Medicare Financial Management Manual 
Part A and Part B Medicare Administrative 
Contractors (A/B MACs) Reports 
 
Table of Contents 
(Rev. 10266, 01-04-21) 
 
 
Transmittals for Chapter 6 
 
10 - Monthly Intermediary and Carrier Workload Report (Form CMS-1566 and 
CMS-1565) - General 
10.1 - Purpose and Scope 
10.2 - Due Date 
20 - Completing Page One of the Monthly Intermediary Workload Report 
20.1 - Heading 
20.2 - Checking Reports 
20.3 - Type of Bill 
20.4 - Body of Report 
30 - Completing Pages 2 through 21 of Intermediary Workload Report 
30.1 - Heading 
30.2 - Checking Reports 
30.3 - Body of Report 
30.4 - Completing Page 22 of Intermediary Workload Report 
30.5 - Heading 
30.6 - Checking Reports 
30.7 - Body of Report 
40 - Monthly PRO Adjustment Bill Report (Inactive) 
40.1 - Heading 
40.2 - Body of Report 
40.3 - Checking Reports 
40.4 - Report Form 
50 - Quarterly Supplement To Intermediary Workload Report (Form CMS-1566A) - 
General 
50.1 - Purpose and Scope 
50.2 - Due Date 
60 - Completing Quarterly Supplement To The Intermediary Workload Report, 
CMS-1566A, Pages 1 And 2 
60.1 - Heading  60.2 - Checking Reports 
60.3 - Type of Bill 
60.4 - Body of Report 
70 - Completing Quarterly Supplement To The Intermediary Workload Report, 
CMS-1566A, Page 3 
70.1 - Heading 
70.2 - Checking Reports 
70.3 - Type of Bill 
70.4 - Body of Report 
70.5 - Completing Medicare Fraud Unit Quarterly Workload Status 
Report, CMS-1566B - General 
70.6 - Heading 
70.7 - Checking Reports 
70.8 - Type of Fraud Workload Item 
70.9 - Body of Report 
70.10 - Completing Quarterly Periodic Interim Payment (PIP) Report, 
CMS-1566C - General 
70.11 - Heading 
70.12 - Checking Reports 
70.13 - PIP Items Reported - The intermediary reports the PIP workload 
items in the following lines for all columns of Form Q 
70.14 - Quarterly Supplement to the Intermediary Workload Report - 
CMS-1566A, Pages 1,2,3 
70.15 - Medicare Fraud Unit Quarterly workload Status Report - CMS-
1566B 
70.16 - Quarterly Periodic Interim Payment (PIP) Report - Form CMS-
1566C 
70.17 - Completing Quarterly Report on Provider Enrollment (Inactive) 
70.18 - Heading 
70.19 - Checking Reports 
70.20 - Type of Provider 
70.21 -Completing Lines One through Eleven - Workload Operations 
70.22 - Completing Lines Twelve through Seventeen - Reason for Denial 
Recommendation 
70.23 - Completing Lines Eighteen through Twenty-Two - Reason for 
Return 
70.24 - Completing Lines Twenty-Three through Twenty-Six - 
Application Processing Times 
70.25 - Completing Lines Twenty-Seven through Thirty-One - Age of 
Applications Pending  70.26 - Completing Lines Thirty-Two through Thirty-Seven - CHOW 
Workloads 
70.27 - Exhibits 
80 - Monthly Intermediary Report On Medicare Secondary Payer Savings (Form 
CMS-1563) 
80.1 - General 
80.2 - Purpose and Scope 
80.3 - Due Date 
80.4 - Form Heading 
80.5 - Savings Calculations 
80.6 - Recording Savings 
80.7 - Source of Savings 
80.8 - Type of Savings 
80.9 - Electronic Submission 
90  Montly Intermediary Part A and Part B Appeals Report (Form CMS-2591) 
90.1  Purpose and Scope 
90.2  Due Date 
100  Completion of Items on Form CMS-2591 
100.1  Heading 
100.2  Section A  Intermediary Appeal Requests 
100.3  Section B  Part B Hearing Results 
100.4  Section C  Part A and Part B ALJ Hearings 
100.5  Section D  Limitation of Liability 
100.6  Section E  Part A and Part B Reopenings 
110  Checking Reports 
110.1  Exhibit 1 
110.2  Exhibit 2 
110.3  Exhibit 3 
110.4  Exhibit 4 
110.5  Exhibit 5 
110.6  Exhibit 6 
120 - Completing Page One of the Carrier Performance Report 
120.1 - Classification of Claims for Counting 
130 - Completion of Items on Page One of Form CMS-1565 
130.1 - Heading 
130.2 - Part A - Monthly Workload Operations 
130.3 - Part B - Inquiries (Inactive) 
130.4 - Part C - Miscellaneous Claims Data 
140 - Completing Pages Two through Eleven of the Carrier Performance Report  140.1 - Heading 
150 - Part D(1) - Claims Processing Timeliness - All Claims 
160 - Part D(2) - Claims Processing Timeliness - EMC Claims and Adjustments for 
CPEP CPT Calculations 
170 - Completing Page 12 of the Carrier Performance Report 
170.1 - Classification of Claims for Counting 
170.2 - Heading 
170.3 - Part E - Interest Payment Data 
180 - Completing Page Thirteen of the Carrier Performance Report (Inactive) 
180.1 - Instructions for Completing the Carrier Performance Report - All 
Trunks Busy (ATB) 
180.2 - Heading 
180.3 - Part F-ATB Data 
190 - Checking Reports Prior to Submittal to CMS 
200 - Exhibits 
210 - Monthly DMEPOS State Report - General (Inactive) 
210.1 - Completion of Items on the DMEPOS State Report 
210.2 - Checking Report 
210.3 - Exhibits 
220 - Quarterly Supplements to Carrier Performance Report (Forms CMS-1565A, 
CMS-1565B, CMS-1565C, CMS-1565D, and CMS-1565E) - General 
220.1 - Purpose and Scope 
220.2 - Due Date 
230 - Completing Form CMS-1565A 
230.1 - Classification of Claims for Counting 
240 - Completion of Items on Form CMS-1565A 
240.1 - Heading 
240.2 - Part A - Claims Reduced and Denied 
240.3 - Checking Form A Prior to Submittal to CMS 
250 - Completing Medicare Fraud Unit Quarterly Workload Status Report, CMS-
1565B - General 
250.1 - Heading 
250.2 - Checking Reports 
250.3 - Type of Fraud Workload Item 
250.4 - Body of Report 
260 - Completing Form CMS-1565C 
260.1 - Classification of Claims for Counting 
270 - Completion of Items on Form CMS-1565C 
270.1 - Heading  270.2 - Part D - Selected Claim Data by Participation Status 
270.3 - Checking Form G Prior to Submittal to CMS 
280 - Completing Comprehensive Limiting Charge Compliance Program 
(CLCCP) Quarterly Report, CMS-1565D - General 
280.1 - Heading 
280.2 - Checking Reports 
280.3 - LCER Data 
280.4 - Monetary Data 
280.5 - Verification Data for Refunds and Adjustments 
280.6 - LCMR Data 
280.7 - Sanction Referral Data 
290 - Completing Health Professional Shortage Area (HPSA) Quarterly Report, 
Form CMS-1565E - General 
290.1 - Heading 
290.2 - Checking Reports 
290.3 - Current Quarter Payments 
290.4 - Current Quarter Reviews 
290.5 - Prior Quarter(s) Reviews 
290.6 - Error Descriptions 
 
300 - Exhibits 
310 - Carrier Beneficiary Overpayment Activity Report (Form CMS-2174) - 
General 
310.1 - Purpose and Scope 
310.2 - Due Date 
320 - Completing Carrier Beneficiary Overpayment Activity Report 
320.1 - Classification of Claims for Counting 
330 - Completion of Items on Form CMS-2174 
330.1 - Heading 
330.2 - Section A - Beneficiary Overpayments 
330.3 - Section B - Cause of Overpayments 
330.4 - Section C - How Overpayments Were Discovered 
330.5 - Checking Reports Prior to Submittal to CMS 
340 - Exhibit - Medicare Program Carrier Beneficiary Overpayment Activity 
Report - (Form CMS-2174) 
350 - Carrier Appeals Report (Form CMS-2590) 
350.1 - Purpose and Scope 
350.2 - Due Date 
360 - Completion of Items on Form CMS-2590  360.1 - Heading 
360.2 - Section A - Carrier Appeal Requests 
360.3 - Section B - ALJ Hearings 
360.4 - Section C - Reopenings (Claim Counts) 
360.5 - Section D - Limitation of Liability (Claim Counts) 
370 - Checking Reports 
380 - Exhibits 
390 - Participating Physician/Supplier Report 
390.1 - Purpose and Scope 
390.2 - Due Date 
400 - Completion of Items on Participating Physician/Supplier Report 
400.1 - Heading 
400.2 - Definitions of Columns One Through Eight 
400.3 - Specialty Codes 
400.4 - Physician/Limited License Physician Specialty Codes 
400.5 - Non-Physician Practitioner/Supplier Specialty Codes 
410 - Checking Reports 
420 - Exhibit 
430 - Completing Quarterly Report On Provider Enrollment (Inactive) 
430.1 - Heading 
430.2 - Checking Reports 
430.3 - Type of Provider 
430.4 - Completing Lines One Through Eleven - Workload Operations 
430.5 - Completing Lines Twelve Through Seventeen - Reason for Denial 
430.6 - Completing Lines Eighteen Through Twenty-Two - Reason for 
Return 
430.7 - Completing Lines Twenty-Three Through Twenty-Six - 
Application Processing Times 
430.8 - Completing Lines Twenty-Seven Through Thirty-Four - Denials 
Appealed 
430.9 - Exhibits 
440 - Monthly Carrier Report on Medicare Secondary Payer Savings (Form CMS-
1564) 
440.1 - General 
440.2 - Purpose and Scope 
440.3 - Due Date 
440.4 - Form Heading 
440.5 - Savings Calculations 
440.6 - Recording Savings  440.7 - Source of Savings 
440.8 - Type of Savings 
440.9 - Electronic Submission 
440.10 - Exhibit 
460 - Monthly Statistical Report on A/B and DME Medicare Administrative 
Contractor (MAC) Part A and Part B Appeals Activity Form (CMS-2592) 
460.1 - General 
460.2  Section I - Redeterminations 
460.3  Section II - Qualified Indepenedent Contractor (QIC) 
Reconsiderations 
460.4  Section III - Administrative Law Judge Results 
460.5  Section IV - Section IV  Medicare Appeals Council Effectuations 
460.6  Clerical Error Reopenings 
460.7  Validation of Reports 
460.8 - Exhibit 
480 - Special Purpose Data 
480.1 - Heading 
480.2 - Exhibit  10 - Monthly Intermediary and Carrier Workload Report (Form CMS-
1566 and CMS-1565) - General 
(Rev. 6, 08-30-02) 
A3-3892 and B3 13300 
 
Intermediaries and carriers must prepare and submit to CMS each month the appropriate 
workload report (Form CMS-1566 for intermediaries and Form CMS-1565 for carriers) 
showing their workloads under the health insurance program.  A separate report is 
required for each office assigned a separate contractor number. A separate report is 
required for each State assigned to the contractor, even if a separate contractor number is 
not assigned. 
 
10.1 - Purpose and Scope 
(Rev. 6, 08-30-02) 
A3-3892.1 and B3 13300.1 
 
The monthly Workload Report is the source of current information on the status of 
workloads.  The data derived from the report, together with information from other 
sources, are used by CMS for such purposes as: 
 
  Estimating workloads, 
 
  Analyzing manpower and material requirements, 
 
  Establishing operating norms and pars, 
 
  Comparing the performance of individual intermediaries, and 
 
  Identifying problem areas for resolution by the intermediary and/or CMS. 
 
The workload report is designed to serve as a basic management tool for individual 
contractors. It provides data needed for budgeting, financing, work-planning, progress 
evaluation, and identification of operating problems. 
 
The form must be submitted in accordance with the following instructions. 
 
10.2 - Due Date 
(Rev. 6, 08-30-02) 
A3-3892.2 
 
The report is transmitted to CMS CO via PC or terminal as soon as possible after the end 
of the month being reported, but no later than the 10th of the following month using 
instructions contained in the Contractor Reporting of Operational and Workload Data 
(CROWD) System User's Guide. 
  20 - Completing Page One of the Monthly Intermediary Workload 
Report 
(Rev. 6, 08-30-02) 
A3-3893 
 
20.1 - Heading 
(Rev. 6, 08-30-02) 
A3-3893.1 
 
This report is referenced as Form D in the CROWD system.  The intermediary completes 
the ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to 
bring the reporting format to its screen.  It first keys in the number of working days 
scheduled for the reporting period, less any days where no claims were processed as a 
result of a strike, snow storm, etc.  It does not count Saturdays, Sundays, or holidays. 
 
20.2 - Checking Reports 
(Rev. 6, 08-30-02) 
A3-3893.2 
 
Before submitting Form D to CMS, the intermediary checks its completeness and 
arithmetical correctness.  This check not only ensures accuracy but also uncovers other 
errors and inconsistencies.  It uses the following checklist: 
 
For each column: 
 
  Line 1 + 2 = 3. 
 
  Line 7 + 8 = 6. 
 
  Line 10 + 11 = 9. 
 
  Line 6 + 9 = 12. 
 
  Line 3 + 4 - 12 = 13. 
 
  Line 5 must be equal to or less than line 4. 
 
  Line 14 must be equal to or less than line 13. 
 
  Line 15 must be equal to or less than line 14. 
 
  Line 18 + 19 + 20 + 21 = 17. 
 
  Line 23 + 24 + 25 + 26 = 22. 
 
  Line 28 + 29 + 30 + 31 = 27. 
    Line 33 must be equal to or less than line 32. 
 
  Line 35 + 36 + 37 = 34. 
 
  Columns 2 + 3 + 4 + 5 + 6 = 1 for lines 1-33.     
 
  Columns 2 + 3 = 1 for lines 34-37. 
 
The intermediary bases all data reported on the CMS-1566 on actual counts and not on 
any types of estimates or samples. 
 
20.3 - Type of Bill 
(Rev. 10521; Issued: 12-16-20; Effective: 01-01-21; Implementation: 01-04-21) 
 
The A/B MAC (A) includes provider bills in the following columns of the report: 
 
Column (1)   Total - All provider bills.  
 
Column (2)   Inpatient Hospital - CMS-1450s submitted by hospitals for inpatient 
services with the following two-digit classification codes in Form Locator 
4: 1-1 (inpatient hospital); and 4-1 (Religious Nonmedical Health Care 
Hospital- inpatient).  
 
Column (3)   Outpatient - CMS-1450s submitted by hospitals or SNFs for outpatient 
services with the following two-digit classification codes in Form Locator 
4: 1-3 (Hospital-outpatient); 2-3 (SNF-outpatient); 4-3 (Religious 
Nonmedical Health Care Hospital-outpatient); 5-3 (Religious Nonmedical 
Health Care-SNF-outpatient); and 8-3 (Hospital-outpatient-surgical 
procedures-ASC).  
 
Column (4)   SNF - CMS-1450s with the following two-digit classification codes in 
Form Locator 4; 1-8 (hospital swing-bed); 2-1 (SNF-inpatient); 2-8 (SNF-
swing bed); and 5-1 (Religious Nonmedical Health Care-SNF-inpatient). 
  
Column (5)   HHA - CMS-1450s submitted by HHAs, with the following two-digit 
classification codes in Form Locator 4: 3-2 (HHA-Part B visits and use of 
DME); 3-3 (HHA-Part A visits and DME); 3-4 (HHA-Other-Part B 
benefits). Include HH PPS Requests for Anticipated Payment (RAPs) with 
three-digit classification code 3-2-2 or 3-3-2 with dates of service 
10/01/2000 and greater in addition to claims in this column.  
 
Column (6)   Other - CMS-1450s with the following two-digit classification codes in 
Form Locator 4:  
 
1-2 (hospital inpatient-Part B benefits), 
 
1-4 (hospital-Other-Part B benefits), 
  2-2 (SNF-inpatient-Part B benefits), 
 
2-4 (SNF-Other-Part B benefits), 
 
4-2 (Religious Nonmedical Health Care-inpatient-Part B benefits), 
 
4-4 (Religious Nonmedical Health Care-inpatient-other), 
 
5-2 (Religious Nonmedical Health Care-SNF inpatient-Part B benefits),  
 
5-4 (Religious Nonmedical Health Care-SNF inpatient-other), 
7-1, 7-2, 7-3, 7-4, 7-5 (Clinics-provider and independent RHCs, ESRD 
hospital-based or independent renal dialysis facilities, FQHCs, CMHCs, 
ORFs, and CORFS), and 
 
8-1 and 8-2 (Hospices) 
 
8-7 (Opioid Treatment Facility) 
 
 
20.4 - Body of Report 
(Rev. 248, Issued: 12-19-14, Effective: 01-23-15, Implementation: 01-23-15) 
 
SECTION A: INITIAL BILL PROCESSING OPERATION 
 
The intermediary completes every type of bill column (1 through 6) for each reporting 
item as described below.  It includes data on all bills received for initial processing from 
providers (including all RHCs) directly or indirectly through a RO, another intermediary, 
etc.  It also includes data on demand bills and no-pay bills submitted by providers with no 
charges and/or covered days/visits.  It does not include: 
 
 Bills received from institutional providers if they are incomplete, incorrect, or 
inconsistent, and consequently returned for clarification.  Individual controls are 
not required for them; 
 
 Adjustment bills; 
 
 Misdirected bills transferred to another intermediary; 
 
 HHA bills where no utilization is chargeable and no payment has been made, but 
which it has requested only to facilitate record keeping processes (There is no 
CMS requirement for HHAs to submit no payment non-utilization chargeable 
bills.); and 
 
 Bills paid by an HMO and processed by the intermediary. 
   Claims submitted by HHAs under the HH PPS with three-digit classification 3-2-9 
or 3-3-9 are processed as adjustments to a previously submitted RAP record.  
However, the intermediary counts both HHPPS RAPs and claims as initial bills 
for this report.  It does not exempt HH PPS claims as adjustments. 
 
Opening Pending 
 
Line 1 - Pending End of Last Month - The system will pre-fill the number pending 
from line 13 on the previous month's report. 
 
Line 2 - Adjustments - If it is necessary to revise the pending figure for the close of the 
previous month because of inventories, reporting errors, etc., the intermediary enters the 
adjustment. It reports bills received near the end of the reporting month and placed under 
computer control sometime after the reporting month as bills received in the reporting 
month and not as bills received in the following month.  In the event that some bills may 
not have been counted in the proper month's receipts, it counts them as adjustments to the 
opening pending in the subsequent month. 
 
It enters on line 2 any necessary adjustments, preceded by a minus sign for negative 
adjustments, as appropriate. 
 
Line 3 - Adjusted Opening Pending - The system will sum line 1 + line 2 to calculate 
the adjusted opening pending. 
 
Receipts 
 
Line 4 - Received During Month  The intermediary enters the total number of bills 
received for initial processing during the month. 
 
It counts all bills immediately upon receipt regardless of whether or not they are put into 
the processing operation with the exception of those discussed below. 
 
NOTE:  It counts bills submitted by providers electronically after they have passed  
intermediary consistency edits.  Prior to that time, it may return these bills or the 
entire tape reel (where magnetic tape is the medium of submission) without 
counting them as "received."  However, once the bills or tapes have passed 
consistency edits and are counted as received, it uses the actual receipt date, not 
the date the edits are passed, in calculating pending and processing times. 
 
If a bill belonging to one of the above-excluded categories is inadvertently counted as an 
initial bill received (e.g., certain adjustment bills unidentifiable at the time of receipt), the 
intermediary subtracts it from the receipt count when the bill is correctly identified. 
 
Line 5 - Electronic Media Bills - The intermediary reports the net number of bills 
included on line 4 which were received in paperless form via electronic media from 
providers or their billing agencies and read directly into the intermediary claims  processing system.  It does not count on this line bills that it received in hardcopy and 
entered using an Optical Character Recognition (OCR) device.  It does not count any bills 
received in hardcopy and transferred into electronic media by any entity working for it 
directly or under subcontract. 
 
Clearances 
 
Line 6 - Total CWF Bills (7 + 8)  The intermediary reports the number of initial bills 
(described in lines 7 and 8 below) processed through CWF and posted to CWF history.  It 
does not include bills sent to CWF and rejected, unless they were resubmitted and posted 
to CWF history in the reporting month.  It reports these bills in the month that it moves 
the bill to a processed location in the intermediary system after receipt of the host's 
response to pay or deny. 
 
Line 7 - Payment Approved (CWF)  The intermediary enters the number of initial 
bills for which it approved some payment and for which the CWF host responded 
accepting the intermediary determination.  It includes bills for which it approved payment 
in full or in part as a result of a determination that both the beneficiary and the provider 
were without fault (liability waiver).  (See the Medicare Claims Processing Manual, 
Chapter 30, Financial Liability Protections.)  The intermediary reports here those fully 
adjudicated, approved-for-payment bills for which it has received a response from the 
host and are holding only due to the payment floor. 
 
Line 8 - No Payment Approved (CWF) - The intermediary enters the number of initial 
bills processed through CWF during the month for which it approved no payment. It 
reports here those bills for which payment is not made because the deductible has not yet 
been met and payment is therefore applied to the deductible. 
 
Line 9 - Total Non-CWF Bills (10 + 11) - The intermediary reports the number of initial 
bills (described in lines 10 and 11 below) processed outside CWF.  Non-CWF bills are 
those either rejected by or not submitted to CWF that the intermediary finally adjudicates 
outside of CWF and, therefore, are not posted to its history in the reporting month.  The 
intermediary reports these bills as non-CWF, even if it plans to submit an informational 
record in the future.  It reports such bills in the month in which it made the determination 
as to their final disposition. 
 
It does not include home health bills where no utilization is chargeable and no payment 
has been made, but which it requested only to facilitate record keeping processes. 
 
Line 10 - Payment Approved (Non-CWF) - The intermediary enters the number of 
initial bills processed outside CWF for which it approved some payment.  It includes 
bills for which it approved payment in full or in part as a result of a determination that 
both the beneficiary and the provider were without fault (liability waiver). (See the 
Medicare Claims Processing Manual, Chapter 30, Financial Liability Protections.) 
  Line 11 - No Payment Approved (Non-CWF)  The intermediary enters the number of 
initial bills processed outside CWF during the month for which it approved no payment. 
 
Line 12 - Total Processed - The intermediary reports the sum of lines 6 and 9. 
 
NOTE:  It reports as processed on line 12 those bills it has moved to a processed location 
after being accepted by the host and is holding only due to the payment floor.  However, 
for pages 2-12 of this report, it reports these bills as processed in the month during which 
the scheduled payment date falls (which may be in a subsequent reporting period). 
 
The intermediary reports HMO bills it paid on line 12 and on pages 2-12.  It does not 
report those bills paid by HMOs and processed by the intermediary on line 12 or on pages 
2-12.  It reports such HMO paid bills only on line 39 of page 1. 
 
Closing Pending 
 
Line 13 - Pending End of Month - The system will calculate the number of bills 
pending at the end of the month by adding line 3 (adjusted opening pending) to line 4 
(receipts) and subtracting line 12 (total processed).  The intermediary does not report as 
pending those bills that it has moved to a processed location after being accepted by the 
host and is holding only due to the payment floor.  It reports such bills as processed on 
line 12. 
 
Line 14 - Pending Longer Than 1 Month  The intermediary reports the number of 
bills included in line 13 pending longer than 1 month, i.e., those received prior to the 
reporting month but not processed to completion by the end of the reporting month.  For 
example, for the reporting month of October 2001, it reports the number of bills pending 
at the end of October 2001 which had been received prior to October 1, 2001.  It excludes 
bills received in the reporting month. 
 
Line 15 - Pending Longer Than 2 Months - The intermediary reports the number of 
bills included in line 13 pending longer than 2 months, i.e., those received prior to the 
month preceding the reporting month but not processed to completion by the end of the 
reporting month.  For example, for the reporting month of October 2001, it reports the 
number of bills pending at the end of October 2001 that had been received prior to 
September 1, 2001.  It excludes bills received in the reporting month and one month prior 
to the reporting month. 
 
Bill Investigations 
 
Line 16 - Bill Investigations Initiated - The intermediary enters the number of initial 
bills that, for purposes of processing the claim to completion, required outside contact 
(via telephone, correspondence, or on-site visit) with providers, social security offices, or 
beneficiaries during the month.  This includes contacting outside parties to resolve 
problems with covered level of care determinations, insufficient medical information or 
missing, inconsistent, or incorrect items on the bill.  It does not count routine submissions  by providers of additional medical evidence with bills as investigations in themselves. It 
counts only the number of bills requiring investigation, not the number of contacts made.  
It excludes bills reported as investigated in a prior month from this count even if the 
investigation continued into the reporting month.  It does not count as bills investigated 
those returned to providers because they were incomplete, incorrect or inconsistent, and 
consequently were not counted as "receipts." 
 
SECTION B:  ADJUSTMENT BILLS 
 
This section includes data on the number of adjustment bills processed and pending for 
the reporting month, including those generated by providers, PROs, or as a result of MSP 
or other activity.  In reporting adjustment bills, the intermediary counts only the number 
of original bills requiring adjustment, not both the debit and credit 
 
Claims submitted by HHAs under the HH PPS with three-digit classification 3-2-9 or 3-
3-9 are processed as adjustments to a previously submitted RAP record.  However, both 
HHPPS RAPs and claims are counted as initial bills.  The intermediary does not report 
HH PPS claims as adjustments. 
 
Clearances 
 
Line 17 - Total CWF Processed (18+19+20+21) - The intermediary reports the number 
of adjustment bills processed through CWF during the month.  It counts adjustment bills 
as processed in final only when acceptance from CWF is received.  Since 3664 
precludes the processing of a utilization adjustment bill until CWF accepts the bill upon 
which the adjustment action is based, no utilization adjustment billing action may be 
processed until CWF has accepted the original bill. 
 
Line 18 - PRO Generated (CWF) - The intermediary reports the number of adjustment 
bills included in line 17 which were generated by PROs. 
 
Line 19 - Provider Generated (CWF) - The intermediary reports the number of 
adjustment bills included in line 17 which were generated by providers. 
 
Line 20 - MSP (CWF) - The intermediary reports the number of adjustment bills 
included in line 17 which were generated as a result of MSP activity. 
 
Line 21 - Other (CWF) - The intermediary reports the number of adjustment bills 
included in line 17 which were generated by other than PROs, providers, or MSP activity.  
It includes HMO adjustments where the HMO acted as an intermediary and made 
payment on the initial bill. 
 
Line 22 - Total Non-CWF Processed (23+24+25+26) - The intermediary reports the 
number of adjustment bills that it processed outside of CWF during the month.  It counts 
such adjustment bills as processed in final only when no further action is required. 
  If it receives an adjustment bill from a provider when the original bill is still in its 
possession, it takes the final adjustment action on the original bill before it is submitted to 
CWF.  It counts the adjustment bill as cleared when acceptance of the original bill is 
received from CWF. 
 
Line 23 - PRO Generated (Non-CWF) - The intermediary reports the number of 
adjustment bills included in line 22 which were generated by PROs. 
 
Line 24 - Provider Generated (Non-CWF) - The intermediary reports the number of 
adjustment bills included in line 22 which were generated by providers. 
 
Line 25 - MSP (Non-CWF) - The intermediary reports the number of adjustment bills 
included in line 22 which were generated as a result of MSP activity. 
 
Line 26 - Other (Non-CWF) - The intermediary reports the number of adjustment bills 
included in line 22 that were generated by other than PROs, providers, or MSP activity.  
It includes HMO adjustments where the HMO acted as an intermediary and made 
payment on the initial bill. 
 
Pending 
 
Line 27 - Total Pending (28+29+30+31) - The intermediary reports the number of 
adjustment bills which were not processed to completion by the end of the reporting 
month. 
 
Line 28 - PRO Generated  The intermediary reports the number of adjustment bills 
included in line 27 which were not processed to completion by the end of the reporting 
month and which were generated by PROs. 
 
Line 29 - Provider Generated - The intermediary reports the number of adjustment bills 
included in line 27 which were not processed to completion by the end of the reporting 
month and which were generated by providers. 
 
Line 30 - MSP - The intermediary reports the number of adjustment bills included in line 
27 which were not processed to completion by the end of the reporting month and which 
were generated by MSP activity. 
 
Line 31 - Other - The intermediary reports the number of adjustment bills included in 
line 27 which were not processed to completion by the end of the reporting month and 
which were generated by it or by a source other than PROs, providers, or MSP activity.  
It includes HMO adjustments not processed to completion where the HMO acted as an 
intermediary and made payment on the initial bill. 
 
SECTION C:  MEDICAID CROSSOVER BILLS 
  This section presents data on the volume of Medicaid crossover bills sent to Medicaid 
State agencies or their fiscal agents. 
 
Clearances 
 
Line 32 - Transmitted to State Agencies - The intermediary enters the total number of 
Medicaid crossover bills transmitted to State agencies or their fiscal agents in the 
reporting month. 
 
Line 33 - Transmitted Electronically  The intermediary enters the number of bills 
included in line 32 which were transmitted via electronic media to State agencies or their 
fiscal agents. 
 
 
SECTION D:  MISCELLANEOUS DATA  
 
INQUIRIES (Inactive) 
 
This section presents data on the volume of provider or beneficiary inquiries that were 
processed during the reporting month.  Include only processed inquiries dealing with 
Medicare bill processing issues.  These issues correspond to the workload budgeted under 
line 1 of the CMS-1523 budget form. 
 
The intermediary counts inquiries as follows: 
 
Beneficiary - It counts one per contact (telephone, walk-in, or written), regardless of the 
number of bills being questioned.  For example, if a letter from a beneficiary requests 
information on the status of one or more bills, it counts the response (interim or final) as 
one written beneficiary inquiry.  It counts each completed reply, terminated telephone 
conversation, or in-person discussion as processed, regardless of the need for subsequent 
contact on the same issue.  Responses resulting from additional intermediary follow up or 
analysis, or from additional contact by the beneficiary, are separate inquiries.  
Beneficiary inquiries include those made by anyone on behalf of the beneficiary, except 
by a provider. 
 
Provider - The intermediary counts one per contact (telephone, walk-in, or written).  For 
example, if a provider calls or writes to obtain the status of 3, 6, or 10 separate bills, it 
count the response as 1 provider telephone or written inquiry. 
 
It includes or excludes beneficiary and provider inquiries as follows: 
 
 It counts as inquiries requests for Medicare information from beneficiaries or 
providers or their representatives that are directed to it for response. 
 
 It does not count processed inquiries that are concerned solely with its line of 
business.   
 It does not count inquiries concerned with professional relations activities. 
 
 It does not count inquiries related solely to payment issues, MR or utilization 
review, MSP, audits, etc.  These are areas for which it receives separate Medicare 
funding.  This exclusion achieves comparability with the CMS-1523 budget form. 
 
 It counts voice inquiries captured electronically as telephone inquiries, and 
electronic mail inquiries as written inquiries.  It counts electronic inquiries only if 
the response is provided by telephone or in writing and requires its involvement.  
It does not count electronic inquiries if the provider can directly access its system 
to determine bill status. 
 
 It counts Congressional inquiries according to whether they were made on behalf of 
a beneficiary or provider. 
 
 It counts inquiries made by ROs or SSA district offices only if they concern a 
Medicare bill and are made on behalf of a beneficiary or provider. 
 
 It counts misdirected telephone inquiries referred to another source for a final 
response.  It does not count misdirected written inquiries. 
 
 It does not count inquiries that are, in fact, explicit or implicit requests for 
reconsiderations or hearing.  See Medicare Claims Processing Manual, Chapter 
29, Appeals of Claims Decisions, for specifics on what is a request for 
reconsideration or review. 
 
 It reports the number of inquiries from beneficiaries (column 2) and providers 
(column 3) processed during the reporting month, as follows: 
 
Line 34 - Total - It reports in the appropriate column the total number of inquiries 
processed. 
 
Line 35 - Telephone Inquiries - It reports in the appropriate column the total number of 
telephone inquiries processed. 
 
Line 36 - Walk-in Inquiries - It reports in the appropriate column the total number of 
walk-in contacts processed. 
 
Line 37 - Written Inquiries - It reports in the appropriate column the total number of 
written inquiries responded to. 
 
 
OPTICAL CHARACTER RECOGNITION BILLS 
  Line 38 - Total Bills Received - It enters the total number of bills that it received in 
hardcopy and entered using an OCR device.  It does not count these bills as electronic 
media bills on line 5, page 1, or in column 8, pages 2-11. 
 
BILLS PAID BY HMOs 
 
Line 39 - Total HMO Bills Processed - It enters the number of bills that were paid by 
HMOs and processed by it during the reporting month.  It reports HMO bills paid by it on 
line 12 but does not report such bills on line 39. 
 
MEDICARE SUMMARY NOTICES (MSNs) 
 
Line 40 - Total MSNs Mailed - It enters the number of MSNs mailed to beneficiaries 
during the reporting month. 
 
30 - Completing Pages 2 through 21 of Intermediary Workload Report 
(Rev. 6, 08-30-02) 
A3-3894 
 
30.1 - Heading 
(Rev. 6, 08-30-02) 
A3-3894.1 
 
These pages are referenced as Form U (pages 2-11) and Form E (pages 12-21) in the 
CROWD system.  The intermediary completes the ADD/UPDATE/DELETE DATA 
criteria screen with the appropriate information to bring the reporting format to its screen. 
 
30.2 - Checking Reports 
(Rev. 6, 08-30-02) 
A3-3894.2 
 
Before submitting Forms U and E to CMS, check for completeness and arithmetical 
accuracy, the intermediary uses the following checklist: 
 
  For each column, line 38 must equal the sum of lines 1-37. 
 
  For lines 1-38 on pages 2-11, column 1 must equal the sum of columns 2-7. 
 
  For each of lines 1-38 on pages 2-11, column 8 must be less than or equal to 
column 1. 
 
  For each of lines 1-38 on pages 12-21, column 1 must be less than or equal to 
column 2 for the corresponding bill type on pages 2-11. 
 
  For each of lines 1-38 on pages 12-21, column 2 must be less than or equal to 
column 3 for the corresponding bill type on pages 2-11.   
  The "Total" pages (pages 11 and 21) must equal the sum of all the bill types 
(pages 2-10 and 12-20, respectively) for each data element on the page, except 
line 39. 
 
30.3 - Body of Report 
(Rev. 6, 08-30-02) 
A3-3894.3 
 
SECTION E (1):  CLAIMS PROCESSING TIMELINESS - ALL CLAIMS 
 
Pages 2-11 of the CMS-1566 include data on intermediary activity in processing all bills 
to completion during the reporting period.  The intermediary counts the bill as processed 
to completion on the "scheduled payment date," which is the date the check it issued is 
mailed, deposited by it in the provider's account, or transferred electronically.  For PIP 
bills and no payment bills, the "scheduled payment date" is the date for payment bills in 
the same adjudication batch.  Base data shown on reliable counts of all bill processing 
activity.  The intermediary does not estimate bill counts.  It reports data on initial bills 
only (including demand bills and no-pay bills submitted by providers with no charges 
and/or covered days/visits).  It does not include: 
 
  Bills received from institutional providers if they are incomplete, incorrect, or 
inconsistent and consequently returned for clarification.  Individual controls are 
not required for these bills; 
 
  Adjustment bills; 
 
  Misdirected bills transferred to a carrier or another intermediary; 
 
  HHA bills where no utilization is chargeable and no payment has been made, but 
which the intermediary requested only to facilitate record keeping processes.  
(There is no CMS requirement for HHAs to submit no payment non-utilization 
chargeable bills); 
 
  Bills paid by an HMO and processed by the intermediary, and 
 
  HH PPS RAPs with three-digit classification code 3-2-2 or 3-3-2 with dates of 
service 10/01/2001 and greater. 
 
Apart from these exceptions, it includes in the report all bills (including PIP, EMC, 
provider and independent RHC, as well as HMO bills paid by it) processed to completion 
(i.e., paid bills, complete denials, and no payment bills) in the reporting month.  It reports 
bills in the month the scheduled date of payment falls.  See The Medicare Claims 
Processing Manual, Chapter 1, General Billing Requirements for the definition of 
scheduled payment date for all bills, including PIP and no payment bills.  "Clean" bills 
are those that do not require investigation or development external to the intermediary  operation on a prepayment basis.  Bills that do not meet the definition of clean are 
"other" bills.  See The Medicare Claims Processing Manual, Chapter 1, General Billing 
Requirements for examples of "clean" and "other."  Bills paid are those for which some 
payment was made (i.e., payment greater than zero).  Bills not paid are those for which 
no payment was made (i.e., bill charges applied completely toward deductible or fully 
denied). 
 
On each page 2-11 (there is a separate page for each type of bill category listed below), 
the intermediary reports: 
 
  In column 1, the total number of bills processed to completion; 
 
  In column 2, the number of "non-PIP clean" bills paid; 
 
  In column 3, the number of "non-PIP other" bills paid; 
 
  In column 4, the number of "PIP clean" bills paid; 
 
  In column 5, the number of "PIP other" bills paid; 
 
  In column 6, the number of "clean" bills not paid; 
 
  In column 7, the number of "other" bills not paid; and 
 
  In column 8, the number of "clean" and "other" bills processed to completion, 
which were received via electronic media from providers or their billing agencies 
and read directly into the intermediary claims processing system.  The 
intermediary does not count on this line bills that it received in hardcopy and 
entered using an OCR device.  It does not count any bills received in hardcopy 
and transformed into electronic media by any entity working for it directly or 
under subcontract. 
 
For each category, it shows the number processed to completion on the line 
corresponding to the number of days from receipt by it to the scheduled date of payment 
or other final action, if a no-pay bill.  See The Medicare Claims Processing Manual, 
Chapter 1, General Billing Requirements for definition of receipt date. 
 
NOTE: For bills received by tape, the date the intermediary receives the tape should be 
used as the receipt date and not the date the tape passes the edits. 
 
To calculate the processing time for a claim, the intermediary subtracts the Julian receipt 
date from the processed to completion Julian date.  When the processed to completion 
date falls in the year following the year of receipt, it adds to the Julian date of completion 
365 (or 366 if the year of receipt is a leap year).  If a claim is processed to completion on 
the same day it is received, the processing time is one day. This definition applies to all 
lines of the report, including line 39.   
On line 39 the intermediary reports the mean processing time (PT) to one decimal place 
for each column. To calculate the mean PT, it adds the processing times for all the bills 
shown in lines 1-37 of that column and divides by line 38.  It does not use the categories 
on the report to calculate the mean PT.  Because of the aggregation of claims in lines 34-
37, it must use the processing times for the individual claims as explained below to make 
this calculation. 
 
Mean Processing Time Calculation for All Claims 
 
  Subtract the Julian date of receipt from the Julian date of payment (or equivalent 
action for those not paid) for each claim. 
 
  Sum the result for each claim into a total number of days for all claims. 
 
  Divide this result by the total number of claims. 
 
  Round to one decimal place. 
 
EXAMPLE: 
 
Claim  Julian Date  Paid  Counter  Counter 
Receipt  by Days  by Claims  
         
  A  91103  91133  30  1 
  B  91105  91206  101  2 
  C  91115  91177  62  3 
  D  91120  91213  93  4 
  E  91122  91215  93  5 
  F  91130  91223  93  6 
 
Total Days = 30 + 101 + 62 + 93 + 93 + 93 = 472 
 
Mean = 472/6 = 78.6666 = 78.7 
 
The intermediary completes the report for each bill type: 
 
  Inpatient Hospital - Of the bills reported on the "All Claims" page, it shows on 
page 2 data on the number of CMS-1450s submitted by hospitals for inpatient 
services with the following two-digit classification codes in Form Locator 4:  1-1 
(inpatient hospital); and 4-1 (Religious Nonmedical Health Care Facility - 
Hospital-inpatient), 
 
  Outpatient - Of the bills reported on the "All Claims" page, it shows on page 3 
data on the number of CMS-1450s submitted by hospitals and SNFs for outpatient 
services with the following two-digit classification codes in Form Locator 4:  1-3  (hospital-outpatient); 2-3 (SNF-outpatient); 4-3 (Religious Nonmedical Health 
Care Facility - Hospital-outpatient); 5-3 (Religious Nonmedical Health Care 
Facility - SNF-outpatient); and 8-3 (hospital-outpatient surgical procedures - 
ASC), 
 
  SNF - Of the bills reported on the "All Claims" page, it shows on page 4 data on 
the number of CMS-1450s with the following two-digit classification codes in 
Form Locator 4:  1-8 (hospital swing-bed); 2-1 (SNF-inpatient); 2-8 (SNF-swing-
bed); and 5-1 (Religious Nonmedical Health Care Facility - SNF-inpatient), 
 
  HHA - Of the bills reported on the "All Claims" page, it shows on page 5 data on 
the number of CMS-1450s with the following two-digit classification codes in 
Form Locator 4:  3-2 (HHA-Part B visits and use of DME); 3-3 (HHA-Part A 
visits and DME); and 3-4 (HHA-other-Part B benefits), 
 
  Hospice - Of the bills reported on the "All Claims" page, it shows on page 6 data 
on the number of CMS-1450s with the following two-digit classification codes in 
Form Locator 4:  8-1 and 8-2 (Hospice), 
 
  CORF - Of the bills reported on the "All Claims" page, it shows on page 7 data 
on the number of CMS-1450s with the following two-digit classification codes in 
Form Locator 4: 7-4 (Other Rehabilitation Facility) and 7-5 (Comprehensive 
Outpatient Rehabilitation Facility), 
 
  ESRD - Of the bills reported on the "All Claims" page, it shows on page 8 data on 
the number of CMS-1450s with the following two-digit classification codes in 
Form Locator 4:  7-2 (hospital-based or independent renal dialysis facilities), 
 
  Lab (All referred outpatient diagnostic services) - Of the bills reported on the "All 
Claims" page, it shows on page 9 data on the number of CMS-1450s with the 
following two-digit classification codes in Form Locator 4:  1-4 (Hospital-Other-
Part B benefits); and 2-4 (SNF-Other-Part B benefits), 
 
  Other - Of the bills reported on the "All Claims" page, it shows on page 10 data 
on the number of CMS-1450s not included in the previous eight bill categories, 
including provider and independent RHC bills, and 
 
  All Claims - On page 11 it includes all bills processed to completion during the 
reporting month. 
 
SECTION E(2):  CLAIMS PROCESSING TIMELINESS - EMC CLAIMS AND 
ADJUSTMENTS FOR CPEP CPT CALCULATIONS 
 
Pages 12-21 of the CMS-1566 the intermediary includes data on the non-PIP bills paid 
during the month they were received via electronic media.  The basic instructions and  definitions that apply to pages 2-11 (see above) also apply to pages 12-21.  For each bill 
type, it reports the following information: 
 
  Column 1 - The intermediary reports the number of EMC claims that were 
included in column 2 (paid non-PIP clean) for the corresponding bill type on 
pages 2-11. 
 
  Column 2 - The intermediary reports the number of EMC claims that were 
included in column 3 (paid non-PIP other) for the corresponding bill type on 
pages 2-11. 
 
For each bill type on pages 12-21, it reports the following adjustments for CPEP CPT 
calculations: 
 
CWF - Claims that were beyond its control due to CWF.  (See The Medicare Claims 
Processing Manual, Chapter 1, General Billing Requirements for definition of claims 
meeting this criteria.) 
 
A. The number of EMC non-PIP clean claims paid beyond the EMC ceiling. 
B. The number of paper non-PIP clean claims paid beyond the paper ceiling. 
C. The number of all claims processed beyond 60 days. 
 
WAIVER - Non-PIP claims paid under the claims payment floor for which the 
intermediary had a waiver from CMS. 
 
D. The number of EMC non-PIP clean claims paid under the EMC floor. 
E. The number of paper non-PIP clean claims paid under the paper floor. 
F. The number of EMC non-PIP claims (clean and other) paid under the EMC floor plus 
the number of paper non-PIP claims (clean and other) paid under the paper floor. 
 
30.4 - Completing Page 22 of Intermediary Workload Report 
(Rev. 6, 08-30-02) 
A3-3894.4 
 
30.5 - Heading 
(Rev. 6, 08-30-02) 
A3-3894.5 
 
This page is referenced as Form W in the CROWD system.  The intermediary completes 
the ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to 
bring the reporting format to its screen. 
 
30.6 - Checking Reports 
(Rev. 6, 08-30-02) 
A3-3894.6 
  Before transmitting page 22 to CMS, the intermediary checks its completeness and 
arithmetical accuracy.  It uses the following checklist: 
 
  For each column, line 1 must equal the sum of lines 2-10. 
 
  For each column, line 11 must equal the sum of lines 12-20. 
 
  For each line, column 1 must equal the sum of columns 2-6. 
 
30.7 - Body of Report 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
SECTION F:  INTEREST PAYMENT DATA 
 
The intermediary reports on Page 22 of the CMS-1566 data on the bills on which it paid 
interest because it paid the bills after the required payment date per 9311 of the 
Omnibus Budget Reconciliation Act of 1986.  Counts of bills processed reflect their 
status as of the last workday of the reporting calendar month. The intermediary bases data 
shown on reliable counts of all bill processing activity and not on estimates.  It reports 
data on initial bills only.  Note that HH PPS RAPs with three-digit classification code 3-
2-2 or 3-3-2 with dates of service 10/01/2000 and greater are not subject to interest 
payment and should be excluded from this section.  The intermediary includes all bills 
requiring interest payments in the month.  It reports bills in the month the scheduled date 
of payment falls.  See The Medicare Claims Processing, Chapter 1, General Billing 
Requirements, for a discussion of interest payments and the definition of scheduled 
payment date. 
 
It the report for each column as follows: 
 
  Column 1 - Total - It includes data for all bills for which interest payments were 
made in the reporting month. 
 
  Column 2 - Hospital - Of the bills reported in column 1, it shows in column 2 
data for CMS-1450s submitted by hospitals for inpatient or outpatient services 
with the following two-digit classification codes in Form Locator 4: 
 
  1-1  (inpatient hospital) 
  1-2  (inpatient hospital - Part B benefits) 
  1-3  (outpatient hospital) 
  1-4  (hospital - other Part B benefits) 
  4-1  (Religious Nonmedical Health Care Hospital - inpatient) 
  4-2  (Religious Nonmedical Health Care Hospital - inpatient Part B benefits) 
  4-3  (Religious Nonmedical Health Care Hospital - outpatient) 
  4-4  (Religious Nonmedical Health Care Hospital - inpatient other) 
  8-3  (Outpatient hospital surgical procedures - ASC) 
    Column 3 - SNF--Of the bills reported in column 1, it shows in column 3 data for 
CMS- 1450s submitted with the following two-digit classification codes in Form 
Locator 4: 
 
  1-8  (hospital swing-bed) 
  2-1  (SNF - inpatient)  
  2-2  (SNF - inpatient Part B benefits) 
  2-3  (SNF - outpatient) 
  2-4  (SNF - other Part B benefits) 
  2-8  (SNF-swing-bed) 
  5-1  (Religious Nonmedical Health Care SNF - inpatient) 
  5-2  (Religious Nonmedical Health Care SNF - inpatient Part B benefits) 
  5-3  (Religious Nonmedical Health Care SNF - outpatient) 
  5-4  (Religious Nonmedical Health Care SNF - inpatient other) 
 
  Column 4 - HHA - Of the bills reported in column 1, it shows in column 4 data 
for CMS-1450s with the following two digit classification codes in Form Locator 
4:  3-2, 3-3, and 3-4. 
 
  Column 5 - Hospice - Of the bills reported in column 1, it shows in column 5 
data for CMS-1450s with the following two-digit classification codes in Form 
Locator 4:  8-1 and 8-2. 
 
  Column 6 - Remainder - Of the bills reported in column 1 it shows in column 6 
data for all CMS-1450s not included in columns 2-5 (including provider and 
independent RHCs). 
 
On line 1, it shows the number of claims on which it paid interest in the reporting month.  
It reports on line 2 the number of claims included in line 1 for which it made payment 
one day after the required payment date (e.g., the required payment date is 25 days in FY 
1999).  Data for lines 3-10 are similar to those for line 2.  It calculates the number of days 
late by subtracting the Julian date of receipt of the bill from the Julian scheduled payment 
date and then subtracting the required payment date (i.e., 25 in FY 1999).  If the bill is 
paid in the year following the year of receipt, it adds 365 or 366 (if the year of receipt is a 
leap year) to the result, as appropriate. 
 
On line 11, it shows the amount paid in interest on the bills reported in line 1.  See The 
Medicare Claims Processing Manual, Chapter 1, General Billing Requirements on how to 
calculate interest payments.  On lines 12-20 it shows the amounts paid in interest for bills 
reported in lines 2-10, respectively.  It shows payment amounts on lines 11-20 to the 
nearest penny, including the decimal point. 
 
    Exhibit 1 
 
Form CMS 1566 - Medicare Program Intermediary Workload Report, Page 1 
 
Intermediary Name:  Reporting Period:    
Intermediary Number:     Number of Working Days:   
SECTION A:  TOTAL  INPATIENT  OUTPATIENT  SNF  HHA  OTHER 
INITIAL BILL PROCESSING  (1)  (2)  (3)  (4)  (5)  (6) 
Opening Pending 
1.    Opening Pending                   
2.    Adjustments (+ or -)                   
3.     Adj Opening Pending                   
Receipts    
4.     Received during Month                   
5. Electronic Media                   
Clearances 
6.    Total CWF Bills                   
7.      Payment Approved                   
8.      No Payment Approved                   
9.     Total Non-CWF Bills                   
10.     Payment Approved                   
11.     No Payment Approved                   
12.     Total Processed                   
Closing Pending                   
13.    Pending End of Month                   
14.     Longer than 1 Month                   
15.     Longer than 2 Months                   
  Exhibit 1 (Cont.) 
 
Form CMS 1566 - Medicare Program Intermediary Workload Report, Page 1  
 
Intermediary Name:  Reporting Period:    
Intermediary Number:     Number of Working Days:   
SECTION A:  TOTAL  INPATIENT  OUTPATIENT  SNF  HHA  OTHER 
INITIAL BILL PROCESSING  (1)  (2)  (3)  (4)  (5)  (6) 
 
Bill Investigations 
16.    Investigations Init                   
SECTION B: ADJUSTMENT BILLS 
CWF Clearances 
17.     Total CWF Processed                   
18.     PRO Generated                   
19.      Provider Generated                   
20.     MSP                   
21.     Other                   
Non-CWF Clearances                   
22.     Total Non-CWF Prcsd                   
23.     PRO Generated                   
24.      Provider Generated                   
25.     MSP                   
26.     Other                   
  Exhibit 1 (Cont.) 
 
Form CMS 1566 - Medicare Program Intermediary Workload Report, Page 1 
 
Intermediary Name:  Reporting Period:    
Intermediary Number:     Number of Working Days:   
OUT 
  TOTAL  INPATIENT  PATIENT  SNF  HHA  OTHER 
SECTION B: ADJUSTMENT BILLS  (1)  (2)  (3)  (4)  (5)  (6) 
             
Pending                   
27.    Total Pending                   
28.     PRO Generated                   
29.      Provider Generated                   
30.      MSP                   
31.     Other                     
SECTION C: MEDICAID  
CROSSOVER BILLS 
Clearances                   
32.    Trans to St Agencies                   
33.     Trans Electronically                   
SECTION D: 
MISCELLANEOUS DATA  TOTAL  BENEFICIARY  PROVIDER  
Inquiries         
34.    Total Inquiries         
35.     Telephone 
       
36.      Walk-In         
37.      Written           
  Exhibit 1 (Cont.) 
 
Form CMS 1566 - Medicare Program Intermediary Workload Report, Page 1 
 
Intermediary Name:  Reporting Period:    
Intermediary Number:     Number of Working Days:   
SECTION D:  TOTAL  INPATIENT  OUTPATIENT  SNF  HHA  OTHER 
MISCELLANEOUS DATA  (1)  (2)  (3)  (4)  (5)  (6) 
             
OCR Bills                     
38.     Total Received                   
Bills Paid by HMOs                   
39.    Total Processed                   
Medicare Summary Notices             
40.    Total MSNs Mailed             
 
  Exhibit 2 
 
SECTION E(1): CLAIMS PROCESSING TIMELINESS - ALL CLAIMS 
 
Form CMS 1566 - Medicare Program Intermediary Workload Report, Pages 2-11 
 
Intermediary Number:  Bill Type:   Report Month:  
      ******  ********  **PAID**  ********  ***NOT PAID***    
      **Non-PIP**  ***PIP****          
DAYS TO  TOTAL  CLEAN  OTHER  CLEAN  OTHER  CLEAN  OTHER  EMC 
PROCESS  (1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
1.1                         
2. 2                         
3. 3                           
4. 4                           
5. 5                           
6. 6                           
7. 7                           
8. 8                           
9. 9                           
10. 10                           
11. 11                           
12. 12                           
  Exhibit 2 (Cont.) 
 
SECTION E(1): CLAIMS PROCESSING TIMELINESS--ALL CLAIMS 
 
Form CMS 1566 - Medicare Program Intermediary Workload Report, Pages 2-11 
 
Intermediary Number:  Bill Type:   Report Month:  
    *******  *******  ***PAID***  NOT PAID   
    **Non-PIP**  ****PIP****       
CLEA OTHE
DAYS TO  TOTAL  CLEAN  OTHER  CLEAN  OTHER  N  R  EMC 
PROCESS  (1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
                 
13. 13                           
14. 14                           
15. 15                           
16. 16                           
17. 17                           
18. 18                           
19. 19                           
20. 20                           
21. 21                           
22. 22                           
23. 23                           
  Exhibit 2 (Cont.) 
 
SECTION E(1): CLAIMS PROCESSING TIMELINESS--ALL CLAIMS 
 
Form CMS 1566 - Medicare Program Intermediary Workload Report, Pages 2-11 
 
Intermediary Number:  Bill Type:   Report Month:  
      ********  *******  **PAID**  *NOT PAID*    
      **Non-PIP**  ****PIP****        
CLEA OTHE EM
DAYS TO  TOTAL  CLEAN  OTHER  CLEAN  OTHER  N  R  C 
PROCESS  (1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
                 
24. 24                         
25. 25                         
26. 26                         
27. 27                         
28. 28                         
29. 29                         
30. 30                         
31. 31                         
32. 32                         
33. 33                         
  Exhibit 2 (Cont.) 
 
SECTION E(1): CLAIMS PROCESSING TIMELINESS--ALL CLAIMS 
 
Form CMS 1566 - Medicare Program Intermediary Workload Report, Pages 2-11 
 
Intermediary Number:  Bill Type:   Report Month:  
      *******  ******  **PAID**  **NOT PAID**    
      **Non-PIP**  ****PIP****          
CLEA OTHE
DAYS TO  TOTAL  CLEAN  OTHER  CLEAN  OTHER  N  R  EMC 
PROCESS  (1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
                 
34. 34-45                 
35. 46-60                 
36. 61-90                 
37. 91+                 
38. Total                 
39. Mean                 
PT 
  CMS-1566, Page  
 
Page number and bill type to be reported as follows: 
 
Page 2 - Inpatient Hospital (INP)  Page 7 - CORF (COR) 
Page 3 - Outpatient (OUT)  Page 8 - ESRD (ERD) 
Page 4 - SNF (SNF)  Page 9 - Lab (LAB) 
Page 5 - HHA (HHA)  Page 10 - Other (OTH) 
Page 6 - Hospice (HPC)  Page 11 - Total (TOT) 
  EXHIBIT 3 
 
SECTION F: INTEREST PAYMENT DATA 
 
Form CMS 1566 - Medicare Program Intermediary Workload Report, Page 22 
 
Intermediary Number:  Report Month: 
BILLS/PAYMENTS  TOTAL  HOSPITAL  SNF  HHA  HOSPICE  REMAINDER 
DAYS LATE   (1)   (2)   (3)   (4)   (5)   (6)  
1. Total Bills             
2. 1             
3. 2             
4. 3             
5. 4             
6. 5             
7. 6-15             
8. 16-30             
9. 31-60             
10. 61+             
11. Total Paid             
12. 1             
13. 2             
14. 3             
15. 4             
  Exhibit 3 (Cont.) 
 
SECTION F: INTEREST PAYMENT DATA 
 
Form CMS 1566 - Medicare Program Intermediary Workload Report, Page 22 
 
Intermediary Number:  Report Month: 
BILLS/PAYMENTS  TOTAL  HOSPITAL  SNF  HHA  HOSPICE  REMAINDER 
DAYS LATE   (1)   (2)   (3)   (4)   (5)   (6)  
16. 5             
17. 6-15             
18. 16-30             
19. 31-60             
20. 61+             
  40 - Monthly PRO Adjustment Bill Report (Inactive) 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
The intermediary prepares and submits to CMS, by the 10th of each month following the 
reporting month, a PRO Adjustment Bill Report using the CROWD system.  It submits a 
total page showing contractor activity for all PROs in the contractors area.  In addition, it 
submits a separate report for each PRO/State.  For example, if the intermediary handles 
adjustment records for a PRO involving separate States, it should submit a separate report 
for each State.  It reports all tape adjustment requests as well as hardcopy adjustment 
request records which the PRO has designated XXP (where XX is a two-digit numeric 
identifier) in accordance with the Medicare Claims Processing Manual, Chapter 4, 
Outpatient Billing.  If the intermediary does not have activity for a certain PRO/State 
combination in a month, it shall not submit a report. 
 
40.1 - Heading 
(Rev. 6, 08-30-02) 
A3-3895.1 
 
The intermediary enters the contractors assigned 5-digit ID and the PRO's 5-digit ID 
number in the indicated spaces.  It shows the 2-digit State abbreviation.  For the total 
page show "Total" in the PRO space.  In the space labeled "Report Month/Year" enter the 
calendar month and year reported, e.g., show 0692 for June 1992. 
 
40.2 - Body of Report 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
For all PRO adjustments, determine the appropriate column.  Complete the report for 
each line as follows: 
 
  Line 1 - Opening Pending - The intermediary enters the total number of 
adjustment request records reported as pending at the end of the previous month. 
 
  Line 2 - Revisions to Opening Pending - The intermediary reports the net result 
of the number of request records that should not have been counted as adjustment 
request records pending at the end of the previous month (minus) and the number 
that were not counted but which should have been (plus). 
 
  Line 3 - Revised Opening Pending - The intermediary enters line 1 plus line 2. 
 
  Line 4 - Electronic Adjustment Request Records Received - The intermediary 
enters the number of electronic adjustment request records received from the PRO 
in the month. 
 
  Line 5 - Electronic Adjustment Request Records Rejected - The intermediary 
enters the number of electronic adjustment request records reported on line 4 that 
failed contractor front end edits.   
  Line 6 - Electronic Adjustment Request Records Accepted - The intermediary 
enters the difference of line 4 minus line 5. 
 
  Line 7 - Hard Copy Adjustment Requests Received - The contractor shall enter 
the number of hard copy adjustment requests it received from its PRO(s).  It shall 
count only hard copy requests the PRO has identified as 11P, 13P, 18P, 21P, or 
83P. 
 
  Line 8 - Additional Bills to be Processed Due to Interim Bills-The intermediary 
enters the number of interim bills to be adjusted as a result of PRO electronic or 
hard adjustment requests.  It does not count interim bills for which no change is 
needed. 
 
  Line 9 - Total Adjustment Bills to be Processed - The intermediary enters the 
total number of adjustment bills to be processed.  This is the sum of lines 3, 6, 7, 
and 8. 
 
  Line 10 - Non-processable Adjustment Bills - Failed Batch/System Edits - The 
intermediary enters the number of bills it could not process due to batch/system 
edits.  It includes any requests which conflict with its history; e.g., utilization.  It 
counts any interim bill which edits out of its system.  These bills will be identified 
as non-processable on the Revisions to the Monthly PRO Adjustment Bill Report. 
 
  Line 11 - Total Adjustment Bills Processed - The intermediary enters the total 
number of adjustment bills it has processed as a result of PRO adjustment 
requests (hard copy and electronic).  It counts each bill when multiple bills are 
processed to satisfy one request. 
 
  Line 12 - Number Completed in 60 Days or Less - The intermediary enters the 
number of adjustment bills processed in 60 days or less from the date it received 
the adjustment request record. 
 
  Line 13 - Number Completed in 61-90 Days - The intermediary enters the 
number of adjustment bill processed in 61 to 90 days. 
 
  Line 14 - Number Completed in 91-120 Days - The intermediary enters the 
number of adjustment bills processed in 91 to 120 days. 
 
  Line 15 - Number Completed Over 120 Days - The intermediary enters the 
number of adjustment bills processed in 121 days or more. 
 
  Line 16 - Closing Pending - The intermediary enters the total number of 
adjustment request records pending at the end of the report month. 
 
  40.3 - Checking Reports 
(Rev. 6, 08-30-02) 
A3-3895.3 
 
Before transmitting the report, the intermediary checks for completeness and arithmetical 
accuracy.  The line item edits apply to all columns.  It uses the following checklist: 
 
  Line 1 plus line 2 = line 3; 
 
  Line 5 plus line 6 = line 4; 
 
  Line 3 plus line 6 plus line 7 plus line 8 = line 9; 
 
  Line 9 minus line 10 minus line 11 = line 16; 
 
  Sum of lines 12 through 15 = line 11; 
 
  Column b plus column c = column a; 
 
  Sum of all PRO pages = Total pages; 
 
  Total page line 11 = line 17, column (i) of CMS-1566; and 
 
  Line 1 of current month's report must equal line 16 of previous month's report.  40.4 - Report Form 
(Rev. 6, 08-30-02) 
A3-3895.4 
 
MONTHLY PRO ADJUSTMENT BILL REPORT 
PRO ID:  MONTH/YEA
INTERMEDIARY ID:   
STATE:  R: 
TOTAL  INPATIENT  OUTPATIENT 
 
(A)  (B)  (C) 
1.Opening Pending       
2.Revisions to Opening Pending       
3.Revises Opening Pending       
4.Elec. Adj. Req. Rec. Received       
5.Elec. Adj. Rec. Rec. Rejected       
6.Elec. Adj. Rec. Received       
7.Hard-Copy Adj. Req. Rec. Accepted       
8.Addtl. Bills to be Proc. Due to Interim Bills       
9.Total Adj. Bills to be Proc.       
  Report Form (Cont.) 
 
MONTHLY PRO ADJUSTMENT BILL REPORT 
PRO ID:  MONTH/YEA
INTERMEDIARY ID:   
STATE:  R: 
TOTAL  INPATIENT  OUTPATIENT 
 
(A)  (B)  (C) 
10.Nonprocessable Adjustment Bills-Failed 
     
Batch/System Edits 
11.Total Adj. Bills Processed       
12.No. Compl. in 60 Days or Less       
13.No. Compl. in 61-90 Days       
14.No. Compl. in 91-120 Days       
15.No. Compl. Over 120 Days       
16.Closing Pending 
 
  50 - Quarterly Supplement To Intermediary Workload Report (Form 
CMS-1566A) - General 
(Rev. 6, 08-30-02) 
A3-3896 
 
In addition to the monthly workload report, prepare and transmit to CMS a Quarterly 
Supplement to the Intermediary Workload Report showing the status and disposition of 
selected workloads.  Complete a separate report for each office assigned a separate 
intermediary number. 
 
50.1 - Purpose and Scope 
(Rev. 6, 08-30-02) 
A3-3896.1 
 
The Quarterly Supplement to the Intermediary Workload Report - Pages 1 and 2, supplies 
CMS with current data on the number of bills processed for each State for which you 
service one or more providers.  The Quarterly Supplement to the Intermediary Workload 
Report - Page 3, provides data on denials, HHA visits and waivers of liability. 
 
50.2 - Due Date 
(Rev. 6, 08-30-02) 
A3-3896.2 
 
Transmit the Quarterly Supplement to CMS CO via PC or terminal as soon as possible 
after the reporting quarter but no later than the 15th of the following month.  Use 
instructions contained in the Contractor Reporting of Operational and Workload Data 
(CROWD) System User's Guide. 
 
60 - Completing Quarterly Supplement To The Intermediary Workload 
Report, CMS-1566A, Pages 1 And 2 
(Rev. 6, 08-30-02) 
A3-3897 
 
60.1 - Heading 
(Rev. 6, 08-30-02) 
A3-3897.1 
 
These pages are referenced as Form C in the CROWD system.  Complete the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to 
bring the reporting format to your screen. 
 
 
60.2 - Checking Reports 
(Rev. 6, 08-30-02) 
A3-3897.2   
Before submitting Form C to CMS, check its completeness and arithmetical accuracy.  
Use the following checklist: 
 
  For each corresponding type of bill, line 1 (ALL) equals the sum of the number of 
bills processed reported on line 12 on the intermediary's monthly workload report 
(CROWD Form D) for the 3 months of the reporting period. 
 
  For each column, line 1 (ALL) equals the sum of the lines reported for each State. 
 
  For all lines of the report, column 1 (Total) equals the sum of the items in 
columns 2 + 3 + 4 + 5 + 6. 
 
  The State code must be the two-letter postal abbreviation.  Use code FO for all 
foreign claims not originating from a state, territory, or the District of Columbia. 
 
60.3 - Type of Bill 
(Rev. 10521; Issued: 12-16-20; Effective: 01-01-21; Implementation: 01-04-21) 
 
The A/B MAC (A) reports counts in total and by type of bill as shown below: 
 
Column   (1)   Total--All provider bills.  
Column   (2)   Inpatient Hospital--CMS-1450s submitted by hospitals for inpatient 
services, with the following two-digit classification codes in Form 
Locator 4: 1-1 (inpatient hospital); and 4-1 (Religious Nonmedical 
Health Care Hospital-inpatient).  
Column   (3)   Outpatient--CMS-1450s submitted by hospitals or SNFs for 
outpatient services with the following two-digit classification codes 
in Form Locator 4: 1-3 (hospital-outpatient); 2-3 (SNF-outpatient); 
4-3 Religious Nonmedical Health Care Hospital- outpatient); 5-3 
(Religious Nonmedical Health Care SNF-outpatient); and 8- 3 
(hospital- outpatient surgical procedures - ASC)  
Column   (4)   SNF--CMS-1450s with the following two-digit classification codes 
in Form Locator 4: 1-8 (hospital-swing-bed); 2-1 (SNF-inpatient); 
2-8 (SNF swing- bed); and 5-1 (Religious Nonmedical Health 
Care-SNF-inpatient).  
Column   (5)   HHA--CMS-1450s submitted by HHAs with the following two 
digit classification codes in Form Locator 4: 3-2 (HHA-Part B 
visits and use of DME); 3-3 (HHA-Part A visits and DME); 3-4 
(HHA-other-Part B-benefits)  
Column   (6)   Other--CMS-1450s with the following two-digit classification 
codes in Form Locator 4: 1-2 (hospital inpatient-Part B benefits); 
1-4 (hospital-other-Part B benefits); 2-2 (SNF-inpatient-Part B 
benefits); 2-4 (SNF-other-Part B benefits); 4-2 (Religious 
Nonmedical Health Care-inpatient-Part B benefits); 4-4 (Religious 
Nonmedical Health Care-inpatient-other); 5-2 (Religious 
Nonmedical Health Care-SNF inpatient-Part B benefits); 5-4  (Religious Nonmedical Health Care-SNF inpatient-other); 7-1, 7-2, 
7-3, 7-4, 7-5 (Clinics - provider and independent RHCs, FQHCs, 
ESRD hospital- based or independent renal dialysis facilities, 
FQHCs, CMHCs, ORFs and CORFs); 8-1 and 8-2 (Hospices); and 
8-7 (Opioid Treatment Programs)   
 
60.4 - Body of Report 
(Rev. 6, 08-30-02) 
A3-3897.4 
 
Section A:  Bills Processed by State of Provider - The intermediary reports in this 
section the claims workload for each State for which you service one or more providers.  
Break out by State the number of initial bills (including demand and no-pay bills) 
reported as processed on line 12 of Form D (see 20.4) over the 3 months of the reporting 
quarter. 
 
NOTE: Categorize the information reported by the State of the individual provider, not 
the home office, if it is part of a chain organization. 
 
Line 1 - All - For each column 1 through 6, the system will sum the number of claims 
reported on the individual State lines completed below.  The numbers so calculated by 
the system must equal the sum of the numbers reported on line 12 of Form D for the 3 
months of the reporting quarter. 
 
State Lines - In the column just left of column (1), the intermediary enters the two-digit 
postal abbreviation of each State (or FO for foreign claims) which includes at least one 
provider for which you processed claims during the quarter. 
 
It enters opposite each listed State the number of initial bills processed during the 
reporting quarter for providers located in the State.  It reports the data in total in column 
1, and by type of bill in columns 2 through 6. 
 
70 - Completing Quarterly Supplement To The Intermediary Workload 
Report, CMS-1566A, Page 3 
(Rev. 6, 08-30-02) 
A3-3898 
 
70.1 - Heading 
(Rev. 6, 08-30-02) 
A3-3898.1 
 
This page is referenced as Form I in the CROWD system. 
 
Complete the ADD/UPDATE/DELETE DATA criteria screen with the appropriate 
information to bring the reporting format to your screen. 
  70.2 - Checking Reports 
(Rev. 6, 08-30-02) 
A3-3898.2 
 
Before submitting Form I to CMS, check for completeness and arithmetical accuracy.  
Use the following checklist: 
 
  For all columns, line 1 + line 7 + line 8 must be equal to or less than line 1 of 
Form C. 
 
  For all columns, line 1A + line 1B + line 1C must equal line 1. 
 
  For all columns, line 1D must be equal to or less than line 1C. 
 
  For all columns, line 2A must be equal to or less than line 1A. 
 
  For all columns, line 2A must be equal to or less than line 2. 
 
  For all columns, line 3A must be equal to or less than line 3. 
 
  For all columns, line 7A must be equal to or less than line 7. 
 
  For all columns, line 8B must be equal to or less than line 8. 
 
  For all columns, lines 3 and 3A must be rounded to whole dollars.  NOTE: This 
may cause you to force column 1 to equal the sum of columns 2-6. 
 
  For lines 1 through 3A, lines 7 and 7A, and lines 8 and 8B, column 1 must equal 
the sum of columns 2-6. 
 
  For columns 4 and 5, line 4 must be equal to or greater than line 1 of Form C. 
 
  For columns 4 and 5, lines 5 through 6A must be equal to or greater than lines 1 
through 2A, respectively (e.g., line 5 must be equal to or greater than line 1, line 
5A must be equal to or greater than line 1A, etc.). 
 
  For columns 4 and 5, line 5A + 5B + 5C must equal line 5. 
 
  For columns 4 and 5, line 6A must be equal to or less than line 5A. 
 
  For columns 4 and 5, line 6A must be equal to or less than line 6. 
 
  For columns 4 and 5, line 7B must be equal to or greater than line 7A. 
 
  For columns 4 and 5, line 8A must be equal to or greater than line 8.   
  For columns 4 and 5, line 5 + line 7B + line 8A must be equal to or less than line 4. 
 
70.3 - Type of Bill 
(Rev. 6, 08-30-02) 
A3-3898.3 
 
The intermediary reports counts in total and by type of bill as outlined in 60.3 for Form C. 
 
70.4 - Body of Report 
(Rev. 6, 08-30-02) 
A3-3898.4 
 
Section B: Bill Denial Data 
 
Line 1: Bills Denied-Total - The intermediary reports all full and partial denial 
determinations that it made during the reporting period.  It reports only denial 
determinations resulting in its preparing and sending a notice to the beneficiary.  It counts 
a denial when it denies (either in full or in part) bills submitted as covered.  It includes 
counts where it made a denial determination but found both the beneficiary and the 
provider to be without fault under 213 of Public Law 92-603 and, therefore, made a 
determination to waive liability in full. 
 
Also, it includes counts when it found only the provider to be at fault (i.e., it waived the 
beneficiary's liability).  It does not count: 
 
  Denials of no-pay or demand bills even though the contractor sends a denial 
notice. 
 
  Denials of future services. 
 
  Denials made by PROs. 
 
Line 2: Bills Paid Under Waiver-Total - The intermediary reports the total number of 
bills on which you made a determination to waive the liability of both the beneficiary and 
the provider. Count determinations made at: 
 
  Initial bill processing, 
 
  Appeals process, and 
 
  Any other time such as when you reopen your initial decision. 
 
The intermediary does not count waiver determinations made by PROs. 
  Line 2A: Initial Bills Paid Under Waiver - The intermediary reports the number of bills 
on which you made a decision to waive the liability of both the beneficiary and the 
provider during the initial adjudication of the bills. 
 
Line 3: Amount Reimbursed Under Waiver - The intermediary reports the amounts 
paid (to the nearest dollar) under the waiver provision for the bills reported on line 2.  Do 
not include coinsurance amounts, charges applied toward the deductible, or 
reimbursement for services not under consideration with respect to the waiver provision.  
Where all services on a bill are paid in full (excluding the applicable deductible and 
coinsurance) as a combination of covered services and noncovered services paid under 
waiver and the exact dollar amount of the waiver payment is not available without 
contacting the provider, it reports an approximation of the waiver payment.  In 
calculating this approximation, apply to total charges the proportion of waiver days to 
total days included on the bill, and subtract any applicable deductible or coinsurance for 
the waiver period. 
 
Line 3A: Amount on Initial Bills - The intermediary reports the amounts paid (to the 
nearest dollar) under the waiver provision for the bills reported on line 2A. 
 
Section C: Day/Visit Data 
 
Line 4: Days/Visits Processed - The intermediary reports under column 4 the total 
number of days (both covered and noncovered) for SNF bills shown as processed in 
column 4, line 1 of Form C, for the same reporting period.  It reports under column 5 the 
number of billed visits for HHA bills shown as processed in column 5, line 1 of Form C, 
for the same reporting period. 
 
Line 5: Days/Visits Denied-Total - The intermediary reports under column 4 the number 
of SNF days denied on the bills reported on line 1.  It reports under column 5 the number 
of HHA visits denied on the bills reported on line 1.  Denied days/visits are those billed 
as covered which you determine to be noncovered. 
 
Line 6: Days/Visits Paid Under Waiver of Liability - The intermediary reports under 
column 4 the number of SNF days on the bills reported on line 2 that were paid under the 
waiver provision. It reports under column 5 the number of HHA visits on the bills 
reported on line 2 that were paid under the waiver provision. 
 
Line 6A: Days/Visits Paid Under Waiver on Initial Bills - The intermediary reports 
under column 4 the number of SNF days on the bills reported on line 2A that were paid 
under the waiver provision.  It reports under column 5 the number of HHA visits on the 
bills reported on line 2A that were paid under the waiver provision. 
 
Section D: Demand Bill Data 
 
Line 7: Total Demand Bills - The intermediary reports under the appropriate column 
bills which the provider determined to be for noncovered services but which the  beneficiary or his representative requested be filed in order to obtain a Medicare decision.  
It reports only bills identified by condition code 20. (See The Medicare Claims 
Processing Manual, Chapter 1, General Billing Requirements.)  It reports the total 
number of bills processed during the reporting quarter, even if not manually reviewed. 
 
Line 7A: Full/Partial Reversals - The intermediary reports the number of demand bills 
on which you fully or partially reversed the provider's decision that the services were 
noncovered. 
 
Line 7B: Days/Visits on Reversals - The intermediary reports under column 4 the 
number of SNF days on the demand bills reported on line 7A.  It reports under column 5 
the number of HHA visits on the demand bills reported on line 7A (i.e., report days/visits 
for which you fully or partially reversed the provider's decision that they were 
noncovered). 
 
Section E: No-Pay Bill Data 
 
Line 8: Total No-Pay Bills - The intermediary reports under the appropriate column the 
total number of no-pay bills (excluding the demand bills reported on line 7 Section D) 
which are included in the total bills processed reported on line 1, page 1 of the Quarterly 
Supplement for the same reporting period.  No-pay bills are those submitted by providers 
with no charges and/or covered days/visits.  It does not report HHA bills where no 
utilization is chargeable and no payment has been made, but which you have requested 
only to facilitate recordkeeping processes. 
 
Line 8A: Days/Visits on No-Pay Bills - The intermediary reports under column 4 the 
number of SNF days on the no-pay bills reported on line 8.  It reports under column 5 the 
number of HHA visits on the no-pay bills reported on line 8. 
 
Line 8B: MSP No-Pay Bills - The intermediary reports the number of no-pay bills 
included on line 8 where payment has been made in full by another insurer as primary 
payer. 
 
70.5 - Completing Medicare Fraud Unit Quarterly Workload Status 
Report, CMS-1566B - General 
(Rev. 6, 08-30-02) 
A3-3898.5 
 
The intermediary prepares and submits to CMS each quarter a report on the number of 
fraud workload items handled by your Medicare fraud unit.  This information is required 
by CMS to budget for fraud and abuse activities, as well as to monitor the flow of work 
through the fraud units.  Submit this form via the CROWD system no later than the 15th 
day following the close of the reporting quarter. 
 
70.6 - Heading 
(Rev. 6, 08-30-02)  A3-3898.6 
 
This page is referenced as Form M in the CROWD system.  Complete the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to 
bring the reporting format to your screen. 
 
70.7 - Checking Reports 
(Rev. 6, 08-30-02) 
A3-3898.7 
 
Before submitting Form M to CMS, check for completeness and arithmetical accuracy.  
Use the following checklist: 
 
  For all columns, line 1 must equal line 8 of Form M for the previous quarter. 
 
  For all columns, line 1 + line 2 = line 3. 
 
  For all columns, line 6 + line 7 = line 5. 
 
  For all columns, line 3 + line 4 - line 5 = line 8. 
 
  For all lines, column 1 = column 2 + column 3 + column 4. 
 
70.8 - Type of Fraud Workload Item 
(Rev. 6, 08-30-02) 
A3-3898.8 
 
The intermediary reports fraud workload items in the following columns for all lines of 
Form M: 
 
Column (1) - Total - All fraud workload items. 
 
Column (2) - Beneficiary Complaints - The intermediary reports the number of 
complaints received from, or on behalf of, beneficiaries alleging fraud.  Do not include 
complaints filed with the Office of the Inspector General (OIG) Hotline. 
 
Column (3) - OIG Hotline - The intermediary reports the number of complaints received 
via the OIG Hotline. 
 
Column (4) - Referrals and Other - The intermediary reports referrals and any other 
workload received by the fraud unit (e.g., provider complaints, internally generated 
referrals from medical review, special requests from OIG or CMS). 
 
70.9 - Body of Report 
(Rev. 6, 08-30-02) 
A3-3898.9   
Line 1 - Opening Pending - The system will pre-fill the number pending from line 8 of 
the previous quarter's report. 
 
Line 2 - Adjustments - If it is necessary to revise the pending figure for the close of the 
previous quarter because of inventories, reporting errors, etc., enter the adjustment on this 
line.  Precede negative adjustments with a minus sign. 
 
Line 3 - Adjusted Pending - The system will sum line 1 + line 2 to calculate the 
adjusted opening pending. 
 
Line 4 - Workload Received - The intermediary reports the number of complaints and 
referrals received in the fraud unit during the reporting period. 
 
Line 5 - Total Cleared - The system will sum line 6 + line 7 to calculate the total 
number of complaints and referrals cleared by the fraud unit during the reporting period. 
 
Line 6 - Cleared by Contractor - The intermediary reports the number of complaints 
and referrals cleared by the fraud unit by means other than referral to the OIG or 
designated agency.  Include those that were: 
 
  Closed as not substantive or not a fraud issue. 
 
  Closed as not a fraud issue but referred to another contractor component for their 
review or action. 
 
  Closed as not being a fraud issue but referred to an external component other than 
the OIG. 
 
Line 7 - Cleared by Referral - The intermediary reports the number of complaints and 
referrals that were incorporated into cases referred formally to the OIG or designated 
agency for action (e.g., sanctions or prosecution). 
 
Line 8 - Closing Pending - The system will calculate the closing pending for the quarter 
by adding line 3 to line 4 and subtracting line 5. 
 
70.10 - Completing Quarterly Periodic Interim Payment (PIP) Report, 
CMS-1566C - General 
(Rev. 6, 08-30-02) 
A3-3898.10 
 
The intermediary prepares and submits to CMS each quarter a report on the number of 
providers that you pay using the PIP method.  This information is required so that CMS 
can monitor the number of providers being paid using the PIP method at each 
intermediary and nationally.  Submit the form via the CROWD system no later than the 
15th day following the close of the reporting quarter.   
70.11 - Heading 
(Rev. 6, 08-30-02) 
A3-3898.11 
 
This page is referenced as Form Q in the CROWD system.  Complete the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to 
bring the reporting format to your screen. 
 
70.12 - Checking Reports 
(Rev. 6, 08-30-02) 
A3-3898.12 
 
Before submitting Form Q to CMS, check for completeness and arithmetical accuracy.  
Use the following checklist: 
 
  For all columns, line 1 + line 2 - line 3 = line 4. 
 
  For all lines, column 1 + column 2 + column 3 = column 4. 
 
70.13 - PIP Items Reported - The intermediary reports the PIP 
workload items in the following lines for all columns of Form Q: 
(Rev. 6, 08-30-02) 
A3-3898.13 
 
Line 1 - PIP Providers - Beginning of Quarter - The intermediary reports the number 
of PIP providers by type (hospital, SNF and HHA) and total at the beginning of the 
quarter. 
 
Line 2 - PIP Providers - Accretions - The intermediary reports the number of providers 
by type (hospital, SNF and HHA) and total who elected during the reporting quarter to be 
paid under PIP. 
 
Line 3 - PIP Providers - Deletions - The intermediary reports the number of providers 
by type (hospital, SNF and HHA) and total who elected during the reporting quarter to 
discontinue being reimbursed under the PIP method. 
 
Line 4 - PIP Providers - End of Quarter - The intermediary reports the number of PIP 
providers by type (hospital, SNF and HHA) and total at the end of the quarter.  70.14 - Quarterly Supplement to the Intermediary Workload Report - CMS-1566A, Pages 1,2,3 
(Rev. 6, 08-30-02) 
A3-3898.14 
 
QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT 
HFCA-1566A, PAGES 1 & 2 (CROWD FORM C) 
INTERMEDIARY NUMBER_______      REPORT PERIOD_______ 
  
SECTION A: 
BILLS PROCESSED BY TOTAL  INP HOSP  OUTPATIENT  SNF  HHA  OTHER 
  
STATE OF PROVIDER  1  2  3  4  5  6 
                 
1 .     TOTAL - ALL                   
      STATE CODE  XXXXXXXXXXX  XXXXXXXXX XXXXXXXXXXXX XXXX  XXXXX  XXXXXX 
                          
                          
                          
                          
                          
                          
                          
                          
                          
                          
                          
                           Quarterly Supplement To Intermediary Workload Report (Cont.) 
 
QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT 
HFCA-1566A, PAGE 3 (CROWD FORM I) 
 
INTERMEDIARY NUMBER_______ 
REPORT PERIOD_______ 
 
TOTAL  INPATIENT  OUTPATIENT  SNF  HHA  OTHER 
  
1    2    3    4    5    6   
SECTION B: BILL DENIAL DATA  XXXXXXX  X  XXXXXXXXX  X  XXXXXXXXXX  X  XXX     XXXX     XXXXX   
  
1. BILLS DENIED - TOTAL                   
  
1A. MEDICAL - SUBJECT   XXXXXX  XXXXXXXXXX XXXXXXXXXXX XXXXXX  XXXXXX  XXXXXX 
TO WAIVER 
  
1B. MEDICAL - NOT SUBJECT   XXXXXX  XXXXXXXXXX XXXXXXXXXXX XXXXXX  XXXXXX  XXXXXX 
TO WAIVER 
  
1C. NONMEDICAL TOTAL  XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX  XXXXXX  XXXXXX 
  
1D. NONMEDICAL MSP  XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX  XXXXXX  XXXXXX 
  
2. BILLS PAID UNDER WAIVER                   
TOTAL 
  
2A. INITIAL BILLS PAID                   
UNDER WAIVER 
  Quarterly Supplement To Intermediary Workload Report (Cont.) 
 
QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT 
HFCA-1566A, PAGE 3 (CROWD FORM I) 
 
INTERMEDIARY NUMBER_______ 
REPORT PERIOD_______ 
 
TOTAL  INPATIENT  OUTPATIENT  SNF  HHA  OTHER 
  
1    2    3    4    5    6   
3. AMOUNT REIMBURSED UNDER                   
WAIVER 
 
3B. AMOUNT ON INITIAL BILLS                   
 
SECTION C: DAY/VISIT DATA  XXXXXXX    XXXXXXXXXX  X XXXXXXXXXX  X XXX     XXXX     XXXXX   
  
4. DAYS/VISITS PROCESSED  XXXXXXX    XXXXXXXXXX  X XXXXXXXXXX         XXXXX   
  
5. DAYS/VISITS DENIED TOTAL               
NO-PAY BILLS  XXXXXXX    XXXXXXXXXX  X XXXXXXXXXX    XXXXX   
  
5A. MEDICAL - SUBJECT TO                                             
WAIVER  XXXXXXX    XXXXXXXXXX  X XXXXXXXXXX  X XXXXX XXXXXX XXXXX   
  
5B. MEDICAL - NOT SUBJECT                                             
TO WAIVER  XXXXXXX    XXXXXXXXXX  X XXXXXXXXXX  X XXXXX X  XXXXX XXXXX   
  
5C. NONMEDICALS  XXXXXXX    XXXXXXXXXX  X XXXXXXXXXX    XXXXX  XXXXXX XXXXX   
   Quarterly Supplement To Intermediary Workload Report (Cont.) 
 
QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT 
HFCA-1566A, PAGE 3 (CROWD FORM I) 
 
INTERMEDIARY NUMBER_______ 
REPORT PERIOD_______ 
 
TOTAL  INPATIENT  OUTPATIENT  SNF  HHA  OTHER 
  
1    2    3    4    5    6   
6. DAYS/VISITS PAID UNDER               
WAIVER - TOTAL  XXXXXXX    XXXXXXXXXX  X XXXXXXXXXX    XXXXX   
  
6A. DAYS/VISITS ON               
INITIAL BILLS  XXXXXXX    XXXXXXXXXX  X XXXXXXXXXX    XXXXX   
  
  Quarterly Supplement To Intermediary Workload Report (Cont.) 
 
QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT 
HFCA-1566A, PAGE 3 (CROWD FORM I) 
 
 
  INTERMEDIARY NUMBER_______  REPORT PERIOD_______ 
 
           
  TOTAL  INPATIENT  OUTPATIENT  SNF  HHA  OTHER 
  1  2  3  4  5  6 
             
SECTION D: DEMAND  XXXXXXX  XXXXXXXXXX XXXXXXXXXXX  XXXX  XXXX  XXXXX 
BILL DATA 
 
             
7. TOTAL DEMAND BILLS             
 
             
  7A. FULL/PARTIAL             
      REVERSALS 
 
             
  7B. DAYS/VISITS ON             
      REVERSALS  XXXXXXX  XXXXXXXXXX XXXXXXXXXXX  XXXXX 
 
             
SECTION E:  NO-PAY  XXXXXXX  XXXXXXXXXX XXXXXXXXXXX  XXXX  XXXX  XXXXX 
BILLS 
 
             
8. TOTAL NO-PAY BILLS             
 
             
  8A. DAYS/VISITS ON             
      NO-PAY BILLS  XXXXXXX  XXXXXXXXXX XXXXXXXXXXX  XXXXX 
 
             
  8B. MSP NO-PAY BILLS             
 
 
  70.15 - Medicare Fraud Unit Quarterly workload Status Report - CMS-1566B 
(Rev. 6, 08-30-02) 
A3-3898.15 
 
MEDICARE FRAUD UNIT QUARTERLY WORKLOAD STATUS REPORT 
HFCA-1566B (CROWD FORM M) 
 
 
  INTERMEDIARY NUMBER_______  REPORT PERIOD_______ 
 
         
  TOTAL  BENEFICIARY  OIG  REFERRAL 
  FRAUD WORKLOAD ITEM    COMPLAINT  HOTLINE  & OTHERS 
1  2  3  4 
         
1. OPENING PENDING         
 
         
2. ADJUSTMENTS         
 
         
3. ADJUSTED PENDING         
 
         
4. WORKLOAD RECEIVED         
 
         
5. TOTAL CLEARED         
 
         
6. BY CONTRACTOR         
 
         
7. BY REFERRAL         
 
         
8. CLOSING PENDING         
 
  70.16 - Quarterly Periodic Interim Payment (PIP) Report - Form CMS-1566C 
(Rev. 6, 08-30-02) 
A3-3898.16 
 
QUARTERLY PERIODIC INTERIM PAYMENT (PIP) REPORT 
FORM CMS-1566C (CROWD FORM Q) 
 
INTERMEDIARY NUMBER_______  REPORT PERIOD 
 
         
  HOSP.   SNF  HHA  TOTAL 
PIP PROVIDERS  (1)   (2)  (3)  (4) 
         
1. BEGINNING OF         
   QUARTER 
         
2. ACCRETIONS         
         
3. DELETIONS         
         
4. END OF QUARTER         
         
         
         
          70.17 - Completing Quarterly Report on Provider Enrollment (Inactive) 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
Each quarter, the intermediary prepares and submits to CMS a report on the number of provider 
enrollment applications received, processed, and pending during the quarter.  Include in your 
counts of provider enrollment applications, any change of ownership (CHOW) notices handled by 
you.  It submits this report via the Contractor Reporting of Operational and Workload Data 
(CROWD) system no later than the fifteenth day following the close of the reporting quarter. 
 
70.18 - Heading 
(Rev. 6, 08-30-02) 
A3-3898.18 
 
This report is referenced as Form 3 in the CROWD system.  Complete the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the 
reporting format to your screen. 
 
70.19 - Checking Reports 
(Rev. 6, 08-30-02) 
A3-3898.19 
 
Before submitting Form 3 to CMS, check for completeness and arithmetical accuracy.  Use the 
following checklist: 
 
  For all lines, column 1 must equal the sum of columns 2-16. 
 
  For all columns, line 1 must equal line 11 from the previous quarter. 
 
  For all columns, line 3 must equal line 1 plus line 2. 
 
  For all columns, line 6 must equal line 4 plus line 5. 
 
  For all columns, line 10 must equal the sum of lines 7-9. 
 
  For all columns, line 11 must equal line 3 plus line 6 minus line 10. 
 
  For all columns, the sum of lines 12-17 must equal line 8. 
 
  For all columns, the sum of lines 18-22 must equal line 9. 
 
  For all columns, the sum of lines 23-26 must equal line 10. 
 
  For all columns, the sum of lines 27-31 must equal line 11. 
 
  For all columns, line 32 must equal line 37 from the previous quarter.   
  For all columns, line 34 must equal line 32 plus line 33. 
 
  For all columns, line 37 must equal line 34 plus line 35 minus line 36.  
 
  For all columns, line 32 must be less than or equal to line 1. 
 
  For all columns, line 34 must be less than or equal to line 3. 
 
  For all columns, line 35 must be less than or equal to line 6. 
 
  For all columns, line 36 must be less than or equal to line 10. 
 
  For all columns, line 37 must be less than or equal to line 11. 
 
70.20 - Type of Provider 
(Rev. 6, 08-30-02) 
A3-3898.20 
 
The intermediary reports provider enrollment application data in the following columns for all 
lines on Form 3. 
 
Column (1) - Total - The sum of columns 2-16 for each line. 
 
Column (2) - Accredited Hospital - Provider applications indicating provider type as an accredited 
hospital. 
 
Column (3) - Non-Accredited Hospital - Provider applications indicating provider type as a non-
accredited hospital. 
 
Column (4) - Religious Nonmedical Health Care Facility - Hospital - Provider applications 
indicating provider type as a Religious Nonmedical Health Care Facility - hospital. 
 
Column (5) - Rural Primary Care Hospital - Provider applications indicating provider type as a 
rural primary care hospital. 
 
Column (6) - SNF - Provider applications indicating provider type as a skilled nursing facility (i.e., 
long term care facility). 
 
Column (7) - HHA. - Provider applications indicating provider type as a home health agency. 
 
Column (8) - Hospice - Provider applications indicating provider type as a hospice facility. 
 
Column (9) - ESRD - Provider applications indicating provider type as an end stage renal disease 
dialysis facility. 
  Column (10) - CORF - Provider applications indicating provider type as a comprehensive 
outpatient rehabilitation facility. 
 
Column (11) - RHC - Provider applications indicating provider type as a rural health clinic. 
 
Column (12) - FQHC - Provider applications indicating provider type as a federally qualified 
health center. 
 
Column (13) - CMHC - Provider applications indicating provider type as a community mental 
health center. 
 
Column (14) - IHS - Provider applications indicating provider type as an Indian Health Service 
facility. 
 
Column (15) - Outp. Speech Path./Phy.Ther - Provider applications indicating provider type as 
either outpatient speech pathology or outpatient physical therapy facility. 
 
Column (16) - Other - Provider applications indicating provider type other than those defined for 
columns 1 through 15. 
 
70.21 - Completing Lines One through Eleven - Workload Operations 
(Rev. 6, 08-30-02) 
A3-3898.21 
 
Line 1 - Pending End of Last Quarter - The CROWD system will automatically enter the value 
from line 11 on the previous quarters report. 
 
Line 2 - Adjustments to Pending - If it is necessary to revise the pending figure for the close of the 
previous quarter because of inventories taken or reporting errors discovered, enter the adjustment 
here.  Adjustments can be positive or negative values.  If entering a negative value, precede the 
number with a minus (-) sign. 
 
Line 3 - Adjusted Opening Pending -The CROWD system will automatically sum the values on 
lines 1 and 2. 
 
Line 4 - New Applications Received - The intermediary enters the number of applications received 
for the first time during the reporting quarter. 
 
Line 5 - Returned Applications Resubmitted - The intermediary enters the number of applications 
received during the reporting quarter that had previously been received and returned to the 
applicant for correction/completion. 
 
Line 6 - Total Applications Received -The CROWD system will automatically sum the values and 
lines 4 and 5. 
  Line 7 - Applications Recommended for Approval - The intermediary enters the number of 
applications that you recommended for approval (i.e., Medicare number issued) during the 
reporting quarter. 
 
Line 8 - Applications Recommended for Denial - The intermediary enters the number of 
applications that you recommended for denial during the reporting quarter. 
 
Line 9 - Applications Returned - The intermediary enters the number of applications returned to 
the applicant for corrections/completion during the reporting quarter. 
 
Line 10 - Total Applications Processed -The CROWD system will automatically sum the values on 
lines 7, 8, and 9. 
 
Line 11 - Pending End of Quarter -The CROWD system will automatically compute the number of 
applications pending at the end of the reporting quarter by adding the value on line 3 to the value 
on line 6 and then subtracting the value on line 10. 
 
70.22 - Completing Lines Twelve through Seventeen - Reason for Denial 
Recommendation 
(Rev. 6, 08-30-02) 
A3-3898.22 
 
Line 12 - Sanctioned From Medicare - The intermediary enters the number of applications that you 
recommended for denial because the applicant is currently excluded/sanctioned from Medicare. 
 
Line 13 - Debarred/Excluded by Other Federal Agency - The intermediary enters the number of 
applications that you recommended for denial because the applicant had been disbarred, 
suspended, or excluded by any other Federal agency. 
 
Line 14 - Not Professionally Licensed - The intermediary enters the number of applications that 
you recommended for denial because the applicant was not professionally licensed. 
 
Line 15 - Business Address Invalid - The intermediary enters the number of applications that you 
recommended for denial because the applicant had an invalid business address. 
 
Line 16 - Business Location Not Licensed - The intermediary enters the number of applications 
that you recommended for denial because the applicant=s business location was not properly 
licensed. 
 
Line 17 - CMS Requirements Not Met - The intermediary enters the number of applications that 
you recommended for denial because the applicant did not meet all CMS requirements. 
 
70.23 - Completing Lines Eighteen through Twenty-Two - Reason for Return 
(Rev. 6, 08-30-02) 
A3-3898.23 
  Line 18 - Incomplete - The intermediary enters the number of applications returned to the 
applicant because the application was incomplete. 
 
Line 19 - Unverifiable Information - The intermediary enters the number of applications returned 
to the applicant because the application included unverifiable information. 
 
Line 20 - Not Signed - The intermediary enters the number of applications returned to the 
applicant because the applicant did not sign the certification statement. 
 
Line 21 - Invalid Billing Agreement - The intermediary enters the number of applications returned 
to the applicant because the billing agreement did not meet CMS requirements. 
 
Line 22 - Other - The intermediary enters the number of applications returned to the applicant for 
any reason other than the ones indicated on lines 18 through 21. 
 
70.24 - Completing Lines Twenty-Three through Twenty-Six - Application 
Processing Times 
(Rev. 6, 08-30-02) 
A3-3898.24 
 
Line 23 - Number Under 21 Days - The intermediary enters the number of applications processed 
in less than 21 days from the date of receipt. 
 
Line 24 - Number in 21-30 Days - The intermediary enters the number of applications processed in 
21 through 30 days from the date of receipt. 
 
Line 25 - Number in 31-40 Days - The intermediary enters the number of applications processed in 
31 through 40 days from the date of receipt. 
 
Line 26 - Number Over 40 Days - The intermediary enters the number of applications processed in 
more than 40 days from the date of receipt. 
 
70.25 - Completing Lines Twenty-Seven through Thirty-One - Age of 
Applications Pending 
(Rev. 6, 08-30-02) 
A3-3898.25 
 
Line 27 - Number Under 11 Days Old - The intermediary enters the number of applications 
included in line 11 which are 1-10 days old. 
 
Line 28 - Number 11-20 Days Old - The intermediary enters the number of applications included 
in line 11 which are 11-20 days old. 
 
Line 29 - Number 21-30 Days Old - The intermediary enters the number of applications included 
in line 11 which are 21-30 days old. 
  Line 30 - Number 31-40 Days Old - The intermediary enters the number of applications included 
in line 11 which are 31-40 days old. 
 
Line 31 - Number Over 40 Days Old - The intermediary enters the number of applications 
included in line 11 which are over 40 days old. 
 
70.26 - Completing Lines Thirty-Two through Thirty-Seven - CHOW 
Workloads 
(Rev. 6, 08-30-02) 
A3-3898.26 
 
The intermediary reports in this section counts of your workloads dealing with CHOW notices 
included in lines 1, 2, 3, 6, 10, and 11. 
 
Line 32 - Pending End of Last Quarter - The CROWD system will automatically enter the value 
from line 37 on the previous quarters report.  (This count represents the number of CHOWs 
included in line 1.) 
 
Line 33 - Adjustments to Pending - If it is necessary to revise the pending figure for the close of 
the previous quarter because of inventories taken or reporting errors discovered, enter the 
adjustment here.  Adjustments can be positive or negative values.  If entering a negative value, 
precede the number with a minus (-) sign.  (This count represents the number of CHOWs included 
in line 2.) 
 
Line 34 - Adjusted Opening Pending -The CROWD system will automatically sum the values in 
lines 32 and 33.  (This count represents the number of CHOWs included in line 3.) 
 
Line 35 - CHOWs Received - The intermediary enters the number of applications shown in line 6 
that represents CHOWs received during the reporting quarter. 
 
Line 36 - CHOWs Processed - The intermediary enters the number of applications shown in line 
10 that represents CHOWs processed during the reporting quarter. 
 
Line 37 - Pending End of Quarter -The CROWD system will automatically compute the number of 
CHOWs pending at end of the reporting quarter by adding the value on line 34 to the value on line 
35 and then subtracting the value on line 36.  (This count represents the number of CHOWs 
included in line 11.)  70.27 - Exhibits 
(Rev. 6, 08-30-02) 
A3-3898.27 
 
Exhibit 1 - Screen 1 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
   
Accrued    Non-  Religious Nonmedical  Rural 
Application Workloads   Total 
Hospital   Accrued  Health Care Hospital  Prim Care 
   
      (2)  Hospital       (4)  Hospital 
    (1) 
      (3)        (5) 
           
 1. Pending End of Last Quarter            
           
 2. Adjustments to Pending           
           
 3. Adjusted Opening Pending           
           
 4. New Applications Received           
           
 5. Returned Appls Resubmitted           
           
 6. Total Applications Received           
           
 7. Applications Approval Recmd           
           
 8. Applications Denial Recmd           
           
 9. Applications Returned           
           
10. Total Applications Processed           
           
11. Pending End of Quarter           
 
SCREEN 1 
  Exhibit 2 - Screen 2 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
 
    SNF     HHA    Hospice     ESRD    CORF 
       Application Workloads   
         
 
     (6)       (7)         (8)       (9)      (10) 
           
 1. Pending End of Last Quarter           
           
 2. Adjustments to Pending           
           
 3. Adjusted Opening Pending           
           
 4. New Applications Received           
           
 5. Returned Appls Resubmitted           
           
 6. Total Applications Received           
           
 7. Applications Approval Recmd           
           
 8. Applications Denial Recmd           
           
 9. Applications Returned           
           
10. Total Applications Processed           
           
11. Pending End of Quarter            
 
SCREEN 2 
  Exhibit 3 - Screen 3 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
 
  FQH     Outpatient Speech   
      Application Workloads  
RHC  C  CMHC  IHS  Pathology  Other 
(11)    (12)      (13)  (14)  PhysicalTherapy  (16) 
   (15) 
             
 1. Pending End of Last Quarter             
             
 2. Adjustments to Pending             
             
 3. Adjusted Opening Pending              
             
 4. New Applications Received             
             
 5. Returned Appls Resubmitted             
             
 6. Total Applications Received             
             
 7. Applications Approval Recmd             
             
 8. Applications Denial Recmd             
             
 9. Applications Returned             
             
10. Total Applications Processed             
             
11. Pending End of Quarter             
 
SCREEN 3 
  Exhibit 4 - Screen 4 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
      Application Workloads      Total   Accrued    Non-  Religious    Rural 
    Hospital   Accrued  Nonmedical  Prime Care 
      (1)    Hospital  Health Care  Hospital 
      (2)       (3)  Hospital       (5) 
     (4) 
 
Reason for Denial Recommendation 
           
12. Sanctioned from Medicare           
           
13. Debarred/Excluded by Other Fed           
           
14. Not Professionally Licensed           
           
15. Business Address Invalid           
           
16. Business Location Not Licensed            
           
17. CMS Requirements Not Met           
 
Reason for Return 
           
18. Incomplete           
           
19. Unverifiable Information           
           
20. Not Signed           
           
21. Invalid Billing Agreement           
           
22. Other           
 
SCREEN 4 
  Exhibit 5 - Screen 5 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
           
       Application     SNF      HHA  Hospice   ESRD   CORF 
           
     (6)       (7)        (8)       (9)      (10) 
 
Reason for Denial Recommendation 
           
12. Sanctioned from Medicare           
           
13. Debarred/Excluded by Other Fed           
           
14. Not Professionally Licensed           
           
15. Business Address Invalid           
           
16. Business Location Not Licensed           
           
17. CMS Requirements Not Met           
 
Reason for Return 
           
18. Incomplete           
           
19. Unverifiable Information           
           
20. Not Signed           
           
21. Invalid Billing Agreement           
           
22. Other           
 
SCREEN 5 
  Exhibit 6 - Screen 6 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
 
  RHC  FQHC  CMHC     IHS  Outpatient Speech   Other 
      Application Workloads   
        Pathology/   
 
  (11)     (12)      (13)      (14)  Physical Therapy     (16) 
   (15) 
 
Reasons for Denial Recommendation  
             
12. Sanctioned from Medicare             
             
13. Debarred/Excld by Other Fed             
             
14. Not Professionally Licensed             
             
15. Business Address Invalid             
             
16. Business Location Not Licens             
             
17. CMS Requirements Not Met             
 
Reason for Return 
             
18. Incomplete             
             
19. Unverifiable Information             
             
20. Not Signed             
             
21. Invalid Billing Agreement             
             
22. Other             
 
SCREEN 6 
  Exhibit 7 - Screen 7 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
      Application Workloads      Total   Accrued    Non-  Religious    Rural 
    Hospital   Accrued  Nonmedical  Prime Care 
      (1)    Hospital  Health Care  Hospital 
      (2)       (3)  Hospital       (5) 
     (4) 
 
 Application Processing Times 
           
23. Number Under 21 Days           
           
24. Number in 21-30 Days           
           
25. Number in 31-40 Days           
           
26. Number Over 40 Days           
 
 Age of Applications Pending 
           
27. Number Under 11 Days Old           
           
28. Number 11-20 Days Old           
           
29. Number 21-30 Days Old           
           
30. Number 31-40 Days Old           
           
31. Number Over 40 Days Old           
 
SCREEN 7 
  Exhibit 8 - Screen 8 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
       Application Workloads    SNF      HHA  Hospice   ESRD   CORF 
           
       (6)       (7)        (8)       (9)      (10) 
 
 Application Processing Times 
           
23. Number Under 21 Days           
           
24. Number in 21-30 Days           
           
25. Number in 31-40 Days           
           
26. Number Over 40 Days           
 
 Age of Applications Pending 
           
27. Number Under 11 Days Old           
           
28. Number 11-20 Days Old           
           
29. Number 21-30 Days Old           
           
30. Number 31-40 Days Old           
           
31. Number Over 40 Days Old           
 
SCREEN 8 
  Exhibit 9 - Screen 9 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
             
      Application Workloads    RHC  FQHC  CMHC     IHS  Outpatient Speech   Other 
          Pathology/   
  (11)     (12)      (13)      (14)  Physical Therapy     (16) 
   (15) 
 
Application Processing Times 
             
23. Number Under 21 Days             
             
24. Number in 21-30 Days             
             
25. Number in 31-40 Days              
             
26. Number Over 40 Days             
 
 Age of Applications Pending 
             
27. Number Under 11 Days Old             
             
28. Number 11-20 Days Old             
             
29. Number 21-30 Days Old             
             
30. Number 31-40 Days Old             
             
31. Number Over 40 Days Old             
 
SCREEN 9 
  Exhibit 10 - Screens 10 and 11 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
SCREEN 10 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
           
      CHOW Workloads    Total   Accrued    Non-  Religious    Rural 
    Hospital   Accrued  Nonmedical  Prime Care 
      Hospital  Health Care  Hospital 
        (1)        (2)       (3)  Hospital       (5) 
     (4) 
           
32. Pending End of Last Quarter           
           
33. Adjustments to Pending           
           
34. Adjusted Opening Pending           
           
35. CHOWs Received           
           
36. CHOWs Processed           
           
37. Pending End of Quarter           
  Exhibit 10 (Cont.) 
 
Exhibit 10 - Screens 10 and 11 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
 
SCREEN 11 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
           
       CHOW Workloads    SNF      HHA  Hospice   ESRD   CORF 
           
           
       (6)       (7)        (8)       (9)      (10) 
           
32. Pending End of Last Quarter           
           
33. Adjustments to Pending           
           
34. Adjusted Opening Pending           
           
35. CHOWs Received           
           
36. CHOWs Processed           
           
37. Pending End of Quarter           
 
  Exhibit 11 - Screen 12 of Intermediary Provider Enrollment Quarterly Workload Report. 
 
   
INTERMEDIARY NAME:  INTERMEDIARY NUMBER: 
REPORT PERIOD:  CROWD FORM 3 
         
    RHC    CMHC     IHS  Outpatient Speech   Other 
      CHOW Workloads    FQHC      Pathology/Physica  
          l Therapy   
    (11)     (12)      (13)      (14)     (15)     (16) 
             
32. Pending End of Last Quarter             
             
33. Adjustments to Pending             
             
34. Adjusted Opening Pending             
             
35. CHOWs Received             
             
36. CHOWs Processed             
             
37. Pending End of Quarter             
 
SCREEN 12  80 - Monthly Intermediary Report On Medicare Secondary Payer Savings 
(Form CMS-1563) 
(Rev. 6, 08-30-02) 
A3-3899 
 
80.1 - General 
(Rev. 188, Issued: 04-22-11, Effective: 07-01-11, Implementation: 07-05-11) 
 
NOTE: For MSP reporting effective April 2005, refer to the manual instructions located 
within Publication 100-05, Chapter 5, Section 60 (MSP Reports). 
 
Each month the intermediary electronically transmits to CO a Monthly Intermediary Report on 
Medicare Secondary Payer Savings (CMS-1563) via the IBM PC.  It continues to use existing 
dialup instructions and the RLINK software sent to it.  (See 80.9).  Hardcopy reports are not 
required.  It transmits a separate report for each office assigned a separate intermediary number 
and also, for each State for which it have been designated the servicing intermediary for one or 
more providers.  It is not required to complete an individual State report for those States in which 
it has had no MSP activity during the month (reports that would show zeros in every category, 
including pending). 
 
80.2 - Purpose and Scope 
(Rev. 6, 08-30-02) 
A3-3899.2 
 
The Monthly Intermediary Report on Medicare Secondary Payer Savings supplies CMS with 
current data on MSP savings and MSP pending workloads. 
 
80.3 - Due Date 
(Rev. 6, 08-30-02) 
A3-3899.3 
 
Form CMS-1563 is due in CO as soon as possible after the end of the month being reported, but 
not later than the 15th of the following month.  Nonreceipt of the report by the 15th will result in a 
telephone contact with the intermediary to obtain required information. 
 
80.4 - Form Heading 
(Rev. 6, 08-30-02) 
A3-3899.4 
 
The intermediary enters its name, assigned number and the State in which the provider is located.  
In the space labeled "Reporting Period", it enters the numeric designation for month and year for 
which the report is being prepared, e.g., it shows 01/02 for January 2002. 
 
80.5 - Savings Calculations 
(Rev. 6, 08-30-02) 
A3-3899.5 
  A.  Reporting Dollar Values - The intermediary rounds all values to nearest whole dollar.  This 
includes all amounts shown on lines 2, 4, 6, 8 and 80. 
 
B.  Checking Reports - Before mailing the reports, it checks their completeness and 
arithmetical accuracy as follows: 
 
  Lines 1 + 3 + 5 = line 7 for all columns. 
 
  Lines 2 + 4 + 6 = line 8 for all columns. 
 
  Line 10 should be equal to, or greater than, line 9 for all columns, unless line 9 is equal 
to "0" in any column; in that case, line 10 should also be equal to "0" for the same 
column. 
 
  For each line of the report column "i" (TOTAL), must equal the sum of the items in 
columns "ii" + "iii" + "iv" + "v" + "vi." 
 
80.6 - Recording Savings 
(Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 
Medicare identification number. For purposes of this manual, Medicare beneficiary identifier 
references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary 
Identifier (MBI) during the new Medicare card transition period and after for certain business areas 
that will continue to use the HICN as part of their processes. 
 
The intermediary controls all claims from which it extracts MSP savings and is able to verify all 
amounts recorded on the CMS-1563. 
 
A.  MSP Savings File - It retains claims specific key identifying information on each claim 
counted as savings on the CMS-1563.  At a minimum, it records the beneficiary's name, Medicare 
beneficiary identifier, type/dates of service, claim control number, billed charges and savings 
amounts reported. 
 
B.  Savings Data From Non-Medicare Sources - If it records savings from data it obtained 
from its "private side" records or any other "outside" source, it must be able to extract the same 
claims specific information noted above, i.e., it must verify that Medicare covered services are 
involved and be able to calculate "what Medicare would have paid."  In addition, it must compare 
this data with the data contained in its MSP savings file to ensure that savings have not previously 
been recorded for the same claims.  If savings have not previously been taken for the claim, it 
counts them as savings on the CMS-1563 and enters them into its MSP savings file. 
 
80.7 - Source of Savings - The intermediary reports data by total and by source as shown 
below: 
(Rev. 6, 08-30-02) 
A3-3899.7 
 
Column (i)  Total--All MSP savings regardless of source.  Column (ii)  Workers' Compensation, Black Lung, and VA - It includes data 
related to all MSP savings resulting from medical benefits provided by 
the WC Plans of the 50 States, the District of Columbia, Guam and 
Puerto Rico. It also includes Federal WC provided under the Federal 
Employee's Compensation Act, the U. S. Longshoremens' and 
Harborworkers' Compensation Act and its extensions, the Federal Coal 
Mine Health and Safety Act of 1969 as amended (the Federal BL 
Program), and any fee-for-service medical care paid for by the VA. It 
keeps separate records for each distinct category (WC, BL or VA) as 
this may become a reporting requirement in the future. 
   
Column (iii)  Working Aged - It includes data related to all MSP savings resulting 
from benefits payable under an EGHP for beneficiaries aged 65 and 
older who are covered by reason of their own employment or the 
employment of a spouse of any age. Section 3491 further defines the 
working aged provisions. 
   
Column (iv)  ESRD - It includes data related to all MSP savings resulting from 
benefits payable under an EGHP for individuals who are entitled to 
Medicare benefits solely on the basis of ESRD during a period of up to 
12 months. The period during which Medicare pays secondary benefits 
is defined in the Medicare Claims Processing Manual, Chapter 29, 
Coordination with Medigap insurers. 
   
Column (v)  Auto Medical, No Fault and Liability Insurance - It includes data 
related to all MSP savings resulting from: 
   
    Automobile Medical or No Fault Insurance - Insurance 
coverage (including a self-insured plan) that pays for all, or part, of the 
medical expenses for injuries sustained in the use of, or occupancy of, 
an automobile, regardless of who may have been responsible for the 
accident. (This insurance is sometimes called "personal injury 
protection," "medical payments coverage" or "medical expense 
coverage.") 
   
    Liability Insurance - Insurance (including a self-insured plan) 
that provides payment based on legal liability for injury, illness or 
damage to property.  It includes, but is not limited to, automobile 
liability insurance, uninsured motorist insurance, homeowners' liability 
insurance, malpractice insurance, product liability insurance, and 
general casualty insurance.  It does not include situations where a 
beneficiary receives medical payment under his or her own 
homeowners' insurance. 
   
Column (vi)  Disabled - It includes data related to all MSP savings resulting from 
situations where Medicare is the secondary payer for disabled 
beneficiaries under age 65 (except ESRD beneficiaries) who elect to be 
covered by a large group health plan (LGHP) as a current employee or  family member of such employee. A LGHP is any health plan that 
covers employees of at least one employer who normally employs 100 
or more employees. The disabled provisions apply to items and services 
furnished on or after January l, 1987 and before January l, 1992 
 
 
80.8 - Type of Savings - The intermediary reports data by type of savings as shown below 
(Rev. 6, 08-30-02) 
A3-3899.8 
 
Unpaid (Cost Avoided) MSP Claims 
 
Unpaid (cost avoided) claims are those that the intermediary has returned without payment 
because it has strong evidence that another insurer is the primary payer and there is no indication 
that payment has been requested from that payer.  The information indicating MSP involvement 
may be contained in the intermediarys files, on the query reply, or on the claim itself.  In addition, 
any information it obtains from a non-Medicare source and uses as the basis for claiming cost 
avoidance savings must meet the criteria in 80.6B. 
 
Information considered adequate for claiming cost avoidance savings includes statements on the 
claim noting "automobile accident," "collision", or the name of the automobile insurer.  Another 
example would be previous information obtained showing EGHP coverage exits.  The 
intermediary does not count claims it develops as "possible" MSP situations based on routine edits 
as cost avoidance savings unless it has previous information that another payer has primary 
responsibility.  For example, "trauma code" edits are not, by themselves, considered strong 
evidence that Medicare is the secondary payer. 
 
Line 1 - Number - The intermediary reports the total number of cost avoided claims from which it 
is recording savings on the report. 
 
Line 2 - Dollar Value - The intermediary reports the total dollar value of the potential Medicare 
payments calculated for the claims on Line 1 that will be saved if the primary payer makes a 
payment which relieves Medicare of all payment liability. 
 
It shows as the amount cost avoided what Medicare would have paid.  It does not count total 
charges as cost avoided savings.  The cost avoided amount is the "Medicare payment rate" or the 
"current Medicare interim reimbursement amount" less any co-insurance amount applicable.  It 
reduces Part B services subject to coinsurance for the coinsurance amount or it may use a 
"coinsurance reduction factor" of 19 percent to calculate coinsurance charges for all Part B 
services.  It does not have to query for deductible status, but may assume that the deductible has 
been met. 
 
Tracking/Adjusting Cost Avoidance Savings 
 
Cost avoidance savings may not duplicate savings reported as full or partial recoveries and may 
not be shown where Medicare ultimately makes primary payment.  To prevent duplicate counting, 
the intermediary suspends all claims it returns unpaid.  It sets up a control on each claim returned 
for development.  It maintains this control for 75 days, unless it receives further information before  that time which allows it to process the claim.  If no further information on the claim is received, it 
may deny the claim after 75 days.  It is not required to continue tracking the claim, but retains the 
key identifying information on the claim, as described in 80.6A. 
 
CMS prefers the intermediary to show cost avoidance savings only after 75 days have elapsed.  
However, it has the option of counting the savings when the claim is initially suspended or at any 
time during the suspension period.  If it chooses the latter alternative, it must adjust its cost 
avoidance savings if the claim is resubmitted during the suspension period with information 
showing it is not a legitimate cost avoidance. 
 
The following situations require special consideration if cost avoidance savings are counted before 
the 75 day suspense period has ended: 
 
  A claim returned (and counted as cost avoided) is paid in part by another payer and the 
provider resubmits it for secondary payment. 
 
  A claim returned (and counted as cost avoided) is denied by the other payer and the 
provider resubmits it for primary payment. 
 
  A claim returned (and counted as cost avoided) is paid in full by the other payer and the 
provider submits a no-payment bill.  The intermediary shows "full recovery" savings and 
not cost avoidance. 
 
In these situations, it adjusts its cost avoidance savings figures by deducting or "backing out" the 
applicable amounts.  It makes the adjustments in the reporting month in which a final 
determination is rendered.  The following chart outlines the correct reporting of savings in each 
situation.  ADJUSTMENTS TO REPORTED MSP COST AVOIDANCE SAVINGS 
 
   
CLAIMS PROCESSING ACTIONS  MSP SAVINGS REPORTED 
           
         Cost  Partial  Full 
Avoidance  Recoveries  Recoveries 
I.  Partial Recovery Adjustment 
   
   o    $ 1,200     
MSP situation indicated. Medicare payment 
calculated to be $1200 if Medicare was 
primary payer. Claim is returned to provider. 
           
   o    $ (1,200) *  $ 900   
Provider resubmits the claim showing $900 
paid by the other insurer. Medicare 
secondary payment of $300 is made. 
           
II.  "Other Payer Denial" Adjustment   
   
     MSP situation indicated - Medicare    $   2,000     
"primary" payment, $2,000. Claim is 
returned to provider. 
           
     Other payer denies claim. Medicare    $ (2,000) *       
found to be primary and Medicare 
payment of $2,000 is made. 
           
III.  Full Recovery Adjustment   
     
     MSP situation indicated - Medicare    $ 900     
"primary" payment, $900. Claim is 
returned to provider. 
           
     Provider submits a "no-payment" bill   $ (900) *     $ 900 
showing full payment by the other 
payer. 
           
*Amounts "backed out" of cost avoidance savings figures.     
 
Full Recoveries 
 
Line 3 - Number - The intermediary reports the number of full recoveries made during the month. 
 
Line 4 - Dollar Value - The intermediary reports the dollar value of full recoveries made during 
the month. 
  Full Recoveries are claims where the primary payer made a payment that relieved Medicare of all 
payment liability.  Full recoveries can be either prepayment or postpayment.  The intermediary 
counts full recoveries in the month in which it recovers the full payment or receives a no-payment 
bill for prepayment full recovery cases.  Where the "full recovery" is paid in installments, it 
counts the claim as pending until all monies have been received.  Instructions for processing full 
recovery claims are in the Medicare Claims Processing Manual, Chapter 29, Coordination with 
Medigap insurers. 
 
A.  Prepayment Full Recovery - A prepayment full recovery occurs when a primary payer 
makes full payment on a charge before Medicare makes any payment. 
 
EXAMPLE:  A hospital identifies an EGHP as the primary payer, submits its charge to that 
insurer, and the EGHP pays the hospital's full cost.  The intermediary subsequently receive a "no 
pay" bill in accordance with the Medicare Claims Processing Manual, Chapter 29, Coordination 
with Medigap insurers.  It determines what it would have paid if the EGHP had not made payment 
and records that total as a full recovery savings. 
 
B.  Postpayment Full Recovery - A postpayment full recovery occurs when a primary payer 
makes full payment on a charge after Medicare has paid. 
 
EXAMPLE:  Medicare paid a hospital bill for charges incurred as a result of an automobile 
accident.  Subsequently, an auto liability insurer reimburses the Medicare beneficiary for the full 
amount of the medical expenses and the beneficiary refunds that amount to the program.  The 
intermediary counts the amount of Medicare's initial payment as a postpayment full recovery. 
 
The intermediary records as savings, that portion of a full recovery paid to an attorney or other 
agent as Medicare's share of the recovery cost.  Consequently, there may be instances where it has 
made a full recovery but does not get back the full amount paid.  When it refers a case to the RO 
for recovery action, however, it does not record any savings at that point. Savings from a 
compromise or "subrogation" case may be recorded only after a final determination.  The 
intermediary does not count these cases for CPEP credit prior to final settlement. 
 
EXAMPLE:  A beneficiary incurs a $1,000 physician's bill and a $5,000 hospital bill as a result 
of injuries sustained in an automobile accident.  Assuming that all deductibles are satisfied, Part B 
pays $800 toward the physician's charges, and Part A covers the hospital bill in full.  After 
litigation, a liability insurer agrees to pay $6,000 for the beneficiary's medical expenses from 
which the attorney takes a fee.  (If the attorney's fee were 33 percent, the dollar recovery would be 
$4,000.)  The Part B contractor can record $800 in Full Recovery savings.  The intermediary is 
also allowed to count its payment as a Full Recovery savings even though the amount recovered, 
due to attorney's fees, does not equal what was paid. 
 
Partial Recoveries 
 
Line 5 - Number - The intermediary reports the number of partial recoveries made during the 
month. 
 
Line 6 - Dollar Value - The intermediary reports the dollar value of partial recoveries made 
during the month. 
  Partial recoveries are those savings realized when a primary payer makes a payment which covers 
only a part of the Medicare allowable charge, leaving Medicare with a balance to pay.  The 
intermediary uses the following formula in computing the savings from a partial recovery: 
 
  The dollar amount of Medicare benefits available for the services or supplies (calculated as 
if Medicare were the primary payer) less the Medicare benefits paid for the services or 
supplies, equals the partial recovery savings.  (Primary Payment -Actual Payment = Partial 
Recovery Savings) 
 
The intermediary counts partial recoveries in the month when it takes final action on the claim 
(either making a payment supplemental to that of the primary payer or making a partial recovery 
from a payment by the primary payer).  Instructions for processing partial recovery claims are in 
the Medicare Claims Processing Manual, Chapter 29, Coordination with Medigap insurers. 
 
It records as savings, that portion of a partial recovery paid to an attorney or other agent as 
Medicare's share of the recovery cost.  When it refers a case to the RO for recovery action, 
however, It does not record any savings at that point.  Savings from a compromise or 
"subrogation" case may be recorded only after a final determination.  These cases may not be 
counted for CPEP credit prior to final settlement. 
 
Totals 
 
In this part of the report (lines 7 and 8), the intermediary reports data on the totals of unpaid claims 
plus full and partial recoveries. 
 
Line 7 - Claims - The intermediary reports the total number of MSP claims handled during the 
month. 
 
Line 8 - Dollar Value - The intermediary reports the total dollar value associated with MSP 
claims during the month. 
 
Pending Claims/Cases 
 
Line 9 - Number - The intermediary reports the number of pending claims/cases as of the close of 
the reporting month. It includes claims/cases for which "Full Recovery" is expected but all money 
due has not been received. 
 
Line 10 - Estimated Value - The intermediary reports the gross charges for all claims/cases 
reported as pending on line 9.  Where "Full Recovery or Partial Recovery" has been determined, 
but all monies have not been received, it reports the gross charges until it receives the full amount 
due or it is reasonable not to expect further payments. 
 
A case is defined as one or more claims filed on behalf of an individual and related to one specific 
occurrence that necessitated medical care.  When recording data for column 1 concerning WC and 
Auto Liability, and No Fault Insurance, the intermediary counts only cases.  For Working Aged 
(column iii), ESRD (column iv), and Disabled (column vi), it counts each individual claim. 
  A case/claim is pending only after it has been developed to the point where it is determined to be 
an MSP claim and no final resolution has been made.  A partial or interim payment is not 
sufficient to remove a case/claim from the pending rolls.  Final resolution occurs when there is no 
longer a practical expectation of further reimbursement. 
 
Remarks - The intermediary enters any comments relevant to the interpretation and analysis of the 
report. 
 
Signature - The report is signed by the individual responsible for its compilation. 
 
Date - The intermediary enters the Date that the report is completed and signed. 
 
80.9 - Electronic Submission 
(Rev. 6, 08-30-02) 
A3-3899.9 
 
A.  Keying CMS-1563 
 
  The intermediary uses existing RLINK dialup instructions. 
 
  The intermediary keys the letter "L" to bring up blank CMS-1563. 
 
  The intermediary enters a valid 5 digit intermediary number.  It uses the tab key to move 
from column to column. 
 
  The intermediary enters the reporting period using numeric designation month and year, 
e.g., 0102 for January 2002. 
 
  The intermediary enters two-position alpha State code. 
 
  The intermediary completes each column of data.  Fields with zero need not be keyed. The 
system will presume all blank fields to be zero. 
 
  The intermediary does not key dollar signs or commas in money fields.  It keys only whole 
dollar amounts. 
 
  After completing the form, the intermediary keys F1. The system will edit and print any 
error messages on the line above "contractor number."  The intermediary tabs to the 
incorrect field and rekeys a correct entry.  When the form passes all edits, the line will read 
"record has been written."  The intermediary keys F4 to return to the menu. 
 
  To abort at any time without writing a record, the intermediary keys F3 and refers to CICS 
instructions. 
 
  To verify that a report has been written, the intermediary returns to the main menu (F4) and 
keys "L" to bring up a blank form.  It keys in contractor number, reporting period and State 
code.  It keys F7.  The completed report appears on the screen. 
  B.  Edits for CMS-1563 
 
  A valid 5-digit intermediary number is required. 
 
  The default value for areas not keyed is zero. 
 
  Appropriate reporting period (MMYY) is required. 
 
  Two-position alpha State code is required. 
 
  Lines 1 + 3 + 5 must equal line 7 for all columns. 
 
  Lines 2 + 4 + 6 must equal line 8 for all columns. 
 
  Line 10 must be equal to or greater than line 9 for all columns unless line 9 is zero.  In that 
case line 10 must also be zero. 
 
  For each line of the report column i must equal the sum of columns ii + iii + iv + v + vi. 
 
90  Montly Intermediary Part A and Part B Appeals Report (Form 
CMS-2591) 
(Rev. 45, 05-28-04) 
 
At the end of each month, prepare and transmit to CMS a report summarizing activity on Part A 
reconsiderations, Part A Administrative Law Judge (ALJ) hearings, Part B reviews, and Part B 
hearings during the month.  Complete a separate report for each office assigned a separate 
intermediary number. 
 
Form CMS-2591 is subject to the Paperwork Reduction Act and requires approval by the Office of 
Management and Budget (OMB).  OMB approval has been requested. 
 
90.1  Purpose and Scope 
(Rev. 45, 05-28-04) 
 
The CMS-2591 (see 3890 - Exhibits 1 thru 6) enables CMS to tabulate data for administrative 
purposes on the following information: 
 
  The number of reconsiderations, reviews and hearings requested, completed, and pending; 
 
  The number of reconsiderations, reviews and hearings resulting in affirmations or reversals 
of previous determinations; 
 
  The number of reconsiderations, reviews and hearings involving waiver of liability 
determinations, and dollar amount of charges allowed; 
 
  Data on timeliness; and 
 
  The number of Part A and Part B reopenings. 
 
90.2  Due Date  (Rev. 45, 05-28-04) 
 
Transmit the CMS-2591 to CO via PC or terminal.  Use instructions in the Contractor Reporting of 
Operational and Workload Data (CROWD) System User's Guide. 
 
The report is due as soon as possible after the end of the reporting month but no later than the 15th 
of the month following the end of the reporting month. 
 
100  Completion of Items on Form CMS-2591 
(Rev. 45, 05-28-04) 
 
100.1  Heading 
(Rev. 45, 05-28-04) 
 
Enter your ID number in the space provided.  In addition, indicate the reporting month and 
calendar year, i.e., 1292 for December 1992. 
 
100.2  Section A  Intermediary Appeal Requests 
(Rev. 45, 05-28-04) 
 
This part concerns data from Part A and Part B appeals processes.  The number of appeals 
requested (received), completed, and pending reflects the status of the workload as of the last day 
of the reporting month.  Base data on actual counts of each activity and not on sampling or other 
estimating techniques. 
 
Appeals fall into the following categories: 
 
1.  Part A Reconsideration.--This is the first level of appeal following denial of a Part A claim.  It 
is a re-evaluation of the facts and findings of a claim to determine whether the initial decision was 
correct. (See 3781.) 
 
Do not count duplicate reconsideration requests or reconsideration requests received before you 
have made an initial determination on a claim.  Do not count telephone requests for 
reconsiderations or inquiries.  Count one reconsideration per request received.  With the exception 
of line 7 of the CMS-2591, do not count the number of claims or beneficiaries involved in the 
requests. 
 
2.  Part B Review.--This is the first formal level of appeal following denial of a Part B claim.  It is 
a second look by a different employee at the claim and supporting evidence.  (See 3792 ff.) 
 
3.  Part B Hearing.--This is an independent determination resulting from an appeal of your review 
decision.  This independent determination is rendered by a Hearing Officer (HO) you assigned.  
The amount in controversy must be at least $100.  (See 3794ff.) 
 
Definition of Columns: 
 
Column (1)   TOTAL--All Part A reconsiderations.  Column 1 must equal the sum of columns 2, 
3 and 4.   
Column (2)   SNF.--All skilled nursing facility reconsiderations. 
 
Column (3)   HHA/HOSPICE.--All home health agency and hospice reconsiderations. 
 
Column (4)   OTHER.--All other Part A reconsiderations. 
 
Column (5)   PART B REVIEWS.--Count one review per request received (i.e., Form CMS-1964 
or equivalent written request).  Do not count duplicate review requests or review 
requests received before you have made an initial determination on a claim.   With 
the exception of line 7 of the CMS-2591, do not count the number of claims or 
beneficiaries involved in the requests.  (Report claim counts in line 7.) 
 
Column (6)   PART B HEARINGS.--Count one hearing per request received (i.e., Form CMS-
1965 or equivalent written request).  Include hearings requested that do not meet the 
minimum $100 requirements and are subsequently dismissed.  With the exception 
of line 7 of the CMS-2591, do not count the number of claims or beneficiaries 
involved in the requests.  (Report claim counts in line 7.)  Do not count hearing 
requests that qualify for a Part B ALJ hearing.  (Part B intermediary hearings are 
those Part B hearings that a hearing officer adjudicates, as opposed to an ALJ).  See 
definition for Section C. 
 
Do not count requests for HO hearings received after you rendered an on-the-record 
(OTR) decision in lines 1-44 of the report.  Count these cases only in lines 45, 46, 
47, 48 and 50 as appropriate. 
 
Line 1.  Opening Pending.--Show under columns 1-4, the number of reconsiderations reported on 
line 19 as the closing pending on the previous month's report.  Show under column 5 the number 
of reviews reported on line 30 as the closing pending on the previous month's report.  Show under 
column 6 the number of hearings reported on line 40 as the closing pending on the previous 
month's report. 
 
Line 2.  Adjustments to Pending.--If it is necessary to revise the pending figure for the close of 
the previous month because of inventories or reporting errors, enter the adjustment.  Report 
requests received near the end of the reporting month and placed under control in the subsequent 
month as received in the reporting month, not as requests received in the subsequent month.  If 
some cases were not counted in the proper month's receipts, count them as adjustments to the 
opening pending in the subsequent month. 
 
If line 3 of the current month differs from the closing pending of the previous month, there must be 
an entry in line 2 for the current month.  Precede the entry by a "+" or "-", as appropriate. 
 
Line 3.  Adjusted Pending.--Enter the result of line 1 + line 2 (taking into account the "-" sign, if 
any). 
 
Line 4.  Requests Received.--Show, under the appropriate columns, the number of requests for 
reconsiderations, reviews, and Part B intermediary hearings received during the reporting month.  
Include requests transferred to you by other intermediaries if you incur administrative costs for  processing the appeals and you report the cost on the Interim Expenditure Report (Form CMS-
1523). 
 
If an appellant submits one request involving several different claims (and several different 
beneficiaries), count it as one request.  If an appellant submits more than one request (for different 
claims) at different times, count each request. 
 
NOTE:  See definition of column (6) for instructions on hearings requested subsequent to OTR 
decisions. 
 
Line 4A. Medical Necessity Documentation Denials.--Show the number of requests included in 
line 4 that involved initial claim denials for lack of medical documentation. 
 
Line 5.  Requests Transferred.--Show under columns 1 thru 5 the number of reconsiderations and 
review requests you transferred to other contractors because you did not process the original 
claim(s).  Report under column 6 the number of Part B hearing requests transferred to other 
contractors because the claimant is not within your geographical area (See 3794.3B) or 
transferred to ROs because the issues are outside the HO's responsibilities. (See 3794.2.)  For 
columns 1-6, if you have reported a reconsideration, review or Part B hearing as transferred, do not 
report any information regarding it on lines 6-51.  The transfer is the final action. 
 
Line 6.  Requests Cleared.--Show, under the appropriate columns, the total numbers of 
reconsiderations, reviews, and Part B hearings completed during the month.  Report all completed 
appeals, regardless if final outcome was affirmation, reversal, withdrawal, or dismissal. 
 
Consider a reconsideration or review cleared when the final determination (EOMB or other notice, 
including dismissal) is printed or typed, or upon notification of withdrawal by the appellant.  In the 
case of a reversal, consider the case cleared when you initiate the adjustment action. 
 
A Part B hearing may be considered cleared when the decision is signed, or the following 
conditions exist: 
 
o  The claimant indicates that he/she is satisfied with the On-The-Record (OTR) decision; 
 
o  The claimant indicates after the OTR decision that he/she wishes to proceed with an ALJ 
hearing (if the amount in controversy is $500 or more); 
 
o  The HO dismisses the hearing request; or 
 
o  The appellant withdraws the hearing request. 
 
Do not consider a hearing completed upon release of an OTR decision unless the appellant 
specifically requested an OTR hearing.  Do not count the OTR hearing as completed until you 
have completed all follow-up actions as required in 3794.9.  If as a result of the follow-up 
actions, the appellant requests an in-person or telephone hearing after release of the OTR decision, 
the OTR hearing and decision are not counted on the report with the exception noted below.  If the 
appellant does not appear for the subsequent hearing, dismiss the hearing.  (See 3794.3K.)  For 
processing time purposes, the case is completed when you dismiss it; however, the decision to 
record in lines 9-11 is the OTR decision.   
NOTE:  If you close a reconsideration, review or hearing after the end of a reporting month but 
before the report is due on the fifteenth of the subsequent month, do not count it until the 
subsequent month's report. 
 
Line 7.  No. of Claims Involved.--Show on line 6 the total number of claims involved in the 
appeals reported as cleared during the month.  For example, if you process one HHA 
reconsideration decision which involves five claims, report five claims under column (3), or if you 
process decisions for two Part B hearings in the month, one of which involved three claims and the 
other seven, report 10 claims under column (6). 
 
Line 8.  Amount in Controversy.--For Part B hearings reported as affirmed (line 9) or reversed 
(line 11) during the month, show the total dollar amount in controversy on the initial requests.  The 
amount in controversy is the difference between the amount billed (less any reductions required by 
legislation, e.g., Gramm-Rudman-Hollings) and the amount you originally allowed less any unmet 
deductible and coinsurance amounts.  In effect, the amount in controversy is the amount of 
payment that the claimant would receive if the denial(s) was fully reversed.  Show results rounded 
to the nearest dollar. 
 
Line 9.  Affirmations.--Under the appropriate columns, show the number of completed 
reconsiderations, reviews, and Part B hearings in which the previous determinations were 
completely upheld; i.e., no change was made.  All parts of all claims in a case must be upheld in 
order for the case to be counted as an affirmation.  An OTR hearing decision does not count as a 
previous decision if the appellant subsequently requests an in-person or telephone hearing.  If the 
in-person/telephone hearing is dismissed because the appellant did not appear, or the request was 
withdrawn, use the OTR decision to determine if the case is counted here.  (See line 11 for partial 
affirmations.  Do not include them here.) 
 
If you uphold your original determination, but pay under limitation of liability, count the 
determination as an affirmation.  Report the appropriate information in Section D of the CMS-
2591. 
 
Line 10.  Dism./Withdr.--Report, under the appropriate column, the number of completed 
reconsiderations, reviews, and Part B hearings that were withdrawn by the appellant or dismissed 
(before determination) by you or the HO.  Report here and in lines 4 and 6 an appeal that is 
requested and withdrawn or dismissed within the same month.  If the appellant requests an in-
person or telephone hearing after receiving an OTR decision, and you dismiss the hearing because 
the appellant failed to appear, the OTR decision is the final decision, not the dismissal.  Similarly, 
for a withdrawal, use the OTR decision. 
 
A dismissal at the reconsideration or review level is done when written correspondence has been 
identified as an appeal request, but the claimant does not have the right to an appeal.  Misrouted 
correspondence and duplicate requests are not dismissals. 
 
If you have incorrectly counted such correspondence as an appeal on a previous report, use line 2 
(adjustments to pending) to correct the count.  Do not count a duplicate request for appeal 
anywhere on the report.  Likewise, do not count on the report a request for appeal received before 
an initial claim determination has been rendered.  (Consider the request an inquiry.) 
  Line 11.  Reversals (Full or Part).--Under the appropriate columns, show the total number of 
completed reconsiderations, reviews, and Part B hearings in which at least part of the prior 
determination was reversed. That is, a change was made and some or all of the new determination 
was in favor of the appellant. 
 
If a reconsideration, review, or Part B hearing involves several claims, and the initial 
determinations for some are affirmed and some are reversed, consider the decision a reversal.  An 
OTR hearing decision does not count as a previous decision if the appellant subsequently requests 
an in-person or telephone hearing.  If the in-person/telephone hearing is dismissed because the 
appellant did not appear, or the request was withdrawn, use the OTR decision to determine if the 
case is counted here. 
 
Line 12.  Amount Awarded.--For cases included in line 11, show the amount of submitted charges 
for services where the determination was reversed.  Show charges prior to application of the 
deductible and coinsurance.  Round results to the nearest dollar. 
 
Processing and Pending Times.--This deals with processing and pending times for Part A and Part 
B appeals. 
 
Computing Time to Process Part A Reconsiderations and Part B Reviews for (Lines 13-18 and 25-
29) 
 
For lines 13-18 and 25-29, use the matrix below to determine the number of days from receipt to 
completion of reconsiderations and reviews.  The date of receipt in all cases is the day the 
processing contractor received it in its corporate mailroom. 
 
Situation    Date Completed 
The date you were notified of the 
  The appellant withdraws the 
  withdrawal. 
request. 
 
  You dismiss the request or 
affirm the original 
  The date of the notice. 
determination. 
 
The date when you submit the claim to 
CWF if payment can be made without 
further development, or when you 
  You process the request to a 
  initiate development; e.g., when you 
reversal. 
must ascertain whether or not the 
provider has refunded payment to the 
beneficiary. 
 
Computing Time to Process Part B Hearings for Lines 35-39 
 
For lines 35-39, use the matrix below to determine the number of days from receipt to completion 
of Part B hearings.  The date of receipt, in all cases, is the day you receive the appeal request in its 
corporate mailroom.  In out-of-area cases, it is the date that the second intermediary receives the 
request. 
 
Situation    Date Completed  An OTR decision is made and the appellant accepts 
the decision or decided to go directly to an ALJ    The date of the OTR decision. 
hearing. 
The date of the second 
An OTR decision is made and the appellant  decision.  If the appellant 
chooses in a timely fashion to proceed with the in-   appears, and you dismiss the 
person or telephone hearing.  hearing, use the date of notice 
of dismissal. 
An in-person or telephone hearing is held without 
  The date of the decision. 
an OTR decision. 
The date you are notified of 
The appellant withdraws the hearing request.   
the withdrawal. 
The date of the dismissal 
The HO dismisses the hearing request.   
notice. 
 
RECONSIDERATIONS 
 
Line 13.  Processing Time - Average.--Report under the appropriate columns the average number 
of days from receipt of the reconsideration to the date of completion. 
 
To compute the average number of days from request to completion, divide the total days elapsed 
for all requests cleared in the month by the number of requests cleared.  Round results to the 
nearest day.  Calculate the days elapsed for an individual request by subtracting the Julian date of 
receipt from the Julian date of completion.  If the request is cleared in the year following the year 
of receipt, add 365 or 366 to the result, as appropriate.  (Otherwise, you will get a negative 
number.)  If a case is cleared the same day it is received, consider it to require 1 day. 
 
NOTE:  Include all cases cleared, regardless of whether they were affirmed, reversed, dismissed, 
or withdrawn. 
 
Line 14.  Reconsiderations Completed 1-45 Days.--Show the number of reconsiderations that 
required 1-45 days, to complete.  If a case is cleared the same day it is received, consider it to 
require 1 day. 
 
Line 15.  Reconsiderations Completed 46-60 Days.--Show the number of reconsiderations that 
required 46-60 days to complete. 
 
Line 16.  Reconsiderations Completed 61-90 Days.--Show the number of reconsiderations that 
required 61-90 days to complete. 
 
Line 17.  Reconsiderations Completed 91-120 Days.--Show the number of reconsiderations that 
required 91-120 days to complete. 
 
Line 18.  Reconsiderations Completed over 120 Days.--Show the number of reconsiderations that 
required more than 120 days to complete. 
 
Line 19.  Closing Pending Reconsiderations.--Show, under the appropriate columns, the total 
number of reconsiderations that have not been completed by the end of the reporting month. 
  Line 20.  Reconsiderations Pending 1-45 Days.--Show the number of reconsiderations included in 
line 19 that have been pending 1-45 days, inclusive, at the end of the reporting month. 
 
Line 21.  Reconsiderations Pending 46-60 Days.--Show the number of reconsiderations included 
in line 19 that have been pending 46-60 days, inclusive, at the end of the reporting month. 
 
Line 22.  Reconsiderations Pending 61-90 Days.--Show the number of reconsiderations included 
in line 19 that have been pending 61-90 days, inclusive, at the end of the reporting month. 
 
Line 23.  Reconsiderations Pending 91-120 Days.--Show the number of reconsiderations included 
in line 19 which have been pending 91-120 days, inclusive, at the end of the reporting month. 
 
Line 24.  Reconsiderations Pending Over 120 Days.--Show the number of reconsiderations 
included in line 19 which have been pending more than 120 days at the end of the reporting month. 
 
REVIEWS 
 
Line 25.  Processing Time - Average.--Report here the average number of days from the receipt of 
the review to the date of completion. 
 
To compute the average number of days from request to completion, divide the total days elapsed 
for all requests cleared in the month by the number of requests cleared.  Round results to the 
nearest day.  Calculate the days elapsed for an individual request by subtracting the Julian date of 
receipt from the Julian date of completion. 
 
If the request is cleared in the year following the year of receipt, add 365 or 366 to the result, as 
appropriate.  (Otherwise, you will get a negative number.)  If a case is cleared the same day it is 
received, consider it to require 1 day. 
 
NOTE:  Include all cases cleared, regardless of whether they were affirmed, reversed, dismissed, 
or withdrawn. 
 
Line 26.  Reviews Completed in 1-30 Days.--Show the number of cases that required 1-30 days to 
complete.  If a case is cleared the same day it is received, consider it to require 1 day. 
 
Line 27.  Reviews Completed in 31-45 Days.--Show the number of reviews that required 31-45 
days to complete. 
 
Line 28.  Reviews Completed in 46-60 Days.--Show the number of reviews that required 46-60 
days to complete. 
 
Line 29.  Reviews Completed in 61+ Days.--Show the number of reviews that required more than 
60 days to complete. 
 
Line 30.  Closing Pending-Reviews.--Show the total number of reviews that have not been 
completed by the end of the reporting month. 
 
Line 31.  Reviews Pending 1-30 Days.--Show the number of reviews included in line 30 that have 
been pending 1-30 days, inclusive, at the end of the reporting month.   
Line 32.  Reviews Pending 31-45 Days.--Show the number of reviews included in line 30 that 
have been pending 31-45 days, inclusive, at the end of the reporting month. 
 
Line 33.  Reviews Pending 46-60 Days.--Show the number of reviews included in line 30 that 
have been pending 46-60 days, inclusive, at the end of the reporting month. 
 
Line 34.  Reviews Pending Over 60 Days.--Show the number of reviews included in line 30 that 
have been pending more than 60 days at the end of the reporting month. 
 
PART B HEARINGS 
 
Line 35.  Hearing Processing Time - Average.--Report the average number of days from receipt of 
the hearing request to date of completion.  See methodology under line 25. 
 
Line 36.  Hearings Completed in 60 Days.--Show the number of hearings that required 1-60 days 
to complete.  If a case is cleared the same day it is received, consider it to require 1 day. 
 
Line 37.  Hearings Completed in 61-90 Days.--Show the number of hearings that required 61-90 
days to complete. 
 
Line 38.  Hearings Completed 91-120 Days.--Show the number of hearings that required 91-120 
days to complete. 
 
Line 39.  Hearings Completed Over 120 Days.--Show the number of hearings that required more 
than 120 days to complete. 
 
Line 40.  Closing Pending-Hearings.--Show the total number of hearings that have not been 
completed by the end of the reporting month.  You may not consider a hearing completed upon 
release of an OTR decision unless the appellant specifically requested an OTR hearing.  See 
definition for line 6. 
 
Line 41.  Hearings Pending 1-60 Days.--Show the number of hearings included in line 40 that 
have been pending 1-60 days, inclusive, at the end of the reporting month. 
 
Line 42.  Hearings Pending 61-90 Days.--Show the number of hearings included in line 40 which 
have been pending 61-90 days, inclusive, at the end of the reporting month. 
 
Line 43.  Hearings Pending 91-120 Days.--Show the number of hearings included in line 40 which 
have been pending 91-120 days, inclusive, at the end of the reporting month. 
 
Line 44.  Hearings Pending Over 120 Days.--Show the number of hearings included in line 40 that 
have been pending more than 120 days at the end of the reporting month. 
 
100.3  Section B  Part B Hearing Results 
(Rev. 45, 05-28-04) 
  Section B deals with data on Part B hearings completed during the month.  Base data shown on 
actual counts of each activity and not derived from sampling or other estimating techniques. 
 
HEARINGS FALL INTO THE FOLLOWING CATEGORIES: 
 
Column (1)    On-the-Record with No Subsequent Hearing.--Include in column 1 hearings 
held where the appellant originally requested an OTR hearing, indicates that 
he/she is satisfied with the OTR decision, that he/she wishes to proceed with 
an ALJ hearing (if the amount in controversy is $500 or more), or fails to 
respond to the OTR within the required time frame.  In addition, if the 
appellant requests an in-person or telephone hearing subsequent to an OTR 
decision, but the hearing is dismissed or withdrawn, include it here and not in 
columns (2) or (3). 
 
Column (2)    All Telephone.--Include in column 2, hearings where the appellant requested 
and had a telephone hearing subsequent to an OTR hearing decision, or a 
telephone hearing was held without a prior OTR decision.  Count all telephone 
hearings including those where the appellant did not follow-up timely to the 
OTR notice, but later requested a telephone hearing. 
 
Column (3)    All In-Person.--Include in column 3 hearings where the appellant requested 
and had an in-person hearing subsequent to an OTR hearing decision, or an in-
person hearing was held without a prior OTR decision.  Count all in-person 
hearings including those where the appellant did not follow-up timely to the 
OTR notice but later requested an in-person hearing. 
 
Column (4)    Number in 120 Days.--For the total cases included in line 47, columns 2 and 3, 
(e.g., the sum) show for lines 49-51 the numbers that were completed within 
120 days of receipt.  Use the methodology shown above the explanation for 
line 13 to determine the completion date.  Where an OTR decision is made and 
the appellant chooses to not follow-up timely and later requests either an in-
person or telephone hearing, completion time for this second reported hearing 
is measured from the date of receipt of original request to the date of the 
second decision.  If the appellant does not appear, dismiss the hearing in 
accordance with 3794.3k, and use the date of notice of dismissal as your date 
completed. 
 
Line 45.  Reversals.--Under the appropriate columns, show the number of OTR, telephone, and in-
person hearings completed in the month in which at least part of the review determination was 
reversed i.e., a change was made and some, or all, of the new determination was in favor of the 
appellant.  (See the definition for line 11.) 
 
Line 46.  Affirmations.--Under the appropriate columns, show the number of OTR, telephone, and 
in-person hearings completed in the month in which the review determination was completely 
upheld, i.e., no change was made.  All parts of all claims must be upheld in order for the case to be 
counted as an affirmation.  (See the definition for line 9.) 
 
Line 47.  Total Decisions.--Show the total number of hearing decisions completed during the 
month that resulted in a reversal or affirmation, excluding dismissals and withdrawals.   
Line 48.  Number in 120 Days.--For cases included in line 47, show the number that were 
completed within 120 days of receipt.  See methodology for column 4 to determine the completion 
date. 
 
Line 49.  No Previous OTR Held.--For cases included in line 47, columns (2) and (3), report the 
number where you held the telephone or in-person hearing without first making an OTR decision, 
i.e., the OTR hearing was bypassed. 
 
In column (4), report the number of cases included in either column (2) or (3) which were 
completed within 120 days. 
 
Line 50.  Previous OTR Counted.--For the cases included in line 47, columns (2) and (3), report 
the number where you included the OTR count on a previous report.  In column (4), report the 
number of cases included in either column (2) or (3) that were completed within 120 days. 
 
Cases reported in line 50 are those where an OTR decision was made and the appellant either 
accepted the OTR decision, did not respond timely, or decided to go directly from the OTR 
decision to an ALJ hearing.  Then, subsequent to this OTR decision "acceptance," the appellant 
changed his/her mind and decided that he/she wanted a telephone or in-person hearing.  Do not 
include these cases in line 6. 
 
Line 51.  Previous OTR Not Counted.--For cases included in line 47, columns (2) and (3), report 
the number where you did not include the OTR count on a previous report.  These are cases where 
you made the OTR decision first, and the appellant indicated in a timely fashion (see 3794.9) that 
he/she wanted a telephone or in-person hearing.  In column (4), report the number of cases 
included in either column (2) or (3) that were completed within 120 days. 
 
100.4  Section C  Part A and Part B ALJ Hearings 
(Rev. 45, 05-28-04) 
 
Use Section C to report requests for ALJ hearings, including those expected to be dismissed for 
failure to meet the amount in controversy requirement or for any other reason, such as the lack of a 
fair hearing in Part B cases. 
 
ALJ HEARINGS FALL INTO THE FOLLOWING CATEGORIES: 
 
Column (1)  TOTAL.--All Part A ALJ hearing requests as originally filed. 
Column 1 must equal the sum of columns 2, 3 and 4. 
 
Column (2)  SNF.--All skilled nursing facility (SNF) hearings. 
 
Column (3)  HHA/HOSPICE.--All home health agency (HHA) and hospice hearings. 
 
Column (4)  OTHER.--All other hearings. 
 
Column (5)  PART B.--All Part B ALJ hearings. 
  Line 52.  Opening Pending.--Show the number of ALJ hearings reported on Line 67 as the closing 
pending on the previous month's report. 
 
Line 53.  Adjustments to Pending.--See definition for line 2.  If line 54 of the current month 
differs from data in line 67 of the previous month, there must be an entry in line 53 for the current 
month.  Precede the entry by a "+" or "-" as appropriate. 
 
Line 54.  Adjusted Pending.--Show the result of line 52 + line 53 (taking into account the "-" sign, 
if any). 
 
Line 55.  Requests Received.--Show the number of ALJ hearings requested during the month.  
(See 3797) 
 
Line 56.  Requests Forwarded to ALJ.--Show the number of ALJ hearing requests forwarded to 
ALJs during the month.  Consider the case forwarded when all necessary material has been mailed 
to the ALJ. 
 
Line 57.  No. of Claims Involved.--Show the number of claims involved in the ALJ hearing 
requests forwarded to ALJs as reported on line 56. 
 
Line 58.  In 1-7 Calendar Days.--Show the number of ALJ hearing requests forwarded to ALJs 
within 7 calendar days from receipt of the request in the corporate mailroom to mailing of the 
necessary information.  Show data for all cases mailed during the month.  The number must be less 
than, or equal to, the number shown in line 56. 
 
Line 59.  In 1-14 Calendar Days.--Show the number of ALJ hearing requests forwarded to ALJs 
within 14 calendar days from receipt of the request in the corporate mailroom to mailing of the 
necessary information to the ALJ.  Show data for all cases mailed during the month.  Note that the 
number in this line must be less than or equal to the number shown in line 56. 
 
Line 60.  Average Time to Forward.--Report the average number of calendar days from receipt of 
the ALJ request to the date of mailing of the necessary information.  Use the methodology 
discussed in 3888.2 for line 13. 
 
Line 61.  Completed.--Show the number of ALJ hearing requests completed during the month.  
Consider a case completed when you have received the completed decision from the ALJ for all 
parts of the case. 
 
Line 62.  Amount in Controversy.--For ALJ hearings reported as affirmed (line 63) or reversed 
(line 65), during the month, show the total dollar amount in controversy according to the initial 
ALJ hearing request.  This should be the amount remaining after previous appeals decisions.  
Round results to the nearest dollar. 
 
Line 63.  Affirmations.--Show the number of completed ALJ hearings in which the previous 
determination was completely upheld, i.e., no change was made.  All parts of all claims in a case 
must be upheld in order for the case to be counted as an affirmation.  See line 65 for partial 
affirmations.  (Do not include partial affirmations on this line.) 
  If the prior determination was upheld, but payment was made under limitation of liability, count 
the ALJ hearing determination as an affirmation.  Report the appropriate information in lines 77 
and 78. 
 
Line 64.  Dismissals/Withdrawals.--Show the number of completed hearings that were withdrawn 
by the appellant or dismissed (before determination) by the ALJ.  Report an appeal that was 
requested and withdrawn or dismissed within the same month here and in lines 55, 56, and 61. 
 
Line 65.  Reversals (Full or Part).--Show the total number of completed ALJ hearings in which at 
least part of the prior determination was reversed; i.e., a change was made and some or all of the 
new determination was in favor of the appellant.  For example, if an ALJ hearing involved several 
claims, and the initial determinations for some were affirmed and some were reversed, consider the 
decision to be a reversal. 
 
Line 66.  Amount Awarded.--For cases included in line 65, show the amount of submitted charges 
for services where the determination was reversed.  Show charges prior to application of the 
deductible and coinsurance.  Round results to the nearest dollar. 
 
Line 67.  Closing Pending.--Show the total number of ALJ hearing requests that were not 
completed by the end of the reporting month.  Consider a case transferred to an ALJ as pending 
until you have received the completed decision from the ALJ for all parts of the case. 
 
ALJ DISPOSITIONS 
 
Line 68.  Number of Dispositions.--Report the number of dispositions rendered by the ALJ(s) in 
cases reported as cleared for the month in Line 61.  There will usually be more ALJ dispositions 
than cases counted in line 61.  Do not count a case in line 61 until the ALJ has cleared all of the 
claims included in the request for hearing. 
 
EXAMPLE:  You forwarded one request to an ALJ involving 20 claims.  The ALJ dismisses 10 
claims at once.  A month later, the ALJ decides to affirm the original decision on 5 
others as one group.  The other five claims receive separate determinations.  This 
would be counted as seven dispositions. 
 
Line 69.  Affirmations.--Of those dispositions shown in line 68, report the number of decisions 
rendered by the ALJ(s) that were completely upheld. 
 
Line 70.  Dismissals/Withdrawals.--Of those dispositions shown in line 68, report the number of 
dismissals and withdrawals issued by the ALJ(s). 
 
Line 71.  Reversals.--Of those dispositions shown in line 68, report the number of decisions 
rendered by the ALJ (s) in which at least part of the prior determination was reversed. 
 
EFFECTUATION OF ALJ DECISIONS 
 
Line 72.  Total Effectuations.--Show the number of ALJ hearing decisions for which you initiated 
effectuation during the month.  Consider effectuation of a decision to be initiated when you: 
 
o  Submit the claim to CWF if payment can be made without further development; or   
o  Initiate development, e.g., when you must determine whether or not the provider has 
refunded payment to the beneficiary. 
 
Line 73.  Number 1-7 Days.--Show the number of cases where you effectuated the decision within 
7 days.  Effectuation days include day of receipt of the decision in your corporate mailroom. 
 
Line 74.  Number 8-15 Days.--Show the number of cases where you effectuated the decision 
within 8-15 days. 
 
Line 75.  Number 16-30 Days.--Show the number of cases where you effectuated the decision 
within 16-30 days. 
 
Line 76.  Number Over 30 Days.--Show the number of cases where you effectuated the decision in 
more than 30 days. 
 
LIMITATION OF LIABILITY DETERMINATION IN ALJ CASES 
 
Line 77.  No. Waived - Ben. and Prov..--Show the number of claims in ALJ hearings during the 
reporting month where the liability of both the beneficiary and provider was limited. 
 
Line 78.  Amount Awarded.--For claims included in line 77, show the amount of the submitted 
charges for services where the liability was limited (including non-covered services where the 
liability of the beneficiary and provider are limited.)  Show charges prior to application of the 
deductible and coinsurance.  Round results to the nearest dollar. 
 
100.5  Section D  Limitation of Liability 
(Rev. 45, 05-28-04) 
 
Section D concerns requests involving limitation of liability determinations in Part A 
reconsiderations, Part B reviews and Part B hearings.  To include a claim in lines 79-82, you must 
have originally denied it or reduced it for medical necessity or custodial care reasons. 
 
Lines 80-82 are mutually exclusive; i.e., a claim meeting the above conditions may be counted on 
only one of three lines.  Therefore, ensure that the sum of the number of the claims recorded on 
each of these lines equals the total number of claims considered for limitation of liability during 
the period as reported on line 79. 
 
The counts in lines 79-82 reflect counts of claims.  Report cases corresponding to the claims 
counted in Section A, as appropriate.  If a claim is considered for limitation of liability at the initial 
claim level, do not count it at the review or hearing level unless you change the limitation of 
liability decision. 
Categorize claims for the columns shown in Section D according to the adjudication level at which 
limitation of liability is considered or granted. 
 
If you make several different limitation of liability decisions on the same claim, use the highest 
numbered line (out of 80-82) on the report that applies to that claim.  Count the claim only once.  For example, if you waive both the beneficiary and provider liability on any part of the claim, 
count the claim on line 82. 
 
Line 79.  Total Number Considered.--Show, under the appropriate columns, the number of claims, 
meeting the conditions above, for which limitation of liability was considered during the month. 
 
Line 80.  No. Considered - Not Waived.--Show, under the appropriate columns the number of 
claims that meet the conditions above, on which limitation of liability was considered, but was not 
granted to the beneficiary.  This also includes cases where only provider liability is waived. 
 
Line 81.  No. Waived - Ben. Only.--Show, under the appropriate columns, the numbers of claims 
that meet the conditions above, where the liability of only the beneficiary was limited. 
 
Line 82.  No. Waived - Ben. and Prov.--Show, under the appropriate columns, the numbers of 
claims where the liability of both the beneficiary and provider was limited. 
 
Line 83.  Amount Awarded.--For cases included in line 82, show the amount of the submitted 
charges for services where liability was limited (including noncovered services where liability of 
the beneficiary and provider are limited).  Show charges prior to application of the deductible and 
coinsurance.  Round results to nearest dollar. 
 
100.6  Section E  Part A and Part B Reopenings 
(Rev. 45, 05-28-04) 
 
Report the number of Part A and Part B claims involved in reopenings completed during the 
month.  See 3795 for discussion of what constitutes a reopening.  Include reopenings which do 
not result in revisions.  Claims review, reconsideration, Part B hearings, and ALJ hearings 
undertaken as part of the appeal process are not reopenings. 
 
PART A REOPENINGS FALL INTO THE FOLLOWING CATEGORIES: 
 
Column (1)  Total.--All reopenings completed. 
 
Column (2)  Pre-Recon.--All reopenings of initial claim determinations.  If a claim has been 
through a reconsideration, do not count it here. 
 
Column (3)  Post-Recon.--All reopenings of reconsideration determinations.  If a claim has been 
through any type of hearing, do not count it here. 
 
Column (4)  Post-ALJ Hearing.--All reopenings of ALJ hearing determinations. Once a claim 
has been through an ALJ hearing, count it here if it is reopened. 
 
Line 84.  Total Number.--Show the number of claims in which the reopening of a claim, 
reconsideration, or hearing determination was completed, whether or not the determination was 
revised. 
 
Line 85.  Unfavorable to Claimant.--Of the claims shown in line 84, show the number which 
resulted in a revision of a previously favorable decision.   
Line 86.  No Change.--Of the claims shown in line 84, show the number of claims that you 
reopened, but on which you did not change the initial determination. 
 
Line 87.  Favorable to Claimant.--Of the claims shown in line 84, show the number which resulted 
in a favorable revision of a previously unfavorable decision. 
 
Line 88.  Amount Awarded.--For cases included in line 87, show the amount of the submitted 
charges for services which involved a revision of a previously unfavorable decision.  Show 
charges prior to application of the deductible and coinsurance.  Round results to the nearest dollar. 
 
PART B REOPENINGS FALL INTO THE FOLLOWING CATEGORIES: 
 
Column (1)  Total.--All reopenings completed. 
 
Column (2)  Pre-Review.--All reopenings of initial claim determinations.  If a claim has been 
through a review, or any type of hearing, do not count it here. 
 
Column (3)  Post-Review.--All reopenings of review determinations.  If a claim has been 
through any type of hearing, do not count it here. 
 
Column (4)  Post-Hearing.--All reopenings of hearing determinations, regardless of the type of 
hearing; e.g., intermediary HO or ALJ.  Once a claim has been through a hearing, 
count it here if it is reopened. 
 
Line 89.  Total Number.--Show the number of claims in which the reopening of a claim, review or 
hearing determination was completed, whether or not the determination was revised. 
 
Line 90.  Unfavorable to Claimant.--Of the claims shown in lines 89, show the number which 
resulted in an unfavorable revision of a previously favorable decision. 
 
Line 91.  No Change.--Of the claims shown in line 89, show the number of claims that you 
reopened, but on which you did not change the initial determination. 
 
Line 92.  Favorable to Claimant.--Of the claims shown in line 89, show the number which resulted 
in a favorable revision of a previously unfavorable decision. 
 
Line 93.  Amount Awarded.--For cases included in line 92, show the amount of the submitted 
charges for services that involved a revision of a previously unfavorable decision.  Show charges 
prior to application of the deductible and coinsurance.  Round results to the nearest dollar. 
 
 
110  Checking Reports 
(Rev. 45, 05-28-04) 
 
Before you send the report to CMS, check for completeness and arithmetical accuracy.  Use the 
following checklist for an arithmetical check for each column: 
  o  Column 1 = Column 2 + Column 3 + Column 4 for lines 1-7, 9-12, 14-24, 52-59, and 61-93. 
 
o  Line 1 for columns 1-4 must be equal to line 19 of the previous month. 
 
o  Line 1 Column 5 must be equal to line 30 of the previous month. 
 
o  Line 1 Column 6 must be equal to line 40 of the previous month. 
 
o  Line 1 + line 2 = line 3. 
 
o  Line 3 + line 4 - line 5 - line 6 = line 19 for columns 1-4. 
 
o  Line 3 + line 4 - line 5 - line 6 for column 5 = line 30. 
 
o  Line 3 + line 4 - line 5 - line 6 for column 6 = line 40. 
 
o  Line 4A must be less than or equal to line 4. 
 
o  Line 6 = line 9 + line 10 + line 11. 
 
o  Line 6 = line 14 + line 15 + line 16 + line 17 + line 18 for column 1-4.  
 
o  Line 6, column 5 = line 26 + line 27 + line 28 + line 29. 
 
o  Line 6, column 6 = line 36 + line 37 + line 38 + line 39. 
 
o  Line 7 must be greater than or equal to line 6. 
 
o  Line 9 + line 11 for column 6 must be less than or equal to the sum of columns 1, 2, and 3 for 
line 47. 
 
o  Line 19 = line 20 + line 21 + line 22 + line 23 + line 24. 
 
o  Line 30 = line 31 + line 32 + line 33 + line 34. 
 
o  Line 40 = line 41 + line 42 + line 43 + line 44. 
 
o  Line 47 = line 45 + line 46 for columns 1-3. 
 
o  Line 47 = line 49 + line 50 + line 51 for columns 2 and 3 only. 
 
o  Line 48 must be less than or equal to line 47 for columns 1, 2, and 3. 
 
o  Line 49 (column 4) must be less than or equal to line 49 (column 2) + line 49 (column 3). 
 
o  Line 50 (column 4) must be less than or equal to the sum of line 50 (column 2) + line 50 
(column 3). 
  o  Line 51 (column 4) must be less than or equal to the sum of line 51 (column 2) + line 51 
(column 3). 
 
o  Line 52 must be equal to line 67 of the previous month. 
 
o  Line 54 = line 52 + line 53. 
 
o  Line 54 + line 55 - line 61 = line 67. 
 
o  Line 57 must be greater than or equal to line 56. 
 
o  Line 58 must be less than or equal to line 56. 
 
o  Line 59 must be less than or equal to line 56. 
 
o  Line 59 must be greater than or equal to line 58. 
 
o  Line 61 = line 63 + line 64 + line 65. 
 
o  Line 62 must be greater than or equal to 500 times the sum of lines 63 and 65 in Column (5) 
only (each case must involve at least $500 per case). 
 
o  Line 66 must be greater than or equal to line 65 (must award at least $1 per case). 
 
o  Line 68 = line 69 + line 70 + line 71. 
 
o  Line 72 = line 73 + line 74 + line 75 + line 76. 
 
o  Line 78 = must be greater than or equal to line 77 (at least $1 per claim). 
 
o  Line 79 = line 80 + line 81 + line 82.  
 
o  Line 83, must be greater than or equal to line 82 (at least $1 per claim). 
 
o  Line 84 = line 85 + line 86 + line 87. 
 
o  Line 88 must be greater than or equal to line 87 (at least $1 per claim). 
 
o  Line 89 = line 90 + line 91 + line 92. 
 
o  Line 93 must be greater than or equal to line 92 (at least $1 per claim). 
 
Public reporting burden for this collection of information is estimated to average 2 hours per 
response, including time for reviewing instructions, searching existing data sources, gathering and 
maintaining data needed, and completing and reviewing the collection of information.  Send 
comments regarding this burden estimate or any other aspect of this collection of information, 
including suggestions for reducing the burden to Office of Financial Management, CMS, P.O. Box 
26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction 
Project Washington, DC  20503.   
110.1  Exhibit 1 
(Rev. 45, 05-28-04) 
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 1. 
 
 
INTERMEDIARY APPEALS REPORT 
   
INTERMEDIARY ID  REPORTING PERIOD 
     
  PART A  PART B 
RECONSIDERATIONS   
             
      HHA/       
  TOT SNF  HOSPIC OTHE REVIE HEARIN
A. INTERMEDIARY APPEAL  AL  (2)  E  R  WS (5)  GS 
REQUESTS  (1)  (3)  (4)  (6) 
             
 1. OPENING PENDING             
             
 2.    ADJUSTMENTS TO PENDING             
             
 3. ADJUSTED PENDING             
             
 4. REQUESTS RECEIVED             
             
 4A.   MED. NEC. DOC. DENIALS             
             
 5. REQUESTS TRANSFERRED             
             
 6. REQUESTS CLEARED             
             
 7.    NO. OF CLAIMS INVOLVED             
             
 8.    AMOUNT IN CONTROVERSY             
             
 9.    AFFIRMATIONS             
             
10.    DISMISSAL/WITHDRAWALS             
             
11.    REVERSALS (FULL OR PART)             
             
12.       AMOUNT AWARDED             
             
             
Form CMS-2591 Screen 1   
110.2  Exhibit 2 
(Rev. 45, 05-28-04) 
 
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 2. 
 
 
INTERMEDIARY APPEALS REPORT 
     
INTERMEDIARY ID    REPORTING PERIOD 
   
  PART A RECONSIDERATIONS 
         
A. INTERMEDIARY APPEAL  TOTAL  SNF  HHA/HOSPI OTHER 
REQUESTS  CE 
       
(1)  (2)  (3)  (4) 
           
   PROCESSING TIMES           
           
13. AVERAGE           
           
14. NO. COMPLETED 1-45 DAYS           
           
15. NO. COMPLETED 46-60 DAYS           
           
16. NO. COMPLETED 61-90 DAYS           
           
17. NO. COMPLETED 91-120           
DAYS 
         
18. NO. COMPLETED OVER 120         
DAYS 
           
       PENDING TIMES           
           
19. CLOSING PENDING           
           
20. NO. PENDING 1-45 DAYS           
           
21. NO. PENDING 46-60 DAYS           
           
22. NO. PENDING 61-90 DAYS            
           
23. NO. PENDING 91-120 DAYS           
            24. NO. PENDING OVER 120           
DAYS 
           
Form CMS-2591 Screen 2           
 
110.3  Exhibit 3 
(Rev. 45, 05-28-04) 
 
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 3 
 
 
INTERMEDIARY APPEALS REPORT 
     
INTERMEDIARY ID    REPORTING PERIOD 
   
  PART B APPEALS 
A. INTERMEDIARY APPEAL        
   REQUESTS REVIEWS  Reviews    Hearings 
     
(1)  HEARINGS  (2) 
         
   PROCESSING TIMES         PROCESSING TIMES   
         
25. AVERAGE      35. AVERAGE   
         
26. NO.  1-30 DAYS      36. NO.   1-60 DAYS   
         
27. NO. 31-45 DAYS      37. NO.  61-90 DAYS   
         
28. NO. 46-60 DAYS      38. NO. 91-120 DAYS   
         
29. NO. OVER 60 DAYS      39. NO. OVER 120 DAYS   
         
   PENDING TIMES         PENDING TIMES   
         
30. CLOSING PENDING      40. AVERAGE   
         
31. NO.  1-30 DAYS      41. NO.   1-60 DAYS   
         
32. NO. 31-45 DAYS      42. NO.  61-90 DAYS   
         
33. NO. 46-60 DAYS       43. NO. 91-120 DAYS   
         
34. NO. OVER 60 DAYS      44. NO. OVER 120 DAYS   
           
B. PART B    OTR  All  All     HEARING RESULTS  With No  Telephone  In-Person  Number 
Subsequent  Hearings  Hearings  In 
(1)  (2)  (3)  120 Days 
(4) 
           
45.     REVERSALS           
           
46.     AFFIRMATIONS           
           
47. TOTAL DECISIONS           
           
48.     NBR IN 120 DAYS           
           
49. NO PREV. OTR HELD           
           
50. PREV. OTR COUNTED           
           
51. PREV. OTR NOT CNTD           
           
Form CMS-2591 Screen 3           
 
110.4  Exhibit 4 
(Rev. 45, 05-28-04) 
 
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 4 
 
 
INTERMEDIARY APPEALS REPORT 
   
INTERMEDIARY ID  REPORT PERIOD 
     
C. PART A AND B ALJ  PART A   
HEARINGS 
           
  Total  SNF  HHA/Hospice  Other  Part B 
(1)  (2)  (3)  (4)  (5) 
           
52. OPENING PENDING           
           
53.    ADJUSTMENTS TO           
PENDING 
           
54. ADJUSTED OPENING           
PENDING 
           
55. REQUESTS RECEIVED                       
56. REQUESTS FRWD. TO ALJ           
           
57.    NO. OF CLAIMS           
INVOLVED 
           
58.    NO. IN 7 CALENDAR           
DAYS 
           
59.    NO. IN 14 CALENDR DAYS           
           
60.    AVG. TIME TO FORWARD           
           
61. COMPLETED           
           
62.    AMT. IN CONTROVERSY           
           
63.    AFFIRMATIONS           
           
64.              
DISMISSALS/WITHDRAWALS 
           
65.    REVERSALS (FULL/PART)           
           
66.       AMOUNT AWARDED           
           
67. CLOSING PENDING           
           
Form CMS-2591 Screen 4           
 
110.5  Exhibit 5 
(Rev. 45, 05-28-04) 
 
Medicare Program - Intermediary Part A and Part B Appeals 
Report - Form CMS-2591, Screen 5 
 
 
INTERMEDIARY APPEALS REPORT 
   
INTERMEDIARY ID           REPORT PERIOD 
     
  PART A   
           
  Total  SNF  HHA/Hospice  Other  PART B 
C. PART A AND B ALJ   (1)  (2)  (3)  (4)  (5) 
HEARINGS             
       DISPOSITIONS           
           
68. NUMBER OF DISPOSITIONS           
           
69.    AFFIRMATIONS           
           
70.           
DISMISSALS/WITHDRAWALS 
           
71. REVERSALS (FULL OR           
PART) 
           
    EFFECTUATIONS           
           
72. TOTAL EFFECTUATIONS           
           
73.    NO. 1-7 DAYS           
           
74.    NO. 8-15 DAYS           
           
75.    NO. 16-30 DAYS           
           
76.    NO. OVER 30 DAYS           
           
   LIMITATION OF LIABILITY           
           
77. WAIVED - BEN & PROV.           
           
78.    AMOUNT AWARDED           
     
D. LIMITATION OF LIABILITY  PART A RECONSIDERATIONS  PART B 
      (CLAIM COUNTS)             
    HHA/       
Total  SNF  Hospice  Other  Reviews  Hearings 
(1)  (2)  (3)  (4)  (5)  (6) 
             
79. TOTAL NUMBER             
CONSIDERED 
             
80. CONSIDERED - NOT             
WAIVED 
             
81. WAIVED - BEN. ONLY             
             
82. WAIVED - BEN. & PROV.                           
83. AMOUNT AWARDED             
             
Form CMS-2591 Screen 5             
 
110.6 - Exhibit 6 
(Rev. 45, 05-28-04) 
 
Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 6 
 
 
INTERMEDIARY APPEALS REPORT 
   
INTERMEDIARY ID  REPORT PERIOD 
         
E. REOPENINGS (Claims Count)    PRE-  Post-  Post-ALJ 
    PART A  TOTAL  Recon  Recon  Hearing 
  (1)  (2)  (3)  (4) 
          
84. TOTAL         
         
85.    UNFAVORABLE TO         
CLAIMANT 
         
86.    NO CHANGE         
         
87.    FAVORABLE TO         
CLAIMANT 
         
88.       AMOUNT AWARDED         
         
    Pre-    Post-   Post-   
                 PART B  TOTAL  Review  Review  Hearing 
         
89. TOTAL         
         
90.    UNFAVORABLE TO            
CLAIMANT 
         
91.    NO CHANGE         
         
92.    FAVORABLE TO         
CLAIMANT 
         
93.       AMOUNT AWARDED         
          Form CMS-2591 Screen 6         
 
120 - Completing Page One of the Carrier Performance Report 
(Rev. 6, 08-30-02) 
B3-13301 
 
120.1 - Classification of Claims for Counting 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
All claims data entered on page one of the performance report must represent counts of claims 
(real and replicate) as defined in the Medicare Claims Processing, Chapter 1, General Billing 
Requirements.  The carrier includes in column (i) the following types of claims:  CMS-1500s, 
CMS-1490s, and CMS-1491s. Of these claims forms, it reports the assigned in column (ii) and the 
unassigned in column (iii). 
 
It includes any claims where processing has been suspended due to CMS directives since they are 
still part of its claims workload.  
 
NOTE:  It does not count assigned claims received from physicians/suppliers if they are 
incomplete, incorrect, or inconsistent and consequently returned for clarification.  It does not have 
to control such claims. 
 
Throughout its process, it includes the date material is received on all claims (real and replicate).  
It shows identifying numbers or codes on all replicate claims through the processing system so that 
they can be counted and reported separately in Part A. 
 
The carrier reports claims as received in the month the claim is received in its mailroom with the 
following exceptions: 
 
  Additional real claims resulting from a split; and  
  Claims identified as replicates. 
 
Split and replicate claims, although carrying the dates the materials were originally received, are to 
be counted as receipts for the month in which they are recognized by the carrier's system as 
created (i.e., split or identified as replicate) for purposes of this report. 
 
EXAMPLE: The carrier splits a claim received in the reporting month into two claims because the 
total number of line items exceeds its system's line item limitation.  If it can recognize this split 
when it occurs, it reports two claims in "Total Claims Received During Month" and in "Net 
Number of Claims Received" (lines 4 and 6, respectively) in Part A of the report.  It reports both 
claims in Part A.  After processing the split (replicate) claim, it reports it in Part A under 
"Replicate Claims Processed" (line 16), as well as under "Total Claims Processed" (line 15).  If its 
system does not indicate when the split occurs, it counts the new claim as a receipt for the month 
in which the system allows it to be recognized, although the date claims materials were originally 
received must be carried forward and remain unchanged. 
  The carrier counts claims received near the end of the reporting month but placed under computer 
control in the following month as received in the reporting month.  It obtains this count by a 
physical inventory or by computer count. 
 
130 - Completion of Items on Page One of Form CMS-1565 
(Rev. 6, 08-30-02) 
B3-13302 
 
130.1 - Heading 
(Rev. 6, 08-30-02) 
B3-13302.1 
 
This report is referenced as Form B in the CROWD system.  The carrier completes the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the 
reporting format to its screen.  It first keys in the number of working days scheduled for the 
reporting period, less any days where no claims were processed as a result of a strike, snow storm, 
etc.  It does not count Saturdays, Sundays, or holidays. 
 
130.2 - Part A - Monthly Workload Operations 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
This part of the report presents data on carrier claims processing activity during the reporting 
period.  Counts of claims (real and replicate) processed, total claims (real and replicate) pending, 
or pending from prior months must reflect the actual status of claims (real or replicate) workloads 
as of the last day of the reporting calendar month.  Data shown must be based on reliable counts of 
all claims (real or replicate) processing activity and the entire "in-house" pending workload.  This 
data may not be derived from estimates. 
 
If a single claim is split into two or more real claims, or into one real claim and one or more 
replicate claims, the carrier considers each split (real and replicate) as a separate, distinct claim for 
purposes of counting claims.  The original real claim is a receipt for the month in which it was 
received.  It counts a claim split from the original, or identified as a replicate, as a receipt for the 
month in which it is actually created or in which its system recognizes it as a separate claim.  To 
determine the age of pending claims, the carrier considers the receipt date as the date the original 
claim was received and not the date it was split from another claim. 
 
It reports, in Part A, only data relating to initial claims (real and replicate) actions.  It does not 
report data on requests for, or dispositions of, reviews, hearings, or reopenings of initial claim 
actions. 
 
Opening Pending 
 
Line 1.  Claims Pending End of Last Month - The system will pre-fill the number 
pending from line 17 on the previous month's report. 
Line 2.  Adjustments - If it is necessary to revise the pending figure for the close of 
the previous month, the carrier enters the adjustment, preceded by a minus 
sign for negative adjustments, as appropriate. Adjustments normally result 
from:      Private claims incorrectly counted as Medicare claims; 
  Beneficiary inquiries or other correspondence incorrectly counted 
as Medicare claims; and 
  Claims consisting of one or more continuation forms incorrectly 
counted as more than one Medicare claim. 
  The carrier reports claims received near the end of the reporting month, and 
placed under computer control sometime after the reporting month, as 
claims received in the reporting month.  It does not count them as claims 
received in the following month.  If some claims have not been counted in 
the proper month's receipts, it counts them as adjustments to the opening 
pending in the subsequent month. 
Line 3.  Adjusted Opening Pending - The system will sum line 1 + line 2 to 
calculate the adjusted opening pending. 
 
Receipts 
 
Line 4.  Total Claims Received During Month - The carrier enters all real claims 
received during the month and all split and replicate claims generated 
(recognized) during the month. (See the Medicare Claims Processing 
Manual for a discussion of what constitutes a claim.)  Claims received 
include all claims received in its mailroom during the reporting month even 
though some of them were placed under computer control in the following 
month. (See 120.1 for counting receipts.) 
  The carrier counts claims submitted electronically after they have passed its 
consistency edits.  Prior to that time, it may return these bills or the entire 
tape (where magnetic tape is the medium of submission), as necessary, 
without counting them as received.  However, once the claims or tapes 
have passed consistency edits and are counted as received, it uses the actual 
receipt date, not the date the edits are passed, in calculating pending and 
processing times. 
Line 5.  Transferred to Other Carriers - The carrier reports the number of claims 
received, but transferred to other carriers or Part A intermediaries, during 
the month because the claimant submitted the claim to the wrong 
contractor.  It includes claims transferred in their entirety or split off from 
other claims because they contained services from physicians/suppliers 
outside of their carrier jurisdiction. 
Line 6.  Net Number of Claims Received - The carrier shows the net number of 
claims (real and replicate) received after subtracting those transferred. 
Line 7.  Electronic Media Claims Received - The carrier reports the net number of 
claims included in line 6 which were received in paperless form via 
electronic media from providers or their billing agencies and read directly 
into its claims processing system.  It does not count on this line claims that 
it received in hardcopy and entered using an Optical Character Recognition 
(OCR) device.  It does not count any claims received in hardcopy and 
transformed into electronic media by any entity working for it directly or 
under subcontract. 
  It counts claims which are split automatically by computer, without manual 
intervention, as electronic media claims.  This includes "required" splits  only. (See the Medicare Claims Processing Manual.  It excludes replicate 
claims). 
 
Claims Processed 
 
Line 8.  Total CWF Claims - The carrier reports the number of initial claims 
(described in lines 9, 10 and 11 below) processed through Common 
Working File (CWF) and posted to CWF history.  It does not include 
claims sent to CWF and rejected, unless they were resubmitted and posted 
to CWF history in the reporting month.  The counts entered in lines 9, 10 
and 11 are exclusive of each other and represent the total number of CWF 
claims (real or replicate) processed during the month.  On page 1, it reports 
these claims in the month it move the claim to a processed location in its 
system after receipt of the host's response to pay, apply entirely toward the 
deductible or deny in full. For pages 2-9, it reports these claims as 
processed in the month during which the scheduled payment date falls, 
which may be in a subsequent reporting period. 
Line 9.  Claims Paid - The carrier reports the number of initial CWF claims (real or 
replicate) that it approved for payment and for which the CWF host 
responded by accepting its determination during the month.  It reports only 
claims which are completely processed.  If payment is made on part of a 
claim and the remainder of the claim requires no payment or is denied for 
any reason, it reports the claim as paid.  It reports claims that have been 
fully adjudicated, with a response having been received from the CWF 
host, and that are being held only due to the payment floor. 
Line 10.  Claims Applied Towards Deductible - The carrier enters the number of 
CWF claims (real or replicate) for which no payment was made because the 
deductible had not been met.  It includes claims for which all charges were 
applied toward the deductible, as well as those for which some charges 
were denied. 
Line 11  Claims Denied - The carrier reports the number of CWF claims (real or 
replicate) for which all services were denied because, for example, the 
beneficiary was not eligible for Part B benefits, the filing limitation was 
exceeded, or services were not covered. 
Line 12.  Total Non-CWF Claims - The carrier reports the number of initial claims 
(real or replicate) processed outside CWF.  Non-CWF claims are those 
either rejected by or not submitted to CWF which it finally adjudicates 
outside of CWF and are, therefore, not posted to its history in the reporting 
month.  It reports these claims as non-CWF, even if it plans to submit an 
informational record in the future. Also, it reports these claims in the month 
in which it made the determination as to their final disposition. 
Line 13.  Claims Approved - Of those claims reported on line 12 as not processed 
through CWF, the carrier reports the number approved for payment or with 
all charges applied toward the deductible. 
Line 14.  Claims Denied - Of those claims reported on line 12, the carrier reports the 
number on which all services were denied. 
Line 15.  Total Claims Processed - The carrier reports the sum of lines 8 and 12. 
Line 16.  Replicate Claims Processed - The carrier reports the number of replicate 
claims included under Total Claims Processed, line 15, column (1).   Replicate claims are those claims split off from original (real) claim.  
Replicate claims are generally created because of computer line item 
limitations, the carrier is making partial payments, or it is carving out 
individual specialty types of services.  (See the Medicare Claims 
Processing Manual, Publication 100-04, Chapter 1, Section 70.2.). 
 
Closing Pending 
 
Line 17.  Claims Pending at End of Month - The system calculates the number of 
bills pending at the end of the month by adding line 3 (adjusted opening 
pending) to line 6 (net receipts) and subtracting line 15 (total processed).  It 
does not report as pending those bills that the carrier has moved to a 
processed location after being accepted by the host and are holding only 
due to the payment floor.  It reports such bills as processed on line 17. 
 
Distribution by Days Elapsed Since Receipt 
 
Line 18.  1-15 Days - The carrier enters the number of claims, by type, included in 
line 17 which are 1-15 days old. 
Line 19.  16-30 Days - The carrier enters the number of claims, by type, included in 
line 17 which are 16-30 days old. 
Line 20.  31-60 Days - The carrier enters the number of claims, by type, included in 
line 17 which are 31-60 days old. 
Line 21.  61-90 Days - The carrier enters the number of claims, by type, included in 
line 17 which are 61-90 days old. 
Line 22.  Over 90 Days - The carrier enters the number of claims, by type, included 
in line 17 which are over 90 days old. 
 
Claim Investigations 
 
Line 23.  Number of Claims Investigated During Month - The carrier reports the 
number of claims (real and replicate) that required contact during the 
month by telephone, correspondence, or automatic inquiry with physician, 
beneficiary, supplier, or social security office, or other entities outside the 
carrier for missing, incorrect, or inconsistent information.  It counts only 
the number of claims investigated, not the number of contacts made. 
 
130.3 - Part B  Inquiries (Inactive) 
(Rev. 248, Issued: 12-19-14, Effective: 01-23-15, Implementation: 01-23-15) 
 
The carrier reports the number of responses it processed as a result of inquiries from, or on behalf 
of, Medicare beneficiaries or providers during the reporting month.  It reports only inquiries 
processed related to the Medicare program.  It excludes inquiries addressing its private line of 
business.  It bases the data on actual counts, not on estimates or samples. 
 
The carrier counts inquiries as follows: 
  Beneficiary - It counts one inquiry per contact (telephone, written, walk-in), regardless of how 
many claims the beneficiary inquires about.  For example, if a beneficiary writes it about the status 
of two claims, it counts the response as one beneficiary written inquiry.  It counts responses to re-
contacts made by that beneficiary as an additional inquiry.  It counts any inquiry made by a 
beneficiary, or by anyone on behalf of the beneficiary, except a provider. 
 
Provider - It counts one inquiry per contact.  For example, if a provider calls or writes it regarding 
the status of 10 claims, it counts the response as one provider-written or phone inquiry.  It counts 
any inquiry made by a provider, or anyone on behalf of the provider, except a beneficiary.  It 
counts inquiries regardless of whether they relate to assigned or unassigned claims. 
 
  It counts beneficiary and provider inquiries as follows: 
 
  It counts Medicare inquiries directed to it for a response if they are requests for information 
from beneficiaries or providers (physicians/suppliers) or their representatives. 
 
  It does not count, as inquiries, professional relations activities and contacts (i.e., its training 
programs for providers on new requirements). 
 
  It counts voice inquiries captured electronically as telephone inquiries, and electronic mail 
inquiries as written inquiries.  It does not count electronic inquiries if the provider can 
access the carrier system to determine claim status without its involvement. 
 
  It does not count inquiries related specifically to the physician fee freeze or MSP. (This is 
to achieve comparability with the CMS-1524 budget form, where all costs related to the fee 
freeze and MSP are reported on separate lines.) 
 
  It counts congressional inquiries in the appropriate category (i.e., as a beneficiary inquiry if 
made on behalf of a beneficiary, and as a provider inquiry if made on behalf of a provider). 
 
  It counts inquiries made by the RO or the SSA DO in the appropriate category if the 
inquiries are on behalf of a beneficiary or a provider and relate to a specific claim.  It does 
not count the inquiries if they are of a general nature (i.e., ongoing liaison necessary during 
monitoring of day-to-day operations). 
 
  It does not count Part A inquiries if it handles all Part A inquiries for an intermediary on a 
routine basis.  In this case, it charges the related costs to the intermediary.  It does not 
include the volume of work on the CMS-1565. 
 
  It counts misdirected telephone inquiries (i.e., those that must be referred to another source 
for response) as processed telephone inquiries.  It does not count misdirected written 
inquiries. 
 
  It does not count requests for reviews or hearings as inquiries.  (See The Medicare Claims 
Processing, Beneficiary Correspondence and Administrative Appeals, for definitions of 
reviews and hearings.)  It reports reviews and hearings on the CMS-2590, not on the CMS-
1565. 
  130.4 - Part C - Miscellaneous Claims Data 
(Rev. 126; Issued:  07-13-07; Effective:  01-01-08; Implementation:  01-07-08) 
 
Medicaid Crossover Claims - This part of the report represents data on the volume of Medicaid 
crossover claims. 
 
Line 28   Number Transferred to State Agencies - The carrier enters the total number of 
Medicaid crossover claims transferred to State agencies or their fiscal agents in the 
reporting month. 
 
Line 29  Number Transferred Electronically - The carrier enters the total number of Medicaid 
crossover claims reported in line 28 which were transferred in the reporting month to 
State agencies, or their fiscal agents, via electronic media. 
 
Optical Character Recognition Claims 
 
Line 30  Total Claims - The carrier enters the number of claims received in hardcopy and 
entered using an OCR device.  It does not count these claims as EMC claims on line 7, 
page 1, or in column 6, pages 2-9. 
 
Medicare Summary Notices (MSNs) 
 
Line 31  Total MSNs Mailed - The carrier enters the number of MSNs mailed to beneficiaries 
during the reporting month. 
 
140 - Completing Pages Two through Eleven of the Carrier Performance 
Report 
(Rev. 6, 08-30-02) 
B3-13305 
 
140.1 - Heading 
(Rev. 6, 08-30-02) 
B3-13305.1 
 
These pages are referenced as Form T (pages 2-9) and Form E (pages 10-11) in the CROWD 
system.  It completes the ADD/UPDATE/DELETE DATA criteria screen with the appropriate 
information to bring the reporting format to its screen. 
 
150 - Part D (1) - Claims Processing Timeliness - All Claims 
(Rev. 10374, Issued: 09-25-20, Effective: 10-01-20, Implementation: 10-05-20) 
 
Pages 2-9 of the CMS-1565 include data on its activity in processing all claims to completion 
during the reporting period.  A claim is counted as processed to completion on the scheduled 
payment date, which is the date the check is mailed, deposited in the providers account, or 
transferred electronically.  For non-paid claims, the date of completion is the date the MSN or 
other notice of final action on the claim is mailed.  Data shown must be based on reliable counts of 
all claims (real and replicate) processing activity.  The A/B MAC (B) does not estimate claim  counts.  It reports only data relating to initial claims (real and replicate) actions.  It does not report 
data on requests for, or dispositions of, reviews, hearings, or reopenings of initial claim actions. 
 
"Clean" claims are defined as those that do not require investigation or development external to the 
A/B MAC (B)s operation on a prepayment basis.  Claims which do not meet the definition of 
"clean" are "other" claims.  Claims paid are those for which some payment was made (i.e., 
payment greater than zero).  Claims not paid are those for which no payment was made (i.e., claim 
charges applied completely toward deductible or fully denied). 
 
On pages 2-9, the A/B MAC (B) reports: 
 
  In column 1, the total number of claims processed to completion; 
  In column 2, the number of "clean" claims paid; 
  In column 3, the number of "other" claims paid; 
  In column 4, the number of "clean" claims not paid; 
  In column 5, the number of "other" claims not paid; and 
  In column 6, the number of "clean" or "other" claims processed to completion, which were 
received via electronic media from providers or their billing agencies and read directly into 
the A/B MAC (B)s claims processing system.  The A/B MAC (B) does not count on this 
line claims that it received in hardcopy and entered using an OCR device.  It does not count 
any claims received in hardcopy and transformed into electronic media by any entity 
working for it directly or under subcontract. 
 
The data in lines 1 through 37 of pages 2 through 9 represent the number of claims processed in 
the number of days shown on that line, counting from the date of receipt.  Line 38 represents the 
sum of lines 1-37.  The date of receipt is defined for hard-copy and magnetic tape claims as the 
date of receipt in the mailroom.  For EMC billed via terminal or equivalent, it is the date the claim 
passes all front-end edits.  For split claims, whether required or replicate, the date of receipt is the 
date of receipt of the original claim material, not the date of the split. 
 
To calculate the processing time for a claim, the A/B MAC (B) subtracts the Julian receipt date 
from the processed to completion Julian date.  When the processed to completion date falls in the 
year following the year of receipt, it adds 365 to the Julian date of completion (or 366 if the year of 
receipt is a leap year).  If a claim is processed to completion on the same day it is received, the 
processing time is 1 day. This definition applies to all lines of the report, including line 39. 
 
On line 39, the A/B MAC (B) reports the mean processing time (PT) to one decimal place for each 
column. To calculate the mean PT, it adds the processing times for the claims shown in line 38 of 
that column, and divides by the number in line 38.  It does not use the categories on the report to 
calculate the mean PT.  Because of the aggregation of claims in lines 34-37, it uses the processing 
times for individual claims, as explained below, to make this calculation. 
 
Mean PT Calculation for All Claims - To determine the mean PT for all claims: 
 
  Subtract the Julian date of receipt from the Julian date of payment or equivalent action for 
those not paid for each claim. 
 
  Accumulate the result to cell counter for number of days for all claims.    Divide this result by the total number of claims. 
 
  Round to one decimal place. 
 
EXAMPLE: 
 
Claim  Julian Date  Paid  Counter by  Counter by 
Receipt  Days  Claims 
A  87103  87133  30  1 
B  87105  87206  101  2 
C  87115  87177  62  3 
D  87120  87213  93  4 
E  87122  87215  93  5 
F  87130  87223  93  6 
 
Total Days = 30 + 101 + 62 + 93 + 93 + 93 = 472 
Mean = 472/6 = 78.6666 = 78.7 
The A/B MAC (B) completes the report for each of the following claim types: 
 
Page 2.  Assigned Physician - It shows the number of assigned claims included on page 9 
which involved services billed by physicians.  Physicians are identified by specialty 
codes 01-14, 16-30, 33-41, 44, 46, 48, 66, 70, 72, 76-79, 81-86, 90-94, 98, 99, C0, or 
C3, C5, C6, C7, C8, C9, D3 D4, D7 or D8. 
Page 3.  Assigned DME - It shows the number of assigned claims included on page 9 which 
involved services billed by DME suppliers.   
Page 4.  Assigned Lab - It shows the number of assigned claims included on page 9 which 
involved services billed by an independent laboratory.  Independent laboratories are 
identified by specialty code 69. 
Page 5.  Assigned Ambulance - It shows the number of assigned claims included on page 9 
which involved services billed by ambulance service suppliers.  Ambulance service 
suppliers are identified by specialty code 59. 
Page 6.  Assigned Other - It shows the number of assigned non-physician claims included on 
page 9 but not represented on pages 3, 4, or 5. 
Page 7.  Unassigned - It shows the number of unassigned claims (real and replicate) included 
on page 9. 
Page 8.  Participating Physician - It shows the number of claims included on page 9 involving 
services rendered by physicians enrolled in the Medicare Physician/Supplier 
Participation Program. 
Page 9.  All Claims - It shows the total number of claims (real and replicate) processed during 
the month. 
 
160 - Part D(2) - Claims Processing Timeliness - EMC Claims and Adjustments 
for CPEP CPT Calculations 
(Rev. 6, 08-30-02) 
B3-13307 
 
Pages 10-11 of the CMS-1565 include data bills paid or denied during the month that were 
received via electronic media.  The basic instructions and definitions that apply to pages 2-9 (see  150) also apply to pages 10-11.  The carrier reports the following information for Participating 
Physician EMC claims (page 10) and all EMC claims (page 11): 
 
  Column 1 - the number of EMC claims that were included in column 2 (paid clean) for the 
corresponding claim type on page 8 or 9, as appropriate. 
 
  Column 2 - the number of EMC claims that were included in column 3 (paid other) for the 
corresponding claim type on page 8 or 9, as appropriate. 
 
  Column 3 - the number of EMC claims that were included in column 4 (not paid clean) for 
the corresponding claim type on page 8 or 9, as appropriate. 
 
For each claim type (PAR and TOT), the carrier reports the following adjustments for CPEP CPT 
calculations: 
 
CWF - Claims which were beyond carrier control due to CWF. 
 
A.  The number of EMC clean claims processed beyond the EMC ceiling. 
B.  The number of paper clean claims processed beyond the paper ceiling. 
C.  The number of all claims processed beyond 60 days. 
 
WAIVER - Claims paid under the floor for which the carrier had a waiver from CMS. 
 
D.   The number of EMC clean claims paid under the EMC floor. 
E.   The number of paper clean claims paid under the paper floor. 
F.   The number of all EMC claims paid under the EMC floor plus the number of all paper 
claims paid under the paper floor. 
 
170 - Completing Page 12 of the Carrier Performance Report 
(Rev. 6, 08-30-02) 
B3-13308 
 
170.1 - Classification of Claims for Counting 
(Rev. 6, 08-30-02) 
B3-13308.1 
 
Claims data entered on page 12 of the performance report represent counts of claims (real and 
replicate) as defined in Ref. 
 
170.2 - Heading 
(Rev. 6, 08-30-02) 
B3-13308.2 
 
This page is referenced as Form V in the CROWD system. 
 
The carrier completes the ADD/UPDATE/DELETE DATA criteria screen with the appropriate 
information to bring the reporting format to its screen. 
  170.3 - Part E - Interest Payment Data 
(Rev. 10374, Issued: 09-25-20, Effective: 10-01-20, Implementation: 10-05-20) 
 
   
The A/B MAC (B) reports on Page 12 of the CMS-1565 data on the claims on which it paid 
interest because it paid the claims after the required payment date per 9311 of the Omnibus 
Reconciliation Act of 1986 (OBRA 1986).  It bases data shown on reliable counts of all claims 
processing activity, not on estimates.  It reports data on initial claims only.  It includes in the report 
all claims requiring interest payments in the month.  It reports claims in the month the date of 
payment falls.  (For a discussion of interest payments refer to the Medicare Claims Processing 
Manual, Publication 100-04, chapter 1, sections 80.2.2 and 80.2.2.1). 
 
The A/B MAC (B) completes the report for each column as follows: 
 
Column 1.  Total - Data for all claims (real and replicate) for which interest payments were 
made during the month. 
Column 2.  Assigned Physician - Data for the assigned claims included in column 1 which 
involved services billed by physicians.  Physicians are identified by specialty 
codes 01-14, 16-30, 33-41, 44, 46, 48, 66, 70, 72, 76-79, 81-86, 90-94, 98, 99, C0, 
C3, C5, C6, C7, C8, C9, D3, D4, D7 or D8. 
Column 3.  Assigned DME - Data for the assigned claims included in column 1 that involved 
services billed by DME suppliers.   
Column 4.  Assigned Lab - Data for the assigned claims included in column 1 that involved 
services billed by an independent laboratory.  Independent laboratories are 
identified by specialty code 69. 
Column 5.  Assigned Ambulance - Data for the assigned claims included in column 1 that 
involved services billed by ambulance service suppliers.  Ambulance service 
suppliers are identified by specialty code 59. 
Column 6.  Assigned Other - Data for the assigned non-physician claims included in column 1 
but not represented in columns 3, 4, or 5. 
Column 7.  Unassigned - Data for the unassigned claims included in column 1. 
Column 8.  Participating Physician - Data for claims involving services rendered by physicians 
enrolled in the Medicare Physician/Supplier Participation Program. 
 
On line 1, the A/B MAC (B) shows the number of claims on which it paid interest in the reporting 
month.  It reports on line 2 the number of claims included in line 1 for which it made payment 1 
day after the required payment date (e.g., the required payment date is 17 days after receipt for 
participating physician claims received in FY 1992.)  (See 9311 of OBRA 1986.)  Data for lines 
3-10 are similar to those for line 2. 
 
The A/B MAC (B) calculates the number of days late by subtracting the Julian date of the required 
payment date from the Julian date of payment. 
 
On line 11, it shows the amount paid in interest for claims reported in line 1.  On lines 12-20, it 
shows the amount paid in interest for claims reported in lines 2-10, respectively.  It shows dollar 
amounts on lines 11-20 to the nearest penny, and includes the decimal point. 
 
  180 - Completing Page Thirteen of the Carrier Performance Report (Inactive) 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
180.1 - Instructions for Completing the Carrier Performance Report - All 
Trunks Busy (ATB) 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
Each month the carrier prepares and submits to CMS Central Office (CO) page 13 of the Carrier 
Performance Report - ATB.  This report contains the monthly data for ATB, for both local and toll 
free calls, the number of beneficiary calls answered in 120 seconds, and the total number of 
beneficiary calls received. 
 
It reports these statistics electronically by the 15th of the month following the reporting month 
using the Medicare Contractor Reporting of Operational and Workload Data (CROWD) System at 
the CMS Data Center (CDC).  It enters data on the ATB report screen for each office that has been 
assigned a separate carrier number. 
 
180.2 - Heading 
(Rev. 6, 08-30-02) 
B3-13309.2 
 
This page is referenced as Form R in the CROWD system. 
 
The carrier completes the ADD/UPDATE/DELETE DATA criteria screen with the appropriate 
information to bring the reporting format to its screen. 
 
180.3 - Part F-ATB Data 
(Rev. 6, 08-30-02) 
B3-13309.3 
 
The carrier completes the report for each line as follows: 
 
Line 1, column 1 - percent, rounded to the nearest tenth, of all trunks busy (ATB) for local calls. 
 
Line 1, column 2 - percent, rounded to the nearest tenth, of all trunks busy (ATB) for toll free 
calls. 
 
Line 2, column 1 - number of local beneficiary calls answered in 120 seconds. 
 
Line 2, column 2 - number of toll free beneficiary calls answered in 120 seconds. 
 
Line 3, column 1 - number of local beneficiary calls received. 
 
Line 3, column 2 - number of toll free beneficiary calls received. 
 
Line 4, column 1 - percent, rounded to the nearest tenth, of local beneficiary calls answered in 120 
seconds. 
  Line 4, column 2 -, rounded to the nearest tenth, of toll free beneficiary calls answered in 120 
seconds. 
 
EXPLANATION OF FAILURES: When the carrier fails the ATB level percentage standard or the 
timeliness standard for responding to telephone inquiries, it enters an explanation in this section.  It 
makes the narrative as brief as possible.  Refer to MCM-2, 5261.7 regarding the standards. 
 
190 - Checking Reports Prior to Submittal to CMS 
(Rev. 6, 08-30-02) 
B3-13310 
 
Prior to transmitting performance reports to CMS the carrier checks for the following: 
 
  Completeness; 
  Accuracy; and 
  Internal consistency. 
 
It uses the following checklists to assure accuracy and consistency: 
 
A.  Page One of Report (CROWD Form B) 
 
  Line 1 of current report must be equal to line 17 of previous report for all columns;  Line 1 
+ Line 2 = Line 3 for all columns; 
  Line 4 - Line 5 = Line 6 for all columns; 
  Line 7 should be equal to or less than Line 6 for all columns; 
  Line 9 + Line 10 + Line 11 = Line 8 for all columns; 
  Line 13 + Line 14 = Line 12 for all columns; 
  Line 8 + Line 12 = Line 15 for all columns; 
  Line 3 + Line 6 - Line 15 = Line 17 for all columns; 
  For each line of this page (except for lines 16, 28, 29 and 30),  column 1 must equal the 
sum of columns 2 and 3; 
  Line 16 should be equal to or less than Line 15 for column 1; 
  Lines 18 + 19 + 20 + 21 + 22 = Line 17 for all columns; 
  Lines 25 + 26 + 27 = Line 24 for all columns; and  
  Line 29 should be equal to or less than line 28. 
 
B.  Pages Two through Eleven (CROWD Forms T and E) 
  For each of lines 1-38 on pages 2-9, column 1 = column 2 + 3 + 4 + 5; 
  For each of lines 1-38 on pages 2-9, column 6 must be equal to or less than column 1; 
  The sum of lines 1-37 must be equal to line 38 for all columns;  
  Each data item on page 9, lines 1-38 = the sum of the corresponding data items on pages 2-
7; 
  Each data item on page 8, lines 1-38, must be equal to or less than the corresponding data 
item on page 2; 
  For each of lines 1-38 on pages 10 and 11, column 1 must be less than or equal to column 2 
on pages 8 and 9, respectively;    For each of lines 1-38 on pages 10 and 11, column 2 must be less than or equal to column 3 
on pages 8 and 9, respectively; and 
  For each of lines 1-38 on pages 10 and 11, column 3 must be less than or equal to column 4 
on pages 8 and 9, respectively. 
 
C.  Page Twelve (CROWD Form V) - 
 
  For each line, column 1 = the sum of columns 2 - 7; 
  For each column, line 1 = the sum of lines 2 - 10; 
  For each column, line 11 = the sum of lines 12 - 20; and 
  For each line, column 8 must be equal to or less than column 2. 
 
D.  Page Thirteen (CROWD Form R) 
 
(Line 2 divided by line 3) times 100 = line 4 for all columns. 
 
200 - Exhibits 
(Rev. 126; Issued:  07-13-07; Effective:  01-01-08; Implementation:  01-07-08) 
 
Exhibit 1 - Medicare Program Carrier Performance Report- Page 1 
 
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 
Report Period  Working 
Carrier   Number   ( Month/Yr)  Days 
  Number and Type of Claim 
Reporting Item  Total   Assigned   Unassigned 
(1)  (2)  (3) 
A. Monthly Workload Operations       
OPENING PENDING       
       
1. Claims Pndg End of Last Mo.       
2.     Adjustments (Show + or -)       
3. Adjusted Opening Pending       
       
RECEIPTS       
       
4. Tot. Clms. Rcvd. During Mo.       
5.     Transferred to Other Carrier       
6. Net Number of Claims Received       
7.     Electronic Media Claims Recvd.       
       
CLAIMS PROCESSED       
        8. Total CWF Claims       
9.     Claims Paid       
10.   Claims Applied To Deductible       
11.   Claims Denied       
12. Total Non-CWF Claims       
13.     Claims Approved       
14.     Claims Denied       
15. Total Claims Processed       
16.     Replicate Claims Processed       
 
Exhibit 1 (Cont.) 
 
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1   (cont) 
Report Period  Working 
Carrier  Number  ( Month/Yr)  Days 
  Number and Type of Claim 
Reporting Item  Total  Assigned  Unassigned 
  (1)  (2)  (3) 
CLOSING PENDING       
       
17. Claims Pending at End of Month       
       
DISTRIBUTION OF DAYS ELAPSED SINCE RECEIPT   
   
18. 1 - 15 Days       
19. 16 - 30 Days       
20. 31 - 60 Days       
21. 61 - 90 Days       
22. Over 90 Days       
       
CLAIMS INVESTIGATIONS       
       
23. No. of Clms. Invest. During Mo.       
       
B. INQUIRIES  TOTAL  BENEFICIARY  PROVIDER 
        24. Tot. No. Processed During Mo.       
25.     Telephone       
26.     Walk-In Contact       
27.     Written       
       
C. MISCELLANEOUS CLAIMS       
DATA 
       
MEDICAID CROSSOVER CLAIMS       
       
28. No. Transferred to St. Agencies       
29. No. Transferred Electronically       
 
Exhibit 1 (Cont.) 
 
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1   (cont) 
Report Period  Working 
Carrier  Number   ( Month/Yr)  Days 
  Number and Type of Claim 
Reporting Item  Total  Assigned  Unassigned 
  (1)  (2)  (3) 
       
OPTICAL CHARACTER RECOGNITION       
CLMS. 
       
30. Total Claims       
       
MEDICARE SUMMARY NOTICES       
       
31. Total MSNs Mailed       
Form CMS-1565 
  Exhibit 2 - Medicare Program Carrier Performance Report - Form CMS-1565, Pages 2-9 
 
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT -  
FORM CMS-1565, Pages 2-9 
CARRIER WORKLOAD REPORT - PAGE __*__ 
PART - D (1) CLAIMS PROCESSING TIMELINESS - ALL CLAIMS 
CARRIER ID________ TYPE OF CLAIM______*_____ REPORT MO.___ 
 
        PAID     NOT PAID        
LINE NO./DAYS     TOTAL  CLEAN  OTHER  CLEAN  OTHER  EMC 
(1)     (2)     (3)     (4)     (5)     (6)    
    1     1                            
    2     2                            
    3     3                            
    4     4                            
    5     5                            
    6     6                            
    7     7                            
    8     8                            
    9     9                            
    10     10                            
    11     11                            
    12     12                            
    13     13                            
    14     14                            
    15     15                            
    16     16                            
    17     17                            
    18     18                            
    19     19                                 20     20                            
    21     21                            
    22     22                            
    23     23                            
    24     24                            
    25     25                            
    26     26                            
    27     27                            
    28     28                            
    29     29                            
  Exhibit 2 (Cont.) 
 
        PAID     NOT PAID        
LINE NO./DAYS     TOTAL  CLEAN  OTHER  CLEAN  OTHER  EMC 
(1)     (2)     (3)     (4)     (5)     (6)    
    30     30                            
    31     31                            
    32     32                            
    33     33                            
    34     34-45                            
    35     46-60                            
    36     61-90                            
    37      91+                            
    38     Tot 1-37                            
    39     Mean Pt                            
CMS-1565 Page _*_ 
 
* PAGE NUMBER AND TYPE OF CLAIM ARE TO BE REPORTED AS FOLLOWS: 
 
Page 2-Assigned Physician 
Page 3-Assigned DME 
Page 4-Assigned Lab 
Page 5-Assigned Ambulance 
Page 6-Assigned Other 
Page 7-Unassigned 
Page 8-Participating Physician 
Page 9-All Claim 
  Exhibit 3 - Adjustments for CPEP CPT 
 
    EMC NOT    
PAID    
EMC PAID 
ADJUSTMENTS FOR CPEP CPT    
LINE NO./DAYS     CLEAN  OTHER  CLEAN  CALCULATIONS:    
(1)     (2)     (3)    
1    1        CWF 
2    2        Claims which were 
3    3        beyond carrier control due 
to CWF. 
4    4       
5    5        A. EMC clean claims 
6    6        Processed beyond EMC 
7    7       
8    8        B. Paper clean claims 
9    9        Processed beyond Paper 
10    10        ceiling 
11    11        C. All claims processed 
12    12        Beyond 60 days ____ 
13    13        WAIVER 
14    14        Claims paid under the 
15    15        floor For which the carrier 
16    16        had a waiver from CMS. 
17    17        D. EMC clean claims 
18    18        Paid under EMC floor 
19    19        _________ 
20    20        E. Paper clean claims 
21    21        Paid under paper floor 
22    22        ________ 
23    23        F. All EMC claims paid 
24    24        under EMC floor and all 
25    25        paper claims paid under 
paper floor __________ 
26    26       
27    27       
28    28         
29    29         
30    30         
31    31         
32    32         
33    33         
  Exhibit 3 (Cont.) 
 
    EMC PAID  EMC     
NOT PAID    
LINE NO./DAYS     CLEAN  OTHER  CLEAN  CALCULATIONS:    
(1)     (2)     (3)    
34    34-45         
35    46-60         
36    61-90         
37    91+         
38    Tot 1-37         
39    Mean Pt         
             
CMS-1565 Page _*_ 
* PAGE NUMBER AND TYPE OF CLAIM ARE TO BE REPORTED AS FOLLOWS:  
Page 10-Participating Physician (PAR) 
Page 11-Total (TOT) 
  Exhibit 4 - Carrier Workload Report - Part-E - Interest Payment Data 
CARRIER WORKLOAD REPORT - PAGE __*__ 
PART-E - INTEREST PAYMENT DATA 
 
CARRIER ID 
REPORT MONTH 
LINE NO    ASTD  ASTD  ASTD  ASTD  ASTD  UNASTD  PARTIC. 
CLAIM/PAYMENT  TOTAL  PHYS  DME  LAB  AMB  OTHER    PHYS 
LATE DAYS  (1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
  1.  No. of Claims                
  2.  1 Day late                 
  3.  2 Days Late                 
  4.  3 Days Late                 
  5.  4 Days Late                 
  6.  5 Days Late                 
  7.  6-15 A Late                 
  8.  16-30 A Late                 
  9.  31-60 A Late                 
10.  61+ A Late                 
11.  Amount paid                 
12.  1 Day late                 
13.  2 Days Late                 
14.  3 Days Late                 
15.  4 Days Late                 
16.  5 Days Late                 
17.  6-15 A Late                 
18.  16-30 A Late                 
19.  31-60 A Late                 
20.  61+ A Late                 
CMS-1565 Page 12  Exhibit 5 - Carrier Workload Report - Part F - All Trunks Busy (ATB) 
 
CARRIER WORKLOAD REPORT 
PART F - ALL TRUNKS BUSY (ATB) 
 
ALL TRUNKS BUSY 
CARRIER ID___________    REPORT MONTH________ 
 
    LOCAL  TOLL FREE 
CALLS  CALLS 
(1)     (2)    
1.    PERCENT OF ATB            
2.    NUMBER OF BENEFICIARY CALLS ANSWERED IN         
120 SECONDS    
3.    TOTAL NUMBER OF         
    BENEFICIARY CALLS RECEIVED    
4.    % OF BENEFICIARY CALLS ANSWERED IN 120         
SECONDS    
EXPLANATION FOR FAILURES:  
CMS-1565 Page 13  210 - Monthly DMEPOS State Report - General (Inactive) 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
If the carrier is a Durable Medical Equipment Regional Carrier (DMERC), it prepares and submits 
a report each month for its region (either A, B, C, or D - see 210.3 for exhibits) to CMS 
summarizing its performance in processing DMEPOS claims.  It transmits the DMEPOS report as 
soon as possible after the end of the reporting month, but no later than the 10th day of the 
following month using the instructions contained in the CROWD User's Guide.  It is also required 
to submit all pages of the CMS-1565 report for its total DMEPOS workload.  It must also submit 
data on forms CMS-2174, CMS-2590, CMS-1564, CMS-1565A, and CMS-1565C via CROWD 
for its total DMEPOS workload. 
 
210.1 - Completion of Items on the DMEPOS State Report 
(Rev. 6, 08-30-02) 
B3-13312.1 
 
Heading - The carrier enters its assigned carrier number in the indicated space.  In the space 
labeled, "Reporting Period", it enters the numerical month and year for which the report is 
prepared, e.g., it shows 1001 for the month October 2001.  For each of the 8 pages of the report, 
the "Type" of claim is pre-entered by the CROWD system.  Page 1 will be labeled "PEN" and be 
used to report PEN claims (HCPCS codes B0000-B9999; J0000-J9999).  The remaining pages (2 
thru 8) will be labeled and defined as follows: 
 
PAGE  TYPE  HCPCS Codes 
2  OXY (oxygen)  E0400-E0499; E1351-E1499 
3  NOE (non-oxygen equipment)  E0000-E0399; E0500-E1350 
4  DIA (dialysis supplies)  A4650-A4927; E1500-E1649 
5  NDS (non-dialysis supplies)  A4200-A4640; A5051-A9999 
6  PRO (prosthetics and orthotics)  L0000-L9999; V0000-V9999 
OTH (other than the previous types 
7  An example would be regional-wide code 
above) 
8  TOT (total DMEPOS claims)   
 
If a claim contains more than one category type, the carrier reports the claim under each type 
identified.  For example, it reports a claim including services for oxygen (OXY), non-oxygen 
equipment (NOE), and dialysis supplies (DIA) under page 2 (OXY), under page 3 (NOE), and 
under page 4 (DIA).  As a result, this claim will end up being counted as 3 claims under page 8 
(TOT). 
 
For each of these types (pages 1 through 8), it enters data for lines and columns as follows: 
 
Lines - data reflecting the total of all States and territories in its jurisdiction (region).  On 
subsequent lines (2 and greater), enter data for each State and territory in its region. 
 
Columns 
 
Column 1, State Code - A code for the total of all States and an alpha code for each State and 
territory is pre-entered by the CROWD system.   
Total Claims Processed for Type Indicated 
 
Column 2, Number - total number of DMEPOS claims processed for type indicated during the 
month for all States and territories in its region. 
 
The carrier reports claims in the month the payment date or other final adjudication occurs.  See 
MCM-2, 5240, functional standard 11, for definition of payment date for all claims, including 
those fully denied or having charges applied completely towards the deductible.  The total number 
of claims for all States (line 1) must be equal to or greater than the number reported on page 9, line 
38, column 1 of the CMS-1565 that the carrier submits for the same month. 
 
Column 3, In 1-60 Days - total number of DMEPOS claims in type indicated processed within 60 
days during the month for all States and territories in its region.  To calculate the processing time 
for a claim, the carrier subtracts the Julian receipt date from the processed to completion Julian 
date.  The total number of claims processed for all States must be equal to or greater than the 
number reported on page 9, lines 1-35, of column 1 of the CMS-1565 submitted by the carrier for 
the same month. 
 
Column 4, In 61-90 Days - total number of DMEPOS claims in type indicated processed in 61-90 
days during the month for all States and territories in its region.  The total number of claims 
processed for all States (line 1) must be equal to or greater than the number reported on page 9, 
line 36, column 1 of the CMS-1565 submitted by the carrier for the same month. 
 
Column 5, Mean Processing Time - mean processing time for number of DMEPOS claims for 
type indicated processed during the month for all States and territories in its region.  See 140.2 
for an explanation on calculating the mean processing time.  The carrier enters data to one decimal 
place. 
 
Column 6, EMC - number of DMEPOS claims for type indicated processed to completion that 
were received via electronic media for all States and territories in its region.  It does not include 
claims that the carrier receives in hardcopy and transfers to electronic media via character 
recognition devices.  The total number of claims processed for all States (line 1) must be equal to 
or greater than the number reported on page 9, line 38, column 6 of the CMS-1565 that the carrier 
submits for the same month. 
 
Clean Claims Processed for Type Indicated 
 
Column 7, Number - total number of clean DMEPOS claims for type indicated processed during 
the month for all States and territories in its region.  "Clean" claims are those that do not require an 
investigation or development external to the carrier operation on a prepayment basis.  See MCM-
2, 5240, functional standard 11, for definition of clean claims.  The total number of "clean" 
claims processed for all States (line 1) must be equal to or greater than the number reported on 
page 9, line 38, column 2 + 4 of the CMS-1565, the carrier submits for the same month. 
 
Column 8, In 1-30 Days - number of clean DMEPOS claims for type indicated processed 1-30 
days for all States and territories in its region. 
  210.2 - Checking Report 
(Rev. 6, 08-30-02) 
B3-13312.2 
 
Before transmitting the report to CMS CO, the carrier checks it for completeness and arithmetical 
accuracy.  It uses the following checklist: 
 
  Total All States, line 1, equals the sum of lines 2-20 for columns 2, 3, 4, 6, 7, and 8. 
  For all lines, column 3 must be equal to or less than column 2. 
  For all lines, column 4 must be equal to or less than column 2. 
  For all lines, column 6 must be equal to or less than column 2. 
  For all lines, column 7 must be equal to or less than column 2. 
  For all lines, column 8 must be equal to or less than column 7. 
  Line 1, column 2, page 8 must be greater than or equal to line 38, column 1, page 9 of the 
CMS-1565 submitted by the carrier for the same month. 
  Line 1, column 3, page 8 must be greater than or equal to the sum of lines 1-35, column 1, 
page 9 of the CMS-1565 that the carrier  submit for the same month. 
  Line 1, column 4, page 8 must be greater than or equal to line 36, column 1, page 9 of the 
CMS-1565 that the carrier submit for the same month. 
  Line 1, column 6, page 8 must be greater than or equal to line 38, column 6, page 9 of the 
CMS-1565 that the carrier submit for the same month. 
  Line 1, column 7, page 8 must be greater than or equal to line 38, column 2 plus column 4, 
page 9 of the CMS-1565 that the carrier submit for the same month.  210.3 - Exhibits 
B3-13312.3 
 
Exhibit 1 - DMEPOS State Report - REGION A 
 
DMEPOS State Report - REGION A  
 
Carrier No._______     Report Period_______    Type_______ 
 
  Total Claims Processed for Type Indicated  Clean Claims Processed for Type 
Indicated 
In  In  Mean   
State    1-60  61-90  Proc.      In 
Code  Number  Days  Days  Time  EMC  Number  1-30 Days 
(1)     (2)     (3)     (4)     (5)     (6)     (7)     (8)    
1-Tot. 
All 
States                             
02 CT                                
03 DE                                
04 MA                                
05 ME                                
06 NH                                
07 NJ                                
08 NY                                
09 PA                                
10 RI                                
11 VT                                
12                                
13                                
14                                
15                                
16                                
17                                
18                                
19                                
20                                
TYPE 
Page 1-PEN 
Page 2-Oxygen  
Page 3-Non-Oxygen Equipment 
Page 4-Dialysis Supplies 
Page 5-Non-Dialysis Supplies  Page 6-Prosthetics and Orthotics 
Page 7-Other 
Page 8-Total 
  Exhibit 2 - DMEPOS State Report - REGION B 
 
DMEPOS State Report - REGION B 
 
Carrier No._______     Report Period_______     Type_______ 
 
   Total Claims Processed  Clean Claims Processed 
for Type Indicated     for Type Indicated    
  In  In  Mean   
State    1-60  61-90  Proc.      In 
Code  Number  Days  Days  Time  EMC  Number  1-30 Days 
(1)     (2)     (3)     (4)     (5)     (6)     (7)     (8)    
1-Tot. All 
States                             
02 DC                                
03 IL                                
04 IN                                
05 MD                                
06 MI                                
07 MN                                
08 OH                                
09 VA                                
10 WI                                
11 WV                                
12                                
13                                
14                                
15                                
16                                
17                                
18                                
19                                
20                                
 
TYPE 
Page 1-PEN 
Page 2-Oxygen  
Page 3-Non-Oxygen Equipment 
Page 4-Dialysis Supplies 
Page 5-Non-Dialysis Supplies 
Page 6-Prosthetics and Orthotics 
Page 7-Other 
Page 8-Total  Exhibit 3 - DMEPOS State Report - REGION C 
 
DMEPOS State Report - REGION C  
Carrier No._______     Report Period_______    Type_______ 
 
    Total Claims Processed  Clean Claims Processed 
for Type Indicated  for Type Indicated 
    In  In  Mean       
State  1-60  61-90  Proc.  In 
Code  Number  Days  Days  Time  EMC  Number  1-30 Days 
(1)     (2)     (3)     (4)     (5)     (6)     (7)     (8)    
1-Tot. 
All  
                           
States 
02 AL                                
03 AR                                
04 CO                                
05 FL                                
06 GA                                
07 KY                                
08 LA                                
09 MS                                
10 NC                                
11 NM                                
12 OK2                                
13 PR2                                
14 SC2                                
15 TN2                                
16 TX2                                
17 VI2                                
18                                
19                                
20                                
                                 
TYPE 
Page 1-PEN 
Page 2-Oxygen  
Page 3-Non-Oxygen Equipment 
Page 4-Dialysis Supplies 
Page 5-Non-Dialysis Supplies 
Page 6-Prosthetics and Orthotics 
Page 7-Other 
Page 8-Total  Exhibit 4 - DMEPOS State Report - REGION D 
 
DMEPOS State Report - REGION D 
Carrier No._______     Report Period_______     Type_______   
 
  Total Claims Processed for Type Indicated   Clean Claims Processed 
for Type Indicated  
In  In  Mean 
State    1-60  61-90  Proc.      In 
Code  Number  Days  Days  Time  EMC  Number  1-30 Days 
(1)     (2)     (3)     (4)     (5)     (6)     (7)     (8)    
1-Tot. 
                           
All States 
02 AK                                
03 AZ                                
04 CA                                
05 CM                                
06 GU                                
07 HI                                
08 IA                                
09 ID                                
10 KS                                
11 MO                                
12 MT                                
13 ND                                
14 NE                                
15 NV                                
16 OR                                
17 SD                                
18 UT                                
19 WA                                
20 WY                                
 
TYPE 
Page 1-PEN  Page 2-Oxygen  
Page 3-Non-Oxygen Equipment 
Page 4-Dialysis Supplies 
Page 5-Non-Dialysis Supplies 
Page 6-Prosthetics and Orthotics 
Page 7-Other 
Page 8-Total  220 - Quarterly Supplements to Carrier Performance Report (Forms CMS-
1565A, CMS-1565B, CMS-1565C, CMS-1565D, and CMS-1565E) - General 
(Rev. 6, 08-30-02) 
B3-13320 
 
In addition to the monthly workload report, the carrier prepares and transmits to CMS a Quarterly 
Supplement to the Carrier Performance Report showing the status and disposition of selected 
workloads.  It prepares a separate report for each office/State that has been assigned a separate 
carrier number. 
 
220.1 - Purpose and Scope 
(Rev. 6, 08-30-02) 
B3-13320.1 
 
The Quarterly Supplements to the Carrier Performance Report (Forms CMS-1565A, CMS-1565B, 
CMS-1565C, CMS-1565D, and CMS-1565E) are the sources of current information on key 
aspects of carrier Medicare operations.  The data, together with information from other sources, 
are used by CMS for: 
 
  Identifying problem areas for resolution; 
 
  Measuring trends in reasonable charge reductions, denial rates, and provider participation; 
Monitoring the workload handled by the carriers Medicare Fraud and Abuse unit; 
 
  Monitoring activity related to the carriers Comprehensive Limiting Charge Compliance 
Program; and 
 
  Monitoring activities dealing with the carriers review of incentive payments made to 
physicians who render covered Medicare services in a rural or urban Health Professional 
Shortage Area (HPSA). 
 
Carrier Instructions 
 
220.2 - Due Date 
(Rev. 6, 08-30-02) 
B3-13320.2 
 
The carrier transmits Forms CMS-1565A, CMS-1565B, CMS-1565C, and CMS-1565D to CO via 
PC or terminal as soon as possible after the end of the reporting quarter, but no later than the 15th 
of the following month, using instructions contained in Contractor Reporting of Operational and 
Workload Data (CROWD) System User's Guide.  With the exception of the due date, it applies 
these same instructions to Form CMS-1565E.  The due date for the CMS-1565E is 75 days 
following the reporting quarter.  
 
The carrier does not submit hardcopies of the reports. 
 
230 - Completing Form CMS-1565A  (Rev. 6, 08-30-02) 
B3-13321 
 
230.1 - Classification of Claims for Counting 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
Claims data entered on the performance report represent counts of claims (real and replicate).  (See 
the Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 70.8.2, for a 
definition of replicate claims).  It includes in column (1) both assigned and unassigned claims.  
The carrier reports assigned claims in column (2) and unassigned claims in column (3). 
 
240 - Completion of Items on Form CMS-1565A 
(Rev. 6, 08-30-02) 
B3-13322 
 
240.1 - Heading 
B3-13322.1 
 
This report is referenced as Form A in the CROWD system.  The carrier completes the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the 
reporting format to its screen. 
 
240.2 - Part A - Claims Reduced and Denied 
(Rev. 6, 08-30-02) 
B3-13322.2 
 
This part of the report provides CMS with: 
 
  Current quarterly data on the results of carrier activity in determining reasonable charges; 
 
  Information on the extent to which claims (real and replicate) are being denied or partially 
denied; 
 
  The amount of charges disallowed as a result of carrier claims screening operations; and  
 
  Information on the reasons items are denied and the savings realized. 
 
The carrier reports only data relating to initial claims (real and replicate) actions in Part A of the 
report.  It does not report data on disposition of informal reviews, hearings, or reopenings of an 
initial claim action in Part A.  In order to be included in lines 1-7, the allowed amount on a service 
must be greater than $0.  A claim must be reflected on more than one of lines 2-6 if appropriate.  
For example, if one service on a claim is reduced due to a fee schedule, and two services are 
reduced due to medical necessity, the carrier counts the claim once on line 2 and once on line 4.  It 
reports the appropriate dollar amounts on lines 3 and 5. 
 
Covered Charges 
  Line 1.  Total Covered Charges for All Claims - total amount (rounded to the nearest dollar) of 
billed charges for covered services on all claims (real and replicate) paid or applied toward the 
deductible during the quarter.  Claims paid or applied toward deductible are those reported in lines 
9, 10, and 13 of the monthly CMS-1565 (CROWD Form B).  For those claims in which reasonable 
charge/fee schedule reductions are made, the carrier reports the total covered charges prior to such 
reductions. 
 
It does not include charges for otherwise covered services that are duplicates of previously 
submitted services, or should have been included in previously submitted services (e.g., global 
fee/rebundling situations). 
 
Reasonable Charge/Fee Schedule Reductions 
 
Line 2.  Number of Claims With Reasonable Charge/Fee Schedule Reductions - number of 
claims (real and replicate) reported as paid (claims included under line 9 of the monthly Form B, 
applied toward the deductible (claims included under line 10 of the monthly Form B), or approved 
outside of Common Working File (CWF) (claims included under line 13 of the monthly Form B) 
in which the charges were reduced as a result of reasonable charge determinations or comparisons 
to fee schedules. 
 
For provider-based physician claims, the separation of charges for physicians' services and 
charges for provider component (institutional) services according to some schedule of charges is 
not a reasonable charge reduction.  The carrier counts a claim of this type as a reduced claim 
only if the submitted charge exceeds the provider billing agreement. 
 
Line 3.  Amount of Reduction (in dollars) - total amount (rounded to the nearest whole dollar) 
by which the claims (real and replicate) reported in line 2 were reduced as a result of reasonable 
charge determinations or fee schedules. 
 
Medical Necessity Reductions 
 
Line 4.  Number of Claims with Medical Necessity Reductions - number of claims (real or 
replicate) where the carrier reduced the billed charges because of a determination that the level of 
service was not medically necessary (i.e., a lower level of service would have sufficed).  It 
includes cases where the service was reduced because medical review determined that a lesser 
service was actually performed. 
 
Line 5.  Amount of Reduction (in dollars) - the difference (rounded to the nearest dollar) 
between the billed and allowed charges for those covered services included on line 4. 
 
Global Fee/Rebundling Reductions 
 
Line 6.  Number of Claims with Global Fee/Rebundling Reductions - the number of claims (real 
or replicate) where the charges were reduced because one or more of the services in a global fee 
was previously paid.  It does not include claims with services denied because they should have 
been included in a previously submitted global fee.  The carrier reports such claims in line 17.  
(See MCM-3, 4630.) 
  Line 7.  Amount of Reduction (in dollars) - the difference (rounded to the nearest dollar) between 
the billed and allowed charges for those covered services included on line 6. 
 
Denials 
 
In this section, the carrier reports data for claims (real and replicate) totally or partially denied.  
Claims totally denied are claims where it determines the allowed amount to be $0 for all services 
billed.  Claims partially denied are claims where it determines the allowed amount to be $0 for 
some, but not all services. 
 
The carrier does not report transfers of claims to other carriers or Part A intermediaries since these 
are not denials.  It does not include claims returned to physicians or suppliers because they were 
lacking necessary information.  (Returns are cases where no attempt was made to develop the 
claim.) 
 
It does not report reductions in billed charges where the fee is deemed to have been included in a 
global fee, such as postsurgical care.  It includes such services only if the allowed amount is $0 
(i.e., the service is denied).  It reports data for such services reduced to an amount greater than $0 
on lines 6 and 7 above. 
 
Line 8.  Claims Denied in Full or in Part - the sum of (l) those claims (real and replicate) 
reported as denied in full on lines 11 and 14 of the Form B submitted for the three months of the 
reporting calendar quarter, plus (2) those claims (real and replicate) reported as paid or applied 
toward the deductible in which some charges, but not all, were denied.  Claims paid or applied 
toward deductible are those reported on lines 9, 10 and 13 of the monthly Form B. 
 
Line 9.  Amount Disallowed (in dollars) - the total amount (rounded to the nearest dollar) of 
charges disallowed (billed charges for denied services) on the claims (real and replicate) reported 
on line 8. 
 
Reason for Denial - On lines 10-18 the carrier enters the number of items denied (column 1), the 
amount (rounded to the nearest dollar) disallowed (column 2), and the number of claims 
disallowed (column 3). 
 
The items reported in column 1 of this section represent the number of separate items coded by the 
carrier which were denied.  These items usually relate to a single service, but may also represent 
more than one service when multiple occasions of the same type of service are coded as a single 
item.  Line 19 for column 1 should contain the total number of items denied.  Since more than one 
item on a claim may be denied, the total on line 19 for items denied (column 1) will usually be 
larger than the total number of claims denied in full or in part shown on line 8, column 1.  
However, the total money shown in column 2 on line 19 for amount disallowed must equal the 
total amount disallowed shown on line 9, column 1. 
 
The carrier shows a claim that contains multiple services, but is denied for only one reason, only 
once in column 3 under that reason for denial.  However, if a claim is denied for more than one 
reason, it shows it under each reason for denial.  Therefore, line 19, for the total number of claims 
disallowed (column 3), will usually be larger than the number of claims denied in part or full on 
line 8 (column 1). 
  Line 10.  Claimant Ineligible - the number of items denied, the related amount (in rounded 
dollars) of total charges disallowed, and the number of claims denied because the recipient of 
services was ineligible for Part B benefits, or because the services billed were rendered before the 
beneficiary's coverage for Part B benefits began, or after coverage was terminated. 
 
Line 11.  Filing Limitation Exceeded - the number of items denied, the related amounts (in 
rounded dollars) of total charges disallowed, and the number of claims denied  because the claim 
was filed later than the time limitation on filing claims.  (See MCM-3, 3004.) 
 
Line 12.  Duplicate Claim - the number of items denied, the related amount (in rounded dollars) 
of total charges disallowed, and the number of claims denied because the services billed duplicated 
those from previously filed claims.  The only denials reported on line 12 are actual duplicate 
charges for the same item or service.  The carrier does not report denials for duplicate medical 
equipment (see line 14) or charges for services which are deemed to be included in a global fee 
(see line 17). 
 
Line 13.  Services Not Covered - the number of items denied, the related amount (in rounded 
dollars) of charges disallowed and the number of claims denied because the services billed are 
determined to be excluded from coverage under the SMI program for reasons other than a finding 
that the services were not medically necessary.  Some examples of services not covered are:  
 
  Services with charges above 62.5 percent of psychiatric charges; 
 
  Services with charges over $1,375 annual psychiatric expenses; 
 
  Services with charges over $100.00 annual therapist expenses; 
 
  First three pints of blood; 
 
  Equipment or services not ordered or prescribed by a physician; 
 
  Manipulation of spine when no X-ray is submitted; 
 
  Services by noncertified labs, nonapproved ambulance services or  supplies; 
 
  Nonambulance transportation; 
 
  Services provided by relative/household member; 
 
  Services provided where there is no legal obligation to pay; 
 
  Routine physical check up, immunization shots, prescription drugs, personal comfort items, 
eyeglasses, hearing aids, etc.; 
 
  Care outside United States; 
 
  Rental or purchase of DME for inpatients of hospitals or SNFs; 
    Service date is before provider's participation effective date or after provider's termination 
date; 
 
  Services, supplies, or rental of equipment not needed during a period when the beneficiary 
was hospitalized; or 
 
  Ambulance beyond nearest appropriate facility. 
 
Line 14.  Services Not Medically Necessary - the number of items denied, the related amount (in 
rounded dollars) of charges disallowed and the number of claims denied because it was determined 
that the services billed were not medically necessary.  Some examples are: 
 
  Ambulance not medically necessary, e.g., transfers between similar hospitals for reasons 
other than medical necessity; 
 
  Care for same illness by another attending physician; 
 
  Medical equipment which is not needed for the patient's condition or which continues to be 
used after medical necessity has ceased; 
 
  Duplicate medical equipment; 
 
  Services not substantiated as necessary by medical review; 
 
  Vitamins or other injections not considered necessary for patient's diagnosis; 
 
  More than one nursing home visit per month by physician unless  medical need is 
documented; and 
 
  Manipulation of spine when subluxation is not verified by X-ray. 
 
Line 15.  MSP - the number of items denied, the amount (in rounded dollars) of charges 
disallowed, and the number of claims denied because it was determined that Medicare should have 
been secondary to another payer.  (See MCM-3, 3330-3340.) 
 
Line 16.  Missing Information - the number of items denied, the amount (in rounded dollars) of 
charges disallowed, and the number of claims denied because the claimant failed to provide 
information necessary to process the claim. 
 
Line 17.  Global Fee/Rebundling - the number of items denied, the amount (in rounded dollars) 
of charges disallowed, and the number of claims denied because the fee was deemed to have been 
included in a previously allowed global fee, or a charge for a rebundled set of codes. 
 
Line 18.  Other - the number of items denied, the related amount (in rounded dollars) of charges 
disallowed, and the number of claims denied for reasons other than those specified on lines 10-16.  
Some examples of items to be reported here are:  
 
  Services or rental is billed in advance; and    Representative payee's form not on file. 
 
Line 19.  Total - the total number of items denied, the related amount (in rounded dollars) 
disallowed and the number of denied claims reported on lines 10-18. 
 
240.3 - Checking Form A Prior to Submittal to CMS 
(Rev. 6, 08-30-02) 
B3-13322.3 
 
Prior to submitting Form A to CMS, the carrier checks for completeness, accuracy, and internal 
consistency. 
 
It uses the following checklist to assure accuracy and consistency: 
 
  For lines 1 through 9 and 20 and 21, column 1 must equal the sum of columns 2 and 3; 
 
  Each of lines 2, 4, and 6 must be less than or equal to the total sum of lines 9, 10 and 13 on 
the Form B submitted for the three months in the quarter; 
 
  The sum of lines 3, 5, and 7 must be less than or equal to line 1 for each column; 
 
  Line 8 should be at least equal to, but in most cases greater than, the accumulated total for 
lines 11 and 14 on the Form B submitted for the three months in the quarter; 
 
  Lines 10 + 11 + 12 + 13 + 14 + 15 + 16 + 17 + 18 = line 19 for all columns; 
 
  The total number of items denied as reported on line 19, column 1 should be at least equal 
to, but in most cases greater than, the total number of claims denied in full or in part as 
reported on line 8 column 1; 
 
  The dollar amount disallowed reported in the first column of line 9 and the second column 
of line 19 must be equal; and 
 
  The total number of claims denied reported on line 19, column 3 must be at least equal to, 
but in most cases greater than the total number of claims denied in full or in part as 
reported on line 8, column 1. 
 
250 - Completing Medicare Fraud Unit Quarterly Workload Status Report, 
CMS-1565B - General 
(Rev. 6, 08-30-02) 
B3-13323 
 
The carrier prepares and submits to CMS each quarter a report on the number of fraud workload 
items handled by its Medicare fraud unit.  This information is required by CMS to budget for fraud 
and abuse activities, as well as to monitor the flow of work through the fraud units.  It submits this 
form via the CROWD system no later than the fifteenth day following the close of the reporting 
quarter.   
250.1 - Heading 
(Rev. 6, 08-30-02) 
B3-13323.1 
 
This report is referenced as Form M in the CROWD system. The carrier completes the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the 
reporting format to its screen. 
 
250.2 - Checking Reports 
(Rev. 6, 08-30-02) 
B3-13323.2 
 
Before submitting Form M to CMS, the carrier checks for completeness and arithmetical accuracy.  
It uses the following checklist: 
 
  For all columns, line 1 must equal line 8 of Form M for the previous quarter. 
  For all columns, line 1 + line 2 = line 3. 
  For all columns, line 6 + line 7 = line 5. 
  For all columns, line 3 + line 4 - line 5 = line 8. 
  For all lines, column 1 = column 2 + column 3 + column 4. 
 
250.3 - Type of Fraud Workload Item 
(Rev. 6, 08-30-02) 
B3-13323.3 
 
The carrier reports fraud workload items in the following columns for all lines of Form M: 
 
Column (1) - Total - All fraud workload items. 
 
Column (2) - Beneficiary Complaints - The number of complaints received from, or on behalf of, 
beneficiaries alleging fraud.  The carrier does not include complaints filed with the Office of the 
Inspector General (OIG) Hotline. 
 
Column (3) - OIG Hotline - The number of complaints received via the OIG Hotline. 
 
Column (4) - Referrals and Other - Referrals and any other workload received by the fraud unit 
(e.g., provider complaints, internally generated referrals from medical review, special requests 
from OIG or CMS). 
 
250.4 - Body of Report 
(Rev. 6, 08-30-02) 
B3-13323.4 
 
Line 1.  Opening Pending - The system will pre-fill the number pending from line 8 of the 
previous quarter's report. 
  Line 2. Adjustments - If it is necessary to revise the pending figure for the close of the previous 
quarter because of inventories, reporting errors, etc., the carrier enters the adjustment on this line.  
It precedes negative adjustments with a minus sign. 
 
Line 3. Adjusted Pending - The system will sum line 1 + line 2 to calculate the adjusted opening 
pending. 
 
Line 4. Workload Received - The number of complaints and referrals received in the fraud unit 
during the reporting period. 
 
Line 5. Total Cleared - The system will sum line 6 + line 7 to calculate the total number of 
complaints and referrals cleared by the fraud unit during the reporting period. 
 
Line 6. Cleared by Contractor - The number of complaints and referrals cleared by the fraud unit 
by means other than referral to the OIG or designated agency.  The carrier includes those that 
were: 
 
  Closed as not substantive or not a fraud issue. 
 
  Closed as not a fraud issue, but referred to another contractor component for their review or 
action. 
 
  Closed as not being a fraud issue, but referred to an external component other than the 
OIG. 
 
Line 7. Cleared by Referral - The number of complaints and referrals that were incorporated into 
cases referred formally to the OIG or designated agency for action (e.g., sanctions or prosecution). 
 
Line 8. Closing Pending - The system will calculate the closing pending for the quarter by adding 
line 3 to line 4, and subtracting line 5. 
 
260 - Completing Form CMS-1565C 
(Rev. 6, 08-30-02) 
B3-13324 
 
260.1 - Classification of Claims for Counting 
(Rev. 10374, Issued: 09-25-20, Effective: 10-01-20, Implementation: 10-05-20) 
 
   
The A/B MAC (B) reports on Page 12 of the CMS-1565 data on the claims on which it paid 
interest because it paid the claims after the required payment date per 9311 of the Omnibus 
Reconciliation Act of 1986 (OBRA 1986).  It bases data shown on reliable counts of all claims 
processing activity, not on estimates.  It reports data on initial claims only.  It includes in the report 
all claims requiring interest payments in the month.  It reports claims in the month the date of 
payment falls.  (For a discussion of interest payments refer to the Medicare Claims Processing 
Manual, Publication 100-04, chapter 1, sections 80.2.2 and 80.2.2.1). 
 
The A/B MAC (B) completes the report for each column as follows:   
Column 1.  Total - Data for all claims (real and replicate) for which interest payments were 
made during the month. 
Column 2.  Assigned Physician - Data for the assigned claims included in column 1 which 
involved services billed by physicians.  Physicians are identified by specialty 
codes 01-14, 16-30, 33-41, 44, 46, 48, 66, 70, 72, 76-79, 81-86, 90-94, 98, 99, C0, 
C3, C5, C6, C7, C8, C9, D3, D4, D7 or D8. 
Column 3.  Assigned DME - Data for the assigned claims included in column 1 that involved 
services billed by DME suppliers.   
Column 4.  Assigned Lab - Data for the assigned claims included in column 1 that involved 
services billed by an independent laboratory.  Independent laboratories are 
identified by specialty code 69. 
Column 5.  Assigned Ambulance - Data for the assigned claims included in column 1 that 
involved services billed by ambulance service suppliers.  Ambulance service 
suppliers are identified by specialty code 59. 
Column 6.  Assigned Other - Data for the assigned non-physician claims included in column 1 
but not represented in columns 3, 4, or 5. 
Column 7.  Unassigned - Data for the unassigned claims included in column 1. 
Column 8.  Participating Physician - Data for claims involving services rendered by physicians 
enrolled in the Medicare Physician/Supplier Participation Program. 
 
On line 1, the A/B MAC (B) shows the number of claims on which it paid interest in the reporting 
month.  It reports on line 2 the number of claims included in line 1 for which it made payment 1 
day after the required payment date (e.g., the required payment date is 17 days after receipt for 
participating physician claims received in FY 1992.)  (See 9311 of OBRA 1986.)  Data for lines 
3-10 are similar to those for line 2. 
 
The A/B MAC (B) calculates the number of days late by subtracting the Julian date of the required 
payment date from the Julian date of payment. 
 
On line 11, it shows the amount paid in interest for claims reported in line 1.  On lines 12-20, it 
shows the amount paid in interest for claims reported in lines 2-10, respectively.  It shows dollar 
amounts on lines 11-20 to the nearest penny, and includes the decimal point. 
 
270 - Completion of Items on Form CMS-1565C 
(Rev. 6, 08-30-02) 
B3-13325 
 
270.1 - Heading 
(Rev. 6, 08-30-02) 
B3-13325.1 
 
This report is referenced as Form G in the CROWD system.  The carrier completes the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the 
reporting format to its screen.  It must submit Form A for the reporting quarter before the system 
will allow it to submit Form G for the same quarter. 
 
270.2 - Part D - Selected Claim Data by Participation Status  (Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
This part provides CMS with current quarterly workload data on the results of carrier activity in 
processing claims for physician and non-physician services according to the participation status of 
the physician/supplier.  It also provides important related information on reasonable charge 
determinations, the extent to which claims for such services are being denied, and the amount of 
charges disallowed. 
 
The carrier reports only data relating to initial claims (real and replicate) actions.  It does not 
report data on the disposition of reviews, hearings, or reopenings of initial claim actions. 
 
It reports data for lines 1-34 for each column (participation/assignment status) as defined in the 
Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 30. unless otherwise 
stated.  Specialty codes for physicians and non-physicians are listed in the Medicare Claims 
Processing Manual, Chapter 26, Sections 10.8.2 and 10.8.3. 
 
Line 1. Number of Claims Approved - total number of claims, processed to completion during 
the quarter, which were paid or applied to the deductible.  Claims paid or applied toward the 
deductible are those reported in lines 9, 10, and 13 of Form B.  The system will pre-fill columns 1 
and 3 based on the total of these lines from the monthly reports. 
 
Line 2. Physician Only - number of claims included in line 1 involving physician services only. 
 
Line 3. Physician and Non-Physician - number of claims included in line 1 involving both 
physician and non-physician services on the same claim.  The carrier shows all claims in this 
category under the "Non-Participant-Unassigned" column 3. Therefore, the numbers for columns 1 
and 3 should be equal. 
 
Line 4. Non-Physician Only - number of claims included in line 1 involving non-physician 
services only. 
 
Line 5. Number of Covered Services - total number of covered services on the claims approved 
as shown on line 1.  The carrier does not include services for which charges were completely 
disallowed. 
 
Line 6. Physician - number of physician services included in line 5. The carrier includes in this 
count the covered services from the claims shown in line 2 plus the covered physician services 
from the claims shown in line 3. 
 
Line 7. Non-Physician - number of non-physician services included in line 5.  The carrier 
includes in this count the covered services from the claims shown in line 4 plus the covered non-
physician services from the claims shown in line 3. 
 
Line 8. Amount of Covered Charges - total amount (rounded to the nearest dollar) of billed 
charges for the covered services shown in line 5.  For those services in which any charges were 
reduced as a result of reasonable charge, medical necessity, or global fee/rebundling 
determinations, the carrier reports the total covered charges prior to such reductions.  The system 
will pre-fill columns 1 and 3 with the data reported in the respective columns on line 1 of Form A 
for the same quarter.   
Line 9. Physician - total amount (rounded to the nearest dollar) of billed charges for the covered 
physician services shown in line 6.  For those services in which any charges were reduced as a 
result of reasonable charge, medical necessity, or global fee/rebundling determinations, the carrier 
reports the total covered charges prior to such reductions. 
 
Line 10. Non-Physician - total amount (rounded to the nearest dollar) of billed charges for the 
covered non-physician services shown in line 7.  For those services in which any charges were 
reduced as a result of reasonable charge, medical necessity, or global fee/rebundling 
determinations, the carrier reports the total covered charges prior to such reductions. 
 
Line 11. Number of Claims Where Billed Charges Were Reduced - number of claims (real and 
replicate) reported on line 1 as approved in which any charges were reduced as a result of 
reasonable charge/fee schedule, medical necessity, or global fee/rebundling determinations.  The 
carrier counts a claim only once, regardless of the number of services reduced or the different 
categories of reductions that apply.  Some examples of such reductions are: 
 
a.  Charges over allowed rental limits 
b.  Tests included in a battery of tests, 
c.  Fee covered in basic allowance or surgical allowance, 
d.  Service included in office charge or surgery fee. 
 
Line 12.  Physician Only - number of claims included in line 11 involving physician services 
only. 
 
Line 13.  Physician and Non-Physician - number of claims included in line 11 involving both 
physician and non-physician services on the same claim.  The carrier shows all claims in this 
category under the "Non-Participant-Unassigned" column 3.  Therefore, the numbers for columns 
1 and 3 should be equal. 
 
Line 14.  Non-Physician Only - number of claims included in line 11 involving non-physician 
services only. 
 
Line 15.  Number of Covered Services Where Charges Were Reduced - From the claims 
shown in line 11, the carrier enters the number of covered services in which any charges were 
reduced as a result of reasonable charge determinations, medical necessity reductions, or global 
fee/rebundling reductions.  It includes services where a fee is deemed to have been included in a 
global fee, such as postsurgical care.  (See examples given for line 11.) 
 
Line 16.  Physician - number of covered physician services included in line 15.  This count 
includes those services where charges were reduced on the claims shown in line 12, plus the 
physician services where charges were reduced on the claims shown in line 13. 
 
Line 17.  Non-Physician - number of covered non-physician services included in line 15.  This 
count includes those services where charges were reduced on the claims shown in line 14, plus the 
non-physician services where charges were reduced on the claims shown in line 13. 
 
Line 18.  Total Amount of Reduction - total amount (rounded to the nearest dollar) by which the 
services reported in line 15 were reduced as a result of reasonable charge, medical necessity, or  global fee/rebundling determinations.  The system will pre-fill columns 1 and 3 with the sum of 
the data reported in the respective columns on lines 3, 5, and 7 of Form A for the same quarter. 
 
Line 19.  Physician - total amount (rounded to the nearest dollar) by which charges for physician 
services reported in line 16 were reduced as a result of reasonable charge, medical necessity, or 
global fee/rebundling determinations. 
 
Line 20.  Non-Physician - total amount (rounded to the nearest dollar) by which charges for non-
physician services reported in line 17 were reduced as a result of reasonable charges, medical 
necessity, or global fee/rebundling determinations. 
 
Line 21.  Number of Claims Denied in Full - total number of claims, processed to completion 
during the quarter, in which charges for all services were completely disallowed.  This number 
must equal the sum of the numbers reported in lines 11 and 14 of Form B for the three months of 
the quarter.  The system will pre-fill columns 1 and 3 based on the total of these lines from the 
monthly reports. 
 
Line 22.  Physician Only - number of claims included in line 21 involving physician services 
only. 
 
Line 23.  Physician and Non-Physician - number of claims included in line 21 involving both 
physician and non-physician services on the same claim.  The carrier shows all claims in this 
category under the "Non-Participant- Unassigned" column 3.  Therefore, the numbers for columns 
1 and 3 should be equal. 
 
Line 24.  Non-Physician Only - number of claims included in line 21 involving non-physician 
services only. 
 
Line 25.  Number of Claims Denied in Full or in Part - sum of (1) those claims (real and 
replicate) reported as denied in full in line 21, plus (2) those claims (real and replicate) reported as 
approved on line 1 in which some services, but not all, were denied.  The system will pre-fill 
columns 1 and 3 with the data reported in the respective columns on line 8 of Form A for the same 
quarter. 
 
Line 26.  Physician Only - number of claims included in line 25 involving physician services 
only. 
Line 27.  Physician and Non-Physician - number of claims included in line 25 involving both 
physician and non-physician services on the same claim.  The carrier shows all claims in this 
category under the "Non-Participant-Unassigned" column 3.  Therefore, the numbers for columns 
1 and 3 should be equal. 
 
Line 28.  Non-Physician Only - number of claims included in line 25 involving non-physician 
services only. 
 
Line 29.  Number of Denied Services - number of services for which charges were fully or 
partially denied on the claims shown in line 25. 
  Line 30.  Physician - number of denied physician services included in line 29.  The carrier 
includes in this count the denied services from the claims shown in line 26 plus the denied 
physician services from the claims shown in line 27. 
 
Line 31.  Non-Physician - number of denied non-physician services included in line 29.  The 
carrier includes in this count the denied services from the claims shown in line 28, plus the denied 
non-physician services from the claims shown in line 27. 
 
Line 32.  Amount Disallowed - total amount (rounded to the nearest dollar) of charges disallowed 
on the services shown in line 29. The system will pre-fill columns 1 and 3 with the data reported in 
the respective columns on line 9 of Form A for the same quarter. 
 
Line 33.  Physician - total amount (rounded to the nearest dollar) included in line 32 as disallowed 
which represented physician services as reported in line 30. 
 
Line 34.  Non-Physician - total amount (rounded to the nearest dollar) included in line 32 as 
disallowed which represented non-physician services as reported in line 31. 
 
270.3 - Checking Form G Prior to Submittal to CMS 
(Rev. 6, 08-30-02) 
B3-13325.3 
 
Prior to submitting Form G to CMS, the carrier checks for completeness, accuracy and internal 
consistency.  It uses the following checklist to assure accuracy and consistency: 
 
1.  For all lines, column 1 must equal the sum of columns 2 through 4, 
2.  Line 1 should equal the sum of lines 2 through 4 for all columns, 
3.  Line 5 should be greater than or equal to line 1 for all columns, 
4.  Line 5 should equal the sum of lines 6 and 7 for all columns, 
5.  Line 8 should be greater than or equal to line 5 for all columns, 
6.  Line 8 should equal the sum of lines 9 and 10 for all columns, 
7.  Line 9 should be greater than or equal to line 6 for all columns, 
8.  Line 10 should be greater than or equal to line 7 for all columns. 
9.  Line 11 should be less than or equal to line 1 for all columns, 
10. Line 11 should equal the sum of lines 12-14 for all columns, 
11. Line 12 should be less than or equal to line 2 for all columns, 
12. Line 13 should be less than or equal to line 3 for all columns, 
13. Line 14 should be less than or equal to line 4 for all columns, 
14. Line 15 should be greater than or equal to line 11 for all columns, 
15. Line 15 should equal the sum of lines 16 and 17 for all columns, 
16. Line 15 should be less than or equal to line 5 for all columns, 
17. Line 16 should be less than or equal to line 6 for all columns, 
18. Line 17 should be less than or equal to line 7 for all columns, 
19. Line 18 should be less than or equal to line 8 for all columns,  20. Line 18 should equal the sum of lines 19 and 20 for all columns, 
21. Line 19 should be less than or equal to line 9 for all columns, 
22. Line 20 should be less than or equal to line 10 for all columns, 
23. Line 21 should equal the sum of lines 22-24 for all columns, 
24. Line 25 should be greater than or equal to line 21 for all columns, 
25. Line 25 should be equal to the sum of lines 26-28 for all columns, 
26. Line 26 should be greater than or equal to line 22 for all columns, 
27. Line 27 should be greater than or equal to line 23 for all columns, 
28. Line 28 should be greater than or equal to line 24 for all columns, 
29. Line 29 should be greater than or equal to line 25 for all columns, 
30. Line 29 should equal the sum of lines 30 and 31 for all columns, 
31. Line 32 should equal the sum of lines 33 and 34 for all columns; 
32. Column 1 should equal column 3 for lines 3, 13, 23 and 27. 
33. The following comparisons should be made between Form G and two other related forms, 
the CMS-1565 (Form B) and the CMS-1565A (Form A): 
 
a.  Line 1, column 1, of Form G must equal the sum of lines 9, 10, + 13, column 1 of 
Form B for the reporting months. 
 
b.  Line 1, sum of columns 2 + 4 of Form G must equal the sum of lines 9, 10, + 13, 
column 2 of Form B for the reporting months. 
 
c.  Line 1, column 3 of Form G must equal sum of lines 9, 10,  + 13, column 3 of Form B 
for the reporting months. 
 
d.  Line 21, column 1 of Form G must equal sum of lines 11 + 14, column 1 of the CMS-
1565 for the reporting months. 
 
e.  Line 21 sum of columns 2 + 4 of Form G must equal sum of lines 11 + 14, column 2 
of Form B for the reporting months. 
 
f.  Line 21, column 3 of Form G must equal sum of lines 11 + 14, column 3 of the Form 
B for the reporting months. 
 
g.  Line 8, column 1 of Form G must equal line 1 column 1 of Form A for the same 
quarter. 
 
h.  Line 8, sum of columns 2 + 4 of Form G must equal line 1 column 2 of the Form A for 
the same quarter. 
 
i.  Line 8, column 3 of Form G must equal line 1 column 3 of Form A for the same 
quarter. 
 
j  Line 11, column 1 of Form G must be less than or equal to the sum of lines 2, 4 + 6, 
column 1 of Form A for the same quarter. 
  k.  Line 11, sum of columns 2 + 4 of Form G must be less than or equal to the sum of 
lines 2, 4 + 6, column 2 of the Form A for the same quarter. 
 
l  Line 11, column 3 of Form G must be less than or equal to the sum of lines 2, 4 + 6 
column 3 of Form A for the same quarter. 
 
m.  Line 18, column 1 of Form G must equal sum of lines 3, 5 + 7, column 1 of Form A 
for the same quarter. 
 
n.  Line 18, sum of columns 2 + 4 of Form G must equal sum of lines 3, 5 + 7, column 2 
of Form A for the same quarter. 
 
o.  Line 18, column 3 of Form G must equal sum of lines 3, 5 + 7, column 3 of Form A 
for the same quarter. 
 
p.  Line 25, column 1 of Form G must equal line 8 column 1 of Form A for the same 
quarter. 
 
q.  Line 25, sum of columns 2 + 4 of Form G must equal line 8 column 2 of Form A for 
the same quarter. 
 
r.  Line 25, column 3 of Form G must equal line 8, column 3 of Form A for the same 
quarter. 
 
s.  Line 32, column 1 of Form G must equal line 9, column 1 of Form A for the same 
quarter. 
 
t.  Line 32 sum of columns 2 + 4 of Form G must equal line 9 column 2 of Form A for 
the same quarter. 
 
u.  Line 32, column 3 of Form G must equal line 9, column 3 of Form A for the same 
quarter. 
 
280 - Completing Comprehensive Limiting Charge Compliance Program 
(CLCCP) Quarterly Report, CMS-1565D - General 
(Rev. 6, 08-30-02) 
B3-13326 
 
The carrier prepares and submits to CMS each quarter, a report on carrier CLCCP activity 
including such items as the number of Limiting Charge Exception Reports (LCERs), Limiting 
Charge Monitoring Reports (LCMRs), and Sanction Referral Letters (SRLs) sent during the 
quarter.  It prepares its quarterly report based on the data captured in its cycle management reports 
in accordance with MCM, 7555.6ff. 
 
280.1 - Heading 
(Rev. 6, 08-30-02) 
B3-13326.1 
  This report is referenced as Form N in the CROWD system.  The carrier completes the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the 
reporting format to its screen. 
 
280.2 - Checking Reports 
(Rev. 6, 08-30-02) 
B3-13326.2 
 
Before submitting Form N to CMS, the carrier checks for completeness and arithmetical accuracy.  
It uses the following checklist: 
 
  Line 5 must be greater than or equal line 4. 
  Line 6 must be less than or equal line 5. 
  Line 7 must be less than or equal line 5. 
  Line 15 must be less than or equal line 14. 
 
280.3 - LCER Data 
(Rev. 6, 08-30-02) 
B3-13326.3 
 
The carrier reports in items 1-4 numbers of LCERs sent, not the number of providers receiving 
LCERs.  Each of these items, therefore, will be the sum of the numbers shown on its cycle reports 
for the period. 
 
Line 1 - LCERs Sent to Individual Physicians - The carrier reports the total number of LCERs 
sent to individual physicians during the period. 
 
Line 2 - LCERs Sent to Group Practices - The carrier reports the total number of LCERs sent to 
group practices of physicians during the period. 
 
Line 3 - LCERs Sent to All Other Providers - The carrier reports the total number of LCERs 
sent to all providers other than individual physicians, or group practices of physicians. 
 
Line 4 - Total LCERs Sent for Period - The system will sum lines 1, 2, and 3 to calculate this 
field. 
 
Line 5 - Total Claims on LCERs Sent - The carrier reports the total number of claims included 
on all of the LCERs sent for the period. 
 
Line 6 - Claims Selected for Verification - The carrier reports the total number of claims selected 
for verification of refund/adjustment during the reporting period. 
 
Line 7 - Beneficiaries with Claims on LCERs - The carrier reports the sum of the number of 
individual beneficiaries counted on its cycle reports for the period.  Although an individual is to be 
counted only once on any particular cycle report, if the individual has claims on more than one 
cycle report, that individual will be counted more than once on the quarterly report. 
 
280.4 - Monetary Data  (Rev. 6, 08-30-02) 
B3-13326.4 
 
The carrier reports all dollar amounts to two decimal places on lines 8-13.  It reports the sum of the 
net figures for all of the cycles in the reporting period.  It calculates and includes changes because 
of adjustments to claims in a cycle, or from a previous cycle, so that these figures accurately 
reflect the relationship between allowed dollars and excess dollars.  Adjustments which leave 
overcharges of less than $1.00 may affect the total dollar value reported on line 13, thus it may not 
always equal the amount reported on line 9. 
 
Line 8 - Total Dollars Allowed - The carrier reports the total dollars allowed from the sum of the 
cycle reports for the period. 
 
Line 9 - Dollars in Excess of Limiting Charge - The carrier reports the total dollars in excess of 
the limiting charge from the sum of the cycle reports for the period. 
 
Lines 10-13 - Procedures with Related Excess Charges - The carrier reports on lines 10-13 the 
total number of procedures (column 1), and related total dollar value of excess charges (column 2) 
that fall within each of the dollar ranges of excess charges on the respective lines:  Line 10 is $1.00 
- 4.99, line 11 is $5.00 -499.99, and line 12 is $500.00 + .  The carrier need not complete line 11, 
as the system will calculate it by subtracting lines 10 and 12 from line 13 (Total). 
 
280.5 - Verification Data for Refunds and Adjustments 
(Rev. 6, 08-30-02) 
B3-13326.5 
 
Line 14 - Verifications Posted to the Limiting Charge Exception File (LCEF) - The carrier 
reports the total number of acceptable verifications posted to the LCEF. 
 
Line 15 - Not Requested on LCER - The carrier reports the number of acceptable verifications 
included on line 14 that were not requested on an LCER. 
 
Line 16 - Unacceptable Verifications - The carrier reports the number of verifications received, 
either because of an LCER or unsolicited, that were unacceptable, (i.e., posted as unacceptable to 
the LCEF or could not be associated with an LCEF record). 
 
280.6 - LCMR Data 
(Rev. 6, 08-30-02) 
B3-13326.6 
 
Line 17 - LCMRs Sent to Individual Physicians - The carrier reports the total number of 
LCMRs sent to individual physicians during the reporting period. 
 
Line 18 - LCMRs Sent to Group Practices - The carrier reports the total number of LCMRs sent 
to group practices of physicians during the reporting period. 
 
Line 19 - LCMRs Sent to All Other Providers - The carrier reports the total number of LCMRs 
sent to all providers other than individual physicians or group practices of physicians.   
Line 20 - Total LCMRs Sent for Period - The system will sum lines 17, 18, and 19 to calculate 
the total number of LCMRs sent. 
 
280.7 - Sanction Referral Data 
(Rev. 6, 08-30-02) 
B3-13326.7 
 
Line 21 - SRLs Sent to Individual Physicians - The carrier reports the number of sanction 
referral letters sent to individual physicians during the reporting period. 
 
Line 22 - SRLs Sent to Group Practices - The carrier reports the number of sanction referral 
letters sent to group practices of physicians during the reporting period. 
 
Line 23 - All Other Providers - The carrier reports the number of sanction referral letters sent to 
all providers other than individual physicians or group practices of physicians. 
 
Line 24 - Total SRLs Sent for Period - The system will sum lines 21, 22, and 23 to calculate the 
total number of sanction referral letters sent. 
 
290 - Completing Health Professional Shortage Area (HPSA) Quarterly Report, 
Form CMS-1565E - General 
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10) 
 
The carriers/Part B MACs prepare and submit to CMS each quarter a report on information 
regarding incentive payments made to physicians who render covered Medicare services in HPSAs 
(see Pub. 100-04, Chapter 12, 90.4  90.4.7) on the results of its review of sample claims for 
HPSA incentive payments processed during the reporting quarter.  It submits this report via the 
Contractor Reporting of Operational Workload Data (CROWD Form S) system no later than the 
75th day following the close of the reporting quarter. 
 
290.1 - Heading 
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10) 
 
This report is referenced as Form S in the CROWD system.  The carrier/Part B MAC completes 
the ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the 
reporting format to its screen. 
 
290.2 - Checking Reports 
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10) 
 
Before submitting Form S to CMS, the carrier/Part B MAC checks for completeness and 
arithmetical accuracy.  It uses the following checklist: 
 
  Line 2 plus line 3 must equal line 1.  Effective with the first quarterly report of 2005, that is 
due no later than 75 days after the close of the first calendar quarter of 2005, this will no 
longer be applicable. 
    Line 5 plus line 6 must equal line 4.  Line 2 plus line 3 must equal line 1.  Effective with 
the first quarterly report of 2005, that is due no later than 75 days after the close of the first 
calendar quarter of 2005, this will no longer be applicable. 
 
  Line 8 must be less than or equal to line 7. 
 
  Line 9 must be greater than or equal to line 7. 
 
  Line 10 must be less than or equal to line 9. 
 
  Line 13 plus line 14 plus line 15 must be less than or equal to line 12. 
 
  Line 16 must be greater than or equal to line 12. 
 
  Line 17 must be less than or equal to line 16. 
 
  Sum of lines 19-30, column 1 must equal line 10. 
 
  Sum of lines 19-30, column 2 must equal line 17. 
 
290.3 - Current Quarter Payments 
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10) 
 
The carrier/Part B MAC reports in lines 1-3 the number of physicians receiving incentive payment 
checks during the current reporting quarter and in lines 4-6 the respective amounts of payment 
issued. 
 
Note:  For data reporting purposes for this report, physicians will be defined as NPI/PIN 
combinations as provided to the carriers/Part B MACs by the Shared System. 
 
Physicians Receiving Checks 
 
Line 1.  Total Physicians - total number of physicians receiving incentive payments. 
 
Line 2.  Urban HPSAs - number of physicians receiving incentive payments classified as 
providing services in a HPSA urban setting.  Effective with the first quarterly report of 2005, that 
is due no later than 75 days after the close of the first calendar quarter of  2005, this line must no 
longer be entered. 
 
Line 3.  Rural HPSAs - number of physicians receiving incentive payments classified as 
providing services in a HPSA rural setting. Effective with the first quarterly report of 2005, that is 
due no later than 75 days after the close of the first calendar quarter of 2005, this line must no 
longer be entered. 
 
Amount Of Incentive Payments 
 
Line 4.  Total Incentive Payments - total amount of incentive payments issued to physicians. 
  Line 5.  Urban HPSAs - amount of incentive payments issued to physicians for services provided 
in a HPSA urban setting.  Effective with the first quarterly report of 2005, that is due no later than 
75 days after the close of the first calendar quarter of 2005, this line must no longer be entered. 
 
Line 6.  Rural HPSAs - amount of incentive payments issued to physicians for services provided 
in a HPSA rural setting.  Effective with the first quarterly report of 2005, that is due no later than 
75 days after the close of the first calendar quarter of 2005, this line must no longer be entered. 
 
290.4 - Current Quarter Reviews 
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10) 
 
The carrier/Part B MAC reports in lines 7-11 information on physicians identified for review based 
on data for the current reporting quarter excluding those physicians reviewed because they were 
noncompliant in the previous quarter. 
 
Note:  For data reporting purposes for this report, physicians will be defined as NPI/PIN 
combinations as provided to the carriers/Part B MACs by the Shared System. 
 
Line 7.  Physicians Reviewed - number of physicians identified for review based on data for the 
current reporting quarter.  The carrier/Part B MAC excludes those physicians reviewed because of 
noncompliance in the previous quarter. 
 
Line 8.  Physicians Paid Incorrectly - number of physicians reviewed on line 7 that incorrectly 
received an incentive bonus on at least one claim. 
 
Line 9.  Claims Reviewed - number of total claims reviewed for physicians reported on line 7. 
 
Line 10.  Claims Paid Incorrectly - number of claims included on line 9 where the physician 
incorrectly received incentive payments. 
 
Line 11.  Incentive Amount Paid Incorrectly - total incentive amount incorrectly paid on claims 
identified on line 10. 
 
290.5 - Prior Quarter(s) Reviews 
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10) 
 
The carrier/Part B MAC reports in lines 12-18 information on physicians reviewed because they 
were noncompliant in the previous quarter(s). 
 
Note:  For data reporting purposes for this report, physicians will be defined as NPI/PIN 
combinations as provided to the carriers/Part B MACs by the Shared System. 
 
Line 12.  Physicians Reviewed - number of physicians who were identified in lines 8, 13, 14, or 
15 on the previous quarter report as noncompliant. 
 
Line 13.  Physicians Noncompliant Two Quarters - number of physicians identified in line 12 
that were noncompliant in the current and previous quarters, but no quarters prior. 
  Line 14.  Physicians Noncompliant Three Quarters - number of physicians identified in line 12 
that were included in line 13 in the previous quarter's report and still noncompliant in the current 
quarter. 
 
Line 15.  Physicians Noncompliant Four or More Quarters - number of physicians identified in 
line 12 that were included in line 14 in the previous quarter's report and still noncompliant in the 
current quarter. 
 
Line 16.  Claims Reviewed - number of claims reviewed for the physicians identified in line 12. 
 
Line 17.  Claims Paid Incorrectly - number of claims in line 16 that were paid incorrectly. 
 
Line 18.  Incentive Amount Paid Incorrectly - total incentive amount paid on those claims 
identified in line 17. 
 
290.6 - Error Descriptions 
(Rev. 176, Issued: 11-12-10, Effective: 12-13-10, Implementation: 12-13-10) 
 
This report breaks down the number of claims found to be paid incorrectly by selected error 
categories for "Current Quarter Reviews" and "Prior Quarter(s) Reviews".  Claims counts reported 
in lines 19-30 under the "Number of Claims Current Quarter" column should total to the number 
reported in line 10.  Similarly, claims counts reported in lines 19-30 under the "Number of Claims 
Prior Quarter(s)" column should total to the number reported in line 17.  In a case where the claim 
could fall into more than one category, the carrier/Part B MAC makes a determination as to which 
category to put the claim in.  Each claim incorrectly receiving a HPSA incentive payment should 
be counted only once under the "Error Descriptions" section. 
 
Line 19.  Office In, Service Outside HPSA - number of claims where the provider's office is 
located in a HPSA, but the provider travels to a non-HPSA to provide services. 
 
Line 20.  Office Outside, Service Outside HPSA - number of claims where neither the provider's 
office nor the place of service is located in a HPSA. 
 
Line 21.  Multiple Offices, Service Non-HPSA Office - number of claims when the physicians 
with multiple offices (some of which may be in a HPSA, and some of which are not) bill for 
services provided in their non-HPSA office. 
 
Line 22.  Beneficiary in HPSA, Services Outside HPSA - number of claims where the provider 
used the beneficiary's address for HPSA incentive eligibility instead of the place of service. 
 
Line 23.  Provider Codes Prior to Effective Date HPSA - number of claims where the services 
were provided before the effective date the area was designated as a HPSA.  The effective date 
providers can begin coding claims for HPSA incentive payments is the first day of the second 
month following the date CMS is notified by PHS. CMS will transmit the effective date to the 
carrier/Part B MAC. Effective January 1, 2005, the effective date of a HPSA designation will be 
the date of the HRSA designation letter which will be reflected on the HRSA Web site. 
  Line 24.  Service Area No Longer HPSA - number of claims requesting HPSA payment after the 
area is no longer classified as a HPSA. CMS will transmit the termination date to the carrier/Part B 
MAC. 
 
Line 25.  Non-Physician Practitioner - number of claims coded for HPSA incentives, but the 
services were provided by someone other than a physician.  An example is a claim submitted with 
the HPSA modifier, and the service was provided by a nurse practitioner. 
 
Line 26.  Non-Physician Service - number of claims coded for HPSA incentives which were for 
services other than physician professional services.  Examples of services furnished by a 
physician, but not subject to the HPSA incentive, are technical components of diagnostic tests, 
drugs, and separately payable supplies. 
 
Line 27.  Carrier/Part B MAC Provided Incorrect Information - number of claims that were 
incorrectly coded by the provider for HPSA incentives as a result of incorrect information the 
carrier/Part B MAC provided. 
 
Line 28.  Carrier/Part B MAC Published Incorrect Notice - number of claims where the 
provider code for HPSA incentives was based on a population group (noncovered) HPSA notice 
the carrier/Part B MAC incorrectly published. 
 
Line 29.  Carrier Keying/Processing Error - number of claims paid for the HPSA incentives 
inappropriately due to keying or processing errors made by carrier/Part B MAC staff. 
 
Line 30.  Other - number of claims that do not fit into any of the other categories.  Although not 
routinely required, carriers/Part B MACs may be asked to expand on the reason for error on these 
types of claims. 
 
 
300 - Exhibits 
(Rev. 6, 08-30-02) 
B3-13329 
 
Exhibit 1 - Medicare Program Quarterly Supplement To The Carrier Performance Report CMS-
1565a (Crowd Form A) 
 
 
MEDICARE PROGRAM QUARTERLY SUPPLEMENT TO THE CARRIER PERFORMANCE 
REPORT CMS-1565A (CROWD FORM A) 
 
CARRIER  REPORTING PERIOD 
(QUARTER AND YEAR) 
   NUMBER AND TYPE OF CLAIM 
REPORTING ITEM  ASSIGNED - 2  UNASSIGNED - 3 
TOTAL - 1  A. CLAIMS REDUCED OR DENIED 
COVERED CHARGES          
1. Tot. Cvrd. Charges For All Claims 
REAS. CHG./FEE SCHED. 
REDUCTIONS 
        
2. No. of Clms w/Reas Chg/Fee Sched 
Red  
3. Amount of Reduction (in $)          
MEDICAL NECESSITY 
REDUCTIONS         
4. Number of Claims w/ Med. Nec. Red. 
5. Amount of Reduction (in $)          
GLOBAL FEE/REBUNDLING 
REDUCTIONS 
        
6. No. of Claims w/ Glo. Fee/Rebun 
Red. 
7. Amount of Reduction (in $)           
DENIALS 
8. Claims Denied in Full or in Part          
9. Amount Disallowed (in $)  
REASONS FOR DENIAL  NUMBER OF  AMOUNT  NUMBER OF 
ITEMS DENIED  DISALLOWED  CLMS DENIED  
(1)  (2)  (3) 
10. Claimant Ineligible            
11. Filing Limitation Exceeded           
12. Duplicate Claim          
13. Services Not Covered           
14. Services Not Medically Necessary          
15. MSP          
16. Missing Information          
17. Global Fee/Rebundling          
18. Other           
19. Total          
FORM-CMS 1565A 
  Exhibit 2 - Medicare Fraud Unit Quarterly Workload Status Report - CMS-1565B (CROWD 
FORM M) 
 
MEDICARE FRAUD UNIT QUARTERLY WORKLOAD STATUS REPORT 
CMS-1565B (CROWD FORM M) 
 
CARRIER NUMBER____________________________ 
REPORT PERIOD_______________________________ 
BENEFICIARY  OIG  REFERRAL 
TOTAL  COMPLAINT  HOTLINE  & OTHERS  
FRAUD WORKLOAD ITEM  1  2  3  4 
1. OPENING PENDING             
2. ADJUSTMENTS             
3. ADJUSTED PENDING             
4. WORKLOAD RECEIVED             
5. TOTAL CLEARED             
6.      BY CONTRACTOR             
7.      BY REFERRAL             
8. CLOSING PENDING             
FORM-CMS 1565B  
  Exhibit 3 - Medicare Program Quarterly Supplement To The Carrier Performance Report 
CMS-1565C (Crowd Form G) 
MEDICARE PROGRAM QUARTERLY SUPPLEMENT TO THE CARRIER 
PERFORMANCE REPORT CMS-1565C (CROWD FORM G) CARRIER REPORTING 
PERIOD 
NON-PAR  NON-PAR  PARTICI-
TOTAL   ASSIGNED  UNASSGNED  PANTS 
REPORTING ITEM  1  2  3  4 
1. CLAIMS APPROVED: TOTAL             
2.      PHYS ONLY             
3.      PHYS AND NONPHYS              
4.      NONPHYS ONLY             
5. COVRD SERVICES: NUMBER             
6.      PHYS             
7.      NONPHYS             
8. AMT COVRD CHRGS: TOTAL             
9.      PHYS             
10.      NONPHYS             
11. CLAIMS REDUCED: TOTAL             
12.      PHYS ONLY             
13.      PHYS AND NONPHYS             
14.      NONPHYS ONLY             
15. COVRD SRVCS RED: NUM             
16.      PHYS             
17.      NONPHYS              
18. AMOUNT REDUCED: TOTAL             
19.      PHYS              
20.      NONPHYS              
21. FULL DENIALS: NUMBER             
22.      PHYS ONLY             
23.      PHYS AND NONPHYS              
24.      NONPHYS ONLY             
25. FULL/PART DENIALS: NUM              
26.      PHYS ONLY             
27.      PHYS AND NONPHYS             
28.      NONPHYS ONLY              
29. DENIED SERVICES: NUM             
30.      PHYS             
31.      NONPHYS              
32. AMT DISALLOWED: TOTAL              33.      PHYS             
34.      NONPHYS             
FORM-CMS 1565C  Exhibit 4 - Comprehensive Limiting Charge Compliance Program Quarterly Report CMS-
1565d (Crowd Form N) 
 
COMPREHENSIVE LIMITING CHARGE COMPLIANCE PROGRAM QUARTERLY 
REPORT - CMS-1565D (CROWD FORM N) 
CARRIER NUMBER________________ REPORT PERIOD___________________ 
   COLUMN 1  COLUMN 2 
1. LCERs SENT TO IND PHYSICIANS 
2. LCERs SENT TO GROUP PRACTICES 
3. LCERs SENT TO ALL OTHER PROVIDERS 
4. TOTAL LCERs SENT FOR PERIOD 
5. TOTAL CLAIMS ON LCERs SENT       
6. CLAIMS SELECTED FOR VERIFICATION 
7. BENEFICIARIES W/CLAIMS ON LCERS 
8. TOTAL DOLLARS ALLOWED 
9. DOLLARS IN ECESS OF LMTNG CHARGE  
10. $1.00-$4.99  
11. $5.00-$499.99   # OF 
TOTAL $ VALUE 
12. $500+   PROCEDURES 
13. TOTAL 
14. VERIFICATIONS POSTED TO LCEF 
15. NOT REQUESTED ON LCER        
16. UNACCEPTABLE VERIFICATIONS 
17. LCMRs SENT TO IND PHYSICIANS 
18. LCMRs SENT TO GROUP PRACTICES 
19. LCMRs SENT TO ALL OTHER PROVIDERS 
20. TOTAL LCMRs SENT FOR PERIOD  
     
21. SRLs SENT TO IND PHYSICIANS  
22. SRLs SENT TO GROUP PRACTICES 
23. SRLs SENT TO ALL OTHER PROVIDERS 
24. TOTAL SRLs SENT FOR PERIOD  
FORM-CMS 1565D  Exhibit 5 - Health Professional Shortage Area (HPSA) Quarterly Report  
 
HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) QUARTERLY REPORT CMS-
1565E (CARRIERS ONLY - CROWD FORM S) 
 
Screen 1 
 
CARRIER NAME______________________________ 
 
CARRIER NUMBER____________________________ 
 
CMS-1565E REPORT PERIOD____________________ 
CURRENT QUARTER PAYMENTS  
PHYSICIANS RECEIVING CHECKS:  
 
    
1. TOTAL  
2. URBAN HPSA'S  
3. RURAL HPSA'S  
AMOUNT OF INCENTIVE PAYMENTS:  
 
4. TOTAL        
5. URBAN HPSA'S  
6. RURAL HPSA'S   Exhibit 6 - Health Professional Shortage Area (HPSA) Quarterly Report CMS-1565E 
(Carriers Only - Crowd Form S) 
 
HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) QUARTERLY REPORT CMS-
1565E (CARRIERS ONLY - CROWD FORM S) 
Screen 2 
 
CARRIER NAME  CMS-1565E 
   
CARRIER NUMBER  REPORT PERIOD 
 
CURRENT QUARTER REVIEWS     
 
7. PHYSICIANS REVIEWED 
8. PHYSICIANS PAID INCORRECTLY 
9. CLAIMS REVIEWED 
10. CLAIMS PAID INCORRECTLY 
11. INCENTIVE AMOUNT PAID INCORRECTLY 
 
PRIOR QUARTER(S) REVIEWS 
12. PHYSICIANS REVIEWED 
13. PHYSICIANS NONCOMPLIANT 2 QRTS. 
14. PHYSICIANS NONCOMPLIANT 3 QRTS. 
15. PHYSICIANS NONCOMPLIANT 4+ QRTS. 
16. CLAIMS REVIEWED 
17. CLAIMS PAID INCORRECTLY 
18. INCENTIVE AMOUNT PAID INCORRECTLY  Exhibit 7 - Health Professional Shortage Area (HPSA) Quarterly Report 
 
HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) QUARTERLY REPORT - CMS-
1565E (CARRIERS ONLY - CROWD FORM S) 
Screen 3 
 
CARRIER NAME __________________  CMS-1565E 
CARRIER NUMBER ________________  REPORT PERIOD _______________ 
 
# OF CLAIMS  # OF CLAIMS 
CURENT  PRIOR 
ERROR DESCRIPTIONS  QUARTER  QUARTER.  
19. OFFICE IN, SERVICE OUTSIDE HPSA        
20. OFFICE OUTSIDE, SERV. OUTSIDE HPSA       
21. MULTI-OFFICE, SERVICE NON-HPSA OFF.      
22. BENE. IN HPSA, SERVICE OUTSIDE HPSA       
23. PROV. CODE PRIOR TO EFF. DATE HPSA        
24. SERVICE AREA NO LONGER HPSA       
25. NON-PHYSICIAN PRACTITIONER        
26. NON-PHYSICIAN SERVICE        
27. CARRIER PROVIDED INCORRECT INFO.       
28. CARRIER PUBLISHED INCORRECT 
     
NOTICE  
29. CARRIER KEYING/PROCESSING ERROR       
30. OTHER        310 - Carrier Beneficiary Overpayment Activity Report (Form CMS-2174) - 
General 
(Rev. 6, 08-30-02) 
B3-13350 
 
At the end of each calendar quarter (i.e., December, March, June, September) the carrier prepares 
and submits to CMS a report summarizing beneficiary overpayment activity completed during the 
reporting quarter.  It completes a separate report for each carrier office that has been assigned a 
separate carrier number. 
 
310.1 - Purpose and Scope 
(Rev. 6, 08-30-02) 
B3-13350.1 
 
This report provides CMS with current data on beneficiary overpayments - nationally as well as 
for each carrier.  The report enables CMS to tabulate for administrative and statistical purposes 
data on beneficiary overpayments: 
 
  The total dollar amount of money overpaid; 
  The causes of overpayments; 
  How overpayments are discovered; and 
  The amount of overpayments you recover. 
 
310.2 - Due Date 
(Rev. 6, 08-30-02) 
B3-13350.2 
 
The carrier transmits the CMS-2174 to CO via PC or terminal as soon as possible after the end of 
the reporting quarter, but no later than the 15th day of the month following the end of the reporting 
quarter, e.g., the October-December report is due on January 15.  Non-receipt of the report by the 
due date will result in CMS contacting it to obtain the required information. 
 
320 - Completing Carrier Beneficiary Overpayment Activity Report 
(Rev. 6, 08-30-02) 
B3-13351 
 
320.1 - Classification of Claims for Counting 
(Rev. 6, 08-30-02) 
B3-13351.1 
 
Data on the CMS-2174 reflects counts of claims for which the carrier has made a determination 
that a beneficiary-recoverable overpayment exists.  The overpayment must have been made to a 
beneficiary or to a without-fault physician/supplier on behalf of a beneficiary.  The carrier should 
not confuse this with an assignee overpayment (i.e., one made to an assignee who is at fault and 
therefore liable). (See Chapter 3, 200-202.)  It counts claims only once regardless of the number 
of separate instances of overpayments found on them. 
  330 - Completion of Items on Form CMS-2174 
(Rev. 6, 08-30-02) 
B3-13360 
 
330.1 - Heading 
(Rev. 6, 08-30-02) 
B3-13360.1 
 
The carrier enters its ID number in the number box.  In the space labeled "Reporting Period" it 
enters the fiscal quarter and year (e.g., 0190 for October-December 1989) for which the report is 
prepared. 
 
330.2 - Section A - Beneficiary Overpayments 
(Rev. 6, 08-30-02) 
B3-13360.2 
 
The carrier reports the number of claims and the dollar amounts for which a determination was 
made during the reporting quarter or a previous quarter that a beneficiary-recoverable overpayment 
had been made.  It does not count potential overpayment claims under investigation.  It includes 
individual overpayments discovered as part of CMS's Carrier Quality Control Program (QA) end-
of-line review sample.  It does not include projections of overpayments from QA samples.  It 
includes overpayments discovered where Medicare is secondary to prime insurers (Department of 
Labor - BL, WC, VA, auto medical or no fault, liability, EGHP under the working aged or ESRD 
provisions or LGHP under the disabled provision) that also paid the beneficiary.  
Round amounts to the nearest whole dollar. 
 
Line 1.  Pending Start of Quarter - The number of claims and dollar amount of beneficiary 
overpayments reported in line 13 as the closing pending on the previous quarter's report. 
 
Line 2. Adjustments to Opening Pending - Any adjustments to the previous quarter's closing 
pending amount due to errors, decisions resulting from reviews and hearings, reopenings, etc.  
Show as a plus or a minus, as appropriate. 
 
Line 3.  Adjusted Opening Pending - The result of line 1 + line 2, as appropriate. 
 
Line 4.  Discovered During Reporting Quarter - The number of claims and the dollar amount 
for which a determination was made during the reporting quarter that a beneficiary-recoverable 
overpayment had been made.  This does not include potential overpayments under investigation.  It 
includes claims where the payee returned or never negotiated the check(s). 
 
Claim counts are treated differently from money amounts in lines 5-9 below.  A claim is counted 
in these lines only when it has been fully disposed.  This line does not include partial dispositions 
in the claim counts for lines 5-9.  It does not include any money amounts partially disposed in 
lines 5-9 as appropriate. 
 
Line 5.  Dispositions - The number of claims for which: 
Recovery of a beneficiary-recoverable overpayment by offset or refund was completed during the 
quarter (see NOTE 3); or    
A determination was made during the quarter that the overpayment is uncollectible or is to be 
abandoned in accordance with Chapter 3, 190 ff. 
 
This includes any amount recouped by offset or refund, or determined to be uncollectible or 
abandoned in accordance with Chapter 3, 190 ff. during the quarter, regardless of whether it was 
a full or partial determination. 
 
NOTES: 
1.  If part of an overpayment is recouped and the remainder is determined to be 
uncollectible or abandoned, the disposition of the overpayment is considered to 
be completed. 
2.  If the disposition of the overpayment is completed and it falls into more than one 
line of lines 7, 8, 10-12, it is counted once under the "number of claims" in the 
line category accounting for the greatest dollar amount.  The carrier reports the 
money amount in each appropriate line, however. (It does not report any money 
amounts reported in previous quarters.) 
3.  If part of the overpayment has been recouped and part is still outstanding at the 
end of the quarter, the carrier includes the amount recouped.  It does not include 
the claim count.  It includes the portion of the overpayment which is still 
outstanding in the claim count and amount for line 10. 
 
Line 6. Collected - The carrier enters the number of overpayments recouped by offset or refund 
during the reporting quarter.  Under the money column, it reports any amount recovered by offset 
or refund. 
 
Line 7. Recouped by Offset - The carrier enters the number of beneficiary-recoverable 
overpayment claims for which it completed disposition during the reporting quarter and for which 
most or all of the dollar amounts were recouped by offsetting payment on subsequent requests for 
payment.  (This includes cases where a letter has been written to the payee requesting a refund, but 
before the refund is received a request for payment is received which completes repayment of the 
overpayment.)  Under the money amount column, it reports any amount recovered by this method, 
whether a full or partial recovery. 
 
Line 8. Recouped by Refund - The carrier enters the number of beneficiary-recoverable 
overpayment claims for which it completed disposition during the reporting quarter and the final 
disposition was made by a refund.  (It includes cases where the payees returned the checks.) Under 
the money amount column, it reports any amount recovered by refund, whether a full or partial 
recovery. 
 
Line 9. Uncollectibles - The carrier reports the number of beneficiary-recoverable overpayment 
claims for which it completed disposition during the reporting quarter by determining for most or 
all of the dollar amount, to be uncollectible and have either referred to the RO, waived, or 
abandoned them.  Under the money column, it reports the amount involved. 
 
Line 10. Referred to RO - The carrier enters the number of beneficiary-recoverable overpayment 
claims for which it completed disposition during the reporting quarter and where, for most or all of 
the dollar amount, it terminated recovery efforts and referred the claim to the RO.  (See Chapter 3, 
190 ff.)  Under the money amount column, it reports the amount referred to RO.   
Line 11.  Waived by Contractor - The carrier enters the number of beneficiary-recoverable 
overpayment claims for which it completed disposition during the reporting quarter and where it 
waived most or all of the dollar amounts.  (See Chapter 3, 190 ff).  Under the recovery amount 
column, it reports any amount waived in this way during the quarter. 
 
NOTE:  A waiver is a case in which the beneficiary is liable and the criteria in Chapter 4, 100B 
for waiver recovery is met; i.e., it appears from the circumstances of the overpayment that the 
beneficiary was without fault and that the recovery would be against equity and good conscience 
or would defeat the purpose of the Medicare Program (i.e., cause the individual financial 
hardship). 
 
Line 12.  Abandoned in Accordance with Manual Instructions - The carrier enters the number 
of beneficiary-recoverable overpayment claims for which it completed disposition during the 
reporting quarter and which it abandoned for most or all of the dollar amount in accordance with 
Chapter 4, 70.  Under the money amount column, it reports any amount abandoned. 
 
A claim is abandoned when recovery has been terminated because: 
 
  The total overpayment is less than $50, 
 
  The carrier has not taken action to reopen the payment decision within 4 years (48months) 
after the date of the initial payment determination, 
 
  Deceased beneficiary has no estate and there are no surviving relatives, or Beneficiary is on 
public assistance 
 
Line 13.  Pending End of Quarter - The carrier enters the number of beneficiary-recoverable 
overpayments claims with any amount outstanding at the end of the reporting quarter.  If part of a 
claim is recouped and part is outstanding, it reports only the amount outstanding. It does not 
include any amounts which have been recouped, either in full or in part. 
 
330.3 - Section B - Cause of Overpayments 
(Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 
Medicare identification number. For purposes of this manual, Medicare beneficiary identifier 
references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary 
Identifier (MBI) during the new Medicare card transition period and after for certain business areas 
that will continue to use the HICN as part of their processes. 
 
This solicits the reasons for overpayments in which a determination was made during the quarter 
that an overpayment had been made to, or on behalf of, the beneficiary.  The data include both the 
number of claims on which beneficiary-recoverable overpayments were discovered and the 
amount of overpayment (not over-allowance) involved. 
  Where more than one cause of overpayment exists, the carrier reports the claim and dollar amount 
of the overpayment on only one of the lines 14 through 23 according to the principal reason for 
overpayment.  The principal reason is that which involves the greatest dollar amount. 
 
The number of claims and amounts of beneficiary overpayments for reasons 14 through 23 
combined should equal the number of claims and amount reported in Section A on line 4. 
 
Line 14.  Beneficiary Not Entitled - The carrier enters under the appropriate columns the number 
and dollar amount of overpayments which resulted because payments were made to, or on behalf 
of, a beneficiary for services rendered during a period of non-entitlement or for claims processed 
under the wrong Medicare beneficiary identifier.  (See Medicare Carrier Quality Assurance 
Handbook 290.1). 
 
Line 15.  Services Not Covered - The carrier enters the number and dollar amount of 
overpayments which resulted because payments were made for non-covered services other than 
medically unnecessary services.  (See Medicare Carrier Quality Assurance Handbook 290.2). 
 
Line 16.  Charge Exceeded Reasonable Charge - The carrier enters under the appropriate 
columns the number and dollar amount of overpayments which resulted when improper charges, 
higher than the reasonable charge amount, were allowed.  (See Medicare Carrier Quality 
Assurance Handbook 290.3). 
 
Line 17.  Payment Made to Wrong Payee - The carrier enters under the appropriate columns the 
number and dollar amount of overpayments which resulted when a person other than the proper 
payee received the payment (e.g., the beneficiary is paid on an assigned claim). It reports duplicate 
payments made to the wrong payee in line 18 instead of here. 
 
Line 18.  Duplicate Payment - The carrier enters under the appropriate columns the number and 
dollar amount of overpayments which occurred when payment was made to, or on behalf of, the 
beneficiary more than once for the same service. 
 
Line 19.  Medically Unnecessary Services - The carrier enters under the appropriate columns the 
number and dollar amount of overpayments discovered which arose because of payments for 
services later determined to be medically unnecessary. 
 
Line 20.  Services Not Rendered - The carrier enters under the appropriate columns the number 
and dollar amount of overpayments discovered which arose because of payments for services not 
actually rendered.  It includes claims which involve forgery or fraudulent billing for noncovered 
services and other identified program abuses. 
 
Line 21.  Medicare Secondary Payor - The carrier enters under the appropriate columns the 
number and dollar amounts of overpayments which arose because Medicare is secondary to prime 
insurers (e.g., Department of Labor, BL, WC, VA, auto, medical or no fault, liability, EGHP under 
the working aged or ESRD provision or LGHP under the disabled provision). 
 
Line 22.  Documentation/Coding/Data Entry - The carrier enters under the appropriate columns 
the number and dollar amount of overpayments which resulted from:   
    Insufficient documentation to support the payment action.  (This could involve a claims 
processor's failure to resolve questions concerning entitlement, coverage, utilization, or 
reasonable charge) 
 
  Incorrect or incomplete coding; and 
 
  Errors in the transferring of data from an external document into a machine readable form, 
including errors in keypunching and other methods for data entry. (See Medicare Carrier 
Quality Assurance Handbook 210.5-210.6). 
 
NOTE: If a documentation/coding data entry error results in an overpayment which may be 
categorized into any of lines 14 - 21, the carrier uses one of lines 14 - 21 instead of using line 22. 
 
Line 23.  Other - The carrier enters under the appropriate columns the number and dollar amount 
of overpayments discovered which are not specifically provided for in lines 14-22 above. 
 
330.4 - Section C - How Overpayments Were Discovered 
(Rev. 6, 08-30-02) 
B3-13360.4 
 
This shows data on beneficiary-recoverable overpayments according to how they were discovered.  
Where more than one method of discovery exists, the carrier reports the claim and dollar amount 
of overpayment on only one of lines 24 - 28 according to the principal method of discovery.  The 
principal method is that which involves the greatest dollar amount. 
 
Line 24.  Reported by Beneficiary or Provider - The carrier enters under the appropriate 
columns the number of overpayments and that part of the dollar amount reported on line 4 which 
were discovered when a beneficiary or provider reported a beneficiary-recoverable overpayment.  
(This includes the situation where the beneficiary was paid instead of the provider.) 
 
Line 25.  CMS's Carrier Quality Control Program - The carrier enters under the appropriate 
columns the number of overpayments and that part of the dollar amount reported on line 4 which 
were discovered through CMS's Carrier Quality Control Program - including both the carrier 
sample and the RO sub-sample. 
 
Line 26.  Carrier Internal Audit or Review - The carrier enters under the appropriate columns 
the number of overpayments and that part of the dollar amount reported on line 4 which were 
discovered through its internal auditing procedures or review of subsequent claims. It excludes 
cases where the overpayment was discovered through CMS's Carrier Quality Control Program.  
(See line 25.) 
 
Line 27.  Government Agency - The carrier enters under the appropriate columns the number of 
overpayments and that part of the dollar amount reported on line 4 which were discovered by 
DHHS, GAO, OIG, or other government agency audit. 
 
Line 28.  Other Methods of Discovery - The carrier enters under the appropriate columns the 
number and dollar amounts involved for overpayments discovered by methods. 
  The number and amount of beneficiary overpayments reported on lines 24 through 28, when 
combined, should equal the number and amount reported in Section A on line 4. 
 
 
330.5 - Checking Reports Prior to Submittal to CMS 
(Rev. 6, 08-30-02) 
B3-13360.5 
 
Before sending reports to CMS, the carrier checks for completeness and arithmetic accuracy.  The 
following checklist assists in the arithmetic check for both the number of claims and the amount of 
money involved. 
 
  A valid 5-digit carrier number is required. 
 
  The default value for areas not keyed is zero. 
 
  Appropriate fiscal quarter (1-4) and year is required. 
 
o  For each column, line 1, plus or minus line 2, must equal line 3.  Line 3cannot be 
negative. 
 
o  For each column line 6 + 9 must equal line 5. 
 
o  For each column line 7 + 8 must equal line 6. 
 
o  For each column line 10 + 11 + 12 must equal line 9. 
 
o  For each column line 3 + 4 - 5 must equal line 13. 
 
o  For each column line 14 + 15 + 16 + 17 + 18 + 19 + 20 + 21 + 22 + 23 must equal 
line 4. 
 
o  For each column line 24 + 25 + 26 + 27 + 28 must equal line 4. 
 
o  For each column line 1 of the current report must equal line 13 of the previous report.  340 - Exhibit - Medicare Program Carrier Beneficiary Overpayment Activity 
Report - (Form CMS-2174) 
(Rev. 6, 08-30-02) 
B3-13379 
 
MEDICARE PROGRAM CARRIER BENEFICIARY OVERPAYMENT ACTIVITY 
REPORT 
CARRIER NUMBER ________________ REPORTING PERIOD ______________ 
NUMBER   AMOUNT 
OF  OF 
  CLAIMS   MONEY 
A.BENEFICIARY OVERPAYMENTS     
1. PENDING START OF QUARTER       
2. ADJUSTMENTS TO OPENING PENDING       
3. ADJUSTED OPENING PENDING       
4. DISCOVERED DURING REPORTING QUARTER       
5. DISPOSITIONS       
6. COLLECTED       
7. RECOUPED BY OFFSET       
8. RECOUPED BY REFUND       
9. UNCOLLECTIBLES       
10. REFERRED TO REGIONAL OFFICE        
11. WAIVED BY CONTRACTOR       
12. ABANDONED IN ACCORD WITH MAN. INSTR.       
13. PENDING END OF QUARTER       
B. CAUSE OF OVERPAYMENTS     
14. BENEFICIARY NOT ENTITLED       
15. SERVICES NOT COVERED       
16. CHARGE EXCEEDED REASONABLE CHARGE       
17. PAYMENT MADE TO WRONG PAYEE       
18. DUPLICATE PAYMENT       
19. MEDICALLY UNNECESSARY SERVICES       
20. SERVICES NOT RENDERED        NUMBER   AMOUNT 
OF  OF 
  CLAIMS   MONEY 
21. MEDICARE SECONDARY PAYER       
22. DOCUMENTATION/CODING/DATA ENTRY        
23. OTHER       
C. HOW OVERPAYMENTS WERE DISCOVERED       
24. REPORTED BY BENEFICIARY OR SUPPLIER     
25. CMS's CARRIER QUALITY CONTROL 
     
PROGRAM 
26. CARRIER INTERNAL AUDIT OR REVIEW       
27. GOVERNMENT AGENCY       
28. OTHER METHODS OF DISCOVERY       
  Monthly Statistical Report on Carrier Appeal Activity 
 
350 - Carrier Appeals Report (Form CMS-2590) 
(Rev. 6, 08-30-02) 
B3-13400 
 
At the end of each month the carrier prepares and transmits to CMS a report summarizing its Part 
B review and hearing activity during the month.  The carrier completes a separate report for each 
office assigned a separate carrier number. 
 
Form CMS-2590 is subject to the Paperwork Reduction Act and requires approval from the Office 
of Management and Budget (OMB).  OMB approval has been requested. 
 
350.1 - Purpose and Scope 
(Rev. 6, 08-30-02) 
B3-13400.1 
 
The CMS-2590 (see 300 - Exhibits 1 through 4) provides CMS with the basic data needed on 
review and hearing (both carrier and ALJ) activity. This report enables CMS to tabulate data for 
administrative purposes on the following information: 
 
  The number of reviews and hearings requested, completed, and pending; 
 
  The number of reviews and hearings resulting in affirmations or reversals of previous 
determinations; 
 
  The number of reviews and hearings involving waiver of liability determinations and dollar 
amount of charges allowed; 
 
  Data on timeliness; and 
 
  The number of Part B reopenings. 
 
350.2 - Due Date 
(Rev. 6, 08-30-02) 
B3-13400.2 
 
The carrier transmits form CMS-2590 to CO via PC or terminal.  It uses instructions in the 
Contractor Reporting of Operational and Workload Data (CROWD) System User's Guide.   
 
The report is due as soon as possible after the end of the reporting month but no later than the 15th 
of the month following the end of the reporting month. 
 
360 - Completion of Items on Form CMS-2590 
(Rev. 6, 08-30-02) 
B3-13410 
  360.1 - Heading 
(Rev. 6, 08-30-02) 
B3-13410.1 
 
The carrier enters its ID number in the space provided.  In addition, it indicates the reporting 
month, i.e., 0202 for February 2002. 
 
360.2 - Section A - Carrier Appeal Requests 
(Rev. 6, 08-30-02) 
B3-13410.2 
 
Section A:  Carrier Appeal Requests - This part concerns data from the Part B appeals process.  
The number of appeals requested (received), completed, and pending reflects the status of the 
workload as of the last day of the reporting month.  The carrier bases data on actual counts of each 
activity and not on sampling or other estimating techniques. 
 
APPEALS FALL INTO THE FOLLOWING CATEGORIES: 
 
Column (1)  Total Reviews - The first formal level of appeal following denial of a Part B claim. 
It is a second look by a different employee at the claim and supporting evidence.  (See The 
Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals). The 
carrier does not count duplicate review requests or review requests received before it has made an 
initial determination on a claim.  It counts one review per request received.  With the exception of 
line 7, it does not count the number of claims or beneficiaries involved in the requests.  It reports 
in Column (1) data relating to all types of reviews (both those requested in writing and those 
conducted by telephone). 
 
Column (2)  Telephone Reviews - The carrier reports in this column, data on those reviews 
included in column 1 that were conducted by telephone.  It reports data in this column on lines 6, 
7, 9, 10, 11, and 12 only.  
 
Column (3)  Carrier Hearings - This column represents independent determinations on claims 
for which the party has appealed the carrier review decision.  Such independent determinations are 
rendered by Hearing Officers (HO) that the carrier assigns.  The amount in controversy must be at 
least $100.  (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary 
Correspondence and Appeals) 
 
The carrier counts one hearing per request received (i.e., form CMS-1965 or equivalent written 
request).  It includes hearings requested that do not meet the minimum $100 requirements and are 
subsequently dismissed.  With the exception of line 7, it does not count the number of claims or 
beneficiaries involved in the requests.  (It reports claim counts in line 7.) It does not count hearing 
requests that qualify for an ALJ hearing (i.e., Part B hearings are those hearings that a hearing 
officer adjudicates, as opposed to an ALJ).  See definition for Section D. 
 
It does not count requests for HO hearings received after it has rendered an OTR decision in lines 
1-32 of the report.  It counts these cases only in lines 33, 34, 35, 36, and 38 as appropriate. 
  Line 1. Opening Pending - It enters, under the appropriate columns, the numbers of reviews on 
line 18 and hearings reported on line 28 as the closing pending on the previous month's report. 
 
Line 2. Adjustments to Pending - If it is necessary to revise the pending figure for the close of 
the previous month because of inventories or reporting errors, the carrier enters the adjustment.  It 
reports requests received near the end of the reporting month and placed under control sometime 
after the reporting month as received in the reporting month, not as requests received in the 
subsequent month.  If some cases were not counted in the proper month's receipts, it counts them 
as adjustments to the opening pending in the subsequent month. 
 
If line 3 of the current month differs from the closing pending of the previous month, there must be 
an entry in line 2 for the current month.  The carrier precedes the entry by a "+" or "-," as 
appropriate. 
 
Line 3. Adjusted Pending - It enters the result of line 1 + line 2 (taking into account the "-" sign, 
if any). 
 
Line 4. Requests Received - It enters, under the appropriate columns, the number of review and 
hearing requests received during the reporting month.  (See definitions for columns 1 and 3 for a 
discussion of what constitutes a request for a review and hearing.)  It includes requests transferred 
to it by other contractors if it incurs the administrative costs for processing the appeals, and reports 
the costs on the Interim Expenditure Report (Form CMS-1524). 
 
If one physician submits one request involving several assigned claims (and several beneficiaries), 
the carrier counts this as one request.  If one beneficiary submits a request involving several 
unassigned bills (from several different physicians), it counts this as one request.  If an appellant 
submits more than one request (for different claims) at different times, the carrier counts each 
request. 
 
NOTE:  See definition of column (3) for instructions on hearings requested subsequent to OTR 
decisions. 
Line 4 A. Medical Necessity Documentation Denials - The carrier enters the number of requests 
included in line 4 that involved initial claim denials for lack of medical documentation. 
 
Line 5. Transferred - The carrier reports, under column 1, the number of review requests it 
transferred to other carriers because it did not process the original claim(s).  It reports, under 
column 3, the number of hearing requests transferred to other carriers because the claimant is not 
within the original carrier's geographical area, or the claim was transferred to ROs because the 
issues are outside the HO's responsibility.  (See  The Medicare Claims Processing Manual, Chapter 
30, Beneficiary Correspondence and Appeals)   For columns 1 and 3, if it reported a review or 
hearing as transferred, it does not report any information regarding it on lines 6-39.  The transfer is 
the final action. 
 
Line 6. Requests Cleared - The carrier reports, under the appropriate columns, the total number 
of all reviews, telephone reviews, and hearings completed during the month.  It reports all 
completed reviews and hearings, regardless of the final outcome, i.e., affirmation, reversal, 
withdrawal, or dismissal. It considers a review cleared when the final determination (EOMB or 
other notice - including dismissal) is printed or typed, or upon notification of withdrawal by the  appellant.  In the case of a reversal, it considers the case cleared when it initiates the adjustment 
action. 
 
A hearing is cleared when the decision is signed, or one of the following conditions is present: 
 
  The claimant indicates satisfaction with the OTR decision; 
 
  The claimant indicates after the OTR decision the desire to proceed with an ALJ hearing (if 
the amount in controversy is $500 or more); 
 
  The HO dismisses the hearing request; or  
 
  The appellant withdraws the hearing request. 
 
The carrier does not consider a hearing completed upon release of an OTR decision unless the 
appellant specifically requested an OTR hearing.  It does not count the OTR hearing as completed 
until it has completed all follow-up actions as required in The Medicare Claims Processing 
Manual, Chapter 30, Beneficiary Correspondence and Appeals.  If, as a result of follow-up actions, 
the appellant requests an in-person or telephone hearing after release of the OTR decision, the 
OTR hearing and decision are not counted on the report with the exception noted below.  If the 
appellant does not appear for the subsequent hearing, the hearing is dismissed.  The dismissal is 
the final action. However, the decision to record in lines 9-11 is the OTR decision. 
 
NOTE:  If the carrier closes a review or hearing after the end of a reporting month, but before the 
report is due on the fifteenth of the subsequent month, it does not count it until the subsequent 
month's report. 
 
Line 7. No. of Claims Involved - The carrier enters the total number of claims (as defined in 
3000-3000.2) involved in the appeals reported as cleared during the month on line 6.  For 
example, if it processes decisions for two hearings in the month, one of which involved three 
claims, and the other involved seven claims, it reports 10 claims under column 3. 
 
Line 8. Amount in Controversy - For the hearings reported as affirmed (line 9) or reversed (line 
11), during the month, the carrier shows the total dollar amount in controversy on the initial 
hearing request. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary 
Correspondence and Appeals on how to determine the amount in controversy.)  It shows results 
rounded to the nearest dollar. 
 
Line 9.  Affirmations - Under the appropriate columns, the carrier shows the number of all 
reviews, telephone reviews, and hearings completed during the month in which the previous 
determination was completely upheld, e.g., no change was made.  All parts of all claims in a case 
must be upheld in order to be counted as an affirmation.  An OTR hearing decision does not count 
as a previous decision if the appellant subsequently requests an in-person or telephone hearing.  If 
the in-person/telephone hearing is dismissed because the appellant did not appear, or the request 
was withdrawn, the carrier uses the OTR decision to determine if the case is counted here. 
 
See line 11 for partial affirmations.  (They are not included here.) 
  If the carrier upholds its original determination, but pays under limitation of liability, it counts the 
review or hearing determination as an affirmation.  It reports the appropriate information in 
Section D. 
 
Line 10. Dism./Withdr - The carrier reports, under the appropriate columns, the number of all 
reviews, telephone reviews, and hearings that were withdrawn by the appellant or dismissed 
(before determination) by the carrier or the HO.  It reports here and in lines 4 and 6 an appeal that 
is requested and withdrawn or dismissed within the same month.  If the appellant requests an in-
person or telephone hearing after receiving an OTR decision and the carrier dismisses the hearing 
because the appellant failed to appear, the OTR decision is the final decision, not the dismissal.  
Similarly, for a withdrawal, the OTR decision is used. 
 
A dismissal at the review level is done when written correspondence or a telephone conversation 
has been identified as a review request, but the claimant does not have the right to an appeal.  
Misrouted correspondence is not a dismissal.  If the carrier has incorrectly counted such 
correspondence as a review on a previous report, it uses line 2 (adjustments to pending) to correct 
the count.  It does not count a duplicate request for review on the report.  Likewise, it does not 
count on the report a request for review received before an initial claim determination has been 
rendered.  (It considers the request an inquiry.) 
 
Line 11. Reversals (Full or Part) - Under the appropriate columns, the carrier shows the number 
of all reviews, telephone reviews, and hearings completed during the month in which at least part 
of the prior determination was reversed (e.g., a change was made and some or all of the new 
determination was in favor of the appellant).  For example, if a review or hearing involves several 
claims, and the initial determinations for some of the claims are affirmed and some are reversed, 
the review or hearing decision is a reversal.  An OTR hearing decision does not count as a 
previous decision if the appellant subsequently requests an in-person or telephone hearing.  If the 
in-person/telephone hearing is dismissed because the appellant did not appear, or the request was 
withdrawn, the carrier uses the OTR decision to determine if the case is counted here. 
 
Line 12. Amount Awarded - For cases included in line 11 where the issue on the appeal was not a 
reasonable charge determination, the carrier shows the amount of allowed charges for services 
where the determination was reversed.  It shows charges after reasonable charge reductions, but 
prior to application of deductible and coinsurance amounts.  If the issue was a reasonable charge 
reduction, it shows the additional amount allowed.  It rounds results to the nearest dollar. 
 
Computing Time to Process Carrier Reviews for Lines 13-17 
 
For lines 13-17, the carrier uses the matrix below to determine the number of days from receipt to 
completion of all reviews (both written and telephone).  The date of receipt in all written review 
requests is the day the processing carrier received it in its corporate mailroom.  The date of receipt 
in all telephone review requests is the day the processing carrier received the request on the 
dedicated lines or in the dedicated area. 
 
Situation    Date Completed 
The appellant withdraws the request    The date the carrier is notified of the 
withdrawal 
Carrier dismisses the request or affirms    The date of the notice 
the original determination  Carrier processes the request to    The date the carrier initiates the adjustment 
reversal  request 
 
Line 13. Review Processing Time - Average - The average number of days from receipt of the 
review request to the date of completion for all review requests (both written and telephone). 
 
To compute the average number of days from request to completion, the carrier divides the total 
days elapsed for all requests cleared in the month by the number of requests cleared.  It rounds 
results to the nearest day.  It calculates the days elapsed for an individual request by subtracting the 
Julian date of receipt of the request from the Julian date of completion. 
 
If the request is cleared in the year following the year of receipt, the carrier adds 365 or 366 to the 
result, as appropriate.  (Otherwise, it will get a negative number.)  If a case is cleared the same day 
it is received, it considers the case to require one day. 
 
NOTE:  The carrier includes all cases cleared regardless of whether they were affirmed, reversed, 
dismissed, or withdrawn. 
 
Line 14. Reviews Completed in 1-30 Days - The number of reviews that required 1-30 days to 
complete.  If a case is cleared the same day it is received, the carrier considers it to require 1 day. 
 
Line 15. Reviews Completed in 31-45 Days - The number of reviews that required 31-45 days to 
complete. 
 
Line 16. Reviews Completed in 46-60 Days - The number of reviews that required 46-60 days to 
complete. 
 
Line 17. Reviews Completed Over 60 Days - The number of reviews that required more than 60 
days to complete. 
 
Line 18. Closing Pending-Reviews - The total number of reviews that have not been completed 
by the end of the reporting month. 
 
Line 19. Reviews Pending 1-30 Days - The number of reviews included in line 18 that have been 
pending 1-30 days, inclusive, at the end of the reporting month. 
 
Line 20. Reviews Pending 31-45 Days - The number of reviews included in line 18 that have 
been pending 31-45 days, inclusive, at the end of the reporting month. 
 
Line 21. Reviews Pending 46-60 Days - The number of reviews included in line 18 that have 
been pending 46-60 days, inclusive, at the end of the reporting month. 
 
Line 22. Reviews Pending Over 60 Days - The number of reviews included in line 18 that have 
been pending more than 60 days at the end of the reporting month. 
 
Computing Time to Process Carrier Hearings for Lines 23-27 
 
For lines 23-27, the carrier uses the matrix below to determine the number of days from receipt to 
completion of hearings. The date of receipt in all cases is the day the carrier who is processing the  case received it in its corporate mailroom. In out-of-area cases the receipt date is the date that the 
second carrier received the request. 
 
Situation  Date Completed 
An OTR decision is made and the appellant  The date of the OTR decision. 
accepts the decision or decides to go directly 
to an ALJ hearing. 
An OTR decision is made, and the appellant The date of the second decision. If the appellant 
chooses in a timely fashion, to proceed with does not appear, and the carrier dismisses the 
the in-person or telephone hearing.  hearing, it uses the date of the dismissal notice.  
An in-person or telephone hearing is held  The date of the decision. 
without an OTR decision. 
The appellant withdraws the hearing  The date the carrier was notified of the withdrawal. 
request. 
The HO dismisses the hearing request.  The date of the dismissal notice. 
 
Line 23. Hearing Processing Time - Average - The carrier reports the average number of days 
from the receipt of the hearing request to the date of completion.  See methodology under line 13. 
 
Line 24. Hearings Completed in 1-60 Days - The number of hearings that required 1-60 days to 
complete.  If a case is cleared the same day it is received, the carrier considers it to require 1 day. 
 
Line 25. Hearings Completed in 61-90 Days - The number of hearings that required 61-90 days 
to complete. 
 
Line 26. Hearings Completed in 91-120 Days - The number of hearings that required 91-120 
days to complete. 
 
Line 27. Number Completed Over 120 Days - The number of cases that required 121 days or 
more to complete. 
 
Line 28. Closing Pending-Hearings - The total number of hearings that have not been completed 
by the end of the reporting month. 
 
Line 29. Hearings Pending 1-60 Days - The number of hearings included in line 28 that were 
pending 1-60 days, inclusive, at the end of the reporting month. 
 
Line 30. Hearings Pending 61-90 Days - The number of hearings included in line 28 that were 
pending 61-90 days, inclusive, at the end of the reporting month. 
 
Line 31. Hearings Pending 91-120 Days - The number of hearings included in line 28 that were 
pending 91-120 days, inclusive, at the end of the reporting month. 
 
Line 32. Hearings Pending Over 120 Days - The number of hearings included in line 28 that 
were pending more than 120 days at the end of the reporting month. 
 
HEARING RESULTS 
 
Hearings fall into the following categories:   
Column (1) On-the-Record with No Subsequent Hearings - This column represents hearings 
where: 
 
  The appellant originally requested an OTR hearing. 
 
  The appellant indicated that the appellant was satisfied with the OTR decision, or 
 
  That the appellant wished to proceed with an ALJ hearing (if the amount in controversy is 
$500 or more).  In addition, if the appellant requests an in-person or telephone hearing 
subsequent to an OTR decision, but the hearing is dismissed or withdrawn, it is included 
here and not in columns (2) or (3). 
 
Column (2) All Telephone - This column represents hearings where the appellant requested and 
had a telephone hearing subsequent to an OTR hearing decision, or a telephone hearing was held 
without a prior OTR decision.  The carrier counts all telephone hearings including those where the 
appellant did not follow-up timely to the OTR notice but later requested a telephone hearing. 
 
Column (3) All In-Person - This column represents hearings where the appellant requested and 
had an in-person hearing subsequent to an OTR hearing decision, or an in-person hearing was held 
without a prior OTR decision.  The carrier counts all in-person hearings including those where the 
appellant did not follow-up timely to the OTR notice but later requested an in-person hearing. 
 
Column (4) Number in 120 Days - For the total cases included in line 35, columns 2 and 3, the 
carrier shows for lines 37-39 the numbers that were completed within 120 days of receipt.  It uses 
the methodology shown for lines 23-27 to determine the completion date.  Where an OTR decision 
is made and the appellant chooses to not follow-up timely and later requests either an in-person or 
telephone hearing, the carrier measures the completion time for this second reported hearing from 
the date of receipt of the original request to the date of the second decision.  If the appellant does 
not appear, it dismisses the hearing, and uses the date of notice of dismissal as its date completed. 
 
Line 33. Reversals - Under the appropriate columns, the carrier shows the number of OTR, 
telephone, and in-person hearings completed in the month in which at least part of the review 
determination was reversed; i.e. a change was made and some, or all, of the new determination was 
in favor of the appellant.  (See line 11 for a definition of a reversal.) 
 
Line 34. Affirmation - Under the appropriate columns, the carrier shows the number of OTR, 
telephone, and in-person hearings completed in the month in which the review determination was 
completely upheld; i.e., no change was made.  (See line 9 for a definition of affirmation.) 
 
Line 35. Total Decisions - The carrier enters the total number of hearing decisions completed 
during the month that resulted in a reversal or affirmation (exclude dismissals and withdrawals).  
This includes those hearings shown in lines 9 and 11. 
 
Line 36. Number in 120 Days - For cases included in line 35, the carrier shows the number that 
were completed within 120 days of receipt.  It uses the methodology shown in column (4) to 
determine the completion date. 
  Line 37. No Previous OTR Held - For cases included in line 35, columns (2) and (3), the carrier 
reports the number where it held the telephone or in-person hearing without first making an OTR 
decision (i.e., the OTR hearing was bypassed.)  In column (4), it reports the number of cases 
included in either column (2) or (3) that were completed within 120 days. 
 
Line 38. Previous OTR Counted - For cases included in line 35, columns (2) and (3), the carrier 
reports the number where it included the OTR count on a previous report.   In column (4), it 
reports the number of cases included in either column (2) or (3) that were completed within 120 
days.  Cases reported in line 38 are those where an OTR decision was made, and the appellant 
either accepted the OTR decision, did not respond timely in accordance with The Medicare Claims 
Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals, or decided to go 
directly from the OTR decision to an ALJ hearing.  Then, subsequent to this OTR decision 
"acceptance," the appellant decided that they wanted a telephone or in-person hearing.  The 
carrier does not include these cases in line 6. 
 
Line 39. Previous OTR Not Counted - For cases included in line 35, columns (2) and (3), the 
carrier reports the number where it did not include the OTR count on a previous report.  These are 
cases where it made the OTR decision first and the appellant indicated in a timely fashion that they 
wanted a telephone or in-person hearing.  In column (4), it reports the number of cases included in 
either column (2) or (3) that were completed within 120 days. 
 
360.3 - Section B - ALJ Hearings 
(Rev. 6, 08-30-02) 
B3-13410.3 
 
Section B is intended for all requests for ALJ hearings including those expected to be dismissed 
for failure to meet the $500 amount in controversy requirement or for any other reason (such as a 
lack of a fair hearing). 
 
The carrier counts ALJ Hearings in Columns 1 and 2 using the following two methodologies: 
 
Column (1)  Total - The total of all ALJ hearing requests as originally filed. 
 
Column (2)  Dispositions - For lines 49 and 51-53 only, the carrier enters the number of 
dispositions rendered by the ALJ(s) in cases reported as cleared for the month in Line 49.  There 
will usually be more ALJ dispositions than cases counted in line 49.  A case is not counted in line 
49 until the ALJ has cleared all of the claims included in the request for hearing. 
 
EXAMPLE:  The carrier forwards one request to an ALJ involving 20 claims.  The ALJ 
dismisses 10 claims at once.  A month later, the ALJ decides to affirm the original 
decision on 5 others as one group.  The other 5 receive separate determinations.  
This is counted as 7 dispositions. 
 
Line 40. Opening Pending - The number of ALJ hearings reported on line 57 as closing pending 
on the previous month's report. 
  Line 41. Adjustments to Pending - If line 42 of the current month differs from data in line 57 of 
the previous month, there must be an entry in line 41 for the current month.  The carrier precedes 
the entry by a "+" or "-", as appropriate.  See definition for line 2. 
 
Line 42. Adjusted Opening Pending - The result of line 40 + line 41 (taking into account the "-" 
sign, if any). 
 
Line 43. Requests Received - The number of ALJ hearings requested during the month.  (See The 
Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals.) 
 
Line 44. Requests Forwarded to ALJ - The number of ALJ hearing requests forwarded to ALJs 
during the month.  The carrier considers the case forwarded when all necessary material has been 
mailed to the ALJ. 
 
Line 45. No. of Claims Involved - The number of claims involved in the ALJ hearing requests 
forwarded to ALJs as reported on line 44.  (See MCM-3, 3000-3000.2 for definition of claim.) 
 
Line 46. No. Forwarded in 1-7 Days - The number of ALJ hearing requests forwarded to ALJs 
within 7 calendar days from receipt of the request to mailing of the necessary information.  The 
carrier shows data for all cases mailed during the month.  The number must be less than, or equal 
to, the number shown in line 44. 
 
Line 47. No. Forwarded in 1-14 Days - The number of ALJ hearing requests forwarded to ALJs 
within 14 days from receipt of the request to mailing of the necessary information.  The carrier 
shows data for all cases mailed during the month.  The number must be less than, or equal to, the 
number shown in line 44. 
 
Line 48. Average Time to Forward - The average number of calendar days from receipt of the 
ALJ request to the mailing date of the necessary information.  The carrier the same methodology 
for counting as discussed in 360.2 for line 13. 
 
Line 49. ALJ Hearings Completed - The number of ALJ hearing requests completed during the 
month.  The carrier considers a case completed when it receives the completed decision from the 
ALJ for all parts of the case. 
 
Line 50. Amount in Controversy - For ALJ hearings reported as affirmed (line 51) or reversed 
(line 53), during the month, the carrier shows the total dollar amount remaining in controversy 
according to the initial ALJ hearing request.  This should be the amount remaining after previous 
appeal decisions.  (See  The Medicare Claims Processing Manual, Chapter 30, Beneficiary 
Correspondence and Appeals on how to determine the amount in controversy.)  It rounds results 
to the nearest dollar. 
 
Line 51. Affirmations - The carrier enters number of completed ALJ hearings in which the 
previous determination was completely upheld i.e., no change was made.  All parts of all claims in 
a case must be upheld in order for the case to be counted as an affirmation.  See line 53 for partial 
affirmations.  (The carrier does not include partial affirmations on this line.) 
  If the prior determination is upheld, but payment is made under limitation of liability, the carrier 
counts the ALJ hearing determination as an affirmation. It reports the appropriate information in 
lines 55 and 56. 
 
Line 52. Dismissals/Withdrawals - The e number of completed ALJ hearings that were 
withdrawn by the appellant or dismissed (before determination) by the ALJ.  The carrier reports an 
appeal that was requested and withdrawn or dismissed within the same month here and in lines 43, 
44, and 49. 
 
Line 53. Reversals (Full or Part) - The total number of completed ALJ hearings in which at least 
part of the prior determination was reversed i.e., a change was made and some or all of the new 
determination was in favor of the appellant.  For example, if an ALJ hearing involves several 
claims, and the initial determinations for some of the claims are affirmed and some are reversed, 
the carrier considers the decision a reversal. 
 
Line 54. Amount Awarded - For cases included in line 53, the carrier shows the amount of 
allowed charges for services where the determination was reversed.  It shows charges after 
reasonable charge reductions, but prior to application of  deductible and coinsurance amounts.  (If 
the appeal involved a reasonable charge reduction, it shows the additional amount allowed.)  It 
rounds results to the nearest dollar. 
 
Line 55. Waived - Ben. and Prov - The number of claims involved in requests for ALJ hearings 
where limitation of liability was granted to both the beneficiary and provider in an assigned claim 
(see  The Medicare Claims Processing Manual, Chapter X, Limitation on Liability), or where the 
provider's liability was limited in an unassigned claim(see 3 The Medicare Claims Processing 
Manual, Chapter X, Limitation on Liability). 
 
Line 56. Amount Awarded - For cases included in line 55, the carrier shows the amount of 
allowed charges for services (including the noncovered services) where the liability of the 
beneficiary and provider were limited.  It shows charges after reasonable charge reductions, but 
prior to application of deductible and coinsurance amounts, rounding results to the nearest dollar. 
 
Line 57. Closing Pending - The total number of ALJ hearing requests that were not completed by 
the end of the reporting month.  The carrier considers a case transferred to an ALJ as pending until 
it has received the complete decision from the ALJ for all parts of the case. 
 
Line 58. Effectuation of ALJ Decisions - The number of ALJ hearing decisions for which it 
initiated effectuation during the month.  The carrier considers effectuation of a decision to be 
initiated when it completes the following: 
 
  Submission of claim to CWF if payment can be made without further development; or 
 
  Initiation of development e.g., when it must ascertain whether or not the provider has 
refunded payment to the beneficiary. 
 
Line 59. Number 1-7 Days - The number of cases where the carrier effectuated the decision 
within 7 days, inclusive, of receipt of the decision in its corporate mailroom. 
  Line 60. Number 8-15 Days - The number of cases where the carrier effectuated the decision 
within 8-15 days, inclusive, of receipt of the decision in its corporate mailroom. 
 
Line 61. Number 16-30 Days - The number of cases where the carrier effectuated the decision 
within 16-30 days, inclusive, of receipt of the decision in its corporate mailroom. 
 
Line 62. Number Over 30 Days - The number of cases where the carrier effectuated the decision 
in more than 30 days, inclusive, of receipt of the decision in its corporate mailroom. 
 
360.4 - Section C - Reopenings (Claim Counts) 
(Rev. 6, 08-30-02) 
B3-13410.4 
 
The carrier reports the number of claims (as defined in 3000-3000.2) involved in reopenings 
completed during the month.  (See The Medicare Claims Processing Manual, Chapter 30, 
Beneficiary Correspondence and Appeals) for discussion of what constitutes a reopening.)  Claims 
review, hearings, and ALJ hearings undertaken as part of the appeal process are not considered 
reopenings. 
 
Reopenings fall into the following categories: 
 
Column (1) Total - The number of reopenings completed. 
 
Column (2) Pre-Review - The number of reopenings of initial claim determinations.  If a claim 
has been through a review or any type of hearing, the carrier does not count it here. 
 
Column (3) Post-Review - The number of reopenings of review determinations.  If a claim has 
been through any type of hearing, the carrier does not count it here. 
 
Column (4) Post-Hearing - The number of reopenings of hearing determinations regardless of the 
type of hearing e.g., carrier HO or ALJ.  Once a claim has been through a carrier hearing, it is 
counted here if it is reopened. 
 
Line 63. Total - The number of claims for which the carrier completed the reopening of a claim 
determination, review determination, or hearing determination, whether or not the determination 
was revised. 
 
Line 64. Unfavorable to Claimant - Of the claims shown in line 63, this is a count of those that 
resulted in an unfavorable revision of a previously favorable decision. 
 
Line 65. No Change - Of the claims shown in line 63, these are those that the carrier reopened but 
did not revise the initial determination. 
 
Line 66. Favorable to Claimant - Of the claims shown in line 63, these are those that resulted in 
a favorable revision of a previously unfavorable decision. 
 
Line 67. Amount Awarded - For cases included in line 66, the carrier shows the amount of 
allowed charges for services that involved a revision of a previously unfavorable decision.  It  shows charges after reasonable charge reductions but prior to application of the deductible and 
coinsurance amounts.  (If the reopening involved a reasonable charge reduction, it shows the 
additional amount allowed.)  It rounds results to the nearest dollar. 
 
360.5 - Section D - Limitation of Liability (Claim Counts) 
(Rev. 6, 08-30-02) 
B3-13410.5 
 
ASSIGNED CASES 
 
To include an assigned claim in lines 68-71, the carrier must have originally denied it or reduced it 
as "not reasonable and necessary" under 1862(a)(1) of the Act.  (see The Medicare Claims 
Processing Manual, Chapter X, Limitation on Liability) 
 
Lines 69-71 are mutually exclusive i.e., a claim meeting the above condition may be counted on 
only one of the three lines.  Therefore, the carrier ensures that the sum of the number of claims 
recorded on each of these lines equals the total number of assigned claims considered for 
limitation of liability during the period  reported on line 68. 
 
The counts in lines 69-71 reflect counts of claims at the initial claim (column 1), review (column 
2), and hearing levels (column 3) (as defined in MCM-3, 3000-3000.2), not review or hearing 
requests.  The carrier reports cases corresponding to the claims counted here in Section A also, as 
appropriate.  If a claim is considered for limitation of liability at the initial claim level, the carrier 
does not count it at the or hearing level unless it changes the limitation of liability decision. 
 
It categorizes claims for columns shown in Section D according to the adjudication level at which 
limitation of liability is considered or granted.  If it makes several different limitation of liability 
decisions on the same claim, it uses the highest numbered line on the report that applies to that 
claim. It counts the claim only once.  For instance, if it waives liability for both the beneficiary and 
provider liability on any part of the claim, it counts the claim only on line 71. 
 
Line 68. Total Number Considered - The carrier enters, under the appropriate columns, the 
number of assigned claims meeting the conditions above for which limitation of liability was 
considered during the month. 
 
Line 69. Considered - Not Waived - The carrier enters under the appropriate columns the number 
of assigned claims meeting the conditions above on which limitation of liability was considered 
but was not granted to the beneficiary. 
 
Line 70. Waived - Bene. Only - The carrier shows, under the appropriate columns, the number of 
assigned claims meeting the conditions above on which it granted limitation of liability to only the 
beneficiary. 
Line 71. Waived - Bene. and Prov. - The carrier enters, under the appropriate columns, the 
numbers of assigned claims where it granted limitation of liability during the reporting month to 
both the beneficiary and provider. 
 
Line 72. Amount Awarded - For cases included in line 71, the carrier shows the amount of 
allowed charges for services (including noncovered services) where limitation of liability is  granted to the beneficiary and provider.  It shows charges after reasonable charge reductions, but 
prior to application of deductible and coinsurance amounts, rounding results to the nearest dollar. 
 
UNASSIGNED CASES 
 
This section applies to claims where waiver of a provider's liability to make refund to the 
beneficiary on unassigned claims for those services found to be not reasonable or necessary is 
considered under Limitation on Liability.  See The Medicare Claims Processing Manual, 
Chapter X, Limitation on Liability. 
 
Line 73. Total Number Considered - The carrier enters, under the appropriate columns, the 
number of unassigned claims that meet the conditions of 7330 for which limitation of liability 
was considered during the month. 
 
Line 74. Phys. Refund Waived - The carrier enters, under the appropriate columns, the number of 
unassigned claims that meet the requirements of 7330 on which it waived the liability of the 
provider to refund to the beneficiary the amount disallowed as not reasonable and necessary. 
 
Line 75. Phys. Refund Upheld - The carrier enters, under the appropriate columns, the number of 
unassigned claims that meet the requirements of The Medicare Claims Processing Manual, 
Chapter X, Limitation on Liability chapter, on which it required the physician to refund the 
amount disallowed. 
 
370 - Checking Reports 
(Rev. 6, 08-30-02) 
B3-13415 
 
Before sending the report to CMS, the carrier checks for completeness and arithmetical accuracy. 
It uses the following checklist for each column: 
 
  Line 1 column (1) must be equal to line 18 of previous month. 
  Line 1 column (3) must be equal to line 28 of previous month.  
  Line 1 + line 2 = line 3 for columns (1) and (3).  
  Line 3 column (1) + line 4 column (1) - line 5 column (1) - line 6 column (1) = line 18.  
  Line 3 column (3) + line 4 column (3) - line 5 column (3) - line 6 column (3) = line 28.  
  Line 4A must be less than or equal to line 4 for columns (1) and (3). 
  Line 6 = line 9 + line 10 + line 11.  
  Line 9 column (3) + line 11 column (3) must be less than or equal to line 35 (sum of all 
columns). 
  Line 6 column (1) = line 14 + line 15 + line 16 + line 17.  
  Line 6 column (3) = line 24 + line 25 + line 26 + line 27. 
  Column (2) must be less than or equal to column (1) for lines 6, 7, 9, 10, 11, and 12. 
  Line 7 must be greater than or equal to line 6. 
  Line 18 = line 19 + line 20 + line 21 + line 22. 
  Line 28 = line 29 + line 30 + line 31 + line 32. 
  Line 35 = line 33 + line 34. 
  Line 35 = line 37 + line 38 + line 39 for columns 2 and 3 only.    Line 36 must be less than or equal to line 35 for columns 1, 2, and 3.  
  Line 37 (column 4) must be less than or equal to line 37 (column 2) + line 37 (column 3). 
  Line 38 (column 4) must be less than or equal to line 38 (column 2) + line 38 (column 3). 
  Line 39 (column 4) must be less than or equal to line 39 (column 2) + line 39 (column 3). 
  Line 40 must be equal to line 57 of the previous month for column 1 only. 
  Line 42 = line 40 + line 41 for column 1. 
  Line 42 + line 43 - line 49 = line 57 for column 1 only. 
  Line 45 must be greater than or equal to line 44 for column 1 only. 
  Line 46 must be less than or equal to line 44 for column 1 only. 
  Line 47 must be less than or equal to line 44 for column 1 only. 
  Line 49 = line 51 + line 52 + line 53. 
  Line 50 must be greater than or equal to 500 times the sum of lines 51 and 53 for column 1 
only (each case must involve at least $500). 
  Column 2 must be greater than or equal to column 1 for lines 49 and 51 - 53. 
  Line 54 must be greater than or equal to line 53 for column 1 only (must award at least $1 
per case). 
  Line 56 must be greater than or equal to line 55 for column 1 only (at least $1 per case). 
  Line 58 = line 59 + line 60 + line 61 + line 62. 
  Line 63 = line 64 + line 65 + line 66. 
  Line 67 must be greater than or equal to line 66 (at least $1 per case).  
  Line 68 = line 69 + line 70 + line 71. 
  Line 72 must be greater than or equal to line 71 (at least $1 per case).  
  Line 73 must be greater than or equal to line 74. 
  Line 73 must be greater than or equal to line 75. 
  Column 1 = column 2 + column 3 + column 4 for lines 63 - 67. 
 
Public reporting burden for this collection of information is estimated to average 2 hours per 
response, including time for reviewing instructions, searching existing data sources, gathering and 
maintaining data needed, and completing and reviewing the collection of information.  Comments 
regarding this burden estimate or any other aspect of this collection of information, including 
suggestions for reducing the burden may be sent to the following: 
 
Centers for Medicare & Medicaid Services 
Office of Financial Management 
P.O. Box 26684 
Baltimore, MD 21207 
 
and to the  
 
Office of Management and Budget 
Paperwork Reduction Project (0938-0452)  
Washington, DC  20503.  380 - Exhibits 
(Rev. 6, 08-30-02) 
B3-13416 
 
Exhibit 1 - Medicare Program - Carrier Appeal Report - Form CMS-2590 
 
MEDICARE PROGRAM - CARRIER APPEAL REPORT - FORM CMS-2590 
 
CARRIER ID ___________________ REPORT PERIOD _____________________ 
TOTAL  TELEPHONE 
REVIEWS  REVIEWS  HEARINGS 
A. CARRIER APPEAL REQUESTS  (1)  (2)  (3) 
1.   OPENING PENDING          
2.   ADJSTMTS TO PNDNG             
3.    ADJUSTED PENDING             
4.    REQUESTS RECEIVED           
4A.  MED. DOC. DENIALS           
5.    REQUESTS TRANSFERRED             
6.    REQUESTS CLEARED             
7.   NO. OF CLAIMS             
8.   AMT IN CONTROVERSY             
9.   AFFIRMATIONS             
10.   DISMISSED/WITHDRAWN             
11.   REVERSALS             
12.   AMOUNT AWARDED             
FORM CMS-2590 SCREEN 1  Exhibit 2 - Medicare Program - Carrier Appeals Report - Form CMS-2590 
 
MEDICARE PROGRAM - CARRIER APPEALS REPORT - FORM CMS-2590 
 
CARRIER ID  __________________ REPORT PERIOD _____________________ 
REVIEW  REVIEWS  HEARING  HEARINGS 
REQUESTS  (1)  REQUESTS  (2) 
PROCESSING TIMES     PROCESSING TIMES   
13. REVIEWS- AVERAGE     23. HEARINGS- AVERAGE    
14.     NBR COMP 1-30 DYS    24.     NBR COMP 1-60 DYS    
15.     NBR COMP 31-45     25.     NBR COMP 61-90 DYS   
DYS 
16.     NBR COMP 46-60     26.     NBR COMP 91-120    
DYS  DYS 
17.     NBR COMP 60 DYS+     27.     NBR COMP 120 DYS+    
PENDING TIMES     PENDING TIMES    
18. CLOSING PENDING     28.     CLOSING PENDING    
19.     NBR COMP 1-30 DYS    29.     NBR COMP 1-60 DYS    
20.     NBR COMP 31-45     30.     NBR COMP 61-90 DYS   
DYS 
21.     NBR COMP 46-60     31.     NBR COMP 91-120    
DYS  DYS 
22.     NBR COMP 60 DYS+     32.     NBR COMP 120 DYS+    
 
OTR 
WITH NO 
SUBSEQUENT  IN- NBR IN 
HEARING  TELEPHONE  PERSON  120 DYS 
HEARING RESULTS  (1)  (2)  (3)  (4) 
33.  REVERSALS             
34.  AFFIRMATIONS             
35.  TOTAL DECISIONS             
36.  NBR IN 120 DYS             
37.  NO PREV OTR HELD             
38.  PREV OTR COUNTED              
39.  PREV OTR NOT            
COUNTED 
FORM CMS-2590 SCREEN 2   Exhibit 3 - Medicare Program - Carrier Appeals Report - Form CMS 2590 
 
MEDICARE PROGRAM - CARRIER APPEALS REPORT - FORM CMS 2590 
 
CARRIER ID  ___________________ REPORT PERIOD _____________________ 
TOTAL  DISPOSITIONS  B. PART B ALJ  TOTAL 
B. PART B ALJ HEARINGS  (1)  (2)  HEARINGS  (1) 
40 OPENING PENDING        55. WAIVED -    
BEN & PROV 
41 ADJUSTMENTS TO         56. AMOUNT     
PENDING  AWARDED 
42. ADJUSTED OPENING        57. CLOSING    
PENDING  PENDING 
43. REQUESTS RECEIVED         58. EFFECT.    
OF ALJ DEC 
44. REQ. FORWARDED TO        59. NO. 1-7    
ALJ  DAYS 
45. NO. OF CLAIMS         60. NO. 8-15     
INVOLVED  DAYS 
46. NO. IN 1-7 CALNDR         61. NO. 16-30    
DAYS  DAYS 
47. NO. IN 1-14 CLNDR          62. NO. OVER    
DAYS  30 DAYS 
48. AVG TIME TO             
FORWARD 
49. COMPLETED             
50. AMOUNT IN             
CONTROVERSY 
51. AFFIRMATIONS             
52.             
DISMISSALS/WITHDRAW
ALS 
53. REVERSALS             
(FULL/PART) 
54. AMOUNT AWARDED               
FORM CMS-2590 SCREEN 3   Exhibit 4 - Medicare Program - Carrier Appeals Report - Form CMS-2590 
 
MEDICARE PROGRAM - CARRIER APPEALS REPORT - FORM CMS-2590 
 
CARRIER ID ___________________ REPORT PERIOD ____________________  
POST-  POST- 
TOTAL  PRE-REVIEW  REVIEW  HEARING 
C. REOPENINGS  (CLAIM COUNTS  (1)  (2)  (3)  (4) 
63. TOTAL             
64. UNFAVORABLE TO             
CLAIMANT 
65. NO CHANGE             
66. FAVORABLE TO CLAIMANT            
67. AMOUNT AWARDED             
 
INITIAL     
D. LIMITATION OF LIABILITY  CLAIM  REVIEW  HEARING 
(CLAIM COUNTS)  (1)  (2)  (3)    
ASSIGNED CASES             
68. TOTAL NUMBER             
CONSIDERED 
69. CONSIDERED - NOT             
WAIVED 
70. WAIVED-BEN. ONLY             
71. WAIVED-BEN.& PROV             
72. AMT AWARDED             
UNASSIGNED CASES             
73. TOTAL NUMBER             
CONSIDERED 
74. PHYS REFUND WAIVED             
75. PHYS REFUND UPHELD             
FORM CMS-2590 SCREEN 4  390 - Participating Physician/Supplier Report 
(Rev. 191, Issued: 07-13-11, Effective: 07-01-11, Implementation: 07-05-11) 
 
Unless otherwise requested, the carrier/A/B MAC prepares and transmits to CMS each year a 
report updating the number and category of participating physicians and suppliers.  It completes a 
separate report for each office assigned a separate carrier number. 
 
390.1 - Purpose and Scope 
(Rev. 191, Issued: 07-13-11, Effective: 07-01-11, Implementation: 07-05-11) 
 
This report enables CMS to gather data for administrative purposes on the number of physicians, 
limited license physicians, non-physician practitioners and suppliers, by specialty code, electing to 
participate in CMS' Participating Physician/Supplier Program. 
 
390.2 - Due Date 
(Rev. 191, Issued: 07-13-11, Effective: 07-01-11, Implementation: 07-05-11) 
 
The carrier/A/B MAC transmits data about the Participating Physician/Supplier Program to CO via 
PC or terminal.  It uses instructions in the Contractor Reporting of Operational and Workload Data 
(CROWD) System User's Guide. 
 
The report is due 45 days after the end of the enrollment period.  It includes updated data as of the 
end of the most recent enrollment period. 
 
The carrier/A/B MAC does not submit hard copies of the report. 
 
400 - Completion of Items on Participating Physician/Supplier Report 
(Rev. 6, 08-30-02) 
B3-13422 
 
400.1 - Heading 
(Rev. 6, 08-30-02) 
B3-13422.1 
 
This report is referenced as Form F in the CROWD system.  The carrier completes the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the 
reporting format to its screen. 
 
400.2 - Definitions of Columns One Through Eight 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
Column 1 - Participating Physicians/LLPs/NPPs/Suppliers - Prior - A count of the number of 
physicians, limited license physicians (LLPs), non-physician practitioners (NPPs), and suppliers 
participating prior to the beginning of the latest enrollment period. 
 
Note: The carrier or A/B MAC adjusts this data if there are changes from the information 
submitted in column 2 on the previous enrollment period. 
  Examples of possible reasons for changes to the data include: 
 
  Addition of new physicians to the Medicare file; 
  Reclassification of physicians, LLPs, NPPs, and suppliers between specialty designations; 
  Deletion of deceased or retired physicians from the Medicare file; or 
  Technical corrections to previously submitted data. 
 
Column 2 - Participating Physicians/LLPs/NPPs/Suppliers - Current - The number of 
physicians, limited license physicians, NPPs, and suppliers who are continuing as participants 
from the prior participation period into the new participation period and the number who have 
newly signed participation agreements in the latest enrollment period. 
 
Column 3 - Participating Physicians/LLPs/NPPs/Suppliers - Continuing - Only the number of 
physicians, limited license physicians, NPPs, and suppliers continuing as participants from the 
prior participation period into the new participation period, not including those who have newly 
signed participation agreements in the latest enrollment period or those who have dropped out. 
 
Column 4 - Non-Participating Physicians/LLPs/NPPs/Suppliers - Prior - A count of 
physicians, limited license physicians, NPPs, and suppliers not participating at the beginning of the 
latest enrollment period. 
 
Note:  The carrier or A/B MAC adjusts this data if the information is different from that 
submitted in column 5 on the previous enrollment period.  (See column 1 for further 
information.) 
 
Column 5 - Non-Participating Physicians/LLPs/NPPs/Suppliers - Current - A count of 
physicians, limited license physicians, NPPs, and suppliers not participating after the latest 
enrollment period, including those who were not participating at the beginning of the latest 
enrollment period and chose not to enroll and those who disenrolled during the latest period. 
 
Column 6 - Participating Drop-Out - Current  Physicians/LLPs/NPPs, and suppliers who, 
prior to this enrollment period, were participating in the program and have now decided to drop 
out. 
 
Column 7 - Non-Participating Sign-Up - Current  Physicians/LLPs/NPPs, and suppliers who 
were non-participating prior to the latest enrollment period and who enrolled in the program during 
the latest enrollment period. 
 
Column 8  Participating Disenrolls - Only the number of participants who disenrolled from the 
Medicare program during an authorized disenrollment period held during the past 12 months.  This 
is blank unless CMS declares an authorized disenrollment period. 
 
400.3 - Specialty Codes 
(Rev. 191, Issued: 07-13-11, Effective: 07-01-11, Implementation: 07-05-11) 
 
The contractor counts individual participants by specialty.  It does not count an individual more 
than once, even if the individual practices in more than one setting. 
  NOTE: Refer to the pre-April 2010 version for DMERC activity (Calendar Years 1993-2007) 
 
400.4 - Physician/Limited License Physician Specialty Codes 
(Rev. 10374, Issued: 09-25-20, Effective: 10-01-20, Implementation: 10-05-20) 
 
 
The following list of codes and narrative describe the kind of medicine physicians practice. 
 
Code  Physician/Limited License Physician (LLP) Specialty Codes 
01  General Practice 
02  General Surgery 
03  Allergy/Immunology 
04  Otolaryngology 
05  Anesthesiology 
06  Cardiology 
07  Dermatology 
08  Family Practice 
09  Interventional Pain Management 
10  Gastroenterology 
11  Internal Medicine 
12  Osteopathic Manipulative Medicine 
13  Neurology 
14  Neurosurgery 
16  Obstetrics/Gynecology 
17  Hospice and Palliative Care 
18  Ophthalmology 
19  Oral Surgery (Dentists only) (LLP) 
20  Orthopedic Surgery 
21  Cardiac Electrophysiology 
22  Pathology 
23  Sports Medicine 
24  Plastic and Reconstructive Surgery 
25  Physical Medicine and Rehabilitation 
26  Psychiatry 
27  Geriatric Psychiatry 
28  Colorectal Surgery (formerly Proctology) 
29  Pulmonary Disease 
30  Diagnostic Radiology 
33  Thoracic Surgery 
34  Urology 
35  Chiropractic (LLP) 
36  Nuclear Medicine 
37  Pediatric Medicine 
38  Geriatric Medicine 
39  Nephrology 
40  Hand Surgery 
41  Optometry (LLP)  Code  Physician/Limited License Physician (LLP) Specialty Codes 
44  Infectious Disease 
46  Endocrinology 
48  Podiatry (LLP) 
66  Rheumatology 
70  Single or Multispecialty Clinic or Group Practice 
72  Pain Management 
76  Peripheral Vascular Disease 
77  Vascular Surgery 
78  Cardiac Surgery 
79  Addiction Medicine 
81  Critical Care (Intensivist) 
82  Hematology 
83  Hematology/Oncology 
84  Preventive Medicine 
85  Maxillofacial Surgery (LLP) 
86  Neuropsychiatry 
90  Medical Oncology 
91  Surgical Oncology 
92  Radiation Oncology 
93  Emergency Medicine 
94  Interventional Radiology 
98  Gynecological/Oncology 
99  Unknown Physician Specialty 
C0  Sleep Medicine 
C3  Interventional Cardiology 
C5  Dentist 
C6  Hospitalist 
C7  Advanced Heart Failure and Transplant Cardiology 
C8  Medical Toxicology 
C9  Hematopoietic Cell Transplantation and Cellular Therapy 
D3  Medical Genetics and Genomics 
D4  Undersea and Hyperbaric Medicine 
D7  Micrographic Dermatologic Surgery 
D8  Adult Congenital Heart Disease 
 
NOTE:  Specialty Code Use for Service in an Independent Laboratory.  For services performed in 
an independent laboratory, show the specialty code of the physician ordering the x-rays and 
requesting payment.  If the independent laboratory requests payment, use supplier code "69". 
 
400.5 - Non-Physician Practitioner/Supplier Specialty Codes 
(Rev. 10374, Issued: 09-25-20, Effective: 10-01-20, Implementation: 10-05-20) 
 
 
The following list of codes and narrative describe the kind of medicine non-
physician practitioners or other healthcare providers/suppliers practice. 
 
Code  Non-Physician Practitioner/Supplier Specialty Codes  15  Speech Language Pathologist in Private Practice 
31  Intensive Cardiac Rehabilitation (ICR) 
32  Anesthesiologist Assistant 
42  Certified Nurse Midwife (effective July 1, 1988) 
43  Certified Registered Nurse Anesthetist (CRNA) 
45  Mammography Screening Center 
47  Independent Diagnostic Testing Facility (IDTF) 
49  Ambulatory Surgical Center 
50  Nurse Practitioner 
59  Ambulance Service Supplier, e.g., private ambulance companies, funeral homes 
60  Public Health or Welfare Agencies (Federal, State, and local) 
61  Voluntary Health or Charitable Agencies (e.g., National Cancer Society, 
National Heart Association, Catholic Charities) 
62  Psychologist (Billing Independently) 
63  Portable X-Ray Supplier (Billing Independently) 
64  Audiologist (Billing Independently) 
65  Physical Therapist in Private Practice 
67  Occupational Therapist in Private Practice 
68  Clinical Psychologist 
69  Clinical Laboratory (Billing Independently) 
71  Registered Dietician/Nutrition Professional 
73  Mass Immunization Roster Billers (Mass Immunizers have to roster bill 
assigned claims and can only bill for immunizations) 
74  Radiation Therapy Centers 
75  Slide Preparation Facilities 
80  Licensed Clinical Social Worker 
88  Unknown Provider 
89  Certified Clinical Nurse Specialist 
95  Unknown Supplier 
97  Physician Assistant 
A5  Pharmacy 
C1  Centralized Flu 
C2  Indirect Payment Procedure 
C4  Restricted Use 
D1  Medicare Diabetes Prevention Program 
D2  Restricted Use 
D5  Opioid Treatment Program 
D6  Home Infusion Therapy Services 
 
Note: Specialty Code Use for Service in an Independent Laboratory. For services performed 
in an independent laboratory, show the specialty code of the physician ordering the x-rays 
and requesting payment.  If the independent laboratory requests payment, use supplier  code 69. 
410 - Checking Reports 
(Rev. 191, Issued: 07-13-11, Effective: 07-01-11, Implementation: 07-05-11) 
 
Before submitting Form F, the carrier/A/B MAC checks for completeness and arithmetical 
accuracy using the following checklist: 
 
  Column 3 must be = to or < column 1 
  Column 3 must be = to or < column 2 
  Column 6 = column 1 - column 3 
  Column 7 = column 2 - column 3 
  Total Physicians = sum of Group PHY for all columns. 
  Total LLPs = sum of Group LLP for all columns. 
  Total NPPs = sum of Group NPP for all columns.  
  Total Suppliers = sum of Group SUP for all columns.  420 - Exhibit 
(Rev. 10374, Issued: 09-25-20, Effective: 10-01-20, Implementation: 10-05-20) 
 
 
Exhibit - Participating Physician/Supplier Report - Screen 1 
 
PARTICIPATING PHYSICIAN/SUPPLIER REPORT 
SPECIALTY CODES 
 
01 General Practice 
02 General Surgery 
03 Allergy/Immunology 
04 Otolaryngology 
05 Anesthesiology 
06 Cardiology 
07 Dermatology 
08 Family Practice 
09 Interventional Pain Management 
10 Gastroenterology 
11 Internal Medicine 
 
      Par  Non-Par   
Participants  Non-Participants  Drop-Out  Sign-Up  Par 
SPECIALTY  Prior  Current  Contin.  Prior  Current  Current  Current  Disenrolls 
CODE/GROUP  (1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
01-PHY                 
02-PHY                 
03-PHY                 
04-PHY                 
05-PHY                 
06-PHY                 
07-PHY                 
08-PHY                 
09-PHY                 
10-PHY                 
11-PHY                  Exhibit 1 - Participating Physician/Supplier Report - Screen 2 
 
PARTICIPATING PHYSICIAN/SUPPLIER REPORT 
SPECIALTY CODES 
 
12 Osteopathic Manipulative Medicine 
13 Neurology 
14 Neurosurgery 
15 Speech Language Pathologist in Private Practice 
16 Obstetrics/Gynecology 
17 Hospice and Palliative Care 
18 Ophthalmology 
19 Oral Surgery (Dentists only) 
20 Orthopedic Surgery 
21 Cardiac Electrophysiology 
22 Pathology 
23 Sports Medicine 
24 Plastic and Reconstructive Surgery 
 
      Par  Non-Par   
SPECIALTY  Participants  Non-Participants  Drop-Out  Sign-Up  Par 
CODE/GROUP  Prior  Current  Contin.  Prior  Current  Current  Current  Disenrolls 
(1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
12-PHY                 
13-PHY                 
14-PHY                 
15-NPP                 
16-PHY                 
17-PHY                 
18-PHY                 
19-LLP                 
20-PHY                 
21-PHY                 
22-PHY                 
23-PHY                 
24-PHY                  Exhibit 1 - Participating Physician/Supplier Report - Screen 3 
 
PARTICIPATING PHYSICIAN/SUPPLIER REPORT 
SPECIALTY CODES 
 
25 Physical Medicine and Rehabilitation 
26 Psychiatry 
27 Geriatric Psychiatry 
28 Colorectal Surgery (formerly Proctology) 
29 Pulmonary Disease 
30 Diagnostic Radiology  
31 Intensive Cardiac Rehabilitation (ICR)  
32 Anesthesiologist Assistant  
33 Thoracic Surgery 
34 Urology 
35 Chiropractic 
36 Nuclear Medicine 
37 Pediatric Medicine 
 
      Par  Non-Par   
SPECIALTY  Participants  Non-Participants  Drop-Out Sign-Up  Par 
CODE/GROUP  Prior Current  Contin.  Prior  Current  Current  Current  Disenrolls 
(1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
25-PHY                 
26-PHY                 
27-PHY                 
28-PHY                 
29-PHY                 
30-PHY                 
31-SUP                 
32-NPP                 
33-PHY                 
34-PHY                 
35-LLP                 
36-PHY                 
37-PHY                 
  Exhibit 1 - Participating Physician/Supplier Report - Screen 4 
 
PARTICIPATING PHYSICIAN/SUPPLIER REPORT 
SPECIALTY CODES 
 
38 Geriatric Medicine 
39 Nephrology 
40 Hand Surgery  
41 Optometry  
42 Certified Nurse Midwife 
43 Certified Registered Nurse Anesthetist (CRNA) 
44 Infectious Disease  
45 Mammography Screening Center 
46 Endocrinology  
47 Independent Diagnostic Testing Facility (DTL) 
48 Podiatry 
49 Ambulatory Surgical Center 
50 Nurse Practitioner 
 
      Par  Non-Par   
SPECIALTY  Participants  Non-Participants  Drop-Out  Sign-Up  Par 
CODE/GROUP  Prior  Current  Contin.  Prior  Current  Current  Current  Disenrolls 
(1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
38-PHY                 
39-PHY                 
40-PHY                 
41-LLP                 
42-NPP                 
43-NPP                 
44-PHY                 
45-SUP                 
46-PHY                 
47-SUP                 
48-LLP                 
49-SUP                 
50-NPP                  Exhibit 1 - Participating Physician/Supplier Report - Screen 5 
 
PARTICIPATING PHYSICIAN/SUPPLIER REPORT 
SPECIALTY CODES 
 
59 Ambulance Service Supplier 
60 Public Health/Welfare Agency 
61 Volunteer Health/Charitable Agency 
62 Psychologist (Billing Independently) 
63 Portable X-Ray Supplier (Billing Independently) 
64 Audiologist (Billing Independently) 
65 Physical Therapist in Private Practice 
66 Rheumatology 
67 Occupational Therapist in Private Practice 
68 Clinical Psychologist 
69 Clinical Laboratory (Billing Independently.) 
70 Single or Multispecialty Clinic or Group Practice 
71 Registered Dietitian/Nutrition Professional 
 
      Par  Non-Par   
SPECIALTY  Participants  Non-Participants  Drop-Out  Sign-Up  Par 
CODE/GROUP  Prior  Current  Contin.  Prior  Current  Current  Current  Disenrolls 
(1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
59-SUP                 
60-SUP                 
61-SUP                 
62-NPP                 
63-SUP                 
64-NPP                 
65-NPP                 
66-PHY                 
67-NPP                 
68-NPP                 
69-SUP                 
70-PHY                 
71-NPP                  Exhibit 1 - Participating Physician/Supplier Report - Screen 6 
 
PARTICIPATING PHYSICIAN/SUPPLIER REPORT 
SPECIALTY CODES 
 
72 Pain Management 
73 Mass Immunization Roster Biller 
74 Radiation Therapy Centers 
75 Slide Preparation Facilities 
76 Peripheral Vascular Disease 
77 Vascular Surgery 
78 Cardiac Surgery 
79 Addiction Medicine 
80 Licensed Clinical Social Worker 
81 Critical Care (Intensivist) 
82 Hematology  
83 Hematology/Oncology 
84 Preventative Medicine 
 
      Par  Non-Par   
SPECIALTY  Participants  Non-Participants  Drop-Out  Sign-Up  Par 
CODE/GROUP  Prior  Current  Contin.  Prior  Current  Current  Current  Disenrolls 
(1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
72-PHY                 
73-SUP                 
74-SUP                 
75-SUP                 
76-PHY                 
77-PHY                 
78-PHY                 
79-PHY                 
80-NPP                 
81-PHY                 
82-PHY                 
83-PHY                 
84-PHY                 
  Exhibit 1 - Participating Physician/Supplier Report - Screen 7 
 
PARTICIPATING PHYSICIAN/SUPPLIER REPORT 
SPECIALTY CODES 
 
85 Maxillofacial Surgery 
86 Neuropsychiatry 
88 Unknown Provider 
89 Certified Clinical Nurse Specialist 
90 Medical Oncology  
91 Surgical Oncology 
92 Radiation Oncology 
93 Emergency Medicine  
94 Interventional Radiology  
95 Unknown Supplier  
97 Physician Assistant 
98 Gynecological Oncology 
99 Unknown Physician Specialty 
 
      Par  Non-Par   
SPECIALTY  Participants  Non-Participants  Drop-Out  Sign-Up  Par 
CODE/GROUP  Prior  Current  Contin.  Prior  Current  Current  Current  Disenrolls 
(1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
85-LLP                 
86-PHY                 
88-NPP                 
89-NPP                 
90-PHY                 
91-PHY                 
92-PHY                 
93-PHY                 
94-PHY                 
95-SUP                 
97-NPP                 
98-PHY                 
99-PHY                  Exhibit 1 - Participating Physician/Supplier Report - Screen 8 
 
PARTICIPATING PHYSICIAN/SUPPLIER REPORT 
SPECIALTY CODES 
 
A5 Pharmacy 
C0 Sleep Medicine 
C1 Centralized Flu 
C2 Indirect Payment Procedure 
C3 Interventional Cardiology  
C4 Restricted Use 
C5 General Dentist 
C6 Hospitalist 
C7 Advanced Heart Failure and Transplant Cardiology 
C8 Medical Toxicology 
C9 Hematopoietic Cell Transplantation and Cellular Therapy 
D1 Medicare Diabetes Prevention Program 
D2 Restricted Use 
D3 Medical Genetics and Genomics 
D4 Undersea and Hyperbaric Medicine 
D5 Opioid Treatment Program 
D6 Home Infusion Therapy Services 
D7 Micrographic Dermatologic Surgery 
D8 Adult Congenital Heart Disease 
 
      Par  Non-Par   
SPECIALTY  Participants  Non-Participants  Drop-Out  Sign-Up  Par 
CODE/GROUP  Prior  Current  Contin.  Prior  Current  Current  Current  Disenrolls 
(1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
A5-SUP                 
C0-PHY                 
C1-NPP                 
C2-NPP                 
C3-PHY                 
C4-RES                 
C5-PHY                 
C6-PHY                 
C7-PHY                 
C8-PHY                 
C9-PHY                 
D1-SUP                 
D2-RES                 
D3-PHY                  D4-PHY                 
D5-SUP                 
D6-SUP                 
D7-PHY                 
D8-PHY                  Exhibit 1 - Participating Physician/Supplier Report - Screen 9 
 
PARTICIPATING PHYSICIAN/SUPPLIER REPORT 
SPECIALTY CODES 
 
Total Physicians - The contractor enters in the appropriate column the total of all specialty codes 
applicable to physicians. 
 
Total LLPs - The contractor enters in the appropriate column the total of all specialty codes 
applicable to limited license physicians. 
 
Total NPPs - The contractor enters in the appropriate column the total of all specialty codes 
applicable to non-physician practitioners. 
 
Total Physicians/LLPs/NPPs - The contractor enters in the appropriate column the sum of all 
physicians, LLPs and NPPs. 
 
Total Suppliers - The contractor enters in the appropriate column the total of all specialty codes 
applicable to suppliers. 
 
      Par  Non-Par   
SPECIALTY  Participants  Non-Participants  Drop-Out Sign-Up  Par 
CODE/GROUP  Prior Current Contin.  Prior  Current  Current  Current  Disenrolls 
(1)  (2)  (3)  (4)  (5)  (6)  (7)  (8) 
                 
   TOTALs                  
                 
   PHYs*                 
   LLPs*                 
   NPPs*                 
                   
PHYs/LLPS/NPPs* 
                 
   SUPs*                 
 
* These lines do not represent specific specialty codes.  They are the totals of the specialty sub-
groups. 
 
430 - Completing Quarterly Report On Provider Enrollment (Inactive) 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
Each quarter, the carrier prepares and submits to CMS a report on the number of provider 
enrollment applications received, processed, and pending during the quarter.  It submits this report 
via the Contractor Reporting of Operational and Workload Data (CROWD) system no later than 
the fifteenth day following the close of the reporting quarter. 
  430.1 - Heading 
(Rev. 6, 08-30-02) 
B3-13430.1 
 
This report is referenced as Form 4 in the CROWD system.  The carrier completes the 
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to bring the 
reporting format to its screen. 
 
430.2 - Checking Reports 
(Rev. 6, 08-30-02) 
B3-13430.2 
 
Before submitting Form 4 to CMS, the carrier checks for completeness and arithmetical accuracy, 
using the following checklist: 
 
  For all lines, column 1 must equal the sum of columns 2-24. 
  For all columns, line 1 must equal line 11 from the previous quarter. 
  For all columns, line 3 must equal line 1 plus line 2. 
  For all columns, line 6 must equal line 4 plus line 5. 
  For all columns, line 10 must equal the sum of lines 7-9. 
  For all columns, line 11 must equal line 3 plus line 6 minus line 10. 
  For all columns, the sum of lines 12-17 must equal line 8. 
  For all columns, the sum of lines 18-22 must equal line 9. 
  For all columns, the sum of lines 23-26 must equal line 10. 
  For all columns, line 27 must equal line 34 from the previous quarter. 
  For all columns, line 29 must equal line 27 plus line 28. 
  For all columns, line 33 must equal line 31 plus line 32. 
  For all columns, line 34 must equal line 29 plus line 30 minus line 33. 
 
430.3 - Type of Provider 
(Rev. 6, 08-30-02) 
B3-13430.3 
 
The carrier reports provider enrollment application data in the following columns for all lines on 
Form 4. 
 
Column (1) - Total - The sum of columns 2-24 for each line. 
 
Column (2) - Physician - Provider applications for specialty codes 1-8, 10-14, 16, 18-20, 22, 24-
26, 28-30, 33-41, 44, 46, 48, 66, 76-79, 81-86, 90-94, 98, and 99. 
 
Column (3) - Group - Provider applications for specialty code 70. 
 
Column (4) - Certified Nurse Midwife - Provider applications for specialty code 42. 
 
Column (5) - Certified Registered Nurse Anesthetist - Provider applications for specialty code 43. 
  Column (6) - Nurse Practitioner - Provider applications for specialty code 50. 
 
Column (7) - Ambulance Service Supplier - Provider applications for specialty code 59. 
 
Column (8) - Independent Audiologist - Provider applications for specialty code 64. 
 
Column (9) - Independent Physical Therapist - Provider applications for specialty code 65. 
 
Column (10) - Independent Occupational Therapist - Provider applications for specialty code 67. 
 
Column (11) - Clinical Psychologist - Provider applications for specialty code 68. 
 
Column  (12) - Licensed Clinical Social Worker - Provider applications for specialty code 80. 
 
Column (13) - Certified Nurse Specialist - Provider applications for specialty code 89. 
 
Column (14) - Independent Physiological Laboratory - Provider applications for specialty code 
95. 
 
Column (15) - Physician Assistant - Provider applications for specialty code 97. 
 
Column (16) - Mammography Screening Center - Provider applications for specialty code 45. 
 
Column (17 - Ambulatory Surgical Center - Provider applications for specialty code 49. 
 
Column (18) - Public Health/Welfare Agency - Provider applications for specialty code 60. 
 
Column (19) - Voluntary Health/Charitable Agency - Provider applications for specialty code 61. 
 
Column (20) - Independent Psychologist - Provider applications for specialty code 62. 
 
Column (21) - Portable X-Ray - Provider applications for specialty code 63. 
 
Column (22) - Independent Clinical Laboratory - Provider applications for specialty code 69. 
 
Column (23) - Unknown Supplier/Provider - Provider applications for specialty code 88. 
 
Column (24) - Flu Immunization Biller - Providers applications from individuals identified as 
flu immunization billers. 
 
430.4 - Completing Lines One Through Eleven - Workload Operations 
(Rev. 6, 08-30-02) 
B3-13430.4  
 
Line 1 - Pending End of Last Quarter - The CROWD system will automatically enter the value 
from line 11 on the previous quarter's report. 
  Line 2 - Adjustments to Pending - If it is necessary to revise the pending figure for the close of 
the previous quarter because of inventories taken or reporting errors discovered, the carrier enters 
the adjustment here.  Adjustments can be positive or negative values.  If entering a negative value, 
it precedes the number with a minus (-) sign. 
 
Line 3 - Adjusted Opening Pending - The CROWD system will automatically sum the values on 
lines 1and 2. 
 
Line 4 - New Applications Received - The number of applications received for the first time 
during the reporting quarter. 
 
Line 5 - Returned Applications Resubmitted - The number of applications received during the 
reporting quarter that had previously been received and returned to the applicant for 
correction/completion. 
 
Line 6 - Total Applications Received - The CROWD system will automatically sum the values 
on lines 4 and 5. 
 
Line 7 - Applications Approved - The number of applications approved (i.e., Medicare number 
issued) during the reporting quarter. 
 
Line 8 - Applications Denied - The number of applications denied during the reporting quarter. 
 
Line 9 - Applications Returned - The number of applications returned to the applicant for 
corrections/completion during the reporting quarter. 
 
Line 10 - Total Applications Processed - The CROWD system will automatically sum the values 
on lines 7, 8, and 9. 
 
Line 11 - Pending End of Quarter - The CROWD system will automatically compute the 
number of applications  pending at the end of the reporting quarter by adding the value on line 3 to 
the value on line 6 and then subtracting the value on line 10. 
 
430.5 - Completing Lines Twelve Through Seventeen - Reason for Denial 
(Rev. 6, 08-30-02) 
B3-13430.5 
 
Line 12 - Sanctioned From Medicare - The number of applications denied because the applicant 
is currently excluded/sanctioned from Medicare. 
 
Line 13 - Debarred/Excluded by Other Federal Agency - The number of applications denied 
because the applicant had been debarred, suspended, or excluded by any other Federal agency. 
 
Line 14 - Not Professionally Licensed - The number of applications denied because the applicant 
was not professionally licensed. 
 
Line 15 - Business Address Invalid - The number of applications denied because the applicant 
had an invalid business address.   
Line 16 - Business Location Not Licensed - The number of applications denied because the 
applicants business location was not properly licensed. 
 
Line 17 - CMS Requirements Not Met - The number of applications denied because the 
applicant did not meet all CMS requirements. 
 
430.6 - Completing Lines Eighteen Through Twenty-Two - Reason for Return 
(Rev. 6, 08-30-02) 
B3-13430.6 
 
Line 18 - Incomplete - The number of applications returned to the applicant because the 
application was incomplete. 
 
Line 19 - Unverifiable Information - The number of applications returned to the applicant 
because the application included unverifiable information. 
 
Line 20 - Not Signed - The number of applications returned to the applicant because the applicant 
did not sign the certification statement. 
 
Line 21 - Invalid Billing Agreement - The number of applications returned to the applicant 
because the billing agreement did not meet CMS requirements. 
 
Line 22 - Other - The number of applications returned to the applicant for any reason other than 
the ones indicated on lines 18 through 21. 
 
430.7 - Completing Lines Twenty-Three Through Twenty-Six - Application 
Processing Times 
(Rev. 6, 08-30-02) 
B3-13430.7 
 
Line 23 - Number Under 21 Days - The number of applications processed in less than 21 days 
from the date of receipt. 
 
Line 24 - Number in 21-30 Days - The carrier enters the number of applications processed in 21 
through 30 days from the date of receipt. 
 
Line 25 - Number in 31-40 Days - The number of applications processed in 31 through 40 days 
from the date of receipt. 
 
Line 26 - Number Over 40 Days - The number of applications processed in more than 40 days 
from the date of receipt. 
 
430.8 - Completing Lines Twenty-Seven Through Thirty-Four - Denials 
Appealed 
(Rev. 6, 08-30-02) 
B3-13430.8 
  Line 27 - Pending End of Last Quarter - The CROWD system will automatically enter the value 
from line 34 on the previous quarter's report. 
 
Line 28 - Adjustments - If it is necessary to revise the pending figure for the close of the previous 
quarter because of inventories taken or reporting errors discovered, the carrier enters the 
adjustment here.  Adjustments can be positive or negative values.  If entering a negative value, it 
precedes the number with a minus (-) sign. 
 
Line 29 - Adjusted Opening Pending - The CROWD system will automatically sum the values 
on lines 27 and 28. 
 
Line 30 - Appeals Received - The number of appeals of previously denied applications received 
during the reporting quarter. 
 
Line 31 - Denials Sustained - The number of appeals processed for which the carrier sustained the 
initial denial. 
 
Line 32 - Denials Overturned - The number of appeals processed for which the carrier 
overturned the initial denial. 
 
Line 33 - Total Appeals Processed - The CROWD system will automatically sum the values on 
lines 31 and 32. 
 
Line 34 - Pending End of Quarter - -The CROWD system will automatically compute the 
number of appeals pending at the end of the reporting quarter by adding the value on line 29 to the 
value on line 30 and then subtracting the value on line 33.  430.9 - Exhibits 
(Rev. 6, 08-30-02) 
B3-13430.9 
 
Exhibit 1 - Screens 1 and 2 of Carrier Provider Enrollment Quarterly Workload Report 
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Total Physician Group Cert Nurse M-W Cert RNA
1 2 3 4 5
Workload Operations
 1. Pending End of Last Quarter
 2.    Adjustments
 3. Adjusted Opening Pending
 4. New Applications Received
 5. Returned Apps Resubmitted
 6. Total Applications Received
 7. Applications Approved
 8. Applications Denied
 9. Applications Returned
10. Total Applications Processed
11. Pending End of Quarter
SCREEN 1
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Nurse Prac Ambulance Audiologist Ind Phys Ther Ind Occ Ther
6 7 8 9 10
Workload Operations
 1. Pending End of Last Quarter
 2.    Adjustments
 3. Adjusted Opening Pending
 4. New Applications Received
 5. Returned Apps Resubmitted
 6. Total Applications Received
 7. Applications Approved
 8. Applications Denied
 9. Applications Returned
10. Total Applications Processed
11. Pending End of Quarter
SCREEN 2   Exhibit 2 - Screens 3 and 4 of Carrier Provider Enrollment Quarterly Workload Report 
 
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Ind Clin Psych Lic Clin SW Cert Nurse Sp Ind Phys Lab Phys Asst
11 12 13 14 15
Workload Operations
 1. Pending End of Last Quarter
 2.    Adjustments
 3. Adjusted Opening Pending
 4. New Applications Received
 5. Returned Apps Resubmitted
 6. Total Applications Received
 7. Applications Approved
 8. Applications Denied
 9. Applications Returned
10. Total Applications Processed
11. Pending End of Quarter
SCREEN 3
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
MSC ASC PH/W Agency VH/C Agency Ind Psych
16 17 18 19 20
Workload Operations
 1. Pending End of Last Quarter
 2.    Adjustments
 3. Adjusted Opening Pending
 4. New Applications Received
 5. Returned Apps Resubmitted
 6. Total Applications Received
 7. Applications Approved
 8. Applications Denied
 9. Applications Returned
10. Total Applications Processed
11. Pending End of Quarter
SCREEN 4  
  Exhibit 3 - Screens 5 and 6 of Carrier Provider Enrollment Quarterly Workload Report 
 
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Port X-Ray Ind Clin Lab Unk Supp/Prov Flu Imm Biller
21 22 23 24
Workload Operations
 1. Pending End of Last Quarter
 2.    Adjustments
 3. Adjusted Opening Pending
 4. New Applications Received
 5. Returned Apps Resubmitted
 6. Total Applications Received
 7. Applications Approved
 8. Applications Denied
 9. Applications Returned
10. Total Applications Processed
11. Pending End of Quarter
SCREEN 5
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Total Physician Group Cert Nurse M-W Cert RNA
1 2 3 4 5
Reasons for Denial
12. Sanctioned from Medicare
13. Debarred/Excluded by Other Fed
14. Not Professionally Licensed
15. Business Address Invalid
16. Business Location Not Licensed
17. HCFA Requirements Not Met
Reason for Return
18. Incomplete
19. Unverifiable Information
20. Not Signed
21. Invalid Billing Agreement
22. Other
SCREEN 6  
  Exhibit 4 - Screens 7 and 8 of Carrier Provider Enrollment Quarterly Workload Report 
 
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Nurse Prac Ambulance Audiologist Ind Phys Ther Ind Occ Ther
6 7 8 9 10
Reasons for Denial
12. Sanctioned from Medicare
13. Debarred/Excluded by Other Fed
14. Not Professionally Licensed
15. Business Address Invalid
16. Business Location Not Licensed
17. HCFA Requirements Not Met
Reason for Return
18. Incomplete
19. Unverifiable Information
20. Not Signed
21. Invalid Billing Agreement
22. Other
SCREEN 7
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Ind Clin Psych Lic Clin SW Cert Nurse Sp Ind Phys Lab Phys Asst
11 12 13 14 15
Reasons for Denial
12. Sanctioned from Medicare
13. Debarred/Excluded by Other Fed
14. Not Professionally Licensed
15. Business Address Invalid
16. Business Location Not Licensed
17. HCFA Requirements Not Met
Reason for Return
18. Incomplete
19. Unverifiable Information
20. Not Signed
21. Invalid Billing Agreement
22. Other
SCREEN 8  
  Exhibit 5 - Screens 9 and 10 of Carrier Provider Enrollment Quarterly Workload Report 
 
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
MSC ASC PH/W Agency VH/C Agency Ind Psych
16 17 18 19 20
Reasons for Denial
12. Sanctioned from Medicare
13. Debarred/Excluded by Other Fed
14. Not Professionally Licensed
15. Business Address Invalid
16. Business Location Not Licensed
17. HCFA Requirements Not Met
Reason for Return
18. Incomplete
19. Unverifiable Information
20. Not Signed
21. Invalid Billing Agreement
22. Other
SCREEN 9
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Port X-Ray Ind Clin Lab Unk Supp/Prov Flu Imm Biller
21 22 23 24
Reasons for Denial
12. Sanctioned from Medicare
13. Debarred/Excluded by Other Fed
14. Not Professionally Licensed
15. Business Address Invalid
16. Business Location Not Licensed
17. HCFA Requirements Not Met
Reason for Return
18. Incomplete
19. Unverifiable Information
20. Not Signed
21. Invalid Billing Agreement
22. Other
SCREEN 10  
  Exhibit 6 - Screens 11 and 12 of Carrier Provider Enrollment Quarterly Workload Report 
 
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Total Physician Group Cert Nurse M-W Cert RNA
1 2 3 4 5
Application Processing Times
23. # under 21 Days
24. # in 21-30 Days
25. # in 31-40 Days
26. # over 40 Days
Denials Appealed
27. Pending End of Last Quarter
28.   Adjustments
29. Adjusted Opening Pending
30. Appeals Received
31. Denials Sustained
32. Denials Overturned
33. Total Appeals Processed
34. Pending End of Quarter
SCREEN 11
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Nurse Prac Ambulance Audiologist Ind Phys Ther Ind Occ Ther
6 7 8 9 10
Application Processing Times
23. # under 21 Days
24. # in 21-30 Days
25. # in 31-40 Days
26. # over 40 Days
Denials Appealed
27. Pending End of Last Quarter
28.   Adjustments
29. Adjusted Opening Pending
30. Appeals Received
31. Denials Sustained
32. Denials Overturned
33. Total Appeals Processed
34. Pending End of Quarter
SCREEN 12   Exhibit 7 - Screen 13 and 14 of Carrier Provider Enrollment Quarterly Workload Report 
 
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Ind Clin Psych Lic Clin SW Cert Nurse Sp Ind Phys Lab Phys Asst
11 12 13 14 15
Application Processing Times
23. # under 21 Days
24. # in 21-30 Days
25. # in 31-40 Days
26. # over 40 Days
Denials Appealed
27. Pending End of Last Quarter
28.   Adjustments
29. Adjusted Opening Pending
30. Appeals Received
31. Denials Sustained
32. Denials Overturned
33. Total Appeals Processed
34. Pending End of Quarter
SCREEN 13
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
MSC ASC PH/W Agency VH/C Agency Ind Psych
16 17 18 19 20
Application Processing Times
23. # under 21 Days
24. # in 21-30 Days
25. # in 31-40 Days
26. # over 40 Days
Denials Appealed
27. Pending End of Last Quarter
28.   Adjustments
29. Adjusted Opening Pending
30. Appeals Received
31. Denials Sustained
32. Denials Overturned
33. Total Appeals Processed
34. Pending End of Quarter
SCREEN 14  
  Exhibit 8 - Screen 15 of Carrier Provider Enrollment Quarterly Workload Report 
 
CARRIER  NAME: CONTRACTOR NUMBER:
REPORT PERIOD: CROWD FORM  4
Port X-Ray Ind Clin Lab Unk Supp/Prov Flu Imm Biller
21 22 23 24
Application Processing Times
23. # under 21 Days
24. # in 21-30 Days
25. # in 31-40 Days
26. # over 40 Days
Denials Appealed
27. Pending End of Last Quarter
28.   Adjustments
29. Adjusted Opening Pending
30. Appeals Received
31. Denials Sustained
32. Denials Overturned
33. Total Appeals Processed
34. Pending End of Quarter
SCREEN 15  
  Monthly Statistical Report on Medicare Secondary Payer Savings 
 
440 - Monthly Carrier Report on Medicare Secondary Payer Savings (Form 
CMS-1564) 
(Rev. 6, 08-30-02) 
B3-13450 
 
440.1 - General 
(Rev. 188, Issued: 04-22-11, Effective: 07-01-11, Implementation: 07-05-11) 
 
NOTE: For MSP reporting effective July 2011 for carriers/Part B MACs and October 2011 
for DME MACs, refer to the manual instructions located within Publication 100-05, Chapter 
5, Section 60 (MSP Reports). 
 
Each month the carrier electronically transmits to CO a Monthly Report on Medicare Secondary 
Payer Savings (CMS-1564) via the IBM PC.  It continues to use existing dialup instructions and 
the RLINK software sent to it.  (See 440.9).  Hard copy reports are not required.  It transmits a 
separate report for each office assigned a separate carrier number.  When its service area covers 
more than one State, however, it transmits a separate report for each State even though it has been 
assigned only one number.  It is not required to complete an individual State report for those States 
in which it has had no MSP activity during the month (reports that would show zeros in every cell, 
including pending). 
 
440.2 - Purpose and Scope 
(Rev. 6, 08-30-02) 
B3-13450.2 
 
The Monthly Carrier Report on Medicare Secondary Payer Savings supplies CMS with current 
data on MSP savings and MSP pending workloads. 
 
440.3 - Due Date 
(Rev. 6, 08-30-02) 
B3-13450.3 
 
Form CMS-1564 is due in CMS as soon as possible after the end of the reporting month, but no 
later than the 15th of the following month.  Nonreceipt of the report by the due date will result in a 
telephone contact with the carrier to obtain the report data. 
 
440.4 - Form Heading 
(Rev. 6, 08-30-02) 
B3-13450.4 
 
The carrier enters its name, assigned number and the State in which the provider is located.  In the 
space labeled "Reporting Period" it enters the numeric designation for month and year for which 
the report is prepared, e.g., show 01/02 for January 2002. 
 
  440.5 - Savings Calculations 
(Rev. 6, 08-30-02) 
B3-13450.5 
 
Reporting Dollar Values - The carrier rounds values to the nearest whole dollar.  This includes all 
amounts shown on lines 2, 4, 6, 8 and 10. 
 
Checking Reports - Before mailing the reports, the carrier checks their completeness and accuracy 
as follows: 
 
  Lines 1 + 3 + 5 = line 7 for all columns. 
 
  Lines 2 + 4 + 6 = line 8 for all columns. 
 
  Line 10 should be equal to or greater than line 9 for all columns, unless line 9 is equal to 
"0" in any column; in that case, line 10 should also be equal to "0" for the same column. 
 
  For each line of the report, column "I" (TOTAL) must equal the sum of the items in 
columns "ii" + "iii" + "iv" + "v" + "vi." 
 
440.6 - Recording Savings 
(Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 
Medicare identification number. For purposes of this manual, Medicare beneficiary identifier 
references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary 
Identifier (MBI) during the new Medicare card transition period and after for certain business areas 
that will continue to use the HICN as part of their processes. 
 
The carrier controls all claims from which it extracts MSP savings and is able to verify all amounts 
recorded on the CMS-1564. 
 
MSP Savings File - The carrier retains claims specific key identifying information on each claim 
counted as savings on the CMS-1564.  At a minimum, it records the beneficiary's name, Medicare 
beneficiary identifier, claim control number, type/dates of service, billed charges and savings 
amounts reported. 
 
Savings Data from Non-Medicare Sources - If the carrier records savings from data which it has 
obtained from its "private side" records or any other "outside" source, it must be able to extract the 
same claims specific information noted above; i.e., it must verify that Medicare covered services 
are involved and be able to calculate "what Medicare would have paid."  In addition, it compares 
these data with the data contained in its MSP savings file to ensure that savings have not 
previously been recorded for the same claim.  If savings have not previously been taken, it counts 
them as savings on the CMS-1564 and enters them into its MSP savings file. 
. 
 
 
  440.7 - Source of Savings 
(Rev. 6, 08-30-02) 
B3-13450.7 
 
The carrier reports data by total and by source as shown below: 
 
Column (i)  Total - All MSP savings regardless of source. 
Column (ii)  Worker's Compensation, Black Lung, and VA - Data related to all 
MSP savings resulting from medical benefits provided by the WC 
Plans of the 50 States, the District of Columbia, Guam and Puerto 
Rico. Also included is Federal WC provided under the Federal 
Employee's Compensation Act, the U. S.  Longshoremen's and Harbor 
Workers' Compensation Act and its extensions, the Federal Coal Mine 
Health and Safety Act of 1969 as amended (the Federal BL Program), 
and any fee-for-service medical care paid for by the VA.  The carrier 
keeps separate records for each distinct category (WC, BL or VA) as 
this may become a reporting requirement in the future. 
Column (iii)  Working Aged - The carrier includes data related to all MSP savings 
resulting from benefits payable under an EGHP for beneficiaries aged 
65 and older who are covered by reason of their own employment or 
the employment of a spouse of any age.  Medicare Claims 
Processing, Chapter 28, Coordinating With Medicaid and Medigap 
Insurers further defines the individuals subject to this limitation on 
payment. 
Column (iv)  ESRD - The carrier includes data related to all MSP savings resulting 
from benefits payable under an EGHP for individuals who are entitled 
to Medicare benefits solely on the basis of ESRD during a period of 
up to 12 months. The period during which Medicare pays benefits is 
defined in Medicare Claims Processing, Chapter 28, Coordinating 
With Medicaid and Medigap Insurers. 
Column (v)  Auto Medical, No Fault and Liability Insurance - The carrier 
includes data related to all MSP savings resulting from both: 
  Automobile Medical or No Fault Insurance - Insurance coverage 
(including a self-insured plan) that pays for all, or part, of the medical 
expenses for injuries sustained in the use of, or occupancy of, an 
automobile, regardless of who may have been responsible for the 
accident.  (This insurance is sometimes called "personal injury 
protection," "medical payments coverage" or "medical expense 
coverage.") 
  Liability Insurance - Insurance (including a self-insured plan) that 
provides payment based on legal liability for injury, illness, or damage 
to property.  It includes, but is not limited to, automobile liability 
insurance, uninsured motorist insurance, homeowners' liability 
insurance, malpractice insurance, product liability insurance, and 
general casualty insurance.  It does not include situations where a 
beneficiary receives medical payment under his or her own 
homeowner's insurance.  Column (vi)  Disabled - The carrier includes data related to all MSP savings 
resulting from situations where Medicare is the secondary payer for 
disabled beneficiaries under age 65 (except ESRD beneficiaries) who 
elect to be covered by a large group health plan (LGHP) as a current 
employee or family member of such employee.  A LGHP is any health 
plan that covers employees of at least one employer who normally 
employs 100 or more employees.  The disabled provisions apply to 
items and services furnished on or after January l, 1987 and before 
January l, 1992. 
 
440.8 - Type of Savings 
(Rev. 6, 08-30-02) 
B3-13450.8 
 
The carrier reports data by type of savings as shown below. 
 
Unpaid (Cost Avoided) MSP Claims 
 
Unpaid (cost avoided) claims are those that the carrier returned without payment because it has 
strong evidence that another insurer is the primary payer and there is no indication that payment 
has been requested from that payer.  Any information the carrier obtains from a non-Medicare 
source and uses as the basis for claiming cost avoidance savings must meet the criteria in 440.6B. 
 
Information considered adequate for claiming cost avoidance savings includes statements on the 
claim noting "automobile accident," "collision", or the name of an automobile insurer.  The carrier 
does not count claims it develops as "possible" MSP situations based on routine edits as cost 
avoidance savings unless it has previous information that another payer has primary responsibility.  
For example, "trauma code" edits are not, by themselves, considered strong evidence that 
Medicare is the secondary payer. 
 
Line 1 - Number - The total number of cost avoided claims from which it is recording savings on 
the report. 
 
Line 2 - Dollar Value - The total dollar value of the potential Medicare payments calculated for 
the claims on Line 1 that will be saved if the primary payer makes a payment which relieves 
Medicare of all payment liability. 
 
The carrier shows as the cost avoided amount what Medicare would have paid.  It does not count 
total charges as cost avoided savings.  It reduces the cost avoided amount based upon reasonable 
charge and coinsurance calculations: 
 
  Reasonable Charge Reductions - The reasonable charge amount may be calculated 
through the actual reasonable charge methodology or through a "reasonable charge reduction 
factor" which is the percentage derived from the most current CMS-1565A by dividing Line 3 
(Total Amount of Reduction) by Line 1 (Total Covered Charges for All Claims).  (See 240.2.) 
 
  Coinsurance - The carrier reduces line items subject to the Part B coinsurance by that 
amount or apply a "coinsurance reduction factor" of 19 percent to all charges.  The carrier may assume that the deductible has been met. 
 
Tracking/Adjusting Cost Avoidance Savings 
 
Cost avoidance savings may not duplicate savings reported as full or partial recoveries and may 
not be shown where Medicare ultimately makes primary payment.  To prevent duplicate counting, 
the carrier suspends all claims which it returns unpaid.  It sets up a control on the claim when it is 
returned for development.  It maintains this control for 75 days, unless it receives further 
information before that time allowing it to process the claim.  If no further information on the 
claim is received after 75 days, it denies the claim.  It is not required to continue tracking the 
claim, but retains the key identifying information on the claim, as described in 440.6A. 
 
The CMS prefers the carrier to show cost avoidance savings only after 75 days have elapsed.  The 
carrier does, however, have the option of counting the savings when the claim is initially 
suspended or at any time during the suspension period.  If it chooses the latter alternative, it must 
adjust its cost avoidance savings if the claim is resubmitted during the suspension period with 
information showing it is not a legitimate cost avoidance. 
 
NOTE: Nonassigned claims may not be returned to beneficiaries (see 3311), but must be 
controlled as described above when being developed for MSP involvement and counted as cost 
avoidance savings. 
 
The following situations require special consideration if cost avoidance savings are counted before 
the 75 day suspense period has ended: 
 
  A claim returned (and counted as cost avoided) is paid in part by another payer and the 
submitter resubmits it for secondary payment. 
 
  A claim returned (and counted as cost avoided) is denied by the other payer and the 
submitter resubmits it for primary payment. 
 
  A claim returned (and counted as cost avoided) is paid in full by the other payer and the 
provider or some other source informs the carrier of this.  The carrier shows "full recovery" 
savings and not cost avoidance. 
 
In these situations the carrier adjusts its cost avoidance savings figures by deducting or "backing 
out" the applicable amounts.  It makes the adjustments in the reporting month in which a final 
determination is rendered.  The following chart outlines the correct reporting of savings in each 
situation:  ADJUSTMENTS TO REPORTED MSP COST AVOIDANCE SAVINGS 
 
CLAIMS PROCESSING ACTIONS  MSP SAVINGS REPORTED 
Cost   Partial   Full 
 
Avoidance  Recoveries  Recoveries 
I.  Partial Recovery Adjustment          
MSP situation indicated. 
Medicare's payment calculated 
to be $50 if Medicare was  $ 50       
primary payer. Claim is 
returned to submitter. 
Claim is resubmitted  
showing $30 paid by the other 
insurer. a Medicare  $(50) *  $ 30    
secondary payment of $20 is 
made. 
II.     "Other" Payer Denial Adjustment          
MSP situation indicated - 
Medicare's "primary" payment 
$ 75       
calculated to be $75. Claim 
is returned to submitter. 
Other payer denies claim.  
Medicare found to be primary 
$ (75)*       
and Medicare payment of $75 
is made. 
III.     Full Recovery Adjustment          
MSP situation indicated - 
Medicare's "primary" payment 
.$ 80       
calculated to be $80. Claim 
is returned to submitter 
Provider or other source  
informs carrier that full 
$ (80)*     $ 80 
payment was made by the  
other payer. 
*Amounts "backed out" of cost avoidance savings figures.  Full Recoveries 
 
Line 3 - Number - The number of full recoveries made during the month. 
 
Line 4 - Dollar Value - The dollar value of full recoveries made during the month. 
Full recoveries represent savings from claims where the primary payer made a payment which 
relieved Medicare of all payment liability.  They can be either prepayment or post-payment.  The 
carrier counts full recoveries in the month in which it renders a final determination on the claim.  
In post payment situations this is when it has recovered the full amount paid by Medicare.  In 
prepayment situations it is when it receives documentation showing that an MSP resource made a 
payment equal to or greater than what Medicare would have paid. 
 
  a.  Prepayment Full Recovery - a prepayment full recovery occurs when an MSP 
resource makes full payment on a charge before Medicare makes any payment.   
 
EXAMPLE:  A physician identifies an EGHP as the primary payer, submits the bill to that 
insurer, and the EGHP pays the charges in full.  The beneficiary informs the carrier of this and 
submits a copy of the EGHP EOB.  The carrier determines what it would have paid if the EGHP 
had not made payment and records that total as full recovery savings. 
 
1.   Post payment Full Recovery - a post payment full recovery occurs when an MSP resource 
makes full payment on a charge after Medicare has paid. 
 
EXAMPLE: Medicare paid a physician's bill for charges incurred as a result of an automobile 
accident.  Subsequently an auto liability insurer reimburses the Medicare beneficiary for the full 
amount and the beneficiary refunds that amount to the carrier.  The carrier counts the amount of 
initial payment as a post payment full recovery. 
It records as savings, that portion of a full recovery paid to an attorney or other agent as Medicare's 
share of the recovery cost.  When it refers a case to the RO for recovery action, however, it does 
not record any savings at that point.  Savings from a compromise or "subrogation" case may be 
recorded only after a final determination.  The carrier does not count these cases for CPEP credit 
prior to final settlement. 
 
EXAMPLE: A beneficiary incurs a $1,000 physician's bill and a $5,000 hospital bill as a result of 
injuries sustained in an automobile accident.  Assuming that all deductibles are satisfied, Part B 
pays $800 toward the physician's charges, and Part A covers the hospital bill in full.  After 
litigation, a liability insurer agrees to pay $6,000 for the beneficiary's medical expenses from 
which the attorney will take a fee.  (If the attorney's fee were 33 percent, the actual dollar recovery 
would be $4,000.) The carrier records $800 in Full Recovery savings (Part Bs full payment).  The 
intermediary is able to count its payment as a Full Recovery savings even though the actual 
amount recovered, due to the attorney's fee did not equal what the intermediary paid. 
Partial Recoveries 
 
Line 5 - Number - The number of partial recoveries made during the month. 
 
Line 6 - Dollar Value - The dollar value of partial recoveries made during the month. 
  Partial recoveries are those savings realized when a primary payer makes a payment which covers 
only a part of the Medicare allowable charge, leaving Medicare with a balance to pay.  The carrier 
uses the following formula in computing the savings from a partial recovery: 
 
  The dollar amount of Medicare benefits available for the services or supplies (calculated as 
if Medicare were the primary payer) less the Medicare benefits paid for the services or 
supplies equals the partial recovery savings. 
(Primary Payment - Actual Payment = Partial Recovery Savings) 
 
It counts partial recoveries in the month when it takes final action on the claim (either making a 
payment supplemental to that of the primary payer or making a partial recovery from a payment by 
the primary payer) on the claim.  Instructions for processing partial recovery claims are in 
Medicare Claims Processing, Chapter 28, Coordination with Medicaid and Medigap Insurers. 
 
The carrier records as savings, that portion of a partial recovery paid to an attorney or other agent 
as Medicare's share of the recovery cost.  When it refers a case to the RO for recovery action it 
does not record any savings at that point.  Savings from a compromise or "subrogation" case may 
be recorded only after a final determination.  These cases may not be counted for CPEP credit 
prior to reaching final settlement. 
 
Totals 
 
In this part of the report (lines 7 and 8), the carrier reports data on the totals of unpaid claims plus 
full and partial recoveries. 
 
Line 7 - Claims - The total number of MSP claims handled during the month. 
 
Line 8 - Dollar Value - The total dollar value associated with MSP claims during the month. 
 
Pending Claims/Cases 
 
Line 9 - Number - The number of pending claims/cases as of the close of the month.  This 
includes claims/cases for which "Full Recovery" is expected but all money due has not been 
received. 
 
Line 10 - Estimated Value - The gross charges for all claims/cases reported as pending on line 9.  
Where "Full Recovery or Partial Recovery" has been determined, but all monies have not been 
received, the carrier reports the gross charges until it receives the full amount due or it is 
reasonable to expect no further payments. 
 
A case is defined as one or more claims filed on behalf of an individual and related to one specific 
occurrence which necessitated medical care.  When recording data for column 1 concerning WC 
and Auto Liability, and No Fault Insurance, the carrier counts only cases.  For Working Aged 
(column iii), ESRD (column iv), and Disabled (column vi), it counts each individual claim. 
 
A case/claim is considered pending only after it has been developed to the point where it is 
determined to be an MSP claim and no final resolution has been made.  A partial or interim  payment is not sufficient to remove a case/claim from the pending rolls.  Final resolution occurs 
when there is no longer a practical expectation of further reimbursement by another resource. 
 
Remarks - The carrier enters any comments relevant to the interpretation and analysis of this 
report. 
 
Signature - The report should be signed by the individual responsible for its compilation. 
 
Date - Date the report is completed and signed. 
 
440.9 - Electronic Submission 
(Rev. 6, 08-30-02) 
B3-13450.9 
 
A.  Keying CMS-1564 - The carrier: 
 
  Uses existing RLINK dialup instructions. 
  Keys letter "K" to bring up blank CMS-1564. 
  Enters valid 5 digit carrier number.  It uses the tab key to move from column to column. 
  Enters reporting period using numeric designation for month and year, e.g., 0102 for 
January 2002. 
  Enters two-position alpha State code. 
  Completes each column of data.  Fields with zero do not have to be keyed. System will 
presume all blank fields to be zero. 
  Does not key dollar signs or commas.  Keys only whole dollar amounts. 
  After completing the form, the carrier keys F1. System edits and prints any error messages 
on the line above "contractor number."  The carrier tabs to incorrect field and rekeys 
correct entry.  When form passes all edits, line will read "record has been written."  Carrier 
keys F4 to return to menu. 
  To abort at any time without writing a record, the carrier keys F3 and refers to CICS 
instructions. 
  To verify that a report has been written, the carrier returns to the main menu (F4) and keys 
"K" to bring up a blank form.  It keys in contractor number, reporting period and State 
code.  It keys F7.  Completed report should appear on the screen. 
 
B.  Edits for CMS-1564: 
 
  A valid 5-digit carrier number is required. 
  The default value for areas not keyed is zero. 
  Appropriate reporting period (MMYY) is required. 
  Two-position alpha State code required. 
  Lines 1 + 3 + 5 must equal line 7 for all columns. 
  Lines 2 + 4 + 6 must equal line 8 for all columns. 
  Line 10 must be equal to or greater than line 9 for all columns, unless line 9 is zero.  In that 
case line 10 must also be zero. 
  For each line of the report column I must equal the sum of columns ii + iii + iv + v + vi.  440.10 - Exhibit 
(Rev. 6, 08-30-02) 
B3-13450.10 
 
 
    460 - Monthly Statistical Report on A/B and DME Medicare Administrative 
Contractor (MAC) Part A and Part B Appeals Activity Form (CMS-2592) 
(Rev. 253, 08-06-15, Effective: 01-01-16, Implementation: 01-04-15) 
 
460.1  General 
(Rev. 253, 08-06-15, Effective: 01-01-16, Implementation: 01-04-15) 
 
At the end of each month, the contractor prepares and transmits to CMS a report summarizing 
monthly activity on redeterminations processed by A/B and DME MACs, as well as those actions 
associated with reconsiderations, and Administrative Law Judge (ALJ) hearings and Part A and 
Part B Medicare Appeals Council effectuations that are processed by A/B and DME MACs.  
Contractors shall complete separate reports for each office where a separate A/B or DME MAC 
Jurisdictional identification number has been assigned. 
 
NOTE:  The report is NOT designed to be completed by the Qualified Independent Contractor 
(QIC) or the Administrative Qualified Independent Contractor (AdQIC).  All data shall be entered 
by the contractor except for those lines that are indicated as Not Applicable (e.g., Medicare 
Approved Amount).  The data in the Not Applicable lines are not required.  Contractors shall 
continue to use the CMS-2591 and CMS-2590 reports to capture data on appeal workloads 
received prior to the implementation date of the CMS-2592 report.  The CMS-2591 and 2590 
reports will be used to record appeals related data received prior to the implementation of the 
CMS-2592 report until all pending appeals workloads have been completed. If a case was received 
prior to the implementation of the CMS-2592, and as such is captured on the CMS-2591 or CMS-
2590, tracking for the case remains on the CMS-2591 or CMS-2590 until all levels of appeal for 
the case have been completed. 
 
Note: The CMS-2591 and 2590 reports will continue to be used to capture reopenings data that is 
not clerical in nature, and as such, is not captured on the CMS-2592 report. 
 
Form CMS-2592 is subject to the Paperwork Reduction Act and requires approval by the Office of 
Management and Budget (OMB). OMB approval has been requested. 
 
Purpose and Scope--The CMS-2592 enables CMS to tabulate data for administrative purposes on 
the following information. 
 
  The number of redeterminations, reconsiderations, and ALJ hearings requested, 
completed, and pending; 
 
  The number of redeterminations resulting in affirmations or reversals of previous 
determinations; 
 
  Timeliness Data (including processing, forwarding and effectuation data at various 
levels of appeal); and, 
 
  Clerical Error Reopenings Data 
 
Unless specifically indicated, data on the CMS-2592 Report is captured in cases.  Where noted, 
information is also requested in claims.  Information on decisions is also requested, as applicable.   
Due Date -Transmit the CMS-2592 to CO via PC or terminal. Use instructions in the Contractor 
Reporting of Operational and Workload Data (CROWD) System User's Guide. 
 
The report is due as soon as possible after the end of the reporting month but no later than the 15th 
of the month following the end of the reporting month. 
 
COMPLETION OF ITEMS ON FORM CMS-2592 
 
Heading  This form is referenced as form 7 in the CROWD system.  Complete the 
ADD/UPDATE/DELETE criteria screen with the appropriate information such as your ID 
Number including Business Segment Identifier (BSI), reporting month and calendar year, 
i.e., 12 2005 for December 2005. 
 
General Information  Completing the Report 
 
Refer to the information below when determining how to count and categorize data for reporting 
purposes. 
 
Controlling Receipt of Cases - In order to ensure that cases are processed timely, cases shall be 
date stamped or controlled in some way upon receipt.  The date of receipt in all cases is the day the 
processing contractor received the request in its corporate mailroom.  The days elapsed for an 
individual request are calculated using the number of days starting from the Julian date of case 
receipt through the Julian date of completion. Include the time required for the response to be 
mailed to the appellant.  For example, a case that is received and processed on January 7 is 
considered to require1 day to clear.  A case received on January 7 and cleared on January 8 is 
considered to require 2 days to clear.  Consider the day of receipt to be Day 1. 
 
Cases that are not received in the mailroom (for example, requests from the QIC for case files 
received by fax or telephone) shall be controlled in some way to ensure that timeliness 
requirements are met. 
 
Counting Cases -- If an appellant submits one request involving several different claims (and 
several different beneficiaries), count it as one case.  If the contractor receives one envelope with 
multiple request forms and supporting documentation, count 1 case per request received.  For 
example, if the envelope contains 10 separate request forms with supporting documentation, count 
as 10 cases. 
 
Counting Part A, B of A and Part B Claims - If an appellant submits one request involving 5 
different claims, count as 5 claims.  If an appellant submits one request involving 1 claim, count as 
1 claim.  If the appellant submits two cases in the same envelope, of which one case has 3 claims 
and the other 4 claims, count as 2 cases with 7 claims.  If an appellant submits a case containing 7 
claims, of which 5 are requests for an appeal and the remaining 2 are determined to be reopenings, 
count the 5 appeal claims among the appeals workload.  The remaining 2 claims shall not be 
counted among the appeals workload, but shall be counted as reopenings (see Line 1 of the 
Reopenings Section). 
 
Counting Part A, B of A and Part B Cases Involving Appeals and Reopenings  If you receive 
a case involving multiple claims and some claims are subject to appeal but others must be handled  as a reopening, count the case as an appeal.  Note:  Reopenings data is captured by claims only.  
Because of this, no case count is recorded for reopenings. 
 
Additional Evidence Submitted After Request is Received -- If you receive a case for which 
additional documentation is submitted for some but not all of the claims, count the case among 
those recorded on Line 7 (Cleared - Evidence Submitted After Request). 
 
When to Consider a Case Reversed -- Consider a case reversed when the initial determination is 
changed upon appeal, (e.g., the claim was denied at the initial determination level but is reversed 
when the case is appealed). 
 
When to Consider a Case Completed  Consider a case to be completed when you complete the 
action that sets in motion correct payment of the claim and you mail the decision letter to the 
appellant.  All redeterminations shall be processed and mailed by the 60th day (unless additional 
evidence is submitted by the party after the request is received, in which case the contractor has up 
to 14 additional days for each submission to process and mail the decision letter to the parties. 
 
See Line 6.1 for additional guidance. 
 
When to Consider a Case Effectuated  Consider effectuation of a decision to be completed 
when payment is issued to the appellant based on a fully favorable or partially favorable decision. 
If you enter the adjustment in the month of July, but payment is not issued to the appellant until 
August, the case is considered to be effectuated in August. 
 
Note:  Considering a case to be completed is different from determining when a case is 
effectuated.  Note the distinctions in the previous paragraphs. It is possible for some overlap of 
completion and effectuation timeframes to occur. 
 
460.2 - Section I  Redeterminations 
(Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 
Medicare identification number. For purposes of this manual, Medicare beneficiary identifier 
references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary 
Identifier (MBI) during the new Medicare card transition period and after for certain business areas 
that will continue to use the HICN as part of their processes. 
 
This section concerns data from Part A and Part B of A appeals processed by A/B MACs (A) as 
well as Part B appeals processed by A/B MACs (B) and DME MACs. 
 
Redeterminations.  The number of redeterminations requested (received), completed, and 
pending reflects the status of the workload as of the last day of the reporting month. Base data on 
actual counts of each activity and not on sampling or other estimating techniques. 
 
A redetermination is the first level of appeal following an initial determination of a Part A claim or 
Part B claim. It is a re-evaluation of the facts and findings of a claim to determine whether the 
initial decision was correct.  (See the Medicare Claims Processing Manual, Publication 100-04, 
Chapter 29, Section 310.)   
Do not count duplicate redetermination requests or redetermination requests received before you 
have made an initial determination on a claim. Do not count inquiries. Count one redetermination 
per request received. With the exception of those lines for which claims counts are specifically 
requested in the report, count only cases.  Do not count a duplicate request for appeal as a 
processed appeal.  Duplicate requests can be reflected in Line 2 (Adjustment to Pending) of the 
CMS-2592 Report for the subsequent month. 
 
Redeterminations fall into the following categories: 
 
Column (1) Part A Cases- Use Column 1 to report information on Part A services processed by 
the A/B MAC (A). 
 
Column (2) Part B of A Cases- Use Column 2 to report information on Part B services processed 
by the A/B MAC (A). 
 
Column (3) Part B Cases- Use Column 3 to report information on Part B services processed by the 
A/B MAC (B) or DME MAC. 
 
Line 1.  Opening Pending - Show under columns 1-3, the number of redetermination cases 
reported on Line 21 as the closing pending redetermination cases on the previous month's report. 
 
Line 2.  Adjustments to Pending - CMS understands that it is often necessary to revise the 
categorization of data from the original categorization given when a case was initially received at 
the contractor.  Likewise, it is often necessary to move data from one line to another in order to 
maintain accuracy.  Prior to the submission of the monthly 2592 report to CMS, contractors are 
permitted to make changes to data during the reporting month to ensure that appeal workloads are 
accurately reflected. 
 
Once the monthly 2592 report has been submitted to CMS, any changes to the closing pending 
figure of the report must be reflected in the Adjustments to Pending line of the subsequent months 
report. If it is necessary to revise the pending figure for the close of the previous months report 
because of inventories or reporting errors, enter the adjustment.  If some cases were not counted in 
the proper month's receipts, count them as adjustments to the opening pending count in the 
subsequent month.  Examples include any instances where something originally categorized as an 
appeal was determined not to be an appeal, or vice-versa. Duplicate requests for redetermination 
are also reflected here.  If the contractor receives a request for appeal near the end of the reporting 
month but the case arrives too late to be reflected as a receipt in the CMS-2592 report for that 
month, count the case in the Adjustment to Pending line of the subsequent months report.  The 
purpose of the Adjustments to Pending line is to allow the contractor to modify Opening Pending 
counts, thereby correcting errors resulting from inventory or reporting problems that were 
identified after the submission of the CMS-2592 previous months report to CMS. 
 
Do not make adjustments to the Pending line or other lines of the 2592 report once the report has 
been submitted to CMS. If there is an entry for Line 2, it should be preceded by a "+" or "-", as 
appropriate. 
 
Line 3.  Adjusted Pending - Enter the result of Line 1 + Line 2 (taking into account the "-" sign, 
if any).   
Line 4.  Requests Received - Show, under the appropriate columns, the number of requests for 
redeterminations received during the reporting month. Include requests transferred to you by other 
A/B or DME MACs or remanded by the Qualified Independent Contractor (QIC). 
 
NOTE:  See the Note under Line 6 (Requests Cleared) regarding the handling of Medicare 
Secondary Payer (MSP) cases. 
 
Line 4.a. Adjusted Requests Received - As a result of actions taken by the A/B and DME MACs 
to process appeals during the reporting month, show on this line the number of receipts that have 
actually been validated by the MAC to be a redetermination. This line should include both RAC 
and non-RAC redeterminations.  
 
NOTE:  See the Note under Line 6 (Requests Cleared) regarding the handling of Medicare 
Secondary Payer (MSP) cases. 
 
Line 4.1.  Number of Claims Received  Show the total number of redetermination claims 
involved in Line 4.a. 
 
Line 4.2.  Recovery Audit Contractor (RAC) Requests Received - Of the redetermination 
requests reported in Line 4.a, show the number that are Recovery Audit related. Line 4.2 is a 
subset of Line 4.a and should contain only RAC redeterminations. 
 
Line 4.2.1.  Number of RAC Claims Received   Show the number of redetermination claims 
involved in Line 4.2. 
 
Line 5.  Misrouted Requests Forwarded to Another Contractor - Show under columns 1 
through 3 the number of redetermination requests the contractor forwarded to other contractors, 
because they were misrouted to you and you did not process the original claim(s). For columns 1-
3, if you have reported a redetermination as forwarded, do not report any information regarding it 
on Lines 6-29. The forwarding of the misrouted request is the final action. 
 
NOTE:  This line is not intended for QIC reconsideration requests that were misrouted. 
 
Line 6.  Requests Cleared - Show, under the appropriate columns, the total number of 
redeterminations completed during the month. Report all completed redeterminations, regardless if 
the final outcome was an affirmation, reversal, withdrawal, or dismissal.  Do not count cases that 
were transferred to another contractor because they were misrouted. 
 
NOTE:  A/B MACs (A) should count received and completed MSP redetermination cases in 
Columns 1 of Lines 4 and 6, as appropriate, regardless of whether claims involved are Part A, Part 
B or a combination.  Do not count or report claims involved in MSP cases. MSP cases should be 
counted in Lines 4, 6, 7, 8, 9, 10 and 11. Do not count MSP claims on Lines 4.1, 6.1, 7.1, 8.1, 9.1, 
10.1 and 11.1. 
 
A/B MACs (B) that handle MSP cases should count them in Column 3. 
 
Line 6.1.  Number of Claims Cleared  Show the total number of claims involved in Line 6. 
  NOTE:  For Lines 6.1 through 11.1 (letters a through i), enter the number and type of claim 
processed.  If no claims from a certain claim type are processed, enter NA.  Refer to instructions 
for the CMS-1565 and 1566, as well as appropriate sections of the Claims Processing Manual for 
guidance on determining the categories and types of claims processed by A/B MACs and DME 
MACs. 
Line 6.1a  Report the number of SNF claims included in Line 6.1. Line 6.1b  Report the number 
of Home Health claims included in Line 6.1.  Line 6.1c  Report the number of Inpatient Hospital 
claims included in Line 6.1.  Line 6.1d  Report the number of Outpatient claims included in Line 
6.1.  Line 6.1e  Report the number of Lab claims included in Line 6.1. Line 6.1f  Report the 
number of Ambulance claims included in Line 6.1. Line 6.1g  Report the number of DME claims 
included in Line 6.1.  Line 6.1h  Report the number of Physician claims reported in Line 6.1.  
Line 6.1i  Report the number of Other claims or claims where the provider type cannot be 
determined based on the information on the claim included in Line 6.1. 
 
Consider a redetermination cleared when: 
 
  For affirmations, when all claims of the case are included in the decision and the 
decision letter is mailed to the parties 
 
  For full and partial reversals: 
 
(1)  all claims within the case are included in the decision and the decision letter is mailed 
to the parties, and 
 
(2)  the contractor completes the action that sets in motion correct payment of the claim. 
 
  For withdrawals and dismissals, the dismissal notice is mailed to the parties. 
 
Note that sending a letter to the mailroom does not constitute mailing the letter.  Letters must be 
mailed to the appellant on or before the 60th day in order for the requirement to be met. 
 
NOTE:  Considering a case to be completed is different from determining when a case is 
effectuated.  Please note the distinctions in the previous paragraphs. 
 
Line 6.2.  Recovery Audit Contractor (RAC) Redeterminations Cleared - Of the cases 
reported in Line 6, how many are RAC related? 
 
Line 6.2.1.  Number of RAC Claims Involved  Show the number of claims involved in Line 
6.2. 
 
Line 7.  Cleared -- Evidence Submitted After Request - Of the cases reported in Line 6, show 
under the appropriate columns, the total number of redetermination cases for which additional 
documentation was submitted by the party on his or her own or when the documentation was 
requested by the contractor after the request was received. 
 
Line 7.1.  Number of Claims Involved  Show the total number of claims involved in Line 6.1 
for which evidence was submitted after the request was received. 
  Lines 7.1a through 7.1i are Not Applicable.  Line 7.1a  Report the number of SNF claims 
included in Line 7.1. Line 7.1b  Report the number of Home Health claims included in Line 7.1.  
Line 7.1c  Report the number of Inpatient Hospital claims included in Line 7.1.  Line 7.1d  
Report the number of Outpatient claims included in Line 7.1.  Line 7.1e  Report the number of 
Lab claims included in Line 7.1.  Line 7.1f  Report the number of Ambulance claims included in 
Line 7.1. Line 7.1g  Report the number of DME claims included in Line 7.1.  Line 7.1h  Report 
the number of Physician claims reported in Line 7.1. Line 7.1i - Report the number of Other claims 
or claims where the provider type cannot be determined based on the information on the claim 
included in Line 7.1. 
 
Line 7.2.  RAC Redeterminations Cleared With Additional Documentation - Of the cases 
reported in Line 7, how many are RAC related? 
 
Line 7.2.1.  Number of RAC Claims Involved  Show the number of claims involved in Line 
7.2. 
 
Note about Lines 8-11: 
 
Count the cases in the following manner: 
 
  If a case has multiple claims and all are affirmed, count the case as an affirmation. 
 
  If a case has multiple claims, some of which are affirmed and others are partially reversed, 
count the case as a partial reversal.  Consider a case reversed when the initial determination 
is changed upon appeal, irrespective of a change in payment. 
 
  If a case has multiple claims, some of which are partially reversed and others are fully 
reversed, count the case as a partial reversal.  Consider a case reversed when the initial 
determination is changed upon appeal, irrespective of a change in payment. 
 
  If a case has multiple claims, all of which are fully reversed, count the case as a full 
reversal. 
 
  If a case has multiple claims, some of which are fully reversed and the others are dismissed 
or withdrawn, count the case as a full reversal. 
 
  If a case has multiple claims, one of which is affirmed, one of which is a partial reversal 
and one of which is dismissed, count the case as a partial reversal. 
 
  If a case has multiple claims which are fully reversed, affirmations and 
withdrawals/dismissals, count the case as a partial reversal. 
 
  If a case has two claims, one of which is affirmed and the other is dismissed, count the case 
as an affirmation. 
 
Full  Partial  Affirmation  Dismissal/  =  Report As 
Withdrawal  X          Full 
  X        Partial 
    X      Affirmation 
      X    Dismissal/ Withdrawal 
X  X        Partial 
X    X      Partial 
X      X    Full 
X  X  X      Partial 
X  X  X  X    Partial 
  X  X      Partial 
  X    X    Partial 
    X  X    Affirmation 
  X  X  X    Partial 
 
Line 8.  Affirmations - Under the appropriate columns, show the number of completed 
redeterminations from Line 6 in which the previous determinations were completely upheld; i.e., 
no change was made.  All claims in a case must be upheld in order for the case to be counted as an 
affirmation.  In instances where claims some are affirmed, but all others are dismissed or 
withdrawn, count the case as an affirmation.  (Do not include partial reversals in this line. See Line 
9 for partial reversals).  Include those instances where the decision was affirmed, but a change in 
liability was noted. 
 
Line 8a.  Waiver of Liability Amount Paid  Not Applicable - Show the amount paid under 
waiver of liability, on the basis that the party did not know that the service wasnt payable under 
Medicare. 
 
Line 8.1.  Number of Claims Affirmed  Show the number of claims involved in Line 6.1 for 
which the decision was affirmed. 
 
NOTE -- The following example is counted as an affirmation:  A claim is denied at the initial 
determination level and a redetermination is requested.  At the redetermination level, the denial is 
upheld but the denial is for a reason other than was determined to be applicable at the initial 
determination level.  Count the claim as an affirmation. 
 
Line 8.1a  Report the number of SNF claims included in Line 8.1. Line 8.1b  Report the number 
of Home Health claims included in Line 8.1.  Line 8.1c  Report the number of Inpatient Hospital 
claims included in Line 8.1.  Line 8.1d  Report the number of Outpatient claims included in Line 
8.1.  Line 8.1e  Report the number of Lab claims included in Line 8.1.  Line 8.1f  Report the 
number of Ambulance claims included in Line 8.1. Line 8.1g  Report the number of DME claims 
included in Line 8.1.  Line 8.1h  Report the number of Physician claims reported in Line 8.1.  
Line 8.1i  Report the number of Other claims or claims where the provider type cannot be 
determined based on the information on the claim included in Line 8.1. 
 
Line 8.2.  RAC Redeterminations Affirmed- Of the affirmation cases reported in Line 8, how 
many are RAC related? 
  Line 8.2.1.  Number of RAC Claims Involved  Show the number of claims involved in Line 
8.2. 
 
Line 9.  Partial Reversals - Under the appropriate columns, show the number of completed 
redeterminations, from Line 6 in which part of the prior determination decision of the appealed 
lines was reversed. That is, a change was made and some part of the new determination was in 
favor of the appellant.  NOTE:  Consider a case reversed when the initial determination is changed 
upon appeal, irrespective of a change in payment. 
 
Line 9.1.  Number of Claims Partially Reversed  Show the number of claims involved in Line 
6.1 for which the decision is partially reversed.  Note:  It is possible to have zero claims in Line 
9.1, even when cases are recorded in Line 9. 
 
Line 9.1a  Report the number of SNF claims included in Line 9.1. Line 9.1b  Report the number 
of Home Health claims included in Line 9.1.  Line 9.1c  Report the number of Inpatient Hospital 
claims included in Line 9.1.  Line 9.1d  Report the number of Outpatient claims included in Line 
9.1.  Line 9.1e  Report the number of Lab claims included in Line 9.1.  Line 9.1f  Report the 
number of Ambulance claims included in Line 9.1. Line 9.1g  Report the number of DME claims 
included in Line 9.1.  Line 9.1h  Report the number of Physician claims reported in Line 9.1.  
Line 9.1i  Report the number of Other claims or claims where the provider type cannot be 
determined based on the information on the claim included in Line 9.1. 
 
Line 9.2.  RAC Redeterminations Partially Reversed Of the partially reversed cases reported 
in Line 9, how many are RAC related? 
 
Line 9.2.1  Number of  RAC Claims Involved  Show the number of claims involved in Line 
9.2. 
 
Line 10.  Full Reversals - Under the appropriate columns, show the total number of completed 
redeterminations from Line 6 in which the previous determination decision of the appealed lines 
was completely reversed.  NOTE:  Consider a case reversed when the initial determination is 
changed upon appeal, irrespective of a change in payment. 
 
Line 10.1.  Number of Claims Fully Reversed  Show the number of claims involved in Line 6.1 
for which the decision is fully reversed. 
 
Line 10.1a  Report the number of SNF claims included in Line 10.1. Line 10.1b  Report the 
number of Home Health claims included in Line 10.1.  Line 10.1c  Report the number of 
Inpatient Hospital claims included in Line 10.1.  Line 10.1d  Report the number of Outpatient 
claims included in Line 10.1.  Line 10.1e  Report the number of Lab claims included in Line 
10.1.  Line 10.1f  Report the number of Ambulance claims included in Line 10.1. Line 10.1g  
Report the number of DME claims included in Line 10.1.  Line 10.1h  Report the number of 
Physician claims reported in Line 10.1.  Line 10.1i  Report the number of Other claims or claims 
where the provider type cannot be determined based on the information on the claim included in 
Line 10.1. 
 
Line 10.2 RAC Redeterminations Fully Reversed  Of the fully reversed cases reported in Line 
10, how many are RAC related? 
  Line 10.2.1 Number of RAC Claims Involved  Show the number of claims involved in Line 
10.2. 
 
Line 11.  Dismissals/Withdrawals - Report, under the appropriate column, the number of cases 
from Line 6 that were withdrawn by the appellant or dismissed (before determination) by you.  In 
order for a case to be recorded in Line 11, all claims in the case must be dismissed or withdrawn. 
 
NOTE:  Do not count cases that were dismissed because they were determined to be incomplete 
in Line 11.  Cases that were dismissed because they were determined to be incomplete should only 
be counted in Line 12. 
 
Line 11.1.  Number of Claims Dismissed or Withdrawn  Show the number of claims involved 
in Line 6.1 which were dismissed or withdrawn. 
 
Line 11.1a  Report the number of SNF claims included in Line 11.1. Line 11.1b  Report the 
number of Home Health claims included in Line 11.1.  Line 11.1c  Report the number of 
Inpatient Hospital claims included in Line 11.1.  Line 11.1d  Report the number of Outpatient 
claims included in Line 11.1.  Line 11.1e  Report the number of Lab claims included in Line 
11.1.  Line 11.1f  Report the number of Ambulance claims included in Line 11.1. Line 11.1g  
Report the number of DME claims included in Line 11.1.  Line 11.1h  Report the number of 
Physician claims reported in Line 11.1.  Line 11.1i  Report the number of Other claims or claims 
where the provider type cannot be determined based on the information on the claim included in 
Line 11.1. 
 
Notes: 
Misrouted correspondence and duplicate requests are not dismissals. 
 
Line 11.2.  RAC Redeterminations Dismissed or Withdrawn - Of the dismissed or withdrawn 
cases reported in Line 11, how many are RAC related? 
 
Line 11.2.1.  Number of RAC Claims Involved  Show the number of claims involved in Line 
11.2. 
 
Line 12.  Number of Incomplete Redetermination Requests Dismissed  - Enter the number of 
cases that were dismissed because the request was incomplete. Report incomplete cases in Line 12 
only if ALL the claims from the case are incomplete.  For information on what constitutes an 
incomplete request, refer to the Medicare Claims Processing Manual, Publication 100-04; Chapter 
29; Section 310.1 
 
NOTE: If one redetermination request contains multiple claims and or line items and is 
split, report the case according to the overall disposition of the individual claims and/or line 
items.  (In many instances, split cases will be reported as partially reversed). 
 
Example:  A supplier submits a redetermination request that contains one request with 50 
claims involving different beneficiaries.  The request contains a name and signature of the 
appellant/supplier, and the supporting documentation identifies individual claims of the 
beneficiaries, pertinent Medicare beneficiary identifier and the dates of service.  However, 
for some of the claims, the supplier does not identify the specific services (among the 
several line items on the claim) that are disputed.  The contractor should not dismiss the  entire redetermination request.  Rather, in this situation, the contractor issues dismissals 
(incomplete requests) with respect to the individual claims for which the requisite 
information is incomplete, and issues favorable and/or unfavorable decisions for the 
remaining claims, as appropriate.  For the purposes of reporting, the case is reported 
according to the overall disposition of the individual claims and/or line items.  If the case 
contains some affirmations, reversals and dismissals, count the case as partially reversed in 
Line 9. 
 
Example:  A supplier submits a redetermination request that contains one request with 50 
claims involving different beneficiaries.  The request is missing the signature of the 
appellant/supplier, but identifies the individual claims of the beneficiaries, pertinent names 
and Medicare beneficiary identifiers, dates of service and the items or services disputed.  
Since the signature is missing, the entire request would be dismissed as incomplete, and 
counted in Line 12 of the CMS-2592. 
 
Do not count cases that were dismissed for reasons other than being incomplete on Line 12.  
Only count those instances for which the entire request is dismissed on Line 12. 
 
Line 13.  Medicare Approved Amount (Not Applicable) - For cases included in Lines 9 and 10, 
show the Medicare Approved Amount for services where the initial determination was reversed at 
the redetermination level, either fully (Line 10) or partially (Line 9). Show charges prior to 
application of the deductible and coinsurance. Round results to the nearest dollar. 
 
Processing and Pending Times -This deals with processing and pending times for Part A and 
Part B appeals. 
 
Computing Time to Process Redeterminations for (Lines 6 through 25) 
 
For Lines 6-25, use the matrix below to determine the number of days from receipt to completion 
of redeterminations. The date of receipt in all cases is the day the processing contractor received 
the request in its corporate mailroom. In order to ensure that cases are processed timely, cases 
should also be date stamped or controlled in some way in the mailroom. 
       Situation     Date Completed 
  
   o   The appellant withdraws the request.     The date the dismissal letter is 
mailed to the party. 
  
   o   The contractor dismisses the request      The date the dismissal letter is 
mailed to the party. 
  
   o    The contractor reverses the initial     For both full and partial reversals, 
  determination.  when the contractor completes the 
    action that sets in motion correct 
    payment of the claim and the 
    contractor mails the decision letter 
    to the party. 
o     
  The contractor affirms the initial  The date the decision letter is 
determination  mailed to the party. 
   
 
REDETERMINATIONS 
 
PROCESSING TIME:  REDETERMINATIONS WITH DOCUMENTATION 
SUBMITTED TIMELY (Lines 14-16) 
 
Line 14.  Redetermination Processing Time  Average  Report, under the appropriate columns, 
the average number of days from receipt of the redetermination in the corporate mailroom to the 
date of completion.  Do not include redeterminations where documentation is submitted after the 
request (i.e., a redetermination cannot be counted in both Line 14 and Line 17). 
 
To compute the average number of days from request to completion, divide the total days elapsed 
for all requests (where the documentation was submitted timely) cleared in the month by the 
number of requests cleared. Round results to the nearest day.  The days elapsed for an individual 
request are calculated using the number of days from the Julian date of case receipt through the 
Julian date of completion. Include the time required for the response to be mailed to the appellant.  
If the request is cleared in the year following the year of receipt, add 365 or 366 to the result, as 
appropriate. (Otherwise, you will get a negative number). If a case is cleared the same day it is 
received, consider it to require one day.  For example, a case that is received and processed on 
January 7 is considered to require one day to clear.  A case received on January 7 and cleared on 
January 8 is considered to require 2 days to clear. 
 
Include all cases cleared, regardless of whether they were affirmed, reversed, dismissed, or 
withdrawn. 
  Line 15.  Redeterminations Completed in 1-60 Days - Show the number of redeterminations that 
required 1-60 calendar days to complete (based on the date of receipt of the request in the 
corporate mailroom).  Do not include redeterminations reported in Lines 18-20. 
 
Line 15a.  RAC Redeterminations Completed in 1-60 Days  Of the total number of appeals 
reported in Line 15, show the number that are RAC related. 
 
Line 16.  Redeterminations Completed in over 60 Days - Show the number of redeterminations 
that required more than 60 calendar days to complete (based on the date of receipt of the request in 
the corporate mailroom).  Do not include redeterminations reported in Lines 18-20. 
 
Line 16a.  RAC Redeterminations Completed in Over 60 Days  Of the number of appeals 
reported in Line 16, show the number that are RAC related. 
 
PROCESSING TIME:  Redeterminations with DOCUMENTATION SUBMITTED AFTER 
REQUEST WAS RECEIVED (Lines 17-20) 
 
NOTE:  This section captures information in instances where the party submits additional 
documentation at the redetermination level (including those instances when the contractor requests 
the additional documentation) after the initial request for redetermination is received.  The 
contractor must receive the documentation before the 60 day timeframe is up in order for data to 
be entered into Lines 17-20. 
 
Line 17.  Redeterminations Processing Time - Average (Documentation Submitted Later)  
For redeterminations where documentation/evidence is submitted after the request is received, 
report under the appropriate columns, the average number of days from receipt of the 
redetermination to the date of completion.  Using redeterminations where documentation was 
submitted later as the basis, follow instructions in Line 14 to calculate the average processing time. 
 
Line 18.  Redeterminations Completed in 1-60 Days (Documentation Submitted Later) - 
Show the number of redeterminations from Line 6 where documentation/evidence is submitted 
after the request is received, and 1-60 calendar days were required to complete the case. 
 
Line 18a.  RAC Redeterminations Completed in 1-60 Days (Documentation Submitted Later) 
 Of the number of appeals reported in Line 18, show the number that are RAC related. 
 
Line 19.  Redeterminations Completed in 61-74 Days (Documentation Submitted Later) - 
Show the number of redeterminations from Line 6 where documentation/evidence is submitted 
after the request is received, and 61-74 calendar days were required to complete the case. 
 
Line 19a.  RAC Redeterminations Completed in 61-74 Days (Documentation Submitted 
Later)  Of the number of appeals reported in Line 19, show the number that are RAC related. 
 
Line 20.  Redeterminations Completed in over 74 Days (Documentation Submitted Later) - 
Show the number of redeterminations from Line 6 where documentation/evidence is submitted 
after the request is received, and more than 74 calendar days were required to complete the case. 
 
Line 20a. RAC Redeterminations Completed in over 74 Days (Documentation Submitted 
Later)  Of the number of appeals reported in Line 20, show the number that are RAC related.   
Pending Time Frames 
 
Line 21.  Closing Pending Redeterminations - Show, under the appropriate columns, the total 
number of redeterminations that have not been completed by the end of the reporting month.  
Note:  Do not include pending effectuations in this line. 
 
Line 22.  Redeterminations Pending 1-30 Days  Show the number of redeterminations included 
in Line 21 that have been pending for 1-30 days, inclusive, at the end of the reporting month. 
 
Line 23.  Redeterminations Pending 31-60 Days - Show the number of redeterminations 
included in Line 21 that have been pending 31-60 days, inclusive, at the end of the reporting 
month. 
 
Line 24.  Redeterminations Pending 61-74 Days - Show the number of redeterminations 
included in Line 21 which have been pending 61-74 days, inclusive at the end of the reporting 
month. 
 
Line 25.  Redeterminations Pending Over 74 Days - Show the number of redeterminations 
included in Line 21 which have been pending more than 74 days at the end of the reporting month. 
 
EFFECTUATION OF REDETERMINATION DECISIONS 
 
Line 26.  Total Effectuations - Show the number of redetermination cases for which you 
effectuated a decision during the month. Consider effectuation of a decision to be completed when 
you issue payment to the appellant based on a fully favorable or partially favorable decision. 
Include effectuation of affirmations where changes in liability are at issue.  Do not include cases 
for which no effectuation is required. 
 
Notes:  Considering a case to be completed is different from determining when a case is 
effectuated.  Please refer to the distinctions in the introductory sections of the2592 report (When 
to Consider a Case Completed and When to Consider a Case Effectuated). 
 
Line 26a.  Number of Claims Involved  Show the number of claims involved in Line 26. 
 
Line 27.  Number Effectuated 1-30 Days - Show the number of claims from Line 26a where you 
effectuated the decision within 30 calendar days of the date of the decision. 
 
Line 28.  Number Effectuated 31-60 Days - Show the number of claims from Line 26a where 
you effectuated the decision within 31- 60 calendar days of the date of the decision. 
 
Line 29.  Number Effectuated Over 60 Days - Show the number of claims from Line 26a where 
you effectuated the decision in more than 60 calendar days of the date of the decision. 
 
 
 
 
  460.3 - Section II - Qualified Independent Contractor (QIC) Reconsiderations 
(Rev. 253, 08-06-15, Effective: 01-01-16, Implementation: 01-04-15) 
 
 - Use Section II to report requests for reconsideration. 
 
Reconsiderations, the second level of appeal, are processed by the QIC.  This section of the report 
captures information related to several distinct pieces associated with the reconsideration process.  
While requests for reconsideration should be sent directly by the appellant to the QIC, it is 
probable that some requests will be sent to A/B MACs and DME MACs, requiring the need for 
forwarding the request, and the associated case file, to the QIC.  In those instances where the 
requests for reconsideration are sent directly to the QIC as required, the QICs will have to request 
case file information from the contractor before the reconsideration can be conducted.  In addition, 
the contractor will effectuate QIC decisions, as appropriate. 
 
QIC RECONSIDERATIONS FALL INTO THE FOLLOWING CATEGORIES: 
 
Column (1) Part A Cases- Use Column 1 to record information on reconsiderations of 
redeterminations for Part A services processed by the A/B MAC (A). 
 
Column (2) Part B of A Cases Use Column 2 to record information on reconsiderations of 
redeterminations for Part B services processed by the A/B MAC (A). 
 
Column (3) Part B Cases- Use Column 3 to record information on reconsiderations of 
redeterminations for Part B services processed by the A/B MAC (B) or DME MAC. 
 
Line 30.  Opening Pending - Show the number of closing pending reconsiderations reported on 
Line 47 on the previous month's report. 
 
Line 31.  Adjustments to Pending - If it is necessary to revise the pending figure for the close of 
the previous month because of inventories or reporting errors, enter the adjustment. Report 
requests received near the end of the reporting month and placed under control in the subsequent 
month as received in the reporting month, not as requests received in the subsequent month. If 
some cases were not counted in the proper month's receipts, count them as adjustments to the 
opening pending in the subsequent month. 
 
Line 32.  Adjusted Opening Pending - Show the result of Line 30 + Line 31 (taking into account 
the - sign, if any). 
 
Line 33.  Requests for QIC Reconsideration Received by the Contractor - Show the number of 
QIC reconsiderations received by the contractor during the month.  Although the requests for 
reconsideration should be sent directly to the QIC, some requests may be sent directly to the 
contractor in error, and as such, are considered to be misrouted.  Enter the number 
reconsideration requests sent by the appellant or their representative directly to the contractor.  The 
contractor must forward these requests, along with the associated case file, to the QIC. 
 
Line 33a.  Misrouted Requests Forwarded to QIC Show the number of misrouted 
reconsideration requests that were forwarded to the QIC, along with the associated case file, during 
the month. Do not include duplicate requests for reconsideration in this line.   
Line 33b.  Misrouted Requests Forwarded Timely   Of the number reflected in Line 33a, show 
the number forwarded to the QIC in 1-30 calendar days. 
 
Line 33c.  Misrouted Requests Forwarded Untimely   Of the number reflected in Line 33a, 
show the number forwarded to the QIC in more than 30 calendar days. 
 
Line 34.  Requests from QIC for Case Files:  Upon receipt of the request for reconsideration, the 
QIC must contact the contractor to request the case file.  Show the number of requests for case 
files received by the contractor from the QIC during the month.  Requests can be received in the 
corporate mailroom, by telephone or by fax.  Consider the date of receipt as the date you receive 
the QIC request for the case file. 
 
Line 35.  Number of Case Files Forwarded to QIC - Show the number of reconsideration case 
files forwarded to QICs during the month. Consider the case forwarded when all necessary 
material has been mailed to the QIC. 
 
Line 36.  Number Forwarded in 1-5 Days  Show the number of Reconsideration case files 
forwarded to the QIC in 1-5 calendar days from the date of receipt of the QIC request to mailing of 
the necessary information to the QIC.  Show data for all cases mailed during the month. 
 
Line 36a.  Number Forwarded In 6 Days - Show the number of Reconsideration case files 
forwarded to the QICs in 6 calendar days from the date of receipt of the QIC request to mailing of 
the necessary information to the QIC.  Show data for all cases mailed during the month. 
 
Line 37.  Number Forwarded In 7-8 Days - Show the number of Reconsideration case files 
forwarded to the QICs in 7-8 calendar days from the date of receipt of the QIC request to mailing 
of the necessary information to the QIC.  Show data for all cases mailed during the month. 
 
Line 37a.  Number Forwarded In Over 8 Days - Show the number of Reconsideration case files 
forwarded to QICs in over 8 calendar days from the date of receipt of the QIC request to mailing 
of the necessary information to the QIC. Show data for all cases mailed during the month. 
 
Line 38.  Average Time to Forward - The average number of calendar days from date of the QIC 
request to the date you mail the necessary information. Refer to instructions contained in Line 14 
to determine average time to forward. 
 
Line 39.  Pending Case File Requests  Show the number of case files yet to be forwarded to the 
QIC.  This could include requests received from, but not yet sent to the QIC, as well as those 
reconsideration requests sent to the contractor instead of the QIC. 
 
Disposition of QIC Decisions 
 
Line 40.  Number of QIC Decisions Received From QIC- Show the number of Reconsideration 
requests completed by the QIC and returned to the contractor during the month. 
 
Line 41.  Number of QIC Decisions That Need Effectuation - Show the number of 
Reconsideration decisions from Line 40 which must be effectuated. 
  41a.  Number of Claims Involved:  Show the number of claims involved in Line 41. 
 
EFFECTUATION OF QIC DECISIONS 
 
Line 42.  Total Effectuations - Show the number of Reconsideration decisions for which you 
effectuated a decision during the month. Consider effectuation of a decision to be completed when 
you issue payment to the appellant based on a fully favorable or partially favorable decision.  
Include effectuation of affirmations where changes in liability are at issue.  Do not include cases 
for which no effectuation is required. 
 
NOTE:  Considering a case to be completed is different from determining when a case is 
effectuated.  Please refer to the distinctions in the introductory sections of the2592 report (When 
to Consider a Case Completed, and When to Consider a Case Effectuated). 
 
NOTE:  If the QICs decision is favorable to the appellant and gives a specific amount to be paid, 
effectuation must occur within 30 calendar days of the date of the QICs decision.  If the decision 
is favorable but the amount to be paid must be computed, effectuation must occur within 30 days 
after the amount is computed.  The amount must be computed as soon as possible, but no later than 
30 calendar days of the date of receipt of the QICs decision. 
 
Line 42a.  Number of Claims Involved  Show the number of claims involved in Line 42. 
 
NOTE:  Information captured in Lines 43, 44 and 45 reflects time to compute the amount to be 
paid as well as the effectuation timeframes.  Information provided in Lines 43-45 also assumes that 
contractors must calculate the amounts to be paid.  Even though all appropriate timeframes are not 
reflected here, contractors are still required to follow applicable manual requirements and 
timeframes with regard to receipt, calculation and effectuation of decisions.  CMS anticipates that 
effectuation of most decisions for which the amount is provided should fall into Line 43. 
 
Line 43.  Number Effectuated in 1-30 Days - Show the number of claims from Line 42a where 
you effectuated the decision within 30 calendar days.  Effectuation days include the day of receipt 
of the reconsideration effectuation notice in your corporate mailroom or electronic transmission, 
such as fax or secure e-mail through the day the payment is issued.   
 
43a.  Contractor Computed Amount  Of the number reflected on Line 43, show the number 
where the contractor was required to compute the amount to be paid.  An entry of zero indicates 
that the contractor was not required to compute the amount for any claim. 
 
Line 44.  Number Effectuated in 31-60 Days - Show the number of claims from Line 42a where 
you effectuated the decision within 31-60 calendar days. Effectuation days include the day of 
receipt of the reconsideration effectuation notice in your corporate mailroom or electronic 
transmission, such as fax or secure e-mail through the day the payment is issued.   
 
44a.  Contractor Computed Amount  Of the number reflected on Line 44, show the number 
where the contractor was required to compute the amount to be paid.   An entry of zero indicates 
that the contractor was not required to compute the amount for any claim. 
 
Line 45.  Number Effectuated in Over 60 Days - Show the number of claims from Line 42a 
where you effectuated the decision in more than 60 calendar days.  Effectuation days include the  day of receipt of the reconsideration effectuation notice in your corporate mailroom or electronic 
transmission, such as fax or secure e-mail through the day the payment is issued.   
 
45a.  Contractor Computed Amount  Of the number reflected on Line 45, show the number 
where the contractor was required to compute the amount to be paid.  An entry of zero indicates 
that the contractor was not required to compute the amount for any claim. 
 
Line 46.  Medicare Approved Amount (Not Applicable)  - For decisions included in Line 42 
show the Medicare approved amount for services at the QIC level where the determination was 
reversed, either fully or partially.  Show the charges prior to application of the deductible and 
coinsurance. Round results to the nearest dollar. 
 
It is preferable to report the Medicare Approved Amount at the time that cases are reported on line 
42.  However, CMS will consider it acceptable for contractors to report the Medicare Approved 
Amount when adjustment claims tied to cases that are reporting or will report to line 42 finalize. 
 
Line 46a.  Waiver of Liability Amount Paid (Not Applicable)  Of the amount recorded on 
Line 46, show the amount applicable to a waiver of liability payment on the basis that the party did 
not know that the service wasnt payable under Medicare. 
 
Line 47.  Closing Pending Reconsiderations - Show the total number of reconsideration requests 
that were not effectuated by the end of the reporting month. Consider a case pending from the date 
of receipt of the request at the contractor, or the date of the request for the case file from the QIC, 
until you have received the completed decision from the QIC for all parts of the case.  This number 
shall also reflect those case files not yet forwarded to the QIC by the contractor as well as those 
decisions that have been received by the contractor from the QIC that still require effectuation on 
the part of the contractor.  For example, if you receive a case from the QIC, and have initiated the 
adjustment into the system, but have not issued the payment, the case is reported in Line 47 as 
pending. 
 
Do not include instances where a misrouted file has been sent to the proper QIC in another 
jurisdiction.  Misrouted files that belong to a QIC in another jurisdiction should be considered 
closed once they have been forwarded to the appropriate QIC.  Files that are forwarded to the QIC 
servicing the same jurisdiction as the contractor should remain open until the effectuation is 
complete. 
 
460.4  Section III- Administrative Law Judge Results 
(Rev. 253, 08-06-15, Effective: 01-01-16, Implementation: 01-04-15) 
 
Line 48.  Opening Pending - Show the number of ALJ decisions reported on Line 57 as the 
closing pending on the previous month's report. 
 
Line 49.  Number of Appeal Requests for ALJ Hearing Misrouted to Contractor  Report the 
number of appeal requests for an ALJ hearing that were misrouted to the contractor when they 
should have been filed with the Office of Medicare Hearings and Appeals instead.  These are ALJ 
requests that were filed with the contractor by mistake. 
  Line 50.  Number of ALJ Decisions Received From Administrative QIC (AdQIC) - Show the 
number of ALJ hearing decisions returned by the AdQIC to the contractor during the month. 
Consider the receipt date to be the date the case is received from the AdQIC.  Include instances 
where decisions were received in the previous month, but were not entered into the system until 
the current month. 
 
Line 51.  Number of ALJ Decisions Received that Need Effectuation - Show the number of 
ALJ decisions from Line 50 which must be effectuated. 
 
Line 51a.  Number of Claims Involved  Show the number of claims involved in Line 51. 
 
Line 52.  Total Effectuations -Show the number of ALJ decisions effectuated during the month. 
Consider effectuation of a decision to occur when you issue payment based on a fully favorable or 
partially favorable decision.  Include effectuation of affirmations where changes in liability are at 
issue.  Do not include cases for which no effectuation is required. 
 
Line 52a.  Number of Claims Involved  Show the number of claims involved in Line 52. 
 
NOTE:  Information captured in Lines 53, 54 and 55 assumes that contractors must calculate the 
amounts to be paid before effectuation can occur. Contractors are required to follow other 
applicable timeframes used when specific amounts to be paid have been provided with the 
information received from the AdQIC.  CMS anticipates that effectuation of most decisions for 
which the amount is provided should fall into Line 53. 
 
Line 53.  Number Effectuated in 1 - 30 Days - Show the number of claims from Line 52a where 
you effectuated the decision within 30 calendar days. Effectuation days include day of receipt of 
the effectuation notice from the AdQIC in your corporate mailroom or electronic transmission, 
such as fax or secure e-mail, through the day the payment is issued. 
 
Line 54.  Number Effectuated in 31 - 60 Days - Show the number of claims from Line 52a where 
you effectuated the decision within 31-60 calendar days.  Effectuation days include day of receipt 
of the effectuation notice from the AdQIC in your corporate mailroom or electronic transmission, 
such as fax or secure e-mail, through the day the payment is issued. 
 
Line 55.  Number Effectuated in Over 60 Days - Show the number of claims from Line 52a 
where you effectuated the decision in more than 60 calendar days. Effectuation days include day of 
receipt of the effectuation notice from the AdQIC in your corporate mailroom or electronic 
transmission, such as fax or secure e-mail, through the day the payment is issued. 
 
Line 56.  Medicare Approved Amount (Not Applicable) - For decisions included in Line 52, 
show the Medicare approved amount for services where the reconsideration determination was 
reversed at the ALJ level, either fully or partially.  Show charges prior to application of the 
deductible and coinsurance. Round results to the nearest dollar. 
 
It is preferable to report the Medicare approved amount at the time that cases are reported on line 
52.  However, CMS will consider it acceptable for contractors to report the Amount Paid when 
adjustment claims tied to cases that are reporting or will report to line 52 finalize. 
  Line 56a.  Waiver of Liability Amount Paid (Not Applicable)  Of the amount recorded on 
Line 56, show the amount applicable to a waiver of liability payment on the basis that the party did 
not know that the service wasnt payable under Medicare. 
 
Line 57.  Closing Pending ALJ Decisions - Show the total number of ALJ decisions that were 
received from the AdQIC, but were not completed by the contractor at the end of the reporting 
month, and as such, are still pending effectuation.  All claims associated with the decision must be 
received from the AdQIC in order for the decision to be considered complete. 
 
460.5 - Section IV  Medicare Appeals Council Effectuations 
(Rev. 130, Issued: 08-31-07, Effective: 01-01-08, Implementation: 01-07-08) 
 
Line 58.  Medicare Appeals Council Effectuations  Show the total number of cases received 
from the Medicare Appeals Council which require effectuation by the contractor.  While it is 
acknowledged that contractors will not have responsibility for forwarding these cases to the 
Medicare Appeals Council, information is requested since the contractor will have ultimate 
responsibility to make payment.  For reporting purposes, the contractor shall consider the date of 
receipt as the date the Medicare Appeals Council case is received from the AdQIC. 
 
460.6 - Clerical Error Reopenings 
(Rev. 144; Issued: 11-28-08; Effective Date:  04-01-09; Implementation Date:  04-06-09) 
 
When a determination is made on a claim for services, the beneficiary (and the provider, physician 
or other supplier of medical services) should be able to rely on the fact that the coverage decision 
and payment amount are correct.  Occasionally, information disclosing an error (on the part of the 
appellant or the contractor) in the determination comes to light after the payment has been 
incorrectly processed.  Regulations do not permit unrestricted reopening of determinations and 
decisions, but rather, set specific circumstances under which a determination or decision may be 
reopened.  Refer to 42 Code of Final Regulations (CFR) 405.980-986, Interim Final Rule, dated 
March 8, 2005.The Clerical Error Reopening section of the 2592 report focuses primarily on those 
clerical error and minor omission reopenings that occur at the pre and post redetermination level.  
Data on requests at the QIC level and above are only captured in Lines13 and 14 of the Clerical 
Error Reopening section of the report.  Requests for a clerical error reopening may be received in 
writing or by telephone.  Contractors shall continue to use the appropriate columns and lines of the 
CMS-2591 and CMS-2590 reports to capture data on reopenings that are not clerical in nature.  Do 
not capture clerical error reopenings data on the 2590/2591. 
 
NOTE:  Clerical Error Reopenings data requested in this section should be reported in 
claims, not cases. 
 
Line  1.  Total Number of Clerical Error Reopenings Received  Show the total number of 
clerical error reopening requests received during the month.  This number includes any requests 
originally categorized as a reopening at the pre or post-redetermination level, as well as those 
requests that were originally categorized as an appeal, but were later determined to be a clerical 
error reopening. 
 
Line  2.  Total Number of Clerical Error Reopenings Processed -- Show the total number of 
clerical error reopenings processed by the contractor during the month.   
Line  3.  Total Number Processed  Own Motion  Of the number reflected on Line 2, show the 
number the contractor reopened the claim on their own motion. 
 
Line  4.  Total Number Processed  Claimant Initiated  Of the number reflected on Line 2, 
show the number of reopenings initiated by the claimant. 
 
Line  5. Total Number of Clerical Error Reopenings Resulting From Contractor Error -- Of 
the reopenings reflected in Line 2, show the total number of claims that were the result of 
contractor error, whether discovered by the contractor or the claimant. 
 
Line  6. Total Number of Clerical Error Reopenings Resulting From Provider Error -- Of the 
reopenings reflected in Line 2, show the total number of claims that were the result of provider 
error, whether discovered by the contractor or the claimant. 
 
NOTE:  Particularly with regard to Lines 3 through 6, it is possible for the same claim to be 
reflected on more than one line. 
 
Line 7:  Reserved for Future Use 
 
Line 8:  Reserved for Future Use 
 
Line 9. Medicare Approved Amount (Not Applicable)  For cases included on Line 2, show the 
amount paid for services where the determination was reversed either fully or partially.  This is the 
amount sent after the reopening has been completed  the check amount. Round results to the 
nearest dollar. 
 
NOTE:  Time frames noted in Lines 10, 11 and 11a are for clerical error reopenings initiated by 
the party only.  The time frames do not apply to contractor initiated reopenings or mass 
adjustments.  In addition, no time frames have been established for other types of reopenings. 
 
Line 10. Clerical Error Reopenings Processed in 1-30 Days  Show the number of clerical error 
reopenings from Line 2 processed in 1-30 calendar days.  The processing time frame starts from 
the date of receipt of the request in the contractors mailroom. 
 
Line 11. Clerical Error Reopenings Processed in 31-60 Days - Show the number of clerical 
error reopenings from Line 2 processed in 31-60 calendar days. The processing time frame starts 
from the date of receipt of the request in the contractors mailroom. 
 
Line 11a.  Clerical Error Reopenings Processed in More than 60 Days  Show the number of 
clerical error reopenings from Line 2 processed in 61 days or more.  The processing time frame 
starts from the date of receipt of the request in the contractors mailroom. 
 
Line 12.  Total Number of Clerical Error Reopening Requests Pending Show the number of 
clerical error reopenings pending at the close of the reporting month. 
 
Line 13.  Total Number of Higher Level Reopenings Requiring Adjustment by the 
Contractor  Show the number of claims that were reopened by the QIC, ALJ or Medicare  Appeals Council that require an adjustment by the contractor.  These are claims for which the 
contractor must effectuate the claim as a result of the reopening decision at the higher level. 
 
Line 14.  Amount Awarded (Not Applicable)  Show the amount approved for services from 
Line 13 where the determination was reversed, either fully or partially.  Show amounts that are 
sent to the provider.  Round results to the nearest dollar. 
 
It is preferable to report the Medicare Approved Amount at the time that cases are reported on line 
13.  However, CMS will consider it acceptable for contractors to report the Medicare Approved 
Amount when adjustment claims tied to cases that are reporting or will report to line 13 finalize. 
 
460.7 - Validation of Reports 
(Rev. 253, 08-06-15, Effective: 01-01-16, Implementation: 01-04-15) 
 
The SSM shall automatically produce the CMS-2592 A/B MAC (B) appeals validation report and 
the A/B MAC (B) performance validation report on a daily and monthly basis without specific 
A/B MAC (B) maintenance or request or without A/B MAC (B) intervention. 
 
Before sending the reports to CMS, check for completeness and arithmetical accuracy.  Note 
that the information provided below is applicable to each separate column.  Use the following 
checklist for an arithmetical check for each column: 
 
  Line 1 equals Line 21 from previous months report. 
  For each column, Line 1 plus Line 2 equals Line 3. 
  Line 3 plus Line 4 minus Line 5 minus Line 6 minus line 12 equals Line 21 for each 
column. 
  Line 4.1 is equal to or greater than Line 4.a. 
  Line 4.2.1 is equal to or greater than Line 4.2. 
  The total of Line 6.1a through 6.1i equals Line 6.1. 
  The total of Line 7.1a through 7.1i equals Line 7.1.  (Not Applicable) 
  The total of Line 8.1a through 8.1i equals Line 8.1. 
  The total of Line 9.1a through 9.1i equals Line 9.1. 
  The total of Line 10.1a through 10.1i equals Line 10.1. 
  The total of Line 11.1a through 11.1i equals Line 11.1. 
  Line 6.1 is equal to or greater than Line 6. 
  Line 7.1 is equal to or greater than Line 7. 
  Line 8.1 is equal to or greater than Line 8. 
  Line 10.1 is equal to or greater than Line 10. 
  Line 11.1 is equal to or greater than Line 11.  NOTE:  For contractors handling MSP claims, totals for Lines 6.1 through 11.1 may or 
may not be equal or greater to Lines 6 through 11, respectively. 
  Line 8 plus Line 9 plus Line 10 plus Line 11 must equal Line 6. 
  Line 8.2 plus Line 9.2 plus Line 10.2 plus Line 11.2 must equal Line 6.2. 
  Line 15 plus Line 16 plus Line 18 plus Line 19 plus Line 20 equals Line 6. 
  Line 15a plus Line 16a plus Line 18a plus Line 19a plus Line 20a equals Line 6.2. 
  Line 22 plus Line 23 plus Line 24 plus Line 25 equals Line 21. 
  Line 27 plus Line 28 plus Line 29 equals Line 26a. 
  Line 30 equals Line 47 of the previous months report. 
  Line 30 plus Line 31 equals Line 32. 
  Line 33b must not exceed Line 33a. 
  Line 33c must not exceed Line 33a. 
  Line 33b plus 33c must equal Line 33a. 
  Line 36 plus Line 36a plus 37 plus Line 37a equals Line 35. 
  Line 41a is equal to or greater than Line 41. 
  Line 42a is equal to or greater than Line 42. 
  Line 43 plus Line 44 plus Line 45 equals Line 42a. 
  Line 46a must not exceed Line 46 (Not Applicable) 
  Line 48 plus Line 51 minus Line 52 equals Line 57. 
  Line 48 equals Line 57 from the previous months report. 
  Line 51a is equal to or greater than Line 51. 
  Line 52a is equal to or greater than Line 52. 
  Line 56a must not exceed Line 56. (Not Applicable) 
  Line 53 plus Line 54 plus Line 55 equals Line 52a. 
  Line 3 (Reopenings) plus Line 4 (Reopenings) equals Line 2 (Reopenings). 
  Line 5 (Reopenings) must not exceed Line 2 (Reopenings). 
  Line 5 (Reopenings) plus Line 6 (Reopenings) equals Line 2 (Reopenings) 
  Line 6 (Reopenings) must not exceed Line 2 (Reopenings). 
  Line 10 (Reopenings) plus Line 11 (Reopenings) plus Line 11a must not exceed Line 4 
(Reopenings). 
 
460.8 - Exhibit 
(Rev. 253, 08-06-15, Effective: 01-01-16, Implementation: 01-04-15) 
 
  Column 1  Column 2  Column 3     Part A Services   Part B Services    Part B Services  
  Processed by A/B  Processed by    Processed by  
MAC (A)  A/B MAC (A)  A/B MAC (B) or 
Durable Medical 
Equipment (DME) 
MAC 
Section I:        
Redeterminations 
1: Opening Pending       
2: Adjustments to Pending       
3: Adjusted Pending       
4: Requests Received       
4.a Adjusted Requests       
Received 
4.1 Number of Claims       
Received 
4.2. Recovery Audit       
Contractor (RAC) Requests 
Received 
4.2.1 Number of RAC       
Claims Received 
5: Misrouted Requests       
Forwarded to Another 
Contractor 
6: Requests Cleared       
6.1 Number of Claims       
Cleared 
a. SNF        
b. Home Health       
c Inpatient Hospital       
d. Outpatient        
e. Lab       
f. Ambulance        
g. DME        
h. Physician       
i. Other       
6.2. Recovery Audit       
Contractor (RAC) 
Redeterminations Cleared 
6.2.1 Number of RAC       
Claims Involved 
7: Cleared -- Evidence       
Submitted after Request 
7.1: Number of Claims       
Involved 
a. SNF (Not Applicable)       
b. Home Health (Not       
Applicable) 
c. Inpatient Hospital (Not       
Applicable)  d. Outpatient (Not       
Applicable) 
e. Lab (Not Applicable)       
f. Ambulance (Not       
Applicable) 
g. DME (Not Applicable)       
h. Physician (Not       
Applicable) 
i. Other (Not Applicable)       
7.2: RAC Redeterminations       
Cleared With Additional 
Documentation 
7.2.1: Number of RAC       
Claims Involved 
8: Affirmations       
8a. Waiver of Liability       
Amount Paid (Not 
Applicable) 
8.1: Number of Claims       
Affirmed 
a. SNF        
b. Home Health       
c. Inpatient Hospital       
d. Outpatient        
e. Lab        
f. Ambulance        
g. DME        
h. Physician       
i. Other       
8.2 RAC Redeterminations       
Affirmed 
8.2.1: Number of RAC       
Claims Involved 
9: Partial Reversals       
9.1: Number of Claims       
Partially Reversed 
a. SNF        
b. Home Health       
c. Inpatient Hospital       
d. Outpatient        
e. Lab        
f. Ambulance        
g. DME        
h. Physician       
i. Other       
9.2: RAC Redeterminations       
Partially Reversed 
9.2.1: Number of RAC       
Claims Involved 
10: Full Reversals        10.1 Number of Claims       
Fully Reversed 
a. SNF        
b. Home Health       
c. Inpatient Hospital       
d. Outpatient       
e. Lab        
f. Ambulance        
g. DME        
h. Physician       
i. Other       
10.2: RAC       
Redeterminations Fully 
Reversed 
10.2.1: Number of RAC       
Claims Involved 
11: Dismissals/Withdrawals       
11.1 Number of Claims       
Dismissed or Withdrawn 
a. SNF        
b. Home Health       
c Inpatient Hospital       
d. Outpatient       
e. Lab        
f. Ambulance        
g. DME        
h. Physician       
i. Other        
11.2: RAC       
Redeterminations 
Dismissed or Withdrawn 
11.2.1: Number of RAC       
Claims Involved 
12: Number of Incomplete       
Redeterminations Requests 
Dismissed 
13:Medicare Approved       
Amount  (Not Applicable) 
14: Redeterminations       
Processing Time Average 
15: Redeterminations       
Completed in 1-60 days 
15a. RAC Redeterminations       
Completed in 1-60 days 
16: Redeterminations       
Completed in Over 60 days 
16 a. RAC       
Redeterminations 
Completed in Over 60 days 
17: Redeterminations       
Processing Time- Average  (Documentation Submitted 
Later) 
18: Redeterminations       
Completed in 1-60 days 
(Documentation Submitted 
Later) 
18a. RAC Redeterminations       
Completed in 1-60 days 
(Documentation Submitted 
Later) 
19: Redeterminations       
Completed in 61-74 days 
(Documentation Submitted 
Later) 
19a. RAC Redeterminations       
Completed in 61-74 days 
(Documentation Submitted 
Later) 
20: Redeterminations       
Completed in over 74 days 
(Documentation Submitted 
Later) 
20a. RAC Redeterminations       
Completed in over 74 days 
(Documentation Submitted 
Later) 
21: Closing Pending       
Redeterminations 
22 Redeterminations       
Pending 1-30 days 
23: Redeterminations       
Pending 31-60 days 
24: Redeterminations       
Pending 61-74 Days 
25: Redeterminations       
Pending Over 74 days 
26: Total Effectuations       
26a: Number of Claims       
Involved 
27: Number Effectuated 1-      
30 Days 
28: Number Effectuated 31-      
60 Days 
29: Number Effectuated       
over 60 Days 
Section II:  QIC       
Reconsiderations 
30: Opening Pending       
31: Adjustments to Pending       
32: Adjusted Opening       
Pending  33: Requests For QIC       
Reconsideration Received 
by the Contractor  
33a. Misrouted Requests       
Forwarded to QIC 
33b. Misrouted Requests       
Forwarded Timely 
33c. Misrouted Requests       
Forwarded Untimely 
34. Requests from QIC for       
Case Files  
35: Number of Case Files       
Forwarded to QIC 
36: Number Forwarded in       
1-5 days 
36a: Number Forwarded in       
6 Days 
37: Number Forwarded in       
7-8 Days  
37a: Number Forwarded in       
Over8 Days 
38: Average Time to       
Forward 
39. Pending Case File       
Requests  
40: Number of QIC       
Decisions Received from 
QIC 
41: Number of QIC       
Decisions that Need 
Effectuation 
41a. Number of Claims       
Involved 
42: Total Effectuations       
42a. Number of Claims       
Involved 
43. Number Effectuated in       
1-30 Days 
43a. Contractor Computed       
Amount 
44: Number Effectuated in       
31-60 Days 
44a. Contractor Computed       
Amount 
45: Number Effectuated in       
Over 60 Days 
45a: Contractor Computed       
Amount 
46 Medicare Approved       
Amount (Not Applicable)  46a. Waiver of Liability       
Amount Paid (Not 
Applicable) 
47: Closing Pending       
Reconsiderations 
Section III:  ALJ Results       
48: Opening Pending       
49: Number of Appeal       
Requests for ALJ Hearing 
Misrouted to Contractor 
50: Number of ALJ       
Decisions Received from 
Administrative QIC 
51: Number of ALJ       
Decisions Received that 
Need Effectuation 
51a Number of Claims       
Involved 
52: Total Effectuations       
52a. Number of Claims       
Involved 
53: Number Effectuated in       
1-30 Days 
54: Number Effectuated in       
31-60 days 
55: Number Effectuated in         
Over 60 Days 
56: Medicare Approved       
Amount (Not Applicable) 
56a. Waiver of Liability       
Amount Paid (Not 
Applicable) 
57: Closing Pending ALJ       
Decisions 
Section IV:  Medicare       
Appeals Council 
Effectuations 
58: Medicare Appeals       
Council Effectuations 
 
 
Clerical Error Reopenings 
1: Total Number of Clerical       
Error Reopenings Received 
2: Total Number of Clerical       
Error Reopenings Processed 
3. Total Number Processed        
Own Motion 
4. Total Number Processed        
Claimant Initiated   5: Total Number of Clerical       
Error Reopenings Resulting 
from Contractor Error 
6: Total Number of Clerical       
Error Reopenings Resulting 
from Provider Error 
7. Reserved for Future Use       
8. Reserved for Future Use       
9. Medicare Approved       
Amount (Not Applicable) 
10. Clerical Error       
Reopenings Processed in 1-
30 days 
11. Clerical Error       
Reopenings Processed in 31-
60 days 
11.a Clerical Error       
Reopenings Processed in 
More than 60 days 
12: Total Number of Clerical       
Error Reopening Requests 
Pending 
13. Total Number of Higher       
Level Reopenings Requiring 
Adjustment by the 
Contractor 
14. Amount Awarded (Not       
Applicable) 
 
480 - Special Purpose Data 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
480.1 - Heading 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
This report, referenced as Form Y in the CROWD system, is used only when program 
requirements compel CMS to collect data on an interim basis before the data elements can be 
incorporated into one of the regular forms.  The Medicare contractor will submit the form via the 
CROWD system no later than the 10th day of the following month.  
 
480.2 - Exhibit 
(Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) 
 
Exhibit - Special Purpose Data
 
 
 
                                                              SPECIAL PURPOSE DATA 
 
CONTRACTOR                             NUMBER    
                 DESCRIPTION                              CODE        COL 1      COL 2      COL 3      COL 4      COL 5       
 
                                                        0000          0                0               0               0               0             
                                                        0000          0                0               0               0               0       
                                                        0000          0                0               0               0               0     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR# 
R10521FM 12/16/2020  New Medicare National Uniform Billing Committee  01/04/2021  11856 
(NUBC) Type of Bill (TOB), Condition Code and 
implementing Billing Codes for Opioid Treatment 
Programs 
 
R10374FM 09/25/2020  New Physician Specialty Code for Micrographic  10/05/2020  11750 
Dermatologic Surgery (MDS) and Adult Congenital 
Heart Disease (ACHD) and a New Supplier Specialty 
Code for Home Infusion Therapy Services 
R10319FM 08/28/2020  Removal of Contractor Requirement to Submit  09/29/2020  11909 
Electronic Data Interchange (EDI) Data into the 
Contractor Reporting of Operational and Workload 
Data (CROWD) System (Form 5) 
 
  08/06/2020  New Medicare National Uniform Billing Committee  01/04/2021  11856 
(NUBC) Type of Bill (TOB), Condition Code and 
implementing Billing Codes for Opioid Treatment 
Programs- Rescinded and replaced by transmittal 10521 
SENSITIVE/CONTROVERSIAL 
R10124FM 05/08/2020  New Physician Specialty Code for Micrographic  10/05/2020  11750 
Dermatologic Surgery (MDS) and Adult Congenital 
Heart Disease (ACHD) and a New Supplier Specialty 
Code for Home Infusion Therapy Services- Rescinded 
and replaced by transmittal 10374 
  12/05/2019  New Medicare Provider Specialty Code (D5) and  01/06/2020  11353 
Billing Codes for Opioid Treatment Programs and New 
Place of Service Code 58 
 
  10/29/2019  New Medicare Provider Specialty Code (D5) and  01/06/2020  11353 
Billing Codes for Opioid Treatment Programs and New 
Place of Service Code 58 
SENSITIVE/CONTROVERSIAL 
  09/23/2019  New Medicare Provider Specialty Code (D5) and  01/06/2020  11353 
Billing Codes for Opioid Treatment Programs and New 
Place of Service Code 58- Rescinded and replaced by 
Transmittal 329 
SENSITIVE/CONTROVERSIAL 
 
  08/01/2019  New Medicare Provider Specialty Code (D5) and  01/06/2020  11353 
Billing Codes for Opioid Treatment Programs and New 
Place of Service Code 58-Rescinded and replaced by 
Transmittal 324 
SENSITIVE/CONTROVERSIAL  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 
R309FM  12/20/2018  New Physician Specialty Code for Undersea and  01/07/2019  10666 
Hyperbaric Medicine 
R304FM  04/27/2018  New Physician Specialty Code for Medical Genetics  10/01/2018  10457 
and Genomics 
 
R302FM  03/30/2018  Removal of Contractor Reporting Requirements for the  07/02/2018  10406 
Physician Scarcity Area (PSA), the Health Professional 
Shortage Area Surgical Incentive Payment Program 
(HSIP) and the Primary Care Payment Incentive 
Program (PCIP) Quarterly Reports 
 
R298FM  02/02/2018  Removal of Contractor Reporting Requirements for the  07/02/2018  10406 
Physician Scarcity Area (PSA), the Health Professional 
Shortage Area Surgical Incentive Payment Program 
(HSIP) and the Primary Care Payment Incentive 
Program (PCIP) Quarterly Reports Rescinded and 
replaced by Transmittal 302 
 
R290FM  07/14/2017  New Specialty Code for Pharmacy  01/02/2018  9821 
R283FM  04/28/2017  New Physician Specialty Code for Advanced Heart  10/02/2017  9957 
Failure and Transplant Cardiology, Medical 
Toxicology, and Hematopoietic Cell Transplantation 
and Cellular Therapy 
R276FM  11/25/2016  New Physician Specialty Code for Hospitalist  04/03/2017  9716 
R274FM  10/28/2016  New Physician Specialty Code for Hospitalist   04/03/2017  9716 
Rescinded and replaced by Transmittal 276 
R269FM  06/22/2016  New Physician Specialty Code for Dentist  07/05/2016  9355 
R268FM  06/15/2016  New Physician Specialty Code for Dentist  Rescinded  07/05/2016  9355 
and replaced by Transmittal 269 
R265FM  03/16/2016  Contractor Reporting of Operational and Workload  07/05/2016  8998 
Data (CROWD) Form 5 Update with Revisions to Pub. 
100-06 Medicare Financial Management Manual, 
Chapter 6 
R263FM  02/05/2016  Contractor Reporting of Operational and Workload  07/05/2016  8998 
Data (CROWD) Form 5 Update with Revisions to Pub. 
100-06 Medicare Financial Management Manual, 
Chapter 6  Rescinded and replaced by Transmittal 265 
R262FM  01/29/2016  New Physician Specialty Code for Dentist  Rescinded  07/05/2016  9355 
and replaced by Transmittal 268  R253FM  08/06/2015  Update the Contractor Reporting of Operational and  01/04/2015  9157 
Workload Data (CROWD) CMS-2592 Report to 
Indicate Requests Received in Claims and Requests 
Received That Are Recovery Audit Related 
R248FM  12/19/2014  Revision of Pub. 100-06 - Medicare Financial  01/23/2015  8906 
Management Manual, Chapter 6 - Intermediary and 
Carrier Financial Reports, and Pub. 100-09 - Medicare 
Contractor Beneficiary and Provider Communications, 
Chapter 6 - Provider Customer Service Program 
R238FM  08/22/2014  New Physician Specialty Code for Interventional  01/05/2015  8812 
Cardiology 
R221FM  06/12/2013  New Non-Physician Code for Complimentary Insurer  10/07/2013  8282 
R219FM  05/03/2013  New Non-Physician Code for Complimentary Insurer   10/07/2013  8282 
Rescinded and replaced by Transmittal 221 
R216FM  12/14/2012  Modification/Addition of Group Codes/Specialty Codes 01/15/2013  8090 
R212FM  08/10/2012  New Non-Physician Specialty Code for Centralized Flu  01/07/2012  7884 
R209FM  04/27/2012  New Physician Specialty Code for Sleep Medicine and  10/01/2012  7600 
Sports Medicine 
R195FM  09/30/2011  To Create Form 9 Within the Contractor Reporting of  07/05/2011  7285 
Operational and Workload Data (CROWD) System for 
the Reporting of Primary Care Incentive Payments 
(PCIP) and HPSA Surgical Incentive Payments (HSIP) 
R191FM  07/13/2011  Add Physician Specialty Codes for Cardiac  07/05/2011  7233 
Electrophysiology (21) and Sports Medicine (23) to 
CROWD Forms F (ParDoc) and 8 (OptOut)  
Rescinded and replaced by Transmittal 191 
R188FM  04/22/2011  Modify CROWD Form K to Allow the Submission of  07/05/2011  7291 
Additional Medicare Summary Payer (MSP) Savings  and 
Information  10/03/2011 
R183FM  02/04/2011  To Create Form 9 Within the Contractor Reporting of  07/05/2011  7285 
Operational and Workload Data (CROWD) System for 
the Reporting of Primary Care Incentive Payments 
(PCIP) and HPSA Surgical Incentive Payments (HSIP) 
 Rescinded and replaced by Transmittal 195 
R181FM  01/04/2011  Add Physician Specialty Codes for Cardiac  07/05/2011  7233 
Electrophysiology (21) and Sports Medicine (23) to 
CROWD Forms F (ParDoc) and 8 (OptOut)  
Rescinded and replaced by Transmittal 191 
R178FM  12/03/2010  Add Physician Specialty Codes for Cardiac  07/05/2011  7233 
Electrophysiology (21) and Sports Medicine (23) to 
CROWD Forms F (ParDoc) and 8 (OptOut) - 
Rescinded and replaced by Transmittal 181  R177FM  12/03/2010  Add Supplier Specialty Code 95 (Advanced Diagnostic  07/05/2011  7226 
Imaging (ADI) Accreditation) to CROWD Form F 
(Participating Physician/Supplier Report)  Rescinded 
and not replaced. 
R176FM  11/12/2010  Clarification for Data Entry on Health Professional  12/13/2010  7223 
Shortage Area Reports 
R175FM  10/28/2010  Change the Name of Physician Specialty Code 12 from  04/04/2011  7093 
Osteopathic Manipulative Therapy to Osteopathic 
Manipulative Medicine 
R173FM  10/15/2010  Update to the Quarterly Opt Out Reporting Form (Form 11/16/2010  7165 
8) in the Contractor Reporting of Operational Workload 
Data (CROWD) 
R171FM  05/28/2010  Expansion of Form 5 of the Contractor Reporting of  10/04/2010  6969 
Operational and Workload Data (CROWD) 
R170FM  05/21/2010  Cardiac Rehabilitation and Intensive Cardiac  10/04/2010  6850 
Rehabilitation 
R163FM  12/04/2009  Add Physician Specialty Code 27 (Geriatric Psychiatry) 04/05/2010  6613 
to CROWD Form F (Participating Physicians/Supplier 
Report) 
R159FM  10/09/2009  Add Physician Specialty Code 27 (Geriatric Psychiatry) 04/05/2010  6613 
to CROWD Form F (Participating Physicians/Supplier 
Report)  Rescinded and replaced by Transmittal 163 
R157FM  08/21/2009  Add Specialty Codes to CROWD Form F (Participating  01/04/2010  6580 
Physicians Data) 
R155FM  07/31/2009  New Reporting Requirements for the Quarterly Opt Out 01/04/2010  6562 
Report in Contractor Reporting of Operational 
Workload Data (CROWD) 
R144FM  11/28/2008  Revisions to the Monthly Statistical Report on  04/06/2009  6251 
Intermediary and Carrier Part A and Part B Appeals 
Activity Form (CMS-2592) to Capture Data on 
Recovery Audit Contractor (RAC) Redeterminations 
R131FM  09/21/2007  Participating Physicians Report  Deletion of  01/07/2008  5697 
Requirement to Forward a Memorandum to CMS 
Detailing Adjustments for Form F Column 1 (PAR 
Prior) (from previous enrollment period) 
R130FM  08/31/2007  Revisions of the CROWD Report  01/07/2008  5555 
R126FM  07/13/2007  Manual Revision Re: MSN Workload Reporting  01/07/2008  5642 
R123FM  06/08/2007  Contractor CROWD Form 5 Completion Changes  10/01/2007  4274 
R121FM  05/02/2007  Contractor CROWD Form 5 Completion Changes   10/01/2007  4274 
Replaced by Transmittal 123 
R119FM  04/20/2007  Contractor CROWD Form 5 Completion Changes -  10/01/2007  4274 
Replaced by Transmittal 121  R98FM  06/16/2006  Correction of CROWD Form 5 Reporting for Internet  07/17/2006  5120 
Pilot Carriers 
R96FM  05/26/2006  Development of New Report to Capture BIPA and  07/03/2006  5056 
MMA Appeals Data 
R88FM  01/06/2006  Clarification to IOM 100-06, Sections 290.7 and 290.8  02/06/2006  4198 
R86FM  12/02/2005  Development of New Report to Capture BIPA and  07/03/2006  4148 
MMA Appeals Data  Replaced by Transmittal 96, CR 
5056 
R85FM  11/17/2005  Expansion of Form 5 of the Contractor Reporting of  04/03/2006  3864 
Operational and Workload Data (CROWD)  Replaced 
by Transmittal 85 
R82FM  10/31/2005  Expansion of Form 5 of the Contractor Reporting of  04/03/2006  3864 
Operational and Workload Data (CROWD)  Replaced 
by Transmittal 85 
R76FM  08/12/2005  Development of New Report to Capture BIPA and  04/03/2006  3837 
MMA Appeals Data  Replaced by Transmittal 86, CR 
4148 
R65FM  02/25/2005  Revised Reporting Requirements for Contractor  07/05/2005  3673 
Reporting of Operational and Workload Data 
(CROWD) Physician Scarcity Area (PSA) Quarterly 
Report (CMS Form-1565F, CROWD Form 6) 
R57FM  10/22/2004  Revised Reporting Requirements for Contractor  04/04/2005  3472 
Reporting of Operational and Workload Data 
(CROWD) Health Professional Shortage Area (HPSA) 
Quarterly Report (CMS Form-1565E, CROWD Form 
S) 
R56FM  10/22/2004  Revision to Balancing Requirements on Form 5, Line  11/22/2004  3486 
10 of the Contractor Reporting of Operational and 
Workload Data (CROWD) 
R45FM  05/28/2004  Workload Reporting  N/A  3246 
R40FM  04/30/2004  Medicare Contractor Transaction Report  10/04/2004  3257 
R36FM  03/12/2004  Medicare Contractor Transaction Report (FormCMS-5)  N/A  2249 
& 
2547 
R06FM  08/30/2002  Initial Publication of Chapter  N/A  N/A 
 
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