column 5, Line 3 CIA, SDP, Straight Refund: CIA  
Column 5, Line 4 CIA, SDP, Straight Refund: Straight Refund 
Column 6, Line 1 Total Number of Refund Checks: 5 
Column 6, Line 2 Total Number of Refund Checks: 3 
Column 6, Line 3 Total Number of Refund Checks: 1 
Column 6, Line 4 Total Number of Refund Checks: 1 
Column 7, Line 1 Total Amount of Refunds: $40.00 
Column 7, Line 2 Total Amount of Refunds: $20.00 
Column 7, Line 3 Total Amount of Refunds: $20.00 
Column 7, Line 4 Total Amount of Refunds: $20.00 
 
410.10  Education 
(Rev. 50, 07-30-04) 
 
On an annual basis, the contractor shall include in the newsletter/bulletin the following 
information:  The acceptance of a voluntary refund as repayment for the claims 
specified in no way affects or limits the rights of the Federal Government, or any of its 
agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies 
arising from or relating to these or any other claims. 
 
A provider education article related to this instruction will be available at 
http://www.cms.hhs.gov/medlearn/matters shortly after the CR is released.  You will 
receive notification of the article release via the established "medlearn matters" listserv. 
Contractors shall post this article, or a direct link to this article, on their Web site and 
include information about it in a listserv message within one week of the availability of 
the provider education article.  In addition, the provider education article must be 
included in your next regularly scheduled bulletin. 
 
411  Exhibits 
(Rev. 50, 07-30-04) 
 
411.1 - Exhibit 1  Overpayment Refund Form 
(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. 
 
SHALL BE COMPLETED BY MEDICARE CONTRACTOR 
 
Date: ________________________________   
Contractor Deposit Control # _____________Date of Deposit: _____________ 
Contractor Contact Name: ________________________  Phone #: _____________ 
Contractor Address: _________________________________________________ 
Contractor Fax: _____________________________________________________ 
________________________________________________________________________
______________ 
 
SHALL BE COMPLETED BY PROVIDER/PHYSICIAN/SUPPLIER, OR OTHER 
ENTITY 
 
Please complete and forward to your Medicare contractor.  This form, or a similar 
document containing the following information, should accompany every 
unsolicited/voluntary refund so that receipt of check is properly recorded and applied. 
 
PROVIDER/PHYSICIAN/SUPPLIER OR OTHER ENTITY NAME: 
________________________________ 
ADDRESS: _____________________________________________________________ 
PROVIDER/PHYSICIAN/SUPPLIER #: _______________ TAX ID #: 
______________ 
CONTACT PERSON: ______________________ PHONE #: _____________________ 
AMOUNT OF CHECK $: ___________ CHECK #: ___________ CHECK DATE: 
______ 
 
REFUND INFORMATION 
 
For each claim, provide the following: 
Patient Name: ____________________________ Medicare beneficiary identifier: 
_____________________ 
Medicare Claim Number: ___________________ Claim Amount Refunded $: 
_________ 
Reason Code for Claim Adjustment: _______ (Select reason code from list below.  Use 
one reason per claim.) 
 
(Please list all claim numbers involved.  Attach separate sheet, if necessary) 
Note: If Specific Patient/Medicare beneficiary identifier Amount data not available for all 
claims due to Statistical Sampling, please indicate methodology and formula used to 
determine amount and reason for overpayment: 
________________________________________ 
 
  NOTE:  If specific patient Medicare beneficiary identifier information is not provided, no 
appeal rights can be afforded with respect to this refund.  Providers/physicians/suppliers, 
and other entities who are submitting a refund under the OIGs Self-Disclosure Protocol 
are not afforded appeal rights as stated in the signed agreement presented by the OIG. 
 
For Institutional Facilities Only: 
Cost Report Year (s) ________________________ 
(If multiple cost report years are involved, provide a breakdown by amount and 
corresponding cost report year.) 
 
For OIG Reporting Requirements: 
Do you have a Corporate Integrity Agreement with OIG? ___ Yes  ___ No 
Are you a participant in the OIG Self-Disclosure Protocol? ___ Yes  ___No 
________________________________________________________________________
______________ 
 
 
Exhibit 1  Overpayment Refund Form (Cont.) 
 
Reason Codes: 
 
Billing/Clerical:      MSP/Other Payer Involvement: 
  Miscellaneous: 
 
01  Corrected Date of Service        07  MSP Group Health Plan Insurance  12  
Insufficient Doc 
02  Duplicate                                  08  MSP No Fault Insurance    13  Patient 
Enroll HMO  
03  Corrected CPT Code                09  MSP Liability Insurance    14  Svcs Not 
Rendered 
04  Not Our Patient(s)                   10  MSP, Workers Comp.      15  
Medical Necessity 
05  Mod. Add/Remove (Incl Black Lung)          16  Other-
Please Specify 
06  Billed in Error                         11  Veterans Administration 
  _____________________ 
   
411.2 - Exhibit 2 - Unsolicited/Voluntary Refund Checks Summary Report 
(Rev. 50, 07-30-04) 
 
CONTRACTORS NAME ___________________________________ 
CONTRACTORS NUMBER (S): _____________________________ 
 
REPORTING PERIOD    FROM _____________  TO ____________ 
DATE OF REPORT                _____________ 
 
(1)  (2)  (3)  (4)  (5)  (6)  (  
PROVIDER/  PROVIDER/  TAX ID  REASON  PROVIDERS/PHYSICIANS/SUPPLIE TOTAL  T    
PHYSICIAN/  PHYSICIAN/  NUMBER  CODES*  RS, AND OTHER ENTITIES  NUMBER  O    
SUPPLIER, OR OTHER  SUPPLIER  (S)  UNDER A CIA, OIG SELF- OF 
ENTITY  NUMBER(S)  DISCLOSURE OR STRAIGHT  REFUND  
NAME (S)  REFUNDS (Choose either A, B, or C  CHECKS 
  from description below 
Example 1:             
Dr. X  99999  9999999999  02  CIA  5  $  
      02  Straight Refund  5  $  
             
Example 2:             
Dr. Y  99999  9999999999  02  CIA  5  $  
      02  Straight Refund  3  $  
      03  CIA  1  $  
      03  Straight Refund  1  $  
             
             
             
            T       
 
 
 
*These codes are found on Exhibit 1 
 
A  Providers/Physicians/Suppliers and Other Entities under a CIA 
B  Providers/Physicians/Suppliers and Other Entities under OIG Self-Disclosure Protocol 
C  Straight Refunds 
 
THIS REPORT SHALL BE USED TO REPORT ALL UNSOLICITED/VOLUNTARY REFUND CHECKS 
RECEIVED DURING THIS PERIOD.  INCLUDE THOSE REPORTED ON EXHIBIT 1 FOR CIA AND OIG 
SELF-DISCLOSURE PROTOCOL PROVIDERS/PHYSICIANS/SUPPLIERS, AND OTHER ENTITIES.  
411.3 - Exhibit 3  OIG Law Enforcement Demand Letter 
(Rev. 50, 07-30-04) 
 
DEPARTMENT OF HEALTH & HUMAN SERVICES 
Office of Inspector General 
Office of Investigations 
 
              [Date] 
 
 
[Provider] 
 
 
Re: Provider Self-Disclosure 
[Provider] 
  OIG Case Number [CIMS#] 
 
Dear [---------]: 
 
We are writing to follow up on your [date of initial submission] disclosure to the Office 
of Inspector General (OIG) pursuant to the OIGs Provider Self-Disclosure Protocol.  
Based upon our review of the materials and information you furnished to us, it appears 
that [Provider] should refund [$-----] in connection with claims it submitted to 
[Medicare/Medicaid] from [-------] to [--------].  Please refund this amount to [contractor 
or state payor] within 30 days.  In addition to [Provider]s refund check, please provide 
[contractor or state payor] with the following information: (i) why the voluntary refund is 
being made (i.e., Self-Disclosure Protocol submission); (ii) how it was identified; (iii) 
what steps were taken to ensure that the issues leading to the Self-Disclosure Protocol 
submission were corrected; (iv) the dates the corrective actions were in place; (v) the time 
period and provider numbers involved in the voluntary refund; and (vi) the fact that a full 
assessment was performed to determine the entire time frame. 
 
To the extent that [Provider] seeks to receive reimbursement for underpayments 
identified in connection with its investigation of the claims described above, it is our 
understanding of CMS policy that [Provider] must resubmit those claims in accordance 
with CMSs [or state payors] policies and procedures.  Medicare Part A claims may only 
be reopened within the time limits prescribed by 42 C.F.R.  405.750.  See also 42 C.F.R. 
 405.1885.  Part B claims may only be reopened within the time limits prescribed by 42 
C.F.R.  405.841.  See generally 42 C.F.R.  405.701-.1889.  In the event that the 
applicable time limit for resubmission of [Provider]s [Part A/Part B] claims has already 
expired, the fact that [Provider] is making the refund described in the first paragraph 
above does not extend those time limits. 
 
Please provide [Special Agent Assigned] and [OCIG Attorney Assigned] with written 
confirmation of [Providers] repayment of the overpayment described above so that we 
may close our file.  Thank you for bringing this matter to our attention. 
   
 
 
Sincerely, 
 
 
          [Name of RIGI] 
          Regional Inspector General 
               for Investigations 
 
 
cc:  [OCIG Attorney Assigned] 
       [CMS Regional Office Contact Person] 
  [Contractor Benefit Integrity Manager or Coordinator] 
 
420 - Procedures for Re-issuance and Stale Dating of Medicare Checks 
(Rev. 49, Issued 07-16-04, Effective/Implementation: 08-16-04) 
 
Introduction 
 
As part of the Centers for Medicare & Medicaid Services (CMS) effort to improve 
financial reporting, we are clarifying the policy for reissuing, stale dating, and reporting 
outstanding Medicare checks.  In December 1993, CMS issued 42 Code of Federal 
Regulations (CFR) Subpart M  Replacement and Reclamation of Medicare Payments 
424.352: Intermediary and carrier checks that are lost, stolen, defaced, mutilated, 
destroyed, or paid on forged endorsements. This section provides instructions to 
Medicare contractors and will establish a standard to manage and report outstanding 
Medicare checks. 
 
Re-issuing Medicare Checks 
 
All Medicare contractors must reissue checks in accordance with 42 CFR 424.352: 
Intermediary and carrier checks that are lost, stolen, defaced, mutilated, destroyed or paid 
on forged endorsements. 
 
The provisions of this regulation require that a Medicare contractor (fiscal intermediary 
or carrier) perform certain tasks upon notification by a payee that a check has been lost, 
stolen, defaced, mutilated, destroyed or paid on forged endorsements.  These steps are as 
follows: 
 
A.  The Medicare contractor must contact the financial institution on which the 
check was drawn to determine whether the check has been negotiated. 
 
B.  If the check has been negotiated: 
 
  1.  The Medicare contractor will provide the payee with a copy of the check 
and other pertinent information (such as a claim form, affidavit or 
questionnaire to be completed by the payee) required to pursue the 
claim in accordance with State law and commercial banking regulations. 
 
2.  To pursue the claim, the payee must examine the check and certify (by 
completing the claim form, questionnaire or affidavit) that the 
endorsement is not the payees. 
 
3.  The claim form and other pertinent information are sent to the Medicare 
contractor for review and processing of the claim. 
 
4.  The Medicare contractor reviews the payees claim. If the Medicare 
contractor determines that the claim appears to be valid, it forwards the 
claim and a copy of the check to the issuing bank. The Medicare 
contractor takes further action to recover the proceeds of the check in 
accordance with State law and regulations. 
 
5.  Once the Medicare contractor recovers the proceeds of the initial check, 
the Medicare contractor issues a replacement check to the payee. 
 
6.  If the bank of first deposit refuses to settle on the check for good cause, 
the payee must pursue the claim on their own, and the Medicare 
contractor will not reissue the check to the payee. 
 
C.  If the check has not been negotiated: 
 
1.  The Medicare contractor arranges with the bank to stop payment on the 
check; and  
 
2.  Except as provided in paragraph (D) of 42 CFR 424.352, the Medicare 
contractor reissues the check to the payee. 
 
D.  No check may be reissued under (C)(2) unless the claim for a replacement 
check is received by the contractor no later than 1 year from the date of 
issuance of the original check, unless State law (including any applicable 
Federal banking laws or regulations that may affect the relevant State 
proceeding) provides a longer period which will control. 
 
Medicare contractors may receive requests for reissuance of Medicare checks that are 
older than 1 year. Based on 42 CFR 424.352 (summarized above), Medicare contractors 
should inform beneficiaries and providers/ physicians/ suppliers regarding the possibility 
that State law may provide a more favorable time frame for reissuance.  Requests for re-
issuance based on State law should be forwarded by Medicare contractors to their 
Regional Office.  The Regional Office will work with the Regional Office General 
Counsel to resolve these requests on a case-by-case basis. 
   
Medicare contractors regularly receive requests for reissuance of Medicare checks that 
are older than 1 year.  Under 42 CFR 424.352 many of these requests must be denied.  
However, 42 CFR 424.352 applies only to checks that have been lost, stolen, defaced, 
mutilated, destroyed or paid on a forged endorsement.  Accordingly, Medicare checks 
that are in the physical possession of the payee, have not been defaced or mutilated, and 
have not been negotiated are not subject to the 1 year time limit for reissuance of 42 CFR 
424.352 (d).  Therefore, if the criteria below are met, such checks may be reissued by the 
Medicare contractor even if they are older than 1 year.  The criteria are: 
 
1.  If the payee (beneficiary, physician, supplier, provider, etc.) and/or authorized 
representative can present the physical check,  
 
2  The Medicare contractor can confirm that the check was not previously 
reissued, and 
 
3  Reissuance is not barred by a Federal and/or state statute of limitations. 
 
Any questions that the Medicare contractors have regarding application of the above 
criteria should be forwarded to their Regional Office.  The Regional Office will work 
with the Regional Office General Counsel to resolve the questions. 
 
Stale Dating of Checks 
 
Medicare contractors are expected to continuously review all outstanding checks, take the 
appropriate action to stale date checks in conformance with Federal and/or State/local 
banking regulations, and adjust financial reporting for these actions. Medicare contractors 
must advise their financial institution of the change in the status of a check. 
 
Outstanding checks are checks that have been issued as payment for Medicare benefits, 
and have not been presented for payment to a financial institution and subsequently 
drawn from the Medicare trust funds.  Checks are voided by rendering them non-
negotiable either physically or by placing a stop payment on them. 
 
Stale dated checks are checks that have reached a specific age from date of issue (e.g., 1 
year from the date of issuance), and have not been presented for payment to a financial 
institution and subsequently drawn from the Medicare trust funds. Additionally, once a 
check has been stale dated and is no longer negotiable, the financial institution must be 
notified in writing. These checks should not be included in the amount reported as 
outstanding checks on Form CMS-1522 (see Financial Reporting section below). 
 
The CMS requires all Medicare contractors to have internal guidelines concerning 
procedures for stale dating checks that are consistent with these instructions. All checks, 
which reach 1 year from the date of issue and remain outstanding, must be stale dated in 
accordance with these instructions.  Medicare contractors must document their stale 
dating procedures and activities as part of their written operating policies and procedures.  
  The CMS recognizes that some Medicare contractors may be required to establish a 
different stale dating policy based on State or local banking regulations.  The Medicare 
contractor must notify CMS Regional Office (Assistant Regional Administrator (ARA) 
for Medicare Financial Management) and Central Office (Office of Financial 
Management/Accounting Management Group) in writing when these regulations exist. In 
the event that a Medicare contractor must stale date checks in less than 1 year (due to 
State or local banking regulations), that Medicare contractor must recognize and report 
the value of these checks as an Other Liability-Other on Form CMS-750 (with a 
corresponding footnote for the total amount of the checks) until 1 year from the date of 
issue, since the payee has the right to reclaim the funds. 
 
As described above, the general rule for financial reporting is that a liability will not be 
recorded for checks that have reached the age of 1 year from date of issuance.  If a 
Medicare contractor determines that application of this rule is not appropriate based on 
experience or knowledge regarding re-issuance of Medicare checks under deference to 
State law, CMS Regional Office (Regional ARA for Medicare Financial Management) 
and Central Office (Office of Financial Management/ Accounting Management Group) 
should be notified in writing so that the accounting implications are properly addressed. 
 
Undeliverable Checks 
 
Medicare providers, physicians, suppliers, and beneficiaries are responsible for providing 
the Medicare contractor with their current and accurate mailing address. 
 
The Medicare contractors must comply with the policy established by the Do Not 
Forward (DNF) Initiative. This policy requires Medicare contractors to reissue the check 
based upon the receipt of updated verified address information per Form CMS-855; and 
if no updated address information has been submitted, then Medicare contractors must 
void any returned checks. 
 
When a Medicare benefit check has been returned as undeliverable due to DNF, the 
Medicare contractor will void the check immediately and recognize and report the value 
of the check(s) as an Other Liability-Other on Form CMS-750 (with a corresponding 
footnote) until 1 year from the date of issuance, since the payee has the right to reclaim 
the funds. Checks voided due to DNF may be reissued in accordance with instructions in 
the preceding section entitled Re-issuing Medicare Checks. 
 
Financial Reporting 
 
Outstanding checks must be reported on the Monthly Contractor Financial Report, Form 
CMS-1522.  Medicare contractors must have supportable and auditable documentation to 
support balances reported. 
 
The Medicare contractors must report: 
 
  1.  The balance of all outstanding checks at the end of each month in section D  
Reconciliation and Analysis of Special Bank Account, of Form CMS-1522; 
 
2.  The amount of any liability for stale dated checks less than 1 year from the 
date of issue in the Other Liabilities section of Form CMS-750; and  
 
3.  The amount of any liability for undeliverable checks that are voided less than 
1 year from the date of issue, in the Other Liabilities section of Form CMS-
750. 
 
Medicare contractors systems must be able to obtain/maintain transaction level detail of 
outstanding checks from their financial institution(s). The Medicare contractor must 
reconcile outstanding checks monthly to Form CMS-1522 and the Medicare contractors 
bank statement. 
 
There are separate data screens for Part A, Hospital Insurance (HI), and Part B, 
Supplementary Medical Insurance (SMI) in the Contractor Administrative Budget 
Financial Management (CAFM) system. Enter outstanding checks data in both data 
screens, as appropriate. 
 
Medicare contractors must maintain an audit trail to identify and support actions taken 
regarding all (beneficiary and provider/physician/supplier) issued checks. 
 
Recording of Stale Dated/Voided Check 
 
Activity  Transaction  Debit  Credit 
Receipt of Claim  Program Expense  xxxxx   
  Accounts Payable    xxxxx 
       
Payment of Claim  Accounts Payable  xxxxx   
  Cash    xxxxx 
       
Stale Dated/Voided Check  Cash  xxxxx   
  Other Liability    xxxxx 
       
Entry after 1 year  Other Liability  xxxxx   
  Program Expense    xxxxx 
 
PROVIDER EDUCATION 
 
This information must be shared with providers/physicians/suppliers through your Web 
site within 2 weeks and published in your next regularly scheduled bulletin.  It should be 
made clear that providers/physicians/suppliers are responsible for monitoring Medicare 
reimbursement, and requesting re-issuance of Medicare checks within applicable time 
frames. Emphasize that providers/physicians/suppliers should ensure that correct address 
information is on file, and complete Form CMS-855 to update their address if necessary. 
   
500 - Procedures for the Reconciliation of Total Funds Expended for 
Fiscal Intermediary Shared System (FISS) Medicare Contractors Used 
in the Preparation of Form CMS-1522  Monthly Contractor Financial 
Report 
(Rev. 93, Issued:  04-04-06; Effective/Implementation Dates:  06-01-06) 
 
The Centers for Medicare & Medicaid Services (CMS) continues to have a material 
internal control weakness for the reconciliation of total funds expended on Form 
CMS-1522 resulting from the Chief Financial Officers Audit.  The reconciliation of total 
funds expended to adjudicated claims and standard system reports is an important control 
that ensures that the amounts reported by Medicare contractors are accurate, supported, 
complete, and properly classified. 
 
The CMS requires that Medicare contractors provide a reconciliation of total funds 
expended reported on the monthly Form CMS-1522 report by the 15th day of the 
following month.  Form CMS-1522 is a cash-based document and is prepared primarily 
from FISS system reports, bank statements, and other internal reports.  The financial 
reconciliation includes adjudicated claims processed, other non-claims based payments, 
overpayment recoveries, and other financial adjustment transactions. 
 
Total funds expended represent payments made for claim and non-claim transactions 
during each claims payment cycle (i.e., the total of all checks issued, electronic funds 
transfers (EFT) payments, voided checks, overpayment recoveries, and other financial 
adjustments).  The claims payment cycle varies at each contractor and can be daily, 
multi-weekly, or weekly. 
 
Claims data files maintained by the fiscal intermediary, produced from FISS Job 
#XXXX0054X, include all claims received and processed during a payment cycle  
adjudicated claims and non-adjudicated claims.  Adjudicated claims represent those 
claims that were processed for payment and included on the remittance advice report.  
Non-adjudicated claims do not appear on the remittance advice and include 
demonstration claims, claims returned to the quality improvement organization (QIO) or 
provider, and other exception claims.  The FISS Systems Maintainer will generate a 
detailed claims data file that includes only the adjudicated claims records processed each 
payment cycle in order for financial reporting personnel to complete the financial 
reconciliation.  Also, the FISS Systems Maintainer will generate a report that summarizes 
the number and dollar value of adjudicated claims on the detailed claims data file. 
 
Although the enclosed reconciliation format has been tested and proven adequate for 
most situations, there may be unique situations at selected contractors that result in an 
unreconciled reconciliation.  When those situations occur, the contractor should 
investigate those differences and identify the source of the difference.  The standard 
format can be adjusted to accommodate those differences so that the reconciliation and 
Form CMS-1522 can be completed.  Contractors should report those differences to CMS 
for further review and adjustment of the standard format. 
   
The lead reconciliation schedule (section 500.4) must be submitted electronically to the 
CMS.  FISS system reports, bank statements, and other internal reports used to create the 
lead reconciliation schedule must be maintained and made available upon request for 
audit and review by CMS financial personnel and other external auditors. 
 
Methodology 
 
Contractors are required to complete the financial reconciliation schedules for each 
claims processing cycle, and provide a copy of the cumulative monthly totals in the 
format established in Section 500.4.  The reconciliation should be completed at the end of 
each claims payment cycle to identify any differences as they occur and provide 
sufficient time to resolve those differences before the next cycle ends.  View Exhibit I by 
clicking on this link to access the electronic spreadsheet in Microsoft Excel format 
to complete the following steps. 
 
To complete the reconciliation for each claims payment cycle, FISS contractors must: 
 
1.  At the top of the Reconciliation Page, enter the estimated HI allocation 
percentage in cell J2.  The SMI allocation will be automatically calculated and 
entered into cell J3.  These allocation percentages are used in the calculation 
of line 6-6, Settlement Payments (including interest); line 6-10, Refund 
Provider Payments; line 6-11, Refund Other Payee Payments; and line 6-18, 
Settlement Withholdings (including interest) if the FISS contractor does not 
know the exact amounts for HI and SMI.  Although the percentage is an 
estimate, the previous method for calculating these lines using the 
inpatient/outpatient ratio created problems in Schedule E of the worksheet 
because the HI/SMI ratio would change after each cycle was entered into the 
spreadsheet.  Using this fixed HI percentage resolves those differences. 
 
2.  The FISS system maintainer will identify and summarize the adjudicated 
claims for each claims payment cycle.  The FISS system maintainer will 
create a detailed claims data file and summary report that must be retained for 
review and audit purpose (section 500.1). 
 
a.  Obtain the detailed claims data file and summary report (FISS Report 
#7859R06) from the FISS system maintainer detailed claims data file 
for each claims payment cycle. 
 
b.  Enter the detailed claims data file totals for each payment cycle onto 
reference lines 1-1 through 1-4 of the electronic spreadsheet (section 
500.3).  Separate reference lines for inpatient and outpatient have been 
added to the input schedule. 
 
c.  Obtain FISS Report #7859R01, Create Claim File Control Report, and 
enter selected data onto reference lines 2-1 through 2-8 of the 
  electronic spreadsheet (section 500.3).  The Error Records Out/Paid 
lines were removed because they are no longer populated with data. 
 
d.  Review the Tape Reconciliation Check lines on reference lines 3-1 
through 3-4.  No entries should be made to these reference lines.  
These reference lines verify the agreement of the 7859R06 and 
7859R01 reports.  The amounts on those reference lines must be 
ZERO; research any differences that are identified and make 
corrections to any of the amounts entered on reference lines 1-1 
through 2-8 and correct as appropriate. 
 
3.  Obtain copies of the primary financial FISS system reports that are used in the 
financial reconciliation process.  A list of those report numbers and report 
descriptions is included in section 500.2.  Instructions for selected line entries 
are included below, either to explain why the entry is necessary or how to 
enter the information properly. 
 
a.  Enter selected financial information from FISS system reports into the 
electronic spreadsheet (section 500.3) on reference lines 4-1 through 
18-1.  Information should only be entered into cells with a light blue 
background.  All other cells on the spreadsheet are locked to prevent 
overwriting of the formulas used to complete the reconciliation. 
 
b.  The allocation for all amounts entered on reference lines 1-1 through 
18-1 as either Part A (HI) or Part B (SMI) are determined based on the 
allocation identified on FISS system reports or by financial personnel 
who enter information from non-FISS system reports, except for the 
following reference lines with a red background. 
 
Line 6-6  Settlement Payments (including interest) 
Line 6-10  Refund Provider Payments 
Line 6-11  Refund Other Payee Payments 
Line 6-19  Settlement Withholdings (including interest) 
 
The spreadsheet has been changed to allow for entering exact amounts 
for Part A and Part B or for entering a fixed HI/SMI percentage for 
these reference lines.  See f. below for a discussion on the allocation 
or actual methodology to allocate the total amounts for these reference 
lines. 
 
c.  Obtain FISS Report #8074R01, Claim Payment Update Report  
Inpatient, and FISS Report #8074R02, Claim Payment Update Report 
 Outpatient.  Enter selected totals from those reports onto reference 
lines 4-1 through 4-6 and 5-1 through 5-2 of the electronic 
spreadsheet. 
 
  d.  Obtain FISS Report #8014R01, Financial Summary Report and enter 
selected amounts from the report onto reference lines 6-1 through 6-
23.  Reference line 6-3 was added for Pass Thru Payments at 100% 
(Part B).  Some contractors indicated that they break out Pass Thru 
Payments by Part A and Part B but there is no FISS system report that 
identifies those amounts.  Contractors should identify the amount that 
is Part B and maintain a subsidiary record of those items that are 
reported on reference line 6-3.  Ensure that the total of reference line 
6-2 and 6-3 equals the total reported on FISS report #8014R01. 
 
e.  Reference line 6-24 shows the total disbursements amount that should 
appear on FISS Report #8014R01.  If the amount on reference line 6-
24 differs from the report total amount, recheck the entries on 
reference lines 6-1 through 6-23 and correct as necessary. 
 
f.  Allocating Amounts from the #8014R01 Report.  While the electronic 
spreadsheet automatically identifies the total for each expenditure 
amount to the appropriate funding classification  Part A, hospital 
insurance (HI) or Part B, supplemental medical insurance (SMI), the 
allocation for four reference lines from the 8014R01 report cannot be 
determined from FISS system reports.  Consequently, the allocation 
for those reference lines must be determined by the contractor using 
one of the following methodologies. 
 
i.  If the contractor cannot accurately break out Part A from the 
total amounts, the spreadsheet will automatically allocate the 
amounts for four reference lines using the HI percentage that is 
entered in cell J2 of the Reconciliation page of the worksheet. 
 
ii.  If a contractor can identify the actual allocation between HI 
and SMI, then the actual amounts for Part A for the four 
reference lines should be entered on reference lines 7-1 
through 7-4, as appropriate.  The contractor only has to enter 
the amounts for those reference lines that are know, not 
necessarily all four reference lines but the contractor must 
identify those lines that are entered by placing a lower case a 
in the highlighted space preceding the description on reference 
lines 7-1 through 7-4. 
 
iii.  The spreadsheet will determine the Part B amounts for the lines 
that are used by the contractor and a checkmark  will show 
which lines they are.  Although the spreadsheet will calculate 
both the allocated amounts and the actual amount for Part A 
and Part B for each of the five reference lines, only one of the 
amounts (allocated or actual) will be used in the schedules.  
The spreadsheet uses the checkmark  to determine which 
  amounts to use and places them in reference lines 19-1 through 
19-8. 
 
g.  Obtain FISS Reports #8015R01, Part A - Penalty Withholding Report, 
and #8015R02, Part B  Penalty Withholding Report and enter 
selected amounts on reference lines 8-1 thru 8-4, respectively.  Please 
note that this section has been changed.  Only use the Penalty 
Withholding Withheld Today and Penalty Medicare Recouped 
Today amounts from these reports.  Do not use the Penalty 
Withholding Released Amount from those reports  those amounts 
are not accurate. 
 
h.  Obtain FISS Reports #8015R05, Part A - Accelerated Payment 
Withholding Report, and #8015R06, Part B  Accelerated Payment 
Withholding Report and enter selected amounts on appropriate 
reference lines in series 9 and 10.  Although accelerated payments are 
not directly provided on these reports, there is sufficient information 
on those reports to determine the dollar amount of accelerated 
payments made each cycle.  Enter the beginning and ending balances 
from the FISS reports onto the spreadsheet reference lines 9-1, 9-3, 10-
1, and 10-3 as positive numbers.  Enter the amount withheld today on 
reference lines 9-2 and 10-2 as negative numbers.  The accelerated 
payments for Part A and Part B will be calculated on reference lines 9-
4 and 10-4, respectively. 
 
i.  NOTE:  Sometimes the beginning balance for one cycle does NOT 
equal the ending balance for the prior period.  This occurs when 
an accelerated payment is not processed by FISS in the usual 
sequence and the FISS reports dont reflect the proper balances.  
To account for those differences, add any missing amounts on 
reference lines 9-5 and 10-5 as appropriate. 
 
j.  Obtain FISS Reports #8019R01, Disbursement Control Account, 
#8021R05, HPSA Check Payment Register, and #8021R06, HPSA 
EFT Payment Register.  Checks and Electronic Funds Transactions are 
made for regular payments whose transaction was processed in FISS 
and other payments for Health Professional Shortage Area (HPSA) 
payments.  Enter the regular payment amounts on reference lines 11-1 
(system checks) and 11-2 (system EFTs).  Enter the quarterly HPSA 
payments on reference lines 11-4 (HPSA checks) and 11-5 (HPSA 
EFTs).  Those amounts will be added together with any adjustments 
entered on the series 12 reference lines (see j. below) to determine the 
total net disbursements amount after adjustment for stripped checks 
and EFTs. 
 
  k.  Occasionally, financial personnel identify system checks and EFTs 
that were written for the wrong amount and those errors are identified 
before the check or EFT is sent to the provider.  Additionally, other 
CA and CB transactions are processed that need to be accounted for on 
these reference lines.  To account for those adjusting transactions, 
financial personnel strip the payment before it is issued by 
processing either a complete Part A (CA) or a complete Part B (CB) 
payment reversal transaction.  Because those reversal transactions can 
only reverse the payment amount as either a complete Part A reversal 
(CA) or as a complete Part B reversal (CB), that ultimately causes an 
imbalance in the benefit payment amounts identified in Schedule E 
(section 500.8). 
 
i.  To correct for that incorrect allocation of Part A and Part B 
benefits, the Series 12 reference lines were added.  Enter the 
total dollar value of the CA or CB amounts processed in FISS 
(checks and EFTs) on reference lines 12-1 and 12-2, 
respectively.  Likewise, when a replacement payment is 
processed as a CA or CB transaction, enter the total dollar 
value of the amounts processed in FISS (checks and EFTs) on 
reference lines 12-5 or 12-6, respectively.  Because those 
transaction amounts are included in the FISS Report #8037R01 
amounts entered on reference lines 13-1 and 13-2, but not 
included in the amounts reported on FISS Reports #8014R01 
and #8042R01 adjustments to various FISS report totals are 
made using the amounts identified on the series 12 reference 
lines. 
 
ii.  Enter the actual amounts of the CA or CB reversal adjustments 
that relate to Part A on reference line 12-3 and to Part B on 
reference line 12-4, and the actual amounts of the CA or CB 
replacement adjustments that relate to Part A on reference line 
12-7 and to Part B on reference line 12-8.  The amounts 
entered on those lines will be used to correct the 
misallocation of those transactions resulting from processing 
a CA and CB transaction.  As noted above, the reconciliation 
of total payments in Section 500.4 and the non-PIP 
reimbursements in Section 500.6 will be adjusted to reflect the 
correct Part A and Part B allocations. 
 
l.  Obtain FISS Reports #8037R01 and #8037R02, Monthly Benefits 
Reconciliation Update reports and enter selected amounts on reference 
lines 13-1 through 14-2.  Please note that the Suspended Payment 
Withheld Amounts (Part A and Part B) are no longer used because 
they include the total amount of the Penalty Withholding Withheld 
Today and Penalty Medicare Recouped Today. 
   
m. Obtain FISS Report #8042R01, Form CMS-1522 Update Report and 
enter selected interest and retroactive adjustment amounts on reference 
lines 15-1 through 15-24. 
 
n.  The remaining financial information needed to complete the 
spreadsheet is not available on FISS system reports.  The contractor 
should obtain that information from available sources, fully document 
the totals for each entry, and enter those amounts onto reference lines 
16-1 through 18-1 of the electronic spreadsheet (section 500.3). 
 
i.  The information for reference lines 16-1 through 16-15 should 
be obtained from the list of deposits processed into FISS each 
cycle.  The Total Depository Items is on reference line 16-16. 
 
ii.  Reference lines 16-1 and 16-2 should represent the portion of 
retroactive adjustments that is included in the amounts reported 
on FISS Report #8042R01.  These amounts are needed here to 
account for the deposits but these amounts are not added to the 
amounts reported in Section 500.8 to avoid duplicate counting 
of those amounts. 
 
iii.  Reference lines 16-3 through 16-15 should represent all other 
non-retroactive adjustment deposits that are not included in any 
of the 8042R01 amounts used in the spreadsheet.  The 
information on these lines should also be obtained from the list 
of deposits made to the bank account. 
 
iv.  The seven categories listed, identify the most common used by 
Medicare contractors.  The amount reported as a PIP 
repayment, reference line 16-9, is included in the PIP Payments 
total calculated for the CMS Form 1522 in Schedule E.  The 
other lines are included in the Aged category of Total 
Benefits Paid for Part A and Part B, as appropriate on Section 
500-8. 
 
v.  NOTE:  When a deposit is returned by the bank, that 
reversal should also be identified on reference lines 16-1 
through 16-15 as a positive number to ensure that 
Retroactive Adjustment, PIP Payments, and Total Benefits 
Paid for Part A and Part B are accurately calculated and 
reported in Schedule E (section 500-8). 
 
vi.  The information for reference lines 17-1 through 17-18 is 
determined from various sources, including the bank 
statements, the manual check listing, the voided and stale-dated 
  check listing, and other manually maintained listings or the 
identified FISS system reports that identify correcting financial 
transactions for the month.  Lines for each type of transaction 
are available for both Part A and Part B cycle totals. 
 
1.  The information for reference lines 17-1 through 17-8 
are available for situations that do not occur on a 
routine basis, generally related to bank problems with 
processing a payment and deposit items or for other 
correcting transactions processed by the bank. 
 
2.  The information for reference lines 17-9 through 17-12 
relate to the issuance of manual checks.  The amount 
entered on reference line 17-9 and 17-10 includes all 
manual checks that are not established using a CA or 
CB transaction and checks written for transfers 
between the disbursement and time accounts.  As stated 
above, CA and CB transactions should be posted on 
reference lines 12-5 through 12-8.  The check amount 
for transfers to the time account is entered on reference 
line 17-11.  Because the transferred amount does not 
impact total funds expended, the amount is also entered 
automatically on reference line 17-12 as a negative 
number. 
 
3.  The information for reference lines 17-13 through 17-
18 relate to stop payment checks, voided checks, and 
stale-dated checks canceled during the month that are 
identified on FISS reports #8010R01 or #8072R03, or 
other manually maintained documentation that may be 
more accurate.  These lines should only be used for 
transactions that are processed by a transaction type 
other than a CA or CB transactions.  Otherwise, the 
transaction should be included on the Series 12 
reference lines. 
 
4.  Obtain FISS Report #8047R02, and enter the amount 
of Total IBPR payments on line 18-1.  That amount 
will be compared to other financial report amounts to 
ensure that there is an agreement for the IBPR 
reconciliation.  Lines E-59 through E-69 in section 
500.8 were added to perform the IBPR reconciliation.  
Because FISS Report #8047R02 represents totals in 
whole dollars, there will always be minor differences 
to account for the rounding.  Line E-68 represents the 
  rounding amount and generally should never be a 
significant amount in excess of $10. 
 
5.  Finalize the standard reconciliation report, print the 
supporting schedules (sections 500.5 through 500.8), 
and submit the consolidated monthly report to CMS as 
part of the monthly contractor financial reports (section 
500.4). 
 
After completing the process outlined in 1. and 2. above, all of the financial 
information needed to identify total funds expended has been entered into the 
standard report format.  That information is transferred into five standard reports 
that are used to document the financial information entered onto Form 
CMS-1522.  Those reports are illustrated in sections 500.4 through 500.8 of this 
instruction. 
 
a.  After entering all of the financial information in reference lines 1-1 
through 18-1 the value of total funds expended has been determined.  The 
next step is to verify that the amount allocated by HI and SMI have been 
properly completed.  As noted above, the standard report format performs 
most of that process automatically.  To identify any potential error, review 
Column J on the electronic spreadsheet and research any entry on the 
schedule reference line A-1 through E-58 that is not ZERO.  For the 
schedules to be reconciled, all entries in Column J must be ZERO. 
 
b.  If the contractor has overridden any of the HI and SMI allocation 
formulas, extra effort should be made to ensure that the allocation amounts 
equal the total amount for those categories.  Again, the formula in Column 
J should produce a value of ZERO if the line is in balance. 
 
The standard report format in section 500.8 calculates the amounts that are 
reported on the end of the Form CMS-1522 (i.e. the categorization of total funds 
expended by payment categories). 
 
Overall Summary 
 
The methodology used to identify the number and dollar value of adjudicated claims on 
the detailed claims data file provided in section 500.1, the FISS systems reports identified 
in section 500.2, the electronic spreadsheet input schedule in Section 500.3, and the 
standard report formats provided in sections 500.4 through 500.8 are a systematic 
approach to reconcile financial activity for each claims payment cycle at Medicare FISS 
contractors. 
 
The information contained on the schedules provides a standard methodology to validate 
financial information contained on FISS system reports to the source claims information 
contained in the detailed claims data file.  The methodology outlined above and the 
  information contained on the standard report formats document a standardized approach 
to calculate and validate the total funds expended at Medicare contractors. 
 
Also, the standard report formats assist in the preparation of a significant portion of the 
Form CMS-1522.  The methodology does not provide information relating to the Funds 
Drawn from the Treasury presented on lines 1 through 6 of Form CMS-1522, or for the 
bank reconciliation information presented on Form CMS-1522, Page 2 and 3, Lines 15 
through 23. 
 
Due Date 
 
A copy of the schedule illustrated in section 500.4, Total Funds Expended (Net 
Disbursements and Adjustments to Net Disbursements), must be provided electronically 
to the appropriate CMS regional offices Associate Regional Administrator for the 
Division of Medicare Financial Management, by the 15th day of the following month, 
concurrent with the submission of other Contractor Financial Reports and submitted 
electronically to 1522recon@cms.hhs.gov.  All of the schedules illustrated in sections 
500.4 through 500.8 should be retained to support the information submitted to the 
appropriate CMS regional office. 
 
500.1  Identification and summarization of Detailed Claims Data 
Records for Use in the Financial Reconciliation of Total Funds 
Expended to Fiscal Intermediary Shared System Reports 
(Rev. 93, Issued:  04-04-06; Effective/Implementation Dates:  06-01-06) 
 
The FISS Systems Maintainer will generate a detailed claims data file for each FISS 
contractors payment cycle, produced from FISS Job #XXXX0054X.  During claims 
processing, the FISS system maintains a record of all claims processed during the 
payment cycle, including both adjudicated and non-adjudicated claims.  Adjudicated 
claims include all PIP and non-PIP reimbursement claims, and rejected and denied claims 
that can be processed by FISS.  The non-adjudicated claims include demonstration 
claims, claims that could not be processed and must be returned to either the provider or 
the Quality Improvement Organization (QIO), and other exception claims. 
 
The FISS Systems Maintainer will identify only those adjudicated claims that appear on 
remittance advices and that are identified on FISS Report #7859R01, and will record 
those claims records onto a detailed claims data file. 
 
The FISS Systems Maintainer will provide an independent report that shows the total 
number of records on the electronic file and the total dollar value for each of the 
following fields from FISS Report #7859R01: 
 
Claims Records Out/Paid - Inpatient 
Claims Records Out/Paid - Outpatient 
Claims Records Out/Modified - Inpatient 
Claims Records Out/Modified - Outpatient 
   
The fiscal intermediary will obtain the detailed claims data file and the summary report 
(FISS Report #7859R06) from the system maintainer for use in the financial 
reconciliation of total funds expended that is reported on Form CMS-1522 each month.  
The fiscal intermediary will retain the detailed data file and the summary report for each 
payment cycle in order to document the information entered onto the standard electronic 
spreadsheet and, when required, for use and review by CMS and other audit personnel. 
 
500.2  Using the Electronic Spreadsheet to Complete the Reconciliation 
of the Detailed Claims Data File to Fiscal Intermediary Shared System 
Reports. 
(Rev. 93, Issued:  04-04-06; Effective/Implementation Dates:  06-01-06) 
 
This section describes the methodology to use the electronic spreadsheet (Section 500.3) 
and identifies the primary FISS system reports needed to complete the financial 
reconciliation. 
 
The electronic spreadsheet (Exhibit 1) consists of two pages  PrintMenu and 
Reconciliation.  Each of those pages is protected to ensure that the user cannot write over 
any formulas or linked areas of the spreadsheet.  The electronic spreadsheet was created 
in Microsoft Excel 2000 and macros must be enabled.  When the spreadsheet is loaded, 
you should receive a message concerning macros.  You must Enable Macros for the 
automatic printing capability to work properly.  Following are some general rules to 
follow when using the electronic spreadsheet. 
 
Protection 
 
As noted above, the spreadsheet pages should be protected during use to avoid 
overwriting any formulas.  Press the Tab key to determine whether the page is 
protected or not.  If the page is protected, the tab key will move the cursor to the next 
unprotected cell.  If the cursor lands on a cell that should be protected  a description, 
total or non-blue cell  then the page is probably not protected. 
 
To protect the page, press Tools on the menu bar, select Protection, and then select 
Protect Sheet.  When prompted for a password, DO NOT enter a password, just press 
OK.  If it becomes necessary to unprotect the page (rare, if ever), perform the same 
process  Tools, Protection, Unprotect Sheet. 
 
Print Menu 
 
This page contains two basic functions: (1) identifying and filling in the cycle dates, and 
(2) printing the cycle and monthly reports. 
 
1.  Cycle Dates.  Generally, payment cycle dates are consistent throughout the 
year (i.e., they occur on the same calendar day(s) each week).  Consequently, 
the actual dates can be determined automatically.  At the top of the 
  PrintMenu enter the calendar year as a 4-digit number in block J4 and 
enter the month as a 1- or 2-digit number in block J5.  In blocks J2 through 
R2 enter an X for each payment cycle day during the week.  The monthly 
cycles and the cycle payment dates will automatically be identified on the left 
side of the screen in blocks A1 thru D32, including leap years.  Those 
cycle dates will also be entered onto the top of the cycle columns and the 
Month and Year will be entered on the top of the Part A and Part B columns 
on the Reconciliation spreadsheet.  When business is not conducted on a 
regularly scheduled business day, primarily for holidays, delete the X in 
blocks B2 through B32 next to the appropriate dates.  This will prevent a 
blank column being allocated on the spreadsheet for those non-work days. 
 
2.  Printing Reports.  The standard format reconciliation reports should be printed 
after each cycle to document the cycle information and the reconciliation 
process.  Pressing the left mouse button when the cursor is positioned over 
one of the buttons on the PrintMenu screen and the cursor appears as a 
pointing hand can print the reports.  There are three types of buttons for 
printing the reports. 
 
a.  Input Schedules - #X (Orange text on Grey background).  There are 
31 buttons on the left center of the screen that will print the input 
schedules for each cycle.  The report will include the reference line 
number, source and description, the total amount to date, and the cycle 
amount entered. 
 
b.  Cycle Report Schedules - Cycle XX (Sea Green text on Grey 
background).  There are 31 buttons in the right center of the screen 
that will print the five reports for each cycle.  The spreadsheet will 
accommodate up to 31 daily cycles for each month.  When selected, 
the report will print the information in Columns A thru G plus the data 
in the column for the selected cycle.  Each report will provide the 
Total Amount to Date plus the selected Cycle columns.  Because 
there is only one Total Amount to Date column, it will change after 
the data for each cycle is entered. 
 
c.  Monthly Reports - (Red/Blue text on Gray background)  There are 
six buttons on the right side of the screen that will print either all five 
of the monthly reports (Red text button) or each of the reports 
separately (Blue text buttons).  The monthly reports will print the 
information in Columns A thru J that include the total amounts for the 
month, the allocation by HI and SMI, and the Zero Check field. 
 
Reconciliation 
 
The reconciliation spreadsheet is the where most of the data is entered to complete the 
financial reconciliation of the Form CMS-1522.  As noted at the top of the page, only 
  enter data in designated cells and avoid entering data in selected unprotected cells unless 
you are sure you want to overwrite the standard formulas.  All cells with formulas or 
transferred data are locked to prevent overwriting, except those with a red background.  
Those cells contain formulas but if the contractor has more accurate information, those 
formulas can be overwritten. 
 
To complete the reconciliation, information from standard FISS system reports is entered 
into a common data input area of the Reconciliation spreadsheet (see section 500.3).  The 
data input area is located on lines 9 thru 202 the electronic spreadsheet in columns L 
through AP.  The information for individual reports is grouped together for easy input 
and is identified by references line numbers (found in Column A of the electronic 
spreadsheet) that begin with a number (for example, FISS Report #7859R01 information 
is found on reference line numbers 2-1 thru 2-12).  The standard FISS reports or other 
source documents used in the financial reconciliation, including the reference line 
numbers, are identified in the following table. 
 
Reference Lines  FISS Report Number and Report Description 
1-1 thru 1-4  FISS #7859R06  Detailed Claims Data Records Summary Report 
2-1 thru 2-8  FISS #7859R01  Claim File Control Report 
3-1 thru 3-4  Tape Reconciliation Check Lines (NO ENTRY REQUIRED) 
4-1 thru 4-6  FISS #8074R01  Claim Payment Update Report - Inpatient 
5-1 thru 5-2  FISS #8074R02  Claim Payment Update Report - Outpatient 
6-1 thru 6-24  FISS #8014R01  Financial Summary Report 
7-1 thru 7-8  Actual amounts for 4 selected lines from the #8014R01 report 
8-1 thru 8-2  FISS #8015R01  Part A  Penalty Withholding Report 
8-3 thru 8-4  FISS #8015R02  Part B  Penalty Withholding Report 
9-1 thru 9-5  FISS #8015R05  Part A  Accelerated Payment Withholding Report 
10-1 thru 10-6  FISS #8015R06  Part B  Accelerated Payment Withholding Report 
11-1 thru 11-3  FISS #8019R01  Disbursement Control Account 
11-4  FISS #8021R05  HPSA Disbursement Register 
11-5  FISS #8021R06  HPSA EFT Register 
12-1 thru 12-8  CA and CB Transaction Amounts  EFTs and Checks 
13-1 thru 13-5  FISS #8037R01  Monthly Benefits Reconciliation Update 
14-1 thru 14-2  FISS #8037R02  Monthly Benefits Reconciliation Update 
  15-1 thru 15-24  FISS #8042R01  Form CMS-1522 Update Report 
16-1 thru 16-15  List of Daily Deposits for the Month or Other Contractor Prepared Schedules 
Bank Statements  Time Account, Disbursement Account, Concentration Account 
List of Manual Checks Issued During the Month, Bank Reconciliation (non-CA/CB) 
17-1 thru 17-18 
List of Stale-Dated, Stop Payment and Voided Checks (non-CA/CB) 
List of Other Financial Adjustment Transactions Occurring During the Month 
18-1  FISS #8047R02  Monthly Intermediary Benefit Payment Report 
  Following are some general rules for using the electronic spreadsheet (Exhibit 1). 
 
1.  Entering Data.  All data must be entered into a data entry area that has 
reference line numbers in Column A that are all numeric (reference lines 1-1 
thru 18-1).  Those amounts are transferred directly into the reconciliation 
reports (reference lines A-1 thru E-58).  Consequently, you must enter data 
into each cell directly.  Do not copy and paste the amounts to different cells, 
doing so will transfer the link to the reconciliation reports and invalidate the 
process.  If you make an error in a cell, edit it using the F2 function key, 
delete the entry, or re-enter the correct amount directly. 
 
2.  Source FISS System Reports.  Column B identifies the source FISS system 
report for the data to be entered on each line of the data entry area on 
reference lines 1-1 thru 18-1.  Column B identifies the primary source FISS 
system report and alternate sources for the same data on each line of the 
reconciliation reports on reference lines A1 thru E-69. 
 
3.  BLUE Background Cells.  Enter financial data only in spreadsheet cells that 
have a BLUE background.  Cycles 1 thru 31 are in Columns L thru AP, 
respectively.  Those lines will have references in Column A that are all 
numeric (1-1 thru 18-1). 
 
4.  GRAY Background Cells.  Do not enter financial data in spreadsheet cells that 
have a GRAY background.  Those cells transfer data from other cells and the 
formulas in those cells cannot be changed without affecting the reconciliation 
process. 
5.  RED Background Cells.  Data in spreadsheet cells with a RED background 
contain formulas that allocate total amounts by HI and SMI using the ratio of 
Inpatient to Outpatient claims paid to date for the month.  Unlike the formulas 
in spreadsheet cells with GRAY backgrounds that are locked, the formulas in 
the spreadsheet cells with RED backgrounds are unlocked and can be 
overwritten.  Only write over those formulas in those cells if you have more 
accurate HI/SMI amounts that differ significantly from the amounts calculated 
by the spreadsheet formulas and only during the end of month processing.  
See the detailed instructions in Section 500, Paragraph 2.j. 
 
6.  GREEN Background Cells.  Spreadsheet cells with a GREEN background are 
check fields to ensure that the data entered from one FISS system report 
reconciles with data entered from other FISS system reports into the data entry 
section.  In all cases, the amount must be zero or the financial reconciliation 
will be unreconciled. 
 
a.  Spreadsheet lines 24 thru 27 (3-1 thru 3-4) verify the accuracy of the 
claims processing tape file reconciliation.  Any amounts other than 
zero indicate that either a wrong amount was entered or there is an 
imbalance between the tape and the FISS system report. 
  b.  Spreadsheet reference line 10-6 checks to see if there is an imbalance 
in the calculated amount of Accelerated Payments for Part A and Part 
B.  Any amount in that line indicates that either a wrong amount was 
entered in reference lines 9-1 thru 9-3 or 10-1 thru 10-3, or that a 
problem occurred with the FISS processing.  Whatever the reason for 
the difference, correcting entries need to be made on reference lines 9-
5 or 10-5. 
 
c.  Spreadsheet reference line A-43 in Section 500.4 verifies that system 
payments agree with system report disbursements. 
 
d.  Spreadsheet reference lines B-23 thru B-25 in Section 500.5 verifies 
the agreement of various Inpatient and Outpatient totals between 
several system reports.  Reference line B-36 verifies the accuracy of 
the number of inpatient and outpatient claims identified from various 
system reports. 
 
e.  Reference lines C-16 thru C-18 on the reconciliation report verify the 
accuracy of the Non-PIP payment amounts used in the financial 
reconciliation.  The amounts on those lines should be zero because the 
detailed line items supporting those amounts are adjusted for any 
CA/CB transaction adjustments for electronic funds transfers and 
checks removed on reference lines 12-1 through 12-8. 
 
f.  Reference lines D-26 thru D-31 on the reconciliation report verifies the 
accuracy of the interest amounts paid, received, and reported on 
various FISS system reports.  There may be minor difference 
identified on those lines that compare the amount on the 8037R02 
report.  Since the implementation of CELIP, the interest amounts on 
that report are not always accurate. 
 
7.  YELLOW Background Cells.  Data in spreadsheet cells with a YELLOW 
background contain either totals for cells directly above it or data transferred 
from one of the other reconciliation worksheets.  Those cells are protected and 
cannot be changed. 
   
500.3 - Electronic Spreadsheet Input Schedule 
(Rev. 93, Issued:  04-04-06; Effective/Implementation Dates:  06-01-06) 
 
This section is an illustration of the electronic spreadsheet (Exhibit 1) that will be used to input selected 
financial information from the claims processed file and FISS reports. 
   
 
 
   
500.4  Total Funds Expended (Net Disbursements and Adjustments to Net 
Disbursements) 
(Rev. 93, Issued:  04-04-06; Effective/Implementation Dates:  06-01-06) 
 
This section calculates the total system and non-system payments that equate to the Total Funds Expended 
amount report on the Form CMS-1522.  It also documents the source FISS system report used in determining 
the amounts to report.  This standard reconciliation format is the only document required to be submitted to 
CMS, in addition to monthly financial reports (Form CMS-1522). 
 
   
 
   
500.5 -- Reconciliation of Detailed Claims Data File to FISS System Reports 
(Rev. 93, Issued:  04-04-06; Effective/Implementation Dates:  06-01-06) 
 
This section shows the reconciliation of the claims process tape file to the FISS system reports and identifies the 
transactions used in reconciling those two amounts. 
 
 
   
500.6 - Reconciliation of Non-PIP Payments on FISS System Reports 
(Rev. 93, Issued:  04-04-06; Effective/Implementation Dates:  06-01-06) 
 
The non-PIP payments are identified on various FISS system reports and this section reconciles those amounts 
to ensure that the amounts are equal and consistent among those reports.  The non-PIP payment amounts are a 
key amount used in the calculation for Total Funds Expended identified in Section 500.4 above. 
 
   
500.7 - Reconciliation of Interest Received and Paid on FISS system reports 
(Rev. 93, Issued:  04-04-06; Effective/Implementation Dates:  06-01-06) 
 
The interest amount paid or received for overpayment interest or claims timeliness are identified on various 
FISS system reports and this section reconciles those amounts to identify any differences.  Differences in the 
interest amounts reported on those FISS system reports have been identified since the implementation of CELIP 
but those differences should be minor.  The financial reconciliation uses the most reliable interest amounts from 
those different reports.  Major differences should be researched and corrective action should be taken if those 
amounts are not minor. 
 
 
 
   
500.8 - Categorization of Total Funds Expended by Category 
(Rev. 93, Issued:  04-04-06; Effective/Implementation Dates:  06-01-06) 
 
This section takes the financial information that was input by the user and allocates those amounts to the various 
descriptive categories identified on the Form CMS-1522 report.  The amounts can generally be used to 
complete the Form CMS-1522 with little additional effort. 
 
   
   
510  Procedures for the Reconciliation of Total Funds Expended for 
Multi-Carrier System (MCS) Medicare Contractors Used in the 
Preparation of Form CMS-1522, Monthly Contractor Financial Report 
(Rev. 21, 08-01-03) 
 
The Centers for Medicare & Medicaid Services (CMS) continues to have a material 
internal control weakness for the reconciliation of total funds expended on Form 
CMS-1522 resulting from the Chief Financial Officers Audit.  The reconciliation of total 
funds expended to adjudicated claims and standard system reports is an important control 
that validates that the amounts reported by Medicare contractors are accurate, supported, 
and complete. 
 
The CMS requires that Medicare contractors provide a reconciliation of total funds 
expended reported on the monthly Form CMS-1522 report by the 15th day of the 
following month.  Form CMS-1522 is a cash-based document and is prepared primarily 
from MCS system reports, bank statements, and other internal reports.  The financial 
reconciliation includes adjudicated claims processed, other non-claims based payments, 
overpayment recoveries, and other financial adjustment transactions. 
 
Total funds expended represent payments made for claim and non-claim transactions 
during each claims payment cycle (i.e., the total of all checks issued, electronic funds 
transfers (EFT) payments, voided checks, overpayment recoveries, and other financial 
adjustments).  The claims payment cycle varies at each contractor and can be daily, 
multi-weekly, or weekly. 
 
All claims submitted during a payment cycle include both adjudicated claims and non-
adjudicated claims.  Adjudicated claims represent those claims that were processed for 
payment (i.e., payments, denials, or adjustments) and included on the remittance advice 
report.  Non-adjudicated claims do not appear on the remittance advice and include 
demonstration claims, returned to provider claims, and other exception claims.  Each 
MCS contractor must retain the electronic file received from the MCS Systems 
Maintainer that documents the detailed claims records that supports the MCS Summary 
Report #2002 for each payment cycle. 
 
Although the enclosed reconciliation format has been tested and proven adequate for 
most situations, there may be unique situations at selected contractors that result in an 
unreconciled difference.  When those situations occur, the contractor should investigate 
those differences and identify the source and cause for the difference.  The standard 
format can be adjusted to accommodate those differences so that the reconciliation and 
Form CMS-1522 can be completed.   Contractors should report those differences to CMS 
for further review and adjustment of the standard format. 
 
The lead reconciliation schedule (Section 510.3) must be submitted electronically to the 
applicable CMS regional office.  MCS system reports, bank statements, and other internal 
reports used to create the lead reconciliation schedule must be maintained for three years, 
   
and made available upon request for audit and review by CMS financial personnel and 
other external auditors. 
 
Methodology 
 
Contractors are required to complete the financial reconciliation schedules for each 
claims processing cycle, and provide a copy of the cumulative monthly totals in the 
format established in Section 510.3.  The reconciliation should be completed at the end of 
each claims payment cycle to identify any differences as they occur and provide 
sufficient time to resolve those differences before the next cycle ends.  View Exhibit I by 
clicking on this link to access the electronic spreadsheet in Mircrosoft Excel 
format to complete the following steps.  
 
To complete the reconciliation for each claims payment cycle, MCS contractors 
must: 
 
1.  Identify and summarize the detailed claims data file.  (Section 510.1) 
 
a.  Obtain and retain detailed claims data records that are produced by the 
MCS Systems Maintainer (Section 510.1). 
 
b.  Identify, summarize, and retain a report of the number and dollar value 
of adjudicated claims that are included on the detailed claims data file.  
Adjudicated claims include all paid, denied and adjusted claims 
processed by MCS.  The non-adjudicated claims include 
demonstration claims, claims that could not be processed and must be 
returned to either the provider or other exceptions claims.  Enter the 
first day of each month in Column A, line 38 of the electronic 
spreadsheet (Section 510.4).  For the following specific fields, enter 
the claim payments, adjustments, reissues, special issues, recoupments, 
and manual issues from the detailed claims data file for each payment 
cycle into Columns B, C, D, E, F, and H, respectively of the electronic 
spreadsheet (Section 510.5), on reference lines 71 through 101. 
 
c.  Obtain MCS Report #2002 or HBDR 2002, Financial Report Month-
To-Date Analysis of Payments, and enter the claim payments, 
adjustments, reissues, special issues, recoupments, and manual issues 
in Columns B, C, D, E, F, and H, respectively of the electronic 
spreadsheet (Section 510.6) on reference lines 105 to 135. 
 
d.  Review the daily claim and adjustment differences in Columns D and 
G, respectively, on lines 38 to 68 (Section 510.4).  The amounts on 
those lines should be ZERO; research any differences that are 
identified and make corrections to any of the amounts entered in Steps 
1b and 1c above. 
 
   
2.  Obtain financial MCS system reports for each claims processing cycle and 
enter selected data from those reports onto the electronic spreadsheet (Sections 
510.6 through Section 510.8).   The CMS will provide an electronic spreadsheet 
in Excel format.  For those contractors that have multiple sites, the electronic 
spreadsheet has separate tabs, to allow data input for up to 5 sites.  The data input 
for each site will be consolidated into a separate tab. 
 
Obtain copies of the primary financial MCS system reports that are used in the 
financial reconciliation process.  A list of those report numbers and report 
descriptions is included in Section 510.2. 
 
a.  Enter selected financial information from MCS system reports into the 
electronic spreadsheet (Sections 510.6 through Section 510.8) that have a 
yellow background and were not completed as part of Steps 1b, 1c, or 1d. 
 
b.  Review the Net Disbursements Check values in Columns F, lines 171 to 
201 (Section 510.8).  The amounts on those lines must be ZERO; research 
any differences that are identified and make corrections to any of the amounts 
entered in Step 2a above. 
 
c.  Enter financial information that is not available from MCS system reports 
onto lines 204 to 234 of the electronic spreadsheet (Section 510.9). 
 
i.  The information for refunds/deposits listed in Column E 
lines 204 to 234 (Section 510.9) generally will be supported by 
cash logs or deposit tickets that were made to record deposits to 
the contractors bank account.  These refunds/deposits are 
generally different from the recoupments generated within MCS 
claims processing system and reported on line F of the MCS 
HBDR 2002 report.  These recoupments are generally controlled 
by edits within the MCS system and represent system 
withholdings and offsets. 
 
d.  The information for voids, stale checks, and stop pays listed in Columns 
B, C, and D, lines 204 to 234 (Section 510.9) are generally supported from 
the bank statements, bank reports, the manual check listing, the voided and 
stale-dated check listing, and other manually maintained listings that identify 
correcting financial transactions for the month.  Experience has shown that 
HBSR0342, HBSR0346, and HBSR0350 can be used to report monthly 
voids, stops, and stale dates, respectively.  Enter the amount of Do Not 
Forward (DNF) checks into Column G, lines 204 to 234 (Section 510.9).  The 
amount of DNF checks for each payment cycle are generally found in 
contractor report, HBDR 6003, Provider Check Register. 
 
3.  Finalize the standard reconciliation report (Section 510.3) and submit to CMS 
as part of the monthly contractor financial reports. 
   
 
After completing the process outlined in Steps 1 and 2 above, all of the 
financial information needed to identify total funds expended should have 
been entered into the standard report format (Section 510.3) automatically. 
 
Overall Summary 
 
The methodology used to identify and summarize the detailed claims data file provided in 
Section 510.1, the MCS systems reports identified in Section 510.2, and the standard 
report format provided in Section 510.3 are a systematic approach to reconcile financial 
activity for each claims payment cycle at MCS Medicare contractors. 
 
The information contained on the attachments provides a standard methodology to 
validate financial information contained on the summary level MCS system reports to the 
detail claims data or transaction level support.  The methodology outlined above and the 
information contained on the standard report formats document a standardized approach 
to calculate and validate the total funds expended at Medicare contractors. 
 
Also, the standard report formats assist in the preparation of a significant portion of the 
Form CMS-1522.  The methodology does not provide information relating to the Funds 
Drawn from the Treasury presented on lines 1 through 6 of Form CMS-1522, or for the 
bank reconciliation information presented on Form CMS-1522, Page 2 and 3, Lines 15 
through 23. 
 
Due Date 
 
A copy of Section 510.3, Standard MCS 1522 Reconciliation Schedule, must be provided 
electronically to the appropriate CMS regional offices Associate Regional Administrator 
for the Division of Medicare Financial Management by the 15th day of the following 
month concurrent with the submission of other Contractor Financial Reports and 
submitted electronically to 1522recon@cms.gov.  All of the Sections (510.3 through 
510.9) should be retained to support the information submitted to the appropriate regional 
office. 
 
510.1 - Reconciliation of Detailed Claims Data File to Multi-Carrier 
System (MCS) Reports 
(Rev. 21, 08-01-03) 
This section provides the requirements for the detailed claims data file that the MCS 
Systems Maintainer must generate for all MCS contractors. 
 
This instruction provides a standard format to perform the reconciliation for contractors 
that use the MCS and requires the MCS Systems Maintainer to generate an electronic file 
for each contractors payment cycle, which includes all detail claim records that support 
the totals found on MCS Report #2002.  Also the MCS System Maintainer will provide 
   
an independent report that shows the total number of records on the electronic file and the 
total dollar value for each of the following fields. 
 
A.  Claim Payments 
B.  Adjustments 
C.  CPT Interest 
D.  Reissues 
E.  Special Issues 
F.  Recoupments 
G.  System Issues 
H.  Manual Issues 
I.  Total Issues 
J.  Voids 
K.  Stale Dates 
L.  Refunds 
M. Stop Pays 
N.  Net Reimbursement 
 
Each MCS Medicare contractor must enter the summary totals from each line item as 
noted above (A through N) from the detailed claims data file into the Excel spreadsheet 
(Exhibit 1).  By reconciling the summary totals from the detailed claims data file on a 
payment cycle basis, to the summary totals from MCS Report #2002, each MCS 
contractor will have assurance that the system report is supported by the detail. 
 
The detailed claims data file must be retained and made available in a format that can be 
reviewed by CMS or its external auditors. 
 
510.2 - List of Primary MCS Reports Used in the Reconciliation of Total 
Funds Expended  This section identifies the primary MCS system 
reports needed to complete the financial reconciliation. 
(Rev. 21, 08-01-03) 
 
HBDR2002 - Financial Report Month-To-Date Analysis of Payments 
HBDR2055 - EFT Transaction Report 
HBDR6000 - Register Summary Report 
HBDR6003  Provider Check Register 
HBSR0342 -  Monthly Voids 
HBSR0346 -  Monthly Stops 
HBSR0350 -  Monthly  Stale Dates 
Beneficiary Check Register 
Bank Statements  Time Account, Disbursement Account, Concentration Account 
Bank Reconciliation 
   
List of Daily Deposits for the Month 
List of Manual Checks Issued During the Month 
List of Voided and State-Dated Checks 
List of Other Financial Adjustment Transactions Occurring During the Month 
 
Comment: 
 
The EFT payments reflected on MCS HBDR2055 Report are part of the provider 
payments shown in the HBDR6000 report.  As a result, the contractor can perform a 
simple reconciliation to identify how payments were disbursed (i.e., EFT payments, 
provider check payments, and beneficiary check payments).
   
510.3 - Standard MCS 1522 Reconciliation Lead Schedule  This section calculates the total system and non-system 
payments that equate to the Total Funds Expended amount reported on the Form CMS-1522.  
(Rev. 21, 08-01-03) 
 
 
                  
          Total         
Line #      Amount  Source Document   
Description 
  Detailed Claims Data Reconciliation Activity           
                   
1  Detailed Claims Data Totals    15,810,912.00  Detailed Claims Data File/Report   
2  Detailed Adjustment Totals                
3                  
4  Subtotal       15,810,912.00  From Line 1    
5                  
6                  
7  Claim Payments per MCS    15,597,653.42  HBDR2002 Report, Line A   
8  Adjustments per MCS    215,103.80  HBDR2002 Report, Line B   
9                  
10   Subtotal      15,812,757.22  Sum of lines 7 & 8   
11                  
12   Difference    (1,845.22) Line 4 - Line 10     
                  
                  
  Detailed Claims Data and Non-Claim System Issues        
                  
13  Detailed Claims Data Totals    15,810,912.00  From Line 4     
14                  
15                  
16  Add:  Reissues      42,631.55  HBDR2002 Report, Line D   
17  Add:  Special Issues    30,670.89  HBDR2002 Report, Line E   
18  Less: Recoupments    (18,362.54) HBDR2002 Report, Line F   
19        0.00          
20  Net Disbursements (System Issues)    15,865,851.90 Sum of Lines 13, 16, 17, & 18   
21                  
22  Add:  Manual Issues    0.00 HBDR2002 Report, Line H   
23                  
24   Total Issues Per MCS  15,865,851.90 Line 20 + Line 22     
                
          
Non-System/Manual adjustments (Cash Activity) 
                  
25  Voids      (55,088.48)   Bank Recs/HBSR 0342/General ledger 
26  Stales      0.00    Bank Recs/HBSR 0350/General ledger 
   
27  Stop Pays    0.00    Bank Recs/HBSR 0346/General ledger 
28  Refunds/Deposits  (112,947.78)   Bank Recs/HBDR 2002/General ledger  
39  Journal Entry Adjustments  0.00    Adjusting journal entries   
30  Less: DNF (Do Not Forward)        HBDR6003 Report       
31         
32   Subtotal - Other Adjustments  (168,036.26) Sum of lines 25 to 30       
                 
33  Net Funds Expended Per Reconcilation  15,697,815.64  Line 25 - Line 32     
34                  
35  Net Funds Expended Per CMS-1522 Report  15,699,660.86  Form CMS-1522, Line 5D   
36                  
37   Calculated Difference  (1,845.22) Line 33 - Line 35     
                  
                
   
510.4  Reconciliation of Claim Payments from the Detailed Claims Data File/Report to the Month-to-Date Analysis of 
Payment (MCS Report #2002 or HBDR2002) - This attachment is an illustration of the electronic spreadsheet (Exhibit 
1) that will be used to input the dollar value of the specific line items from the detailed claims data file on a cycle basis. 
(Rev. 21, 08-01-03) 
 
  Section 510.4:  Reconciliation of Claim Payments from the Detailed Claims Data File/Report to the Month-to-Date Analysis of Payment (HBDR2002) 
  Col. A  Col. B  Col. C  Col. D  Col. E  Col. F  Col. G   
                 
 
    DETAILED    DAILY DIFFERENCE  DETAILED    DAILY DIFFERENCE 
 
    CLAIM PAYMENTS  CLAIM PAYMENTS  CLAIM PAYMENTS  ADJUSTMENTS  ADJUSTMENTS  ADJUSTMENTS 
 
LINE  DATE  Report Title ##  HBDR2002  (B-C)  Report Title ##  HBDR2002  (E-F) 
 
38  12/1/2002  0.00   0.00   0.00   0.00   0.00   0.00  
 
39  12/2/2002  0.00   0.00     0.00   350,782.36   (350,782.36) 
0.00    
40  12/3/2002  0.00     0.00   386,166.12   (386,166.12) 
0.00    
41  12/4/2002  0.00     0.00   504,327.28   (504,327.28) 
0.00    
42  12/5/2002  0.00     0.00   309,629.56   (309,629.56) 
0.00    
43  12/6/2002  0.00     0.00   451,525.15   (451,525.15) 
0.00    
44  12/7/2002  0.00     0.00   0.00   0.00  
0.00    
45  12/8/2002  0.00     0.00   0.00   0.00  
0.00    
46  12/9/2002  0.00     0.00   360,978.06   (360,978.06) 
0.00    
47  12/10/2002  0.00     0.00   363,366.69   (363,366.69) 
0.00    
48  12/11/2002  0.00     0.00   361,998.44   (361,998.44) 
0.00    
49  12/12/2002  0.00     0.00   352,961.21   (352,961.21) 
0.00    
50  12/13/2002  0.00     0.00   372,426.91   (372,426.91) 
0.00    
51  12/14/2002  0.00     0.00   0.00   0.00  
0.00    
52  12/15/2002  0.00     0.00   0.00   0.00  
0.00    
53  12/16/2002  0.00     0.00   299,624.59   (299,624.59) 
0.00    
54  12/17/2002  0.00     0.00   695,311.73   (695,311.73) 
0.00    
55  12/18/2002  0.00     0.00   448,313.96   (448,313.96) 
0.00    
56  12/19/2002  0.00     0.00   378,403.93   (378,403.93) 
0.00    
57  12/20/2002  0.00     0.00   391,304.93   (391,304.93) 
0.00    
58  12/21/2002  0.00     0.00   0.00   0.00  
0.00    
59  12/22/2002  0.00     0.00   0.00   0.00  
0.00    
60  12/23/2002  0.00     0.00   338,378.43   (338,378.43) 
0.00    
61  12/24/2002  0.00     0.00   0.00   0.00  
0.00    
62  12/25/2002  0.00     0.00   0.00   0.00  
0.00    
63  12/26/2002  0.00     0.00   416,537.31   (416,537.31) 
   
0.00    
64  12/27/2002  0.00     0.00   347,191.72   (347,191.72) 
0.00    
65  12/28/2002  0.00     0.00   0.00   0.00  
0.00    
66  12/29/2002  0.00     0.00   0.00   0.00  
0.00    
67  12/30/2002  0.00     0.00   286,326.18   (286,326.18) 
0.00    
68  12/31/2002  0.00     0.00   0.00   0.00  
 
69               
 
70  Totals  15,810,912.00   15,597,653.42   (1,845.22)  0.00   215,103.80   (7,415,554.56) 
                 
 
 
510.5 - Proof of Net Disbursements and Total Issues per Detailed Claims Data File/Report 
(Rev. 21, 08-01-03) 
 
This attachment is an illustration of the electronic spreadsheet (Exhibit 1) that will be used to input selected financial information from the detailed 
claims data file and MCS reports. 
 
  Section 510.5: Proof of Net Disbursements and Total Issues per Detailed Claims Data File/Report       
  Col. A  Col. B  Col. C  Col. D  Col. E  Col. F  Col. G  Col. H  Col. I 
              Net Disbursements    Total System 
              / System Issues    Issues per MCS 
    CLAIMS  ADJUSTMENTS  REISSUES  SPECIAL ISSUES  RECOUPMENTS  per Report Title##  MANUAL ISSUES  Report Title ## 
LINE  DATE  per Report Title##  per Report Title##  per Report Title##  per Report Title##  per Report Title##  (B + C + D + E - F)    (G + H) 
 
71  12/1/2002  10,912.00   0.00   0.00       0.00     0.00  
72  12/2/2002  0.00   0.00           0.00     0.00  
73  12/3/2002  0.00              0.00     0.00  
74  12/4/2002  0.00              0.00     0.00  
75  12/5/2002  13,000,000.00              0.00     0.00  
76  12/6/2002  0.00              0.00     0.00  
77  12/7/2002  0.00              0.00     0.00  
78  12/8/2002  0.00              0.00     0.00  
79  12/9/2002  0.00              0.00     0.00  
80  12/10/2002  0.00              0.00     0.00  
81  12/11/2002  0.00              0.00     0.00  
82  12/12/2002  0.00              0.00     0.00  
83  12/13/2002  0.00              0.00     0.00  
84  12/14/2002  2,000,000.00              0.00     0.00  
85  12/15/2002  0.00              0.00     0.00  
86  12/16/2002  0.00              0.00     0.00  
   
87  12/17/2002  750,000.00              0.00     0.00  
88  12/18/2002  0.00              0.00     0.00  
89  12/19/2002  50,000.00              0.00     0.00  
90  12/20/2002  0.00              0.00     0.00  
91  12/21/2002  0.00              0.00     0.00  
92  12/22/2002  0.00              0.00     0.00  
93  12/23/2002  0.00              0.00     0.00  
94  12/24/2002  0.00              0.00     0.00  
95  12/25/2002  0.00              0.00     0.00  
96  12/26/2002  0.00              0.00     0.00  
97  12/27/2002  0.00              0.00     0.00  
98  12/28/2002  0.00    215,103.80          0.00     0.00  
99  12/29/2002  0.00              0.00     0.00  
100 12/30/2002  0.00              0.00     0.00  
101 12/31/2002  0.00              0.00     0.00  
102                  
103 Totals  15,810,912.00    215,103.80   0.00   0.00   0.00  0.00       
 
   
510.6 - Proof of Net Disbursements and Total Issues Per MCS Report #2002- This attachment is an illustration of the 
electronic spreadsheet (Exhibit 1) that will be used to input selected financial information from the detailed claims 
data file and MCS reports 
(Rev. 21, 08-01-03) 
 
  Section 510.6: Proof of Net Disbursements and Total Issues per MCS Report 2002         
  Col. A  Col. B  Col. C  Col. D  Col. E  Col. F  Col. G  Col. H  Col. I 
              Net Disbursements    Total System 
              System Issues    Issues per MCS 
    Claim Payments  Adjustments  Reissues  Special Issues  Recoupments  per 2002 Rpt  Manual Issues  per 2002 Rpt 
LINE  DATE  per 2002 Rpt  per 2002 Rpt  per 2002 Rpt  per 2002 Rpt  per 2002 Rpt  (B + C + D + E - F)  per 2002 Rpt  (G + H) 
105  12/1/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
106  12/2/2002  56,837,614.91   350,782.36   0.00   0.00   19,577.76   57,168,819.51   0.00   57,168,819.51  
107  12/3/2002  28,657,694.40   386,166.12   446,167.54   31,232.72   62,446.16   29,458,814.62   0.00  29,459,715.02  
108  12/4/2002  25,836,609.72   504,327.28   458,444.77   4,215.56   24,027.84   26,779,569.49   0.00   26,779,569.49  
109  12/5/2002  1,611,374.85   309,629.56   1,621,431.99   5,486.74   6,527.87   3,541,395.27   0.00   3,541,395.27  
110  12/6/2002  36,459,555.90   451,525.15   993,362.07   6,094.26   25,019.12   37,885,518.26   0.00   37,885,518.26  
111  12/7/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
112  12/8/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
113  12/9/2002  61,886,815.20   360,978.06   151,348.03   1,990.18   55,071.84   62,346,059.63   0.00  62,420,963.57  
114  12/10/2002  6,746,915.52   363,366.69   281,943.38   4,916.06   10,154.04   7,386,987.61   0.00   7,386,987.61  
115  12/11/2002  1,560,978.91   361,998.44   412,686.95   7,019.02   9,052.52   2,333,630.80   0.00  2,333,953.99  
116  12/12/2002  1,438,627.03   352,961.21   110,819.57   22,974.50   4,249.05   1,921,133.26   0.00   1,921,133.26  
117  12/13/2002  45,570,085.67   372,426.91   424,291.27   5,656.62   26,999.81   46,345,460.66   0.00   46,345,460.66  
118  12/14/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
119  12/15/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
120  12/16/2002  54,844,402.41   299,624.59   130,391.23   348,707.86   73,868.17   55,549,257.92   0.00   55,549,257.92  
121  12/17/2002  31,679,689.47   695,311.73   201,368.02   88,705.27   37,226.64   32,627,847.85   0.00   32,627,847.85  
122  12/18/2002  24,924,910.27   448,313.96   311,922.33   283,847.01   15,539.89   25,953,453.68   0.00   25,953,453.68  
123  12/19/2002  1,730,017.16   378,403.93   161,007.85   2,533.69   4,923.56   2,267,039.07   0.00   2,267,039.07  
124  12/20/2002  38,248,499.74   391,304.93   221,290.52   18,299.27   26,548.11   38,852,846.35   0.00   38,852,846.35  
125  12/21/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
126  12/22/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
127  12/23/2002  75,308,262.54   338,378.43   355,736.19   4,717.85   61,550.75   75,945,544.26   0.00   75,945,544.26  
128  12/24/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
129  12/25/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
130  12/26/2002  25,424,150.73   416,537.31   141,062.01   2,293.54   24,470.26   25,959,573.33   0.00   25,959,573.33  
131  12/27/2002  38,298,027.24   347,191.72   254,271.45   2,661.11   21,756.08   38,880,395.44   0.00  38,880,436.54  
132  12/28/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
   
133  12/29/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
134  12/30/2002  75,414,126.51   286,326.18   132,848.84   1,521.28   95,808.02   75,739,014.79   0.00  75,739,039.82  
135  12/31/2002  0.00   0.00   0.00   0.00   0.00   0.00   0.00   0.00  
136                   
137  Totals  15,597,653.42   215,103.80  42,631.55   30,670.89   (18,362.54)   15,865,851.90  0.00   647,018,555.46  
                            
 
   
510.7 - Reconciliation of Net Disbursements and System Issues from the Detailed Claims Data File/Report to the 
Month-to-Date Analysis of Payment (HBDR2002) - This attachment is an illustration of the electronic spreadsheet (Exhibit 1) that will 
be used to input selected financial information from the detailed claims data file and MCS reports. 
(Rev. 21, 08-01-03) 
 
  Section 510.7: Reconciliation of Net Disbursements and System Issues from the Detailed Claims Data File/Report to the Month-to-Date    
   Analysis of Payment (HBDR2002) 
  Col. A  Col. B  Col. C  Col. D  Col. E  Col. F  Col. G 
    Net Disbursements  Net Disbursements         
    System Issues  System Issues  DAILY DIFFERENCE  Total Issues  Total Issues  DAILY DIFFERENCE 
    (Col. G)  (Col. G)  DISBURSEMENTS  (Col. I)  (Col. I)  ISSUES 
LINE  DATE  Report Title ##  HBDR2002  (B-C)  Report Title ##  HBDR2002  (E-F) 
138  12/1/2002  0.00   0.00   0.00   0.00   0.00   0.00  
139  12/2/2002  0.00   57,168,819.51   (57,168,819.51)  0.00   57,168,819.51   (57,168,819.51) 
140  12/3/2002  0.00   29,458,814.62   (29,458,814.62)  0.00   29,459,715.02   (29,459,715.02) 
141  12/4/2002  0.00   26,779,569.49   (26,779,569.49)  0.00   26,779,569.49   (26,779,569.49) 
142  12/5/2002  0.00   3,541,395.27   (3,541,395.27)  0.00   3,541,395.27   (3,541,395.27) 
143  12/6/2002  0.00   37,885,518.26   (37,885,518.26)  0.00   37,885,518.26   (37,885,518.26) 
144  12/7/2002  0.00   0.00   0.00   0.00   0.00   0.00  
145  12/8/2002  0.00   0.00   0.00   0.00   0.00   0.00  
146  12/9/2002  0.00   62,346,059.63   (62,346,059.63)  0.00   62,420,963.57   (62,420,963.57) 
147  12/10/2002  0.00   7,386,987.61   (7,386,987.61)  0.00   7,386,987.61   (7,386,987.61) 
148  12/11/2002  0.00   2,333,630.80   (2,333,630.80)  0.00   2,333,953.99   (2,333,953.99) 
149  12/12/2002  0.00   1,921,133.26   (1,921,133.26)  0.00   1,921,133.26   (1,921,133.26) 
150  12/13/2002  0.00   46,345,460.66   (46,345,460.66)  0.00   46,345,460.66   (46,345,460.66) 
151  12/14/2002  0.00   0.00   0.00   0.00   0.00   0.00  
152  12/15/2002  0.00   0.00   0.00   0.00   0.00   0.00  
153  12/16/2002  0.00   55,549,257.92   (55,549,257.92)  0.00   55,549,257.92   (55,549,257.92) 
154  12/17/2002  0.00   32,627,847.85   (32,627,847.85)  0.00   32,627,847.85   (32,627,847.85) 
155  12/18/2002  0.00   25,953,453.68   (25,953,453.68)  0.00   25,953,453.68   (25,953,453.68) 
156  12/19/2002  0.00   2,267,039.07   (2,267,039.07)  0.00   2,267,039.07   (2,267,039.07) 
157  12/20/2002  0.00   38,852,846.35   (38,852,846.35)  0.00   38,852,846.35   (38,852,846.35) 
158  12/21/2002  0.00   0.00   0.00   0.00   0.00   0.00  
159  12/22/2002  0.00   0.00   0.00   0.00   0.00   0.00  
160  12/23/2002  0.00   75,945,544.26   (75,945,544.26)  0.00   75,945,544.26   (75,945,544.26) 
161  12/24/2002  0.00   0.00   0.00   0.00   0.00   0.00  
162  12/25/2002  0.00   0.00   0.00   0.00   0.00   0.00  
163  12/26/2002  0.00   25,959,573.33   (25,959,573.33)  0.00   25,959,573.33   (25,959,573.33) 
164  12/27/2002  0.00   38,880,395.44   (38,880,395.44)  0.00   38,880,436.54   (38,880,436.54) 
   
165  12/28/2002  0.00   0.00   0.00   0.00   0.00   0.00  
166  12/29/2002  0.00   0.00   0.00   0.00   0.00   0.00  
167  12/30/2002  0.00   75,739,014.79   (75,739,014.79)  0.00   75,739,039.82   (75,739,039.82) 
168  12/31/2002  0.00   0.00   0.00   0.00   0.00   0.00  
169              
170 Totals  0.00   15,865,851.90   (646,942,361.80)  0.00   647,018,555.46   (647,018,555.46) 
 
   
510.8 - Proof of Net Disbursement per MCS Register Summary Report (HBDR6000) to the Month-to-Date Analysis of 
Payments (HBDR2002 Report, Line G)- This attachment is an illustration of the electronic spreadsheet (Exhibit 1) that will be used to 
input selected financial information from the detailed claims data file and MCS reports. 
(Rev. 21, 08-01-03) 
 
  Section 510.8: Proof of Net Disbursement per MCS Register Summary Report 
(HBDR6000)   
  to the Month-to-Date Analysis of Payments (HBDR2002 Report, Line 
G)     
  Col. A  Col. B  Col. C  Col. D  Col. E  Col. F  Col. G 
          Net Disbursement     
    Provider  Beneficiary    (System Issues)     
    Amounts Per  Amounts Per  Total Amounts  HBDR2002 Line G /   Differences   
LINE DATE  HBDR6000  HBDR6000  (B + C)  Detail Data Report  (D - E)  REASON 
171  12/1/2002  0.00   0.00   0.00   0.00   0.00    
172  12/2/2002  56,797,987.94   370,831.57   57,168,819.51   57,168,819.51   0.00    
173  12/3/2002  29,260,656.54   198,158.08   29,458,814.62   29,458,814.62   0.00    
174  12/4/2002  26,639,387.24   140,182.25   26,779,569.49   26,779,569.49   0.00    
175  12/5/2002  3,517,320.61   24,074.66   3,541,395.27   3,541,395.27   0.00    
176  12/6/2002  37,581,035.44   304,482.82   37,885,518.26   37,885,518.26   0.00    
177  12/7/2002  0.00   0.00   0.00   0.00   0.00    
178  12/8/2002  0.00   0.00   0.00   0.00   0.00    
179  12/9/2002  62,035,371.68   310,687.95   62,346,059.63   62,346,059.63   0.00    
180  12/10/2002  7,304,404.76   82,582.85   7,386,987.61   7,386,987.61   0.00    
181  12/11/2002  2,307,689.22   25,941.58   2,333,630.80   2,333,630.80   0.00    
182  12/12/2002  1,887,402.09   33,731.17   1,921,133.26   1,921,133.26   0.00    
183  12/13/2002  45,991,947.26   353,513.40   46,345,460.66   46,345,460.66   0.00    
184  12/14/2002  0.00   0.00   0.00   0.00   0.00    
185  12/15/2002  0.00   0.00   0.00   0.00   0.00    
186  12/16/2002  55,267,001.36   282,256.56   55,549,257.92   55,549,257.92   0.00    
187  12/17/2002  32,468,909.40   158,938.94   32,627,848.34   32,627,847.85   0.49    
188  12/18/2002  25,867,280.72   86,172.96   25,953,453.68   25,953,453.68   0.00    
189  12/19/2002  2,233,805.64   33,233.43   2,267,039.07   2,267,039.07   0.00    
190  12/20/2002  38,529,814.78   323,031.57   38,852,846.35   38,852,846.35   0.00    
191  12/21/2002  0.00   0.00   0.00   0.00   0.00    
192  12/22/2002  0.00   0.00   0.00   0.00   0.00    
193  12/23/2002  75,527,135.84   418,408.42   75,945,544.26   75,945,544.26   0.00    
194  12/24/2002  0.00   0.00   0.00   0.00   0.00    
195  12/25/2002  0.00   0.00   0.00   0.00   0.00    
   
196  12/26/2002  25,872,664.06   86,909.27   25,959,573.33   25,959,573.33   0.00    
197  12/27/2002  38,612,629.55   267,765.89   38,880,395.44   38,880,395.44   0.00    
198  12/28/2002  0.00   0.00   0.00   0.00   0.00    
199  12/29/2002  0.00   0.00   0.00   0.00   0.00    
200  12/30/2002  75,266,723.33   472,291.46   75,739,014.79   75,739,014.79   0.00    
201  12/31/2002  0.00   0.00   0.00   0.00   0.00    
202               
203  Totals  642,969,167.46   3,973,194.83   646,942,362.29   646,942,361.80   0.49   
               
 
   
510.9 - Input Sheet for Cash Activity Items - This attachment is an illustration of the electronic 
spreadsheet (Exhibit 1) that will be used to input selected financial information that is not available from 
MCS system reports. 
(Rev. 21, 08-01-03) 
 
Section 510.9: Input Sheet for Cash Activity Items        
  Col. A  Col. B  Col. C  Col. D  Col. E  Col. F  Col. G 
            Journal Entry   
LINE  DATE  Voids  Stale Checks  Stop Pays  Refunds/Deposits  Adjustments  Do Not Forward 
204  12/1/2002  0.00   0.00   0.00   0.00   0.00    
205  12/2/2002  0.00   14,703.51   0.00   210,449.81   0.00    
206  12/3/2002  411,354.19   0.00   67,887.51   122,233.34   0.00    
207  12/4/2002  486,321.97   0.00   54.98   70,959.51   0.00    
208  12/5/2002  1,634,262.78   0.00   243.45   169,532.86   0.00    
209  12/6/2002  987,998.85   0.00   9,652.67   67,502.88   0.00    
210  12/7/2002  0.00   0.00   0.00   0.00   0.00    
211  12/8/2002  0.00   0.00   0.00   0.00   0.00    
212  12/9/2002  154,369.09   0.00   9,346.12   206,965.75   0.00    
213  12/10/2002  263,936.94   0.00   25,719.05   79,635.48   0.00    
214  12/11/2002  408,658.22   0.00   12,780.47   96,806.14   0.00    
215  12/12/2002  91,313.72   0.00   25,012.61   58,085.88   0.00    
216  12/13/2002  420,237.34   0.00   5,594.63   133,095.66   0.00    
217  12/14/2002  0.00   0.00   0.00   0.00   0.00    
218  12/15/2002  0.00   0.00   0.00   0.00   0.00    
219  12/16/2002  126,330.56   0.00   25,884.59   99,784.51   0.00    
220  12/17/2002  200,225.96   0.00   2,460.61   93,383.17   0.00    
221  12/18/2002  322,815.37   0.00   114,260.96   51,931.80   0.00    
222  12/19/2002  173,552.81   0.00   5,989.32   116,754.07   0.00    
223  12/20/2002  144,426.08   0.00   78,315.05   134,309.62   0.00    
224  12/21/2002  0.00   0.00   0.00   0.00   0.00    
225  12/22/2002  0.00   0.00   0.00   0.00   0.00    
226  12/23/2002  372,536.52   0.00   0.00   396,332.04   0.00    
227  12/24/2002  0.00   0.00   0.00   0.00   0.00    
228  12/25/2002  0.00   0.00   0.00   0.00   0.00    
229  12/26/2002  136,346.03   0.00   4,980.70   128,880.21   0.00    
230  12/27/2002  278,585.61   0.00   41.10   128,987.55   0.00    
231  12/28/2002  0.00   0.00   0.00   0.00   0.00    
232  12/29/2002  0.00   0.00   0.00   0.00   0.00    
233  12/30/2002  133,114.31   0.00   0.00   93,635.05   0.00    
234  12/31/2002  0.00   0.00   0.00   0.00   0.00    
235               
236  Totals  (55,088.48)   0.00   0.00   112,947.78   0.00   0.00  
   
520  Instructions for Completion of the Contractors Monthly Bank 
Reconciliation Worksheet 
(Rev. 125; Issued:  06-29-07; Effective/Implementation Dates:  07-30-07) 
 
BACKGROUND 
 
Before conversion to the Healthcare Integrated General Ledger Accounting System 
(HIGLAS), Medicare Contractors (MC) were required to file the Centers for Medicare & 
Medicaid Services (CMS) Form CMS 1521, Contractor Draws on Letter of Credit, and 
the Form CMS 1522, Monthly Contractor Financial Report each month via the 
Contractor Accounting and Financial Management System (CAFM).  These reports are 
designed to provide a reconciliation of Medicare program cash benefit payments between 
CMS, the contractors, and the contractors bank.  After conversion to HIGLAS, 
transactions are integrated into the general ledger and those reports are no longer needed. 
 
For non-HIGLAS MCs, the Form CMS 1521 reports the amount of payment vouchers 
drawn during the month, which is an aggregate total of funds drawn down from the 
Federal Reserve by the contractors bank each day during the month.  The draw downs 
are used to fund Medicare benefit payments and are based on current benefit payment and 
overpayment activity.  In HIGLAS, the draws are recorded directly into the general 
ledger in account 119504, OTR Mon Aset-Contr LOC Dep. 
 
For non-HIGLAS MCs, the Form CMS 1522 reports all monthly paid claim (i.e., benefit 
payments) and non-claim transactions (i.e. periodic interim payments (PIP), accelerated 
payments, settlement payments, interest income, and expenses) which, when netted, 
account for total funds expended for the month.  At the contractor level, total funds 
expended is the sum of all checks drawn and electronic fund transfer payments issued 
during the calendar month less voided checks, overpayment recoveries, and other 
adjustments as necessary.  CMS uses certain information from this report to prepare its 
financial statements. 
 
The Contractors Monthly Bank Reconciliation Worksheet (Worksheet) is designed to 
provide a monthly reconciliation of the Medicare Contractors benefit and time account 
activity to the CMS Monthly Balance Sheet and Summary 2 Trial Balance. 
 
In HIGLAS, The Medicare Contractor bank reconciliation process is comprised of 
reconciling the bank cleared check payments, the bank settled EFT payments, Zero 
Dollar payments (Checks and EFTs) and creating and reconciling miscellaneous 
transactions.  The claim payments are adjudicated in the shared system (FISS and MCS) 
and interfaced into HIGLAS.  Payments are processed in HIGLAS and the relevant 
payment and remittance information is sent to the shared systems.  The bank cleared 
check payments, bank settled EFT payments, Zero Dollar payments, and miscellaneous 
transactions are maintained for each bank account in a separate bank statement for each 
day. 
 
DUE DATE 
   
 
Contractor shall provide a copy of the Worksheet electronically to the appropriate CMS 
regional office Associate Regional Administrator (ARA) for the Division of Medicare 
Financial Management by the 15th day of the following month and shall be submitted 
electronically to Higlasbankrecon@cms.hhs.gov.  All bank statements and other internal 
reports used to complete the Worksheet shall be maintained for three years and made 
available upon request for audit and review by CMS financial personnel and other 
external auditors.    Internal reports may be saved as text files. 
 
Section A.  Bank Statement and Cash Balance 
 
This section is to determine the total end-of-the-month cash balance using the bank 
statement(s) from the Benefits Account and the Time Account. 
 
Line 1.  Balance Beginning of the Month (Benefits Account).  Contractor shall 
enter the balance in the Benefits Account as of the beginning of the calendar 
month as shown on the bank statement. 
 
Line 1a.  Add:  Line of Credit Draws.  Contractor shall enter the total amount of 
funds drawn on payment vouchers during the month and credited to the Benefits 
Account as shown on the bank statement. 
 
Line 1b.  Cash Deposits.  Contractor shall enter all other deposits credited during 
the month to the Benefits Account as shown on the bank statement. 
 
Line 1c.  Transfer In From Time Account.  Contractor shall include funds 
withdrawn from the Time Account and deposited in the Benefits Account. 
 
Line 1d.  Miscellaneous Add Backs (Briefly explain in Section ERemarks in 
the area labeled Section A, Line 1d) Contractor shall enter any miscellaneous 
adjustments, i.e., credit memos, to the Benefits Account during the calendar 
month. 
 
Line 1e.  Total Additions.  This is the total of Lines 1a through 1d.  Contractor 
shall make no entry on this line. 
 
Line 1f.  Less:  Checks Honored By Bank.  Contractor shall enter the total funds 
charged to the Benefits Account as a result of checks honored by the bank during 
the month.  Transfers to the Time Account shall be excluded from this total. 
 
Line 1g.  EFTs.  Contractor shall enter the electronic funds transferred by the 
bank during the month.  Transfers to the Time Account shall be excluded from 
this total. 
 
   
Line 1h.  Transfer Out To Time Account.  Contractor shall enter only amount 
of funds withdrawn from the Benefits Account and deposited in the Time Account 
during the month. 
 
Line 1i.  Miscellaneous Deductions (Briefly explain in Section ERemarks in 
the area labeled Section A, Line 1i).  Contractor shall enter any miscellaneous 
adjustments, i.e., debit memos, and charges made to the Benefits Account that are 
part of the bank statement. 
 
Line 1j.  Total Deductions.  This is the total of Lines 1f through 1i.  Contractor 
shall make no entry on this line. 
 
Line 2.  Balance End of Month Per Bank Statement(s) - This is the total of 
Lines 1 + 1e  1j.  Contractor shall make no entry on this line. This total shall 
equal the balance of the bank statement(s) for the Benefit Account(s) at month-
end. 
 
Line 2a.  Add: Deposits-In-Transit - Contractor shall enter deposits made and 
recorded in the General Ledger during the month that the bank has not yet 
credited to the Benefits Account according to the bank statement. 
 
Line 3.  Adjusted Bank Balance (Benefits Account) - (Explain in Section E
Remarks, Other, if not equal to Section B, Line 1a, Col D) This is the total of 
Lines 2 + 2a.  Contractor shall make no entry on this line.  This total should equal 
the Benefits Account per the balance sheets as summarized in Section B, Line 1a, 
Column D.  Contractor shall explain any difference. 
 
Line 4. Beginning Balance (Time Account) - Contractor shall enter the balance 
in the Time Account as of the beginning of the calendar month. 
 
Line 4a.  Add: Transfer In From Benefits Account - Contractor shall include 
funds withdrawn from the Benefits Account and deposited in the Time Account. 
 
Line 4b.  Less: Transfer Out To Benefits Account - Contractor shall enter only 
amount of funds withdrawn from the Time Account and deposited in the Benefits 
Account during the month. 
 
Line 5.  Ending Balance (Time Account) - (Explain in Section ERemarks, 
Other, if not equal to Section B, Line 1b, Col D) This is the total of Lines 4 + 
4a  4b.  Contractor shall make no entry on this line. This total should equal the 
Time Account per the balance sheets as summarized in Section B, Line 1b, 
Column D.  Contractor shall explain any difference. 
 
Line 6.  Add: Un-deposited Collections - (Explain in Section ERemarks, 
Other, if not equal to Section B, Line 1c, Col D) Contractor shall enter 
collections received during the month, but not yet recorded as unapplied receipts 
   
in HIGLAS and not yet deposited in the Benefits Account. This line should equal 
the Un-deposited Collections per the balance sheets as summarized in Section B, 
Line 1c, Column D.  Contractor shall explain any difference. 
 
Line 7.  Adjusted Bank Statement Cash Balance - This is the total of Lines 3 + 
5 + 6, the adjusted ending balance of the Benefits Account, the ending balance of 
the Time Account and the balance of the Un-deposited Collections.  This balance 
should reconcile to the Total Cash per the balance sheets as summarized in 
Section B, Line 2, Column D.  Contractor shall make no entry on this line. 
 
Section B.  Balance Sheet & Summary 2 Trial Balance 
 
This section summarizes the cash balances for the General Fund (050720), the SMI Trust 
Fund (050960), and the HI Trust Fund (050961) using the corresponding end-of-the-
month Balance Sheets and Summary 2 Trial Balances for each fund.  Contractor shall 
compare these cash balances to the Adjusted Bank Statement Cash Balance computed in 
Section A and verify that the total cash ending balance for the month reflected in the 
General Ledger is properly reported in the Balance Sheets for the three funds 
respectively.  The Total amount for each line item is automatically computed after the 
required amounts are entered for each of the three funds. 
 
Line 1.  Balance Sheet (Title) 
 
Line 1a.  Total Benefits Account - Using the three Balance Sheets, contractor 
shall enter the Total Benefits Account ending balance for each corresponding 
fund. 
 
Line 1b.  Total Time Account - Using the three Balance Sheets, contractor shall 
enter the Total Time Account ending balance for each corresponding fund. 
 
Line 1c.  Un-deposited Collections - Using the three Balance Sheets, contractor 
shall enter the Un-deposited Collections ending balance for each corresponding 
fund. 
 
Line 2. Total Cash (Per Balance Sheet) - This is the total of Lines 1a + 1b + 1c.  
Contractor shall make no entry on this line.   
 
Line 3. Summary 2 Trial Balance (Title) 
 
Line 3a.  119502 Other Mon Asset-Disb Contrl - Using the three Summary 2 
Trial Balances, contractor shall enter the ending balance from this GL account for 
each corresponding fund. 
 
Line 3b.  119503 Other Mon Asset-Contr Deposit - Using the three Summary 2 
Trial Balances, contractor shall enter the ending balance from this GL account for 
each corresponding fund. 
   
 
Line 3c.  119504 Other Mon Asset-LOC - Using the three Summary 2 Trial 
Balances, contractor shall enter the ending balance from this GL account for each 
corresponding fund. 
 
Line 3d.  119505 Other Mon Asset-Tsf Frm/To Time - Using the three 
Summary 2 Trial Balances, contractor shall enter the ending balance from this GL 
account for each corresponding fund. 
 
Line 3e.  119520 Other Mon Asset-YE Rollover - Using the three Summary 2 
Trial Balances, contractor shall enter the ending balance from this GL account for 
each corresponding fund. 
 
Line 4.  Total Benefits Account Cash Balance - This is the total of Lines 3a 
through 3e.  Contractor shall make no entry on this line. 
 
Line 4a.  119002 Other Cash-Time Account - Using the three Summary 2 Trial 
Balances, contractor shall enter the ending balance from this GL account for each 
corresponding fund. 
 
Line 4b.  111002 Un-deposited Collections - Using the three Summary 2 Trial 
Balances, contractor shall enter the ending balance from this GL account for each 
corresponding fund. 
 
Line 5.  Total Cash (Per Summary 2 Trial Balance) - This is the total of Lines 
4 + 4a + 4b.  Contractor shall make no entry on this line. 
 
Section C. Cash Reconciliation - Bank Statement, Balance Sheet & Summary 2 Trial 
Balance 
 
This section is a comparison of the cash balances of the Summary 2 Trial Balance, 
balance sheets and the adjusted bank statement cash balance as computed in Section A of 
the Worksheet. 
 
Line 1.  Cash Balance (per Summary 2 Trial Balance)  The amount for this 
line is equal to Section B, Line 5, Column D of the Worksheet, Total Cash per the 
Summary 2 Trial Balance.   The cell reference for this value has been placed on 
this line.  Contractor shall make no entry. 
 
Line 2.  Less: Adjusted Bank Statement Cash Balance  The amount for this 
line is equal to Section A, Line 7, Column B of the Worksheet, Adjusted Bank 
Statement Cash Balance.  The cell reference for this value has been placed on this 
line.  Contractor shall make no entry. 
 
Line 3.  Net Difference  The template computes the difference between Line 1 
and Line 2 amounts.  Contractor shall make no entry on this line.  Ordinarily, 
   
there should be no difference between total cash as computed from the Summary 
2 Trial Balance account balances and the adjusted bank statement cash balance as 
computed in Section A.  If there is a difference, the contractor shall briefly 
explain the difference in Section E. Remarks in the area labeled Section C, Line 3. 
 
Line 4.  Cash Balance (Per Summary 2 Trial Balance)  The amount for this 
line is equal to Section B, Line 5, Column D of the Worksheet, Total Cash (per 
Summary 2 Trial Balance).  The cell reference for this value has been placed on 
this line.  Contractor shall make no entry. 
 
Line 5.  Less: Cash Balance (Per Balance Sheet) - The amount for this line is 
equal to Section B, Line 2, Column D of the Worksheet, Total Cash (Per Balance 
Sheet).   The cell reference for this value has been placed on this line.  Contractor 
shall make no entry. 
 
Line 6.  Net Difference  The template computes the difference between Line 4 
and Line 5 amounts.  Contractor shall make no entry on this line.  Ordinarily, 
there should be no difference between total cash as computed from the Summary 
2 Trial Balance account balances and the Total Cash (Per Balance Sheet).  If there 
is a difference, the contractor shall briefly explain the difference in Section E. 
Remarks in the area labeled Section C, Line 6. 
 
Section D. Disbursements in Transit 
 
Disbursements in Transit is the HIGLAS term for what is commonly referred to as 
outstanding checks and EFTs.  This section is a verification of general ledger account 
212001-A/P Disbursement in Transit and the line item in the balance sheet liability 
section-Disbursements in Transit.  The Disbursements in Transit Reconciliation is a proof 
of the balance of the Disbursements in Transit amount as of the end of the current month, 
starting from the months beginning balance of the CMS Cash in Transit Report and 
computing the ending balance using HIGLAS summary reports and bank statement 
information.  The total of the computed CMS Cash in Transit Report as of the end of the 
month is then compared to the ending balance of the Actual CMS Cash in Transit Report, 
the ending balance of the Disbursements in Transit in the trial balance and the month end 
balance of Disbursements in Transit line in the balance sheet.  The contractor shall enter 
all amounts in Lines 1a through 1f as positive numbers.  The contractor shall enter a 
positive number in Line 1g if the amount is intended to be added to the total in Line 1h 
and shall enter a negative number in Line 1g if the amount is intended to be subtracted 
from the total in Line 1h. 
 
Line 1.  HIGLAS Cash in Transit Report Reconciliation  (Title) 
 
Line 1a.  HIGLAS Cash in Transit Report  End of prior month  Contractor 
shall enter the grand total from the prior month end CMS Cash in Transit Report.  
This is the beginning balance for the reconciliation. 
 
   
Line 1b.  Less: Checks and EFTs honored by the bank in the previous month 
but reconciled in HIGLAS in the current month  Contractor shall enter the 
total checks and EFTs that the contractor reconciled in HIGLAS in the current 
month that the bank honored in the prior month based on the total of the CMS 
Cleared Transaction Report for the time period recorded.  The contractor shall 
enter zero if there are no checks or EFTs in this category. 
 
Line 1c.  Add: Checks and EFTs honored by the bank in the current month 
but reconciled in HIGLAS in the next month  Contractor shall enter the total 
checks and EFTs that the contractor reconciled in HIGLAS in the next month that 
the bank honored in the current month based on the CMS Cleared Transaction 
Report for the time period recorded.  The contractor shall enter zero if there are no 
checks or EFTs in this category. 
 
Line 1d.  Add: Checks and EFTs issued per the CMS Payment Register for 
the month (excluding false confirms)  Contractor shall enter the total checks 
and EFTs issued during the current month, including manual checks, per the total 
of the CMS Payment Registers for each day of the current month less the amount 
of false confirms for the month.  This net amount of the checks and EFTs issued 
during the month is an addition to the disbursements in transit. 
 
Line 1e.  Less: Checks and EFTs voided in HIGLAS (excluding false 
confirms)  Contractor shall enter the total checks and EFTs voided during the 
current month per the total of the CMS AP Daily Voids Report for the current 
month less the amount of false confirms.  This net amount of checks voided 
during the month is a subtraction to the disbursements in transit. 
 
Line 1f.  Less: Checks and EFTs honored by the bank  This is an amount 
computed by the template.  It is the sum of the checks and EFTs entered on lines 
1f and 1g of Section A.  The checks and EFTs honored by the bank are 
subtractions to the disbursements in transit.  Contractor shall make no entry on 
this line. 
 
Line 1g.  Add/(Less): Bank payment adjustments (Briefly explain in Section E. 
Remarks in the section labeled Section D, Line 1g)  This is an amount of checks 
and EFTs that have not been reconciled in HIGLAS because the bank charged a 
different amount or bank adjustments that the contractor has not had time to enter 
in HIGLAS before the month close.  This can be a positive or negative amount. 
The contractor shall enter zero if there are no bank payment adjustments in this 
status. 
 
Line 1h.  Calculated HIGLAS Cash in Transit  End of current month  This 
is an amount computed by the template. It is the net result of the additions and 
subtractions to the beginning balance of the HIGLAS Cash in Transit Report.  
This amount should reconcile to the balance of account 212001 A/P Disbursement 
in Transit (Section D, Line 2a, Column D), the balance sheet line item amount, 
   
Disbursement in Transit (Section D, Line 4a, Column D) and should equal the 
actual HIGLAS Cash in Transit Report as of the end of the current month. 
Contractor shall make no entry on this line. 
 
Line 1i.  Actual HIGLAS Cash in Transit  End of current Month  
Contractor shall enter the total checks and EFTs outstanding at the end of the 
current month per the total of the CMS Cash in Transit Report run in HIGLAS as 
of the last day of the current month after all transactions affecting the report for 
the month have been entered. 
 
Line 2.  Summary 2 Trial Balance  (Title) 
 
Line 2a.  212001 A/P Disbursements in Transit - The template adds the ending 
balance of account 212001 in the Summary 2 Trial Balance for the three funds, 
General, SMI and HI to obtain the total Disbursements in Transit as of the end of 
the month per the Summary 2 Trial Balance.  Contractor shall enter the ending 
balance of account 212001 from the Summary 2 Trial Balance for each fund.  The 
contractor shall enter credit balances as negative numbers and debit balances as 
positive numbers. Fund 050720, General Fund, is entered in Line 2a, Column A; 
Fund 050960, SMI Trust Fund, is entered in Line 2a, Column B; Fund 050961, HI 
Trust Fund is entered in Line 2a, Column C.  The formula for the sum of Line 2a, 
Columns A, B and C has been entered in Line 2a, Column D.  Contractor shall not 
make an entry in Line 2a, Column D. 
 
Line 3.  Balance Sheet  (Title) 
 
Line 3a.  Disbursements in Transit  The template adds the balance of the 
Disbursements in Transit line in the balance sheet for the three funds, General, 
SMI and HI to obtain the total Disbursements in Transit for the current month per 
the balance sheet.  Contractor shall enter the balance of the Disbursement in 
Transit line of the balance sheet for each fund for the current month.  Fund 
050720, General Fund, is entered in Line 3a, Column A; Fund 050960, SMI Trust 
Fund, is entered in Line 3a, Column B; Fund 050961, HI Trust Fund is entered in 
Line 3a, Column C.  The formula for the sum of Line 3a, Columns A, B and C has 
been entered in Line 3a, Column D.  Contractor shall not make an entry in Line 
3a, Column D. 
 
Line 4.  Differences  (Title) 
 
Line 4a.  Difference  Trial Balance and Actual HIGLAS Cash in Transit 
Report total  The template computes the difference between Section D Line 2a 
Column D and Section D Line 1i. If there is a difference between the ending 
balance of the HIGLAS Cash in Transit Report as produced in HIGLAS and the 
Disbursements in Transit per the Summary 2 Trial Balance, the contractor shall 
briefly explain the difference in Section E Remarks in the area labeled Section D, 
Line 4a. Contractor shall make no entry on this line. 
   
 
Line 4b.  Difference  Trial Balance and Balance Sheet   The template 
computes the difference between Section D, Line 2a, Column D and Section D, 
Line 3a, Column D.  If there is a difference between the ending balance of 
Disbursements in Transit per the month end balance sheet(s) and the 
Disbursements in Transit per the Summary 2 Trial Balance, the contractor shall 
briefly explain the difference in Section E Remarks in the area labeled Section D, 
Line 4b. Contractor shall make no entry on this line. 
 
Line 4c.  Difference  Calculated and Actual Cash in Transit Reports  End 
of current month  The template computes the difference between Section D, 
Line 1h and Section D, Line 1i.  If there is a difference between the end of month 
totals of the Cash in Transit Reports as calculated in the template and as produced 
by HIGLAS, the contractor shall briefly explain the difference in Section E 
Remarks in the area labeled Section D, Line 4c.  Contractor shall make no entry 
on this line. 
 
Section E. Remarks 
 
This section of the Worksheet is for explanations of specific differences and 
miscellaneous line items as previously described in other sections. 
 
Section A, Line 1d  Contractor shall enter a brief description of the 
miscellaneous add backs that the bank has reported in the current bank statement. 
 
Section A, Line 1i  Contractor shall enter a brief description of the 
miscellaneous deductions that the bank has reported in the current bank statement. 
 
Section C, Line 3  Contractor shall enter a brief explanation for the difference 
between the cash balance per the Summary 2 Trial Balance and the adjusted bank 
statement cash balance. 
 
Section C, Line 6  Contractor shall enter a brief explanation for the difference 
between the cash balance per the Summary 2 Trial Balance and the cash balance 
per the balance sheet(s). 
 
Section D, Line 1g  Contractor shall enter a brief description of the bank 
payment adjustments entered on this line. 
 
Section D, Line 4a - Contractor shall enter a brief explanation for the difference 
between the Disbursements in Transit per the Summary 2 Trial Balance and the 
ending balance of the HIGLAS Cash in Transit Report. 
 
Section D, Line 4b - Contractor shall enter a brief explanation for the difference 
between the Disbursements in Transit per the Summary 2 Trial Balance and the 
Disbursements in Transit per the balance sheet(s). 
   
 
Section D, Line 4c  Contractor shall enter a brief explanation for the difference 
between the calculated HIGLAS Cash in Transit amount as calculated in Section 
D Line 1h and the total of the actual Cash in Transit Report run in HIGLAS as of 
the end of the month. 
 
Request IDs  Contractor shall enter the HIGLAS request IDs of the reports run 
by the contractor that are the source of the information in Sections B and D. 
 
False Confirms Excluded  Contractor shall enter the amount of the false 
confirms subtracted from the CMS Payment Register Report total of the checks 
and EFTs issued to compute the entry in Section D Line 1d.  Contractor enters the 
amount of the false confirms subtracted from CMS AP Daily Voids Report(s) to 
compute the entry in Section D Line 1e. 
 
Other  Contractor shall enter a brief explanation if any of the following 
conditions are met: 
 
The adjusted bank balance (Section A, Line 3) does not equal the total 
benefits account per the balance sheet (Section B, Column D, Line 1a) 
 
The ending balance of the Time Account (Section A, Line 5) does not 
equal the total Time Account per the balance sheet (Section B, Column D, 
Line 1b) 
 
The Un-deposited Collections (Section A, Line 6) does not equal the Un-
deposited Collections per the balance sheet (Section B, Column D, Line 
1c) 
 
Contractor may enter any additional information relevant to this bank 
reconciliation worksheet in this section of the worksheet. 
 
HIGLAS contractor shall click on the following link to access the Contractor's Monthly 
Bank Reconciliation Worksheet:   HIGLAS~BankRecon-Worksheet 05-03-07 (2).xls 
 
   
Transmittals Issued for this Chapter 
 
   
Rev #  Issue Date  Subject  Impl Date  CR# 
R315FM 05/17/2019 Update to Publication (Pub.) 100-06 to Provide  06/18/2019 11211 
Language-Only Changes for the New Medicare 
Card Project 
R236FM 06/13/2014 Revisions to Pub. 100-06, Section 100.2   07/15/2014 8663 
Amending Letter of Credit 
R158FM 09/25/2009 Revised Bank Account Analysis Procedure and  10/26/2009 6644 
Letter-of-Credit List 
R125FM 06/29/2007 Instructions for Completion of the Contractors  07/30/2007 5592 
Monthly Bank Reconciliation Worksheet 
R122FM 05/25/2007 CMS Reporting Requirements With the  06/25/2007 5570 
Exception of MSP for Unsolicited/Voluntary 
Refunds 
R120FM 04/24/2007 Accounts Receivable Trending Analysis  07/02/2007 5506 
Procedures 
R115FM 01/26/2007 Clarification of the Protocol for Estimating  04/02/2007 5451 
Allowance for Uncollectible Accounts From 
CMS-H/M751A/B, Status of Accounts 
Receivable 
R111FM 10/27/2006 Status Codes for Financial Reporting of Debts  04/02/2007 5397 
Once the MMA Section 935 Appeal Process Has 
Been Completed 
R105FM 08/25/2006 Benefits Payable Survey and Trending Analysis  09/30/2006 5130 
Procedures 
R93FM  04/04/2006 Clarification of the Form CMS-1522 Monthly  06/01/2006 4248 
Contractor Financial Report  
R92FM  03/10/2006 Clarification of the Form CMS-1522 Monthly  04/10/2006 4248 
Contractor Financial Report - Replaced by 
Transmittal 93 
R91FM  02/17/2006 Clarification of Instructions in Pub. 100-06,  03/17/2006 4151 
Chapter 5 Financial Reporting, Section 310.4-
Line 4(a) through (e), Reclassified CNC Debt 
(Principal &amp; Interest) 
R80FM  10/21/2005 Medicare Contractors' Monthly Cash Collections 11/21/2005 4074 
R50FM  07/30/2004 Unsolicited/Voluntary Refunds  10/04/2004 3274 
R49FM  07/16/2004 Procedures For Re-Issuance and Stale Dating of  08/16/2004 2951 
Medicare Checks 
R48FM  07/09/2004 Unsolicited/Voluntary Refunds - Replaced by  10/04/2004 3274 
Transmittal 50 
   
R42FM  04/30/2004 Unsolicited/Voluntary Refunds - Replaced by  10/04/2004 3274 
Transmittal 48 
R35FM  02/09/2004 Unsolicited/Voluntary Refunds  10/04/2004 1444 
R28FM  12/24/2003 Estimating Allowance for Uncollectible  01/31/2004 2875 
Accounts 
R21FM  08/01/2003 Funds Expended for Multi-Carrier System  01/01/2004 2795 
(MCS) 
R20FM  08/01/2003 Funds Expended for Fiscal Intermediary Shared  01/01/2004 2794 
System (FISS) 
R18FM  05/02/2003 Reporting Currently not Collectible (CNC) Debt  10/01/2003 2640 
R17FM  05/02/2003 Reporting Debt and Receivables  10/01/2003 2641 
R14FM  02/03/2003 Shared System Preparation of Financial Reports  07/01/2003 2514 
R05FM  08/30/2002 Initial Publication of Chapter  N/A  N/A 
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