100-06 Medicare Financial Management Manual: Chapter 6 - Medicare Administrator Contractor (MAC) Financial Reports

Medicare Financial Management Manual
Part A and Part B Medicare Administrative
Contractors (A/B MACs) Reports
Table of Contents
(Rev. 12894 ; Issued: 10-17-24)
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 (Inactive)
70.6 - Heading (Inactive)
70.7 - Checking Reports (Inactive)
70.8 - Type of Fraud Workload Item (Inactive)
70.9 - Body of Report (Inactive)
70.10 - Completing Quarterly Periodic Interim Payment (PIP) Report,
CMS-1566C - General
70.11 - Heading
70.12 - Checking Reports
70.13 - PIP Items Reported - The intermediary reports the PIP workload
items in the following lines for all columns of Form Q
70.14 - Quarterly Supplement to the Intermediary Workload Report -
CMS-1566A, Pages 1,2,3
70.15 - Medicare Fraud Unit Quarterly Workload Status Report - CMS-
1566B
70.16 - Quarterly Periodic Interim Payment (PIP) Report - Form CMS-
1566C
70.17 - Completing Quarterly Report on Provider Enrollment (Inactive)
70.18 - Heading (Inactive)
70.19 - Checking Reports (Inactive)
70.20 - Type of Provider (Inactive)
70.21 - Completing Lines One through Eleven - Workload Operations
(Inactive)
70.22 - Completing Lines Twelve through Seventeen - Reason for Denial
Recommendation (Inactive)
70.23 - Completing Lines Eighteen through Twenty-Two - Reason for
Return (Inactive)
70.24 - Completing Lines Twenty-Three through Twenty-Six -
Application Processing Times (Inactive)
70.25 - Completing Lines Twenty-Seven through Thirty-One - Age of

Applications Pending (Inactive)
70.26 - Completing Lines Thirty-Two through Thirty-Seven - CHOW
Workloads (Inactive)
70.27 - Exhibits
80 - Monthly Intermediary Report On Medicare Secondary Payer Savings (Form
CMS-1563)
80.1 - General
80.2 - Purpose and Scope
80.3 - Due Date
80.4 - Form Heading
80.5 - Savings Calculations
80.6 - Recording Savings
80.7 - Source of Savings
80.8 - Type of Savings
80.9 - Electronic Submission
90 – Monthly Intermediary Part A and Part B Appeals Report (Form CMS-2591)
90.1 – Purpose and Scope
90.2 – Due Date
100 – Completion of Items on Form CMS-2591
100.1 – Heading
100.2 – Section A – Intermediary Appeal Requests
100.3 – Section B – Part B Hearing Results
100.4 – Section C – Part A and Part B ALJ Hearings
100.5 – Section D – Limitation of Liability
100.6 – Section E – Part A and Part B Reopenings
110 – Checking Reports
110.1 – Exhibit 1
110.2 – Exhibit 2
110.3 – Exhibit 3
110.4 – Exhibit 4
110.5 – Exhibit 5
110.6 – Exhibit 6
120 - Completing Page One of the Carrier Performance Report
120.1 - Classification of Claims for Counting
130 - Completion of Items on Page One of Form CMS-1565
130.1 - Heading
130.2 - Part A - Monthly Workload Operations
130.3 - Part B - Inquiries (Inactive)
130.4 - Part C - Miscellaneous Claims Data

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 (Inactive)
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 (Inactive)
310.1 - Purpose and Scope
310.2 - Due Date
320 - Completing Carrier Beneficiary Overpayment Activity Report (Inactive)
320.1 - Classification of Claims for Counting
330 - Completion of Items on Form CMS-2174 (Inactive)
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3892 and B3 13300
Intermediaries and carriers must prepare and submit to CMS each month the appropriate
workload report (Form CMS-1566 for intermediaries and Form CMS-1565 for carriers)
showing their workloads under the health insurance program. A separate report is
required for each office assigned a separate contractor number. A separate report is
required for each Business Segment Identifier (BSI) assigned to the contractor, even if a
separate contractor number is not assigned.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3892.2
The report is transmitted to CMS CO via PC or terminal as soon as possible after the end
of the month being reported, but no later than the 10th of the following month using
instructions in the Contractor Reporting of Operational and Workload Data (CROWD)
User Guide available via the CMS Enterprise Portal.

20 - Completing Page One of the Monthly Intermediary Workload
Report
(Rev. 6, 08-30-02)
A3-3893
20.1 - Heading
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3893.1
This report is referenced as Form D for CROWD. The intermediary submits the
appropriate information for the reporting period for each office assigned a separate
contractor number and BSI. It reports the number of working days scheduled for the
reporting period, less any days where no claims were processed as a result of a strike,
snowstorm, etc. It does not count Saturdays, Sundays, or holidays.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
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 reports the
adjustment. It reports bills received near the end of the reporting month and placed under
computer control sometime after the reporting month as bills received in the reporting
month and not as bills received in the following month. In the event that some bills may
not have been counted in the proper month's receipts, it counts them as adjustments to the
opening pending in the subsequent month.
It reports on line 2 any necessary adjustments, preceded by a minus sign for negative
adjustments, as appropriate.
Line 3 - Adjusted Opening Pending - The system will sum line 1 + line 2 to calculate
the adjusted opening pending.
Receipts
Line 4 - Received During Month – The intermediary reports the total number of bills
received for initial processing during the month.
It counts all bills immediately upon receipt regardless of whether or not they are put into
the processing operation with the exception of those discussed below.
NOTE: It counts bills submitted by providers electronically after they have passed
intermediary consistency edits. Prior to that time, it may return these bills or the
entire tape reel (where magnetic tape is the medium of submission) without
counting them as "received." However, once the bills or tapes have passed
consistency edits and are counted as received, it uses the actual receipt date, not
the date the edits are passed, in calculating pending and processing times.
If a bill belonging to one of the above-excluded categories is inadvertently counted as an
initial bill received (e.g., certain adjustment bills unidentifiable at the time of receipt), the
intermediary subtracts it from the receipt count when the bill is correctly identified.
Line 5 - Electronic Media Bills - The intermediary reports the net number of bills
included on line 4 which were received in paperless form via electronic media from
providers or their billing agencies and read directly into the intermediary claims

processing system. It does not count on this line bills that it received in hardcopy and
entered using an Optical Character Recognition (OCR) device. It does not count any bills
received in hardcopy and transferred into electronic media by any entity working for it
directly or under subcontract.
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 reports the number of initial
bills for which it approved some payment and for which the CWF host responded
accepting the intermediary determination. It includes bills for which it approved payment
in full or in part as a result of a determination that both the beneficiary and the provider
were without fault (liability waiver). (See the Medicare Claims Processing Manual,
Chapter 30, Financial Liability Protections.) The intermediary reports here those fully
adjudicated, approved-for-payment bills for which it has received a response from the
host and are holding only due to the payment floor.
Line 8 - No Payment Approved (CWF) - The intermediary reports the number of initial
bills processed through CWF during the month for which it approved no payment. It
reports here those bills for which payment is not made because the deductible has not yet
been met and payment is therefore applied to the deductible.
Line 9 - Total Non-CWF Bills (10 + 11) - The intermediary reports the number of initial
bills (described in lines 10 and 11 below) processed outside CWF. Non-CWF bills are
those either rejected by or not submitted to CWF that the intermediary finally adjudicates
outside of CWF and, therefore, are not posted to its history in the reporting month. The
intermediary reports these bills as non-CWF, even if it plans to submit an informational
record in the future. It reports such bills in the month in which it made the determination
as to their final disposition.
It does not include home health bills where no utilization is chargeable and no payment
has been made, but which it requested only to facilitate record keeping processes.
Line 10 - Payment Approved (Non-CWF) - The intermediary reports the number of
initial bills processed outside CWF for which it approved some payment. It includes
bills for which it approved payment in full or in part as a result of a determination that
both the beneficiary and the provider were without fault (liability waiver). (See the
Medicare Claims Processing Manual, Chapter 30, Financial Liability Protections.)

Line 11 - No Payment Approved (Non-CWF) – The intermediary reports the number
of initial bills processed outside CWF during the month for which it approved no
payment.
Line 12 - Total Processed - The intermediary reports the sum of lines 6 and 9.
NOTE: It reports as processed on line 12 those bills it has moved to a processed location
after being accepted by the host and is holding only due to the payment floor. However,
for pages 2-12 of this report, it reports these bills as processed in the month during which
the scheduled payment date falls (which may be in a subsequent reporting period).
The intermediary reports HMO bills it paid on line 12 and on pages 2-12. It does not
report those bills paid by HMOs and processed by the intermediary on line 12 or on pages
2-12. It reports such HMO paid bills only on line 39 of page 1.
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 reports the number of initial
bills that, for purposes of processing the claim to completion, required outside contact
(via telephone, correspondence, or on-site visit) with providers, social security offices, or
beneficiaries during the month. This includes contacting outside parties to resolve
problems with covered level of care determinations, insufficient medical information or

missing, inconsistent, or incorrect items on the bill. It does not count routine submissions
by providers of additional medical evidence with bills as investigations in themselves. It
counts only the number of bills requiring investigation, not the number of contacts made.
It excludes bills reported as investigated in a prior month from this count even if the
investigation continued into the reporting month. It does not count as bills investigated
those returned to providers because they were incomplete, incorrect or inconsistent, and
consequently were not counted as "receipts."
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 reports the total number of
Medicaid crossover bills transmitted to State agencies or their fiscal agents in the
reporting month.
Line 33 - Transmitted Electronically – The intermediary reports the number of bills
included in line 32 which were transmitted via electronic media to State agencies or their
fiscal agents.
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
counts 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 reports the total number of bills that it received in
hardcopy and entered using an OCR device. It does not count these bills as electronic
media bills on line 5, page 1, or in column 8, pages 2-11.

BILLS PAID BY HMOs
Line 39 - Total HMO Bills Processed - It reports the number of bills that were paid by
HMOs and processed by it during the reporting month. It reports HMO bills paid by it on
line 12 but does not report such bills on line 39.
MEDICARE SUMMARY NOTICES (MSNs)
Line 40 - Total MSNs Mailed - It reports 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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3894.1
These pages are referenced as Form U (pages 2-11) and Form E (pages 12-21) for
CROWD. The intermediary submits the appropriate information for the reporting period
for each office assigned a separate contractor number and BSI.
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
Receipt
Paid Counter
by Days
Counter
by Claims
A 91103 91133 30 1
B 91105 91206 101 2
C 91115 91177 62 3
D 91120 91213 93 4
E 91122 91215 93 5
F 91130 91223 93 6
Total Days = 30 + 101 + 62 + 93 + 93 + 93 = 472
Mean = 472/6 = 78.6666 = 78.7
The intermediary completes the report for each bill type:
• 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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3894.5
This page is referenced as Form W for CROWD. The intermediary submits the
appropriate information for the reporting period for each office assigned a separate
contractor number and BSI.
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:
INITIAL BILL PROCESSING
TOTAL
(1)
INPATIENT
(2)
OUTPATIENT
(3)
SNF
(4)
HHA
(5)
OTHER
(6)
Opening Pending
1. Opening Pending
2. Adjustments (+ or -)
3. Adj Opening Pending
Receipts
4. Received during Month
5. Electronic Media
Clearances
6. Total CWF Bills
7. Payment Approved
8. No Payment Approved
9. Total Non-CWF Bills
10. Payment Approved
11. No Payment Approved
12. Total Processed
Closing Pending
13. Pending End of Month
14. Longer than 1 Month
15. Longer than 2 Months

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:
INITIAL BILL PROCESSING
TOTAL
(1)
INPATIENT
(2)
OUTPATIENT
(3)
SNF
(4)
HHA
(5)
OTHER
(6)
Bill Investigations
16. Investigations Init
SECTION B: ADJUSTMENT BILLS
CWF Clearances
17. Total CWF Processed
18. PRO Generated
19. Provider Generated
20. MSP
21. Other
Non-CWF Clearances
22. Total Non-CWF Prcsd
23. PRO Generated
24. Provider Generated
25. MSP
26. Other

Exhibit 1 (Cont.)
Form CMS 1566 - Medicare Program Intermediary Workload Report, Page 1
Intermediary Name: Reporting Period:
Intermediary Number: Number of Working Days:
SECTION B: ADJUSTMENT BILLS
TOTAL
(1)
INPATIENT
(2)
OUT
PATIENT
(3)
SNF
(4)
HHA
(5)
OTHER
(6)
Pending
27. Total Pending
28. PRO Generated
29. Provider Generated
30. MSP
31. Other
SECTION C: MEDICAID
CROSSOVER BILLS
Clearances
32. Trans to St Agencies
33. Trans Electronically
SECTION D:
MISCELLANEOUS DATA TOTAL BENEFICIARY PROVIDER
Inquiries
34. Total Inquiries
35. Telephone
36. Walk-In
37. Written

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:
MISCELLANEOUS DATA
TOTAL
(1)
INPATIENT
(2)
OUTPATIENT
(3)
SNF
(4)
HHA
(5)
OTHER
(6)
OCR Bills
38. Total Received
Bills Paid by HMOs
39. Total Processed
Medicare Summary Notices
40. Total MSNs Mailed

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
PROCESS
TOTAL
(1)
CLEAN
(2)
OTHER
(3)
CLEAN
(4)
OTHER
(5)
CLEAN
(6)
OTHER
(7)
EMC
(8)
1.1
2. 2
3. 3
4. 4
5. 5
6. 6
7. 7
8. 8
9. 9
10. 10
11. 11
12. 12

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****
DAYS TO
PROCESS
TOTAL
(1)
CLEAN
(2)
OTHER
(3)
CLEAN
(4)
OTHER
(5)
CLEA
N
(6)
OTHE
R
(7)
EMC
(8)
13. 13
14. 14
15. 15
16. 16
17. 17
18. 18
19. 19
20. 20
21. 21
22. 22
23. 23

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****
DAYS TO
PROCESS
TOTAL
(1)
CLEAN
(2)
OTHER
(3)
CLEAN
(4)
OTHER
(5)
CLEA
N
(6)
OTHE
R
(7)
EM
C
(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****
DAYS TO
PROCESS
TOTAL
(1)
CLEAN
(2)
OTHER
(3)
CLEAN
(4)
OTHER
(5)
CLEA
N
(6)
OTHE
R
(7)
EMC
(8)
34. 34-45
35. 46-60
36. 61-90
37. 91+
38. Total
39. Mean
PT

CMS-1566, Page
Page number and bill type to be reported as follows:
Page 2 - Inpatient Hospital (INP) Page 7 - CORF (COR)
Page 3 - Outpatient (OUT) Page 8 - ESRD (ERD)
Page 4 - SNF (SNF) Page 9 - Lab (LAB)
Page 5 - HHA (HHA) Page 10 - Other (OTH)
Page 6 - Hospice (HPC) Page 11 - Total (TOT)

EXHIBIT 3
SECTION F: INTEREST PAYMENT DATA
Form CMS 1566 - Medicare Program Intermediary Workload Report, Page 22
Intermediary Number: Report Month:
BILLS/PAYMENTS
DAYS LATE
TOTAL
(1)
HOSPITAL
(2)
SNF
(3)
HHA
(4)
HOSPICE
(5)
REMAINDER
(6)
1. Total Bills
2. 1
3. 2
4. 3
5. 4
6. 5
7. 6-15
8. 16-30
9. 31-60
10. 61+
11. Total Paid
12. 1
13. 2
14. 3
15. 4

Exhibit 3 (Cont.)
SECTION F: INTEREST PAYMENT DATA
Form CMS 1566 - Medicare Program Intermediary Workload Report, Page 22
Intermediary Number: Report Month:
BILLS/PAYMENTS
DAYS LATE
TOTAL
(1)
HOSPITAL
(2)
SNF
(3)
HHA
(4)
HOSPICE
(5)
REMAINDER
(6)
16. 5
17. 6-15
18. 16-30
19. 31-60
20. 61+

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 contractor’s area. In addition, it
submits a separate report for each PRO/State. For example, if the intermediary handles
adjustment records for a PRO involving separate States, it should submit a separate report
for each State. It reports all tape adjustment requests as well as hardcopy adjustment
request records which the PRO has designated XXP (where XX is a two-digit numeric
identifier) in accordance with the Medicare Claims Processing Manual, Chapter 4,
Outpatient Billing. If the intermediary does not have activity for a certain PRO/State
combination in a month, it shall not submit a report.
40.1 - Heading
(Rev. 6, 08-30-02)
A3-3895.1
The intermediary enters the contractor’s assigned 5-digit ID and the PRO's 5-digit ID
number in the indicated spaces. It shows the 2-digit State abbreviation. For the total
page show "Total" in the PRO space. In the space labeled "Report Month/Year" enter the
calendar month and year reported, e.g., show 0692 for June 1992.
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
INTERMEDIARY ID: PRO ID:
STATE:
MONTH/YEA
R:
TOTAL
(A)
INPATIENT
(B)
OUTPATIENT
(C)
1.Opening Pending
2.Revisions to Opening Pending
3.Revises Opening Pending
4.Elec. Adj. Req. Rec. Received
5.Elec. Adj. Rec. Rec. Rejected
6.Elec. Adj. Rec. Received
7.Hard-Copy Adj. Req. Rec. Accepted
8.Addtl. Bills to be Proc. Due to Interim Bills
9.Total Adj. Bills to be Proc.

Report Form (Cont.)
MONTHLY PRO ADJUSTMENT BILL REPORT
INTERMEDIARY ID: PRO ID:
STATE:
MONTH/YEA
R:
TOTAL
(A)
INPATIENT
(B)
OUTPATIENT
(C)
10.Nonprocessable Adjustment Bills-Failed
Batch/System Edits
11.Total Adj. Bills Processed
12.No. Compl. in 60 Days or Less
13.No. Compl. in 61-90 Days
14.No. Compl. in 91-120 Days
15.No. Compl. Over 120 Days
16.Closing Pending

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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3896.2
Transmit the Quarterly Supplement to CMS CO via PC or terminal as soon as possible
after the reporting quarter but no later than the 15th of the following month. Use
instructions in the CROWD User Guide available via the CMS Enterprise Portal.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3897.1
These pages are referenced as Form C for CROWD. It submits the appropriate
information for the reporting period for each office assigned a separate contractor
number and BSI.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3897.4
Section A: Bills Processed by State of Provider - The intermediary reports in this
section the claims workload for each State for which you service one or more providers.
Break out by State the number of initial bills (including demand and no-pay bills)
reported as processed on line 12 of Form D (see §20.4) over the 3 months of the reporting
quarter.
NOTE: Categorize the information reported by the State of the individual provider, not
the home office, if it is part of a chain organization.
Line 1 - All - For each column 1 through 6, the system will sum the number of claims
reported on the individual State lines completed below. The numbers so calculated by
the system must equal the sum of the numbers reported on line 12 of Form D for the 3
months of the reporting quarter.
State Lines - In the column just left of column (1), the intermediary reports the two-digit
postal abbreviation of each State (or FO for foreign claims) which includes at least one
provider for which you processed claims during the quarter.
It reports opposite each listed State the number of initial bills processed during the
reporting quarter for providers located in the State. It reports the data in total in column
1, and by type of bill in columns 2 through 6.
70 - Completing Quarterly Supplement To The Intermediary Workload
Report, CMS-1566A, Page 3
(Rev. 6, 08-30-02)
A3-3898
70.1 - Heading
(Rev.)
A3-3898.1
This page is referenced as Form I for CROWD. It submits the appropriate information
for the reporting period for each office assigned a separate contractor number and BSI.
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 (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.5
The intermediary prepares and submits to CMS each quarter a report on the number of
fraud workload items handled by your Medicare fraud unit. This information is required
by CMS to budget for fraud and abuse activities, as well as to monitor the flow of work
through the fraud units. Submit this form via CROWD no later than the 15th day
following the close of the reporting quarter.
70.6 – Heading (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.6

This page is referenced as Form M in the CROWD system. Complete the
ADD/UPDATE/DELETE DATA criteria screen with the appropriate information to
bring the reporting format to your screen.
70.7 – Checking Reports (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.7
Before submitting Form M to CMS, check for completeness and arithmetical accuracy.
Use the following checklist:
• 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 (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.8
The intermediary reports fraud workload items in the following columns for all lines of
Form M:
Column (1) – Total – All fraud workload items.
Column (2) – Beneficiary Complaints – The intermediary reports the number of
complaints received from, or on behalf of, beneficiaries alleging fraud. Do not include
complaints filed with the Office of the Inspector General (OIG) Hotline.
Column (3) – OIG Hotline – The intermediary reports the number of complaints
received via the OIG Hotline.
Column (4) – Referrals and Other – The intermediary reports referrals and any other
workload received by the fraud unit (e.g., provider complaints, internally generated
referrals from medical review, special requests from OIG or CMS).
70.9 – Body of Report (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)

A3-3898.9
Line 1 – Opening Pending – The system will pre-fill the number pending from line 8 of
the previous quarter’s report.
Line 2 – Adjustments – If it is necessary to revise the pending figure for the close of the
previous quarter because of inventories, reporting errors, etc., enter the adjustment on this
line. Precede negative adjustments with a minus sign.
Line 3 – Adjusted Pending – The system will sum line 1 + line 2 to calculate the
adjusted opening pending.
Line 4 – Workload Received – The intermediary reports the number of complaints and
referrals received in the fraud unit during the reporting period.
Line 5 – Total Cleared – The system will sum line 6 + line 7 to calculate the total
number of complaints and referrals cleared by the fraud unit during the reporting period.
Line 6 – Cleared by Contractor – The intermediary reports the number of complaints
and referrals cleared by the fraud unit by means other than referral to the OIG or
designated agency. Include those that were:
• 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
(Rev12894; Issued:10-17-24-Effective: 11-01-24; Implementation:11-01-24)
A3-3898.10
The intermediary prepares and submits to CMS each quarter a report on the number of
providers that you pay using the PIP method. This information is required so that CMS

can monitor the number of providers being paid using the PIP method at each
intermediary and nationally. Submit the form via CROWD no later than the 15th day
following the close of the reporting quarter.
70.11 – Heading
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.11
This page is referenced as Form Q for CROWD. It submits the appropriate information
for the reporting period for each office assigned a separate contractor number and BSI.
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. 12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
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
STATE OF PROVIDER
TOTAL
1
INP HOSP
2
OUTPATIENT
3
SNF
4
HHA
5
OTHER
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
1
INPATIENT
2
OUTPATIENT
3
SNF
4
HHA
5
OTHER
6
SECTION B: BILL DENIAL DATA XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX
1. BILLS DENIED - TOTAL
1A. MEDICAL - SUBJECT
TO WAIVER
XXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX XXXXXX XXXXXX
1B. MEDICAL - NOT SUBJECT
TO WAIVER
XXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX XXXXXX XXXXXX
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
1
INPATIENT
2
OUTPATIENT
3
SNF
4
HHA
5
OTHER
6
3. AMOUNT REIMBURSED UNDER
WAIVER
3A. AMOUNT ON INITIAL BILLS
SECTION C: DAY/VISIT DATA XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX
4. DAYS/VISITS PROCESSED XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX
5. DAYS/VISITS DENIED TOTAL
NO-PAY BILLS XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX
5A. MEDICAL - SUBJECT TO
WAIVER XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX
5B. MEDICAL - NOT SUBJECT
TO WAIVER XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX
5C. NONMEDICALS XXXXXXX XXXXXXXXXX XXXXXXXXXXX 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
1
INPATIENT
2
OUTPATIENT
3
SNF
4
HHA
5
OTHER
6
6. DAYS/VISITS PAID UNDER
WAIVER - TOTAL XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX
6A. DAYS/VISITS ON
INITIAL BILLS XXXXXXX XXXXXXXXXX XXXXXXXXXXX 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
1 INPATIENT
2 OUTPATIENT
3 SNF
4 HHA
5 OTHER
6
SECTION D: DEMAND
BILL DATA XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX
7. TOTAL DEMAND BILLS
7A. FULL/PARTIAL
REVERSALS
7B. DAYS/VISITS ON
REVERSALS XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX
SECTION E: NO-PAY
BILLS XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.15
MEDICARE FRAUD UNIT QUARTERLY WORKLOAD STATUS REPORT
HFCA-1566B (CROWD FORM M)
INTERMEDIARY NUMBER_______ REPORT PERIOD_______
FRAUD WORKLOAD ITEM TOTAL
1
BENEFICIARY
COMPLAINT
2
OIG
HOTLINE
3
REFERRAL
& OTHERS
4
1. OPENING PENDING
2. ADJUSTMENTS
3. ADJUSTED PENDING
4. WORKLOAD RECEIVED
5. TOTAL CLEARED
6. BY CONTRACTOR
7. BY REFERRAL
8. CLOSING PENDING

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
PIP PROVIDERS HOSP.
(1) SNF
(2) HHA
(3) TOTAL
(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 (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
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 (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
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 (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.20
The intermediary reports provider enrollment application data in the following columns for all
lines on Form 3.
Column (1) - Total - The sum of columns 2-16 for each line.
Column (2) - Accredited Hospital - Provider applications indicating provider type as an accredited
hospital.
Column (3) - Non-Accredited Hospital - Provider applications indicating provider type as a non-
accredited hospital.
Column (4) - Religious Nonmedical Health Care Facility - Hospital - Provider applications
indicating provider type as a Religious Nonmedical Health Care Facility - hospital.
Column (5) - Rural Primary Care Hospital - Provider applications indicating provider type as a
rural primary care hospital.
Column (6) - SNF - Provider applications indicating provider type as a skilled nursing facility (i.e.,
long term care facility).
Column (7) - HHA. - Provider applications indicating provider type as a home health agency.
Column (8) - Hospice - Provider applications indicating provider type as a hospice facility.
Column (9) - ESRD - Provider applications indicating provider type as an end stage renal disease
dialysis facility.

Column (10) - CORF - Provider applications indicating provider type as a comprehensive
outpatient rehabilitation facility.
Column (11) - RHC - Provider applications indicating provider type as a rural health clinic.
Column (12) - FQHC - Provider applications indicating provider type as a federally qualified
health center.
Column (13) - CMHC - Provider applications indicating provider type as a community mental
health center.
Column (14) - IHS - Provider applications indicating provider type as an Indian Health Service
facility.
Column (15) - Outp. Speech Path./Phy.Ther - Provider applications indicating provider type as
either outpatient speech pathology or outpatient physical therapy facility.
Column (16) - Other - Provider applications indicating provider type other than those defined for
columns 1 through 15.
70.21 - Completing Lines One through Eleven - Workload Operations (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.21
Line 1 - Pending End of Last Quarter - The CROWD system will automatically enter the value
from line 11 on the previous quarter’s report.
Line 2 - Adjustments to Pending - If it is necessary to revise the pending figure for the close of the
previous quarter because of inventories taken or reporting errors discovered, enter the adjustment
here. Adjustments can be positive or negative values. If entering a negative value, precede the
number with a minus (-) sign.
Line 3 - Adjusted Opening Pending -The CROWD system will automatically sum the values on
lines 1 and 2.
Line 4 - New Applications Received - The intermediary enters the number of applications received
for the first time during the reporting quarter.
Line 5 - Returned Applications Resubmitted - The intermediary enters the number of applications
received during the reporting quarter that had previously been received and returned to the
applicant for correction/completion.
Line 6 - Total Applications Received -The CROWD system will automatically sum the values and
lines 4 and 5.

Line 7 - Applications Recommended for Approval - The intermediary enters the number of
applications that you recommended for approval (i.e., Medicare number issued) during the
reporting quarter.
Line 8 - Applications Recommended for Denial - The intermediary enters the number of
applications that you recommended for denial during the reporting quarter.
Line 9 - Applications Returned - The intermediary enters the number of applications returned to
the applicant for corrections/completion during the reporting quarter.
Line 10 - Total Applications Processed -The CROWD system will automatically sum the values on
lines 7, 8, and 9.
Line 11 - Pending End of Quarter -The CROWD system will automatically compute the number of
applications pending at the end of the reporting quarter by adding the value on line 3 to the value
on line 6 and then subtracting the value on line 10.
70.22 - Completing Lines Twelve through Seventeen - Reason for Denial
Recommendation (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.22
Line 12 - Sanctioned From Medicare - The intermediary enters the number of applications that you
recommended for denial because the applicant is currently excluded/sanctioned from Medicare.
Line 13 - Debarred/Excluded by Other Federal Agency - The intermediary enters the number of
applications that you recommended for denial because the applicant had been disbarred,
suspended, or excluded by any other Federal agency.
Line 14 - Not Professionally Licensed - The intermediary enters the number of applications that
you recommended for denial because the applicant was not professionally licensed.
Line 15 - Business Address Invalid - The intermediary enters the number of applications that you
recommended for denial because the applicant had an invalid business address.
Line 16 - Business Location Not Licensed - The intermediary enters the number of applications
that you recommended for denial because the applicant=s business location was not properly
licensed.
Line 17 - CMS Requirements Not Met - The intermediary enters the number of applications that
you recommended for denial because the applicant did not meet all CMS requirements.
70.23 - Completing Lines Eighteen through Twenty-Two - Reason for Return
(Inactive)

(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.23
Line 18 - Incomplete - The intermediary enters the number of applications returned to the
applicant because the application was incomplete.
Line 19 - Unverifiable Information - The intermediary enters the number of applications returned
to the applicant because the application included unverifiable information.
Line 20 - Not Signed - The intermediary enters the number of applications returned to the
applicant because the applicant did not sign the certification statement.
Line 21 - Invalid Billing Agreement - The intermediary enters the number of applications returned
to the applicant because the billing agreement did not meet CMS requirements.
Line 22 - Other - The intermediary enters the number of applications returned to the applicant for
any reason other than the ones indicated on lines 18 through 21.
70.24 - Completing Lines Twenty-Three through Twenty-Six - Application
Processing Times (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.24
Line 23 - Number Under 21 Days - The intermediary enters the number of applications processed
in less than 21 days from the date of receipt.
Line 24 - Number in 21-30 Days - The intermediary enters the number of applications processed in
21 through 30 days from the date of receipt.
Line 25 - Number in 31-40 Days - The intermediary enters the number of applications processed in
31 through 40 days from the date of receipt.
Line 26 - Number Over 40 Days - The intermediary enters the number of applications processed in
more than 40 days from the date of receipt.
70.25 - Completing Lines Twenty-Seven through Thirty-One - Age of
Applications Pending (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
A3-3898.25
Line 27 - Number Under 11 Days Old - The intermediary enters the number of applications
included in line 11 which are 1-10 days old.
Line 28 - Number 11-20 Days Old - The intermediary enters the number of applications included
in line 11 which are 11-20 days old.

Line 29 - Number 21-30 Days Old - The intermediary enters the number of applications included
in line 11 which are 21-30 days old.
Line 30 - Number 31-40 Days Old - The intermediary enters the number of applications included
in line 11 which are 31-40 days old.
Line 31 - Number Over 40 Days Old - The intermediary enters the number of applications
included in line 11 which are over 40 days old.
70.26 - Completing Lines Thirty-Two through Thirty-Seven - CHOW
Workloads (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
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 quarter’s report. (This count represents the number of CHOWs
included in line 1.)
Line 33 - Adjustments to Pending - If it is necessary to revise the pending figure for the close of
the previous quarter because of inventories taken or reporting errors discovered, enter the
adjustment here. Adjustments can be positive or negative values. If entering a negative value,
precede the number with a minus (-) sign. (This count represents the number of CHOWs included
in line 2.)
Line 34 - Adjusted Opening Pending -The CROWD system will automatically sum the values in
lines 32 and 33. (This count represents the number of CHOWs included in line 3.)
Line 35 - CHOWs Received - The intermediary enters the number of applications shown in line 6
that represents CHOWs received during the reporting quarter.
Line 36 - CHOWs Processed - The intermediary enters the number of applications shown in line
10 that represents CHOWs processed during the reporting quarter.
Line 37 - Pending End of Quarter -The CROWD system will automatically compute the number of
CHOWs pending at end of the reporting quarter by adding the value on line 34 to the value on line
35 and then subtracting the value on line 36. (This count represents the number of CHOWs
included in line 11.)

70.27 - Exhibits
(Rev. 6, 08-30-02)
A3-3898.27
Exhibit 1 - Screen 1 of Intermediary Provider Enrollment Quarterly Workload Report.
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
Application Workloads Total
(1)
Accrued
Hospital
(2)
Non-
Accrued
Hospital
(3)
Religious Nonmedical
Health Care Hospital
(4)
Rural
Prim Care
Hospital
(5)
1. Pending End of Last Quarter
2. Adjustments to Pending
3. Adjusted Opening Pending
4. New Applications Received
5. Returned Appls Resubmitted
6. Total Applications Received
7. Applications Approval Recmd
8. Applications Denial Recmd
9. Applications Returned
10. Total Applications Processed
11. Pending End of Quarter
SCREEN 1

Exhibit 2 - Screen 2 of Intermediary Provider Enrollment Quarterly Workload Report.
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
Application Workloads SNF
(6)
HHA
(7)
Hospice
(8)
ESRD
(9)
CORF
(10)
1. Pending End of Last Quarter
2. Adjustments to Pending
3. Adjusted Opening Pending
4. New Applications Received
5. Returned Appls Resubmitted
6. Total Applications Received
7. Applications Approval Recmd
8. Applications Denial Recmd
9. Applications Returned
10. Total Applications Processed
11. Pending End of Quarter
SCREEN 2

Exhibit 3 - Screen 3 of Intermediary Provider Enrollment Quarterly Workload Report.
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
Application Workloads RHC
(11)
FQH
C
(12) CMHC
(13) IHS
(14)
Outpatient Speech
Pathology
PhysicalTherapy
(15)
Other
(16)
1. Pending End of Last Quarter
2. Adjustments to Pending
3. Adjusted Opening Pending
4. New Applications Received
5. Returned Appls Resubmitted
6. Total Applications Received
7. Applications Approval Recmd
8. Applications Denial Recmd
9. Applications Returned
10. Total Applications Processed
11. Pending End of Quarter
SCREEN 3

Exhibit 4 - Screen 4 of Intermediary Provider Enrollment Quarterly Workload Report.
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
Application Workloads Total
(1)
Accrued
Hospital
(2)
Non-
Accrued
Hospital
(3)
Religious
Nonmedical
Health Care
Hospital
(4)
Rural
Prime Care
Hospital
(5)
Reason for Denial Recommendation
12. Sanctioned from Medicare
13. Debarred/Excluded by Other Fed
14. Not Professionally Licensed
15. Business Address Invalid
16. Business Location Not Licensed
17. CMS Requirements Not Met
Reason for Return
18. Incomplete
19. Unverifiable Information
20. Not Signed
21. Invalid Billing Agreement
22. Other
SCREEN 4

Exhibit 5 - Screen 5 of Intermediary Provider Enrollment Quarterly Workload Report.
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
Application SNF
(6)
HHA
(7)
Hospice
(8)
ESRD
(9)
CORF
(10)
Reason for Denial Recommendation
12. Sanctioned from Medicare
13. Debarred/Excluded by Other Fed
14. Not Professionally Licensed
15. Business Address Invalid
16. Business Location Not Licensed
17. CMS Requirements Not Met
Reason for Return
18. Incomplete
19. Unverifiable Information
20. Not Signed
21. Invalid Billing Agreement
22. Other
SCREEN 5

Exhibit 6 - Screen 6 of Intermediary Provider Enrollment Quarterly Workload Report.
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
Application Workloads RHC
(11)
FQHC
(12)
CMHC
(13)
IHS
(14)
Outpatient Speech
Pathology/
Physical Therapy
(15)
Other
(16)
Reasons for Denial Recommendation
12. Sanctioned from Medicare
13. Debarred/Excld by Other Fed
14. Not Professionally Licensed
15. Business Address Invalid
16. Business Location Not Licens
17. CMS Requirements Not Met
Reason for Return
18. Incomplete
19. Unverifiable Information
20. Not Signed
21. Invalid Billing Agreement
22. Other
SCREEN 6

Exhibit 7 - Screen 7 of Intermediary Provider Enrollment Quarterly Workload Report.
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
Application Workloads Total
(1)
Accrued
Hospital
(2)
Non-
Accrued
Hospital
(3)
Religious
Nonmedical
Health Care
Hospital
(4)
Rural
Prime Care
Hospital
(5)
Application Processing Times
23. Number Under 21 Days
24. Number in 21-30 Days
25. Number in 31-40 Days
26. Number Over 40 Days
Age of Applications Pending
27. Number Under 11 Days Old
28. Number 11-20 Days Old
29. Number 21-30 Days Old
30. Number 31-40 Days Old
31. Number Over 40 Days Old
SCREEN 7

Exhibit 8 - Screen 8 of Intermediary Provider Enrollment Quarterly Workload Report.
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
Application Workloads SNF
(6)
HHA
(7)
Hospice
(8)
ESRD
(9)
CORF
(10)
Application Processing Times
23. Number Under 21 Days
24. Number in 21-30 Days
25. Number in 31-40 Days
26. Number Over 40 Days
Age of Applications Pending
27. Number Under 11 Days Old
28. Number 11-20 Days Old
29. Number 21-30 Days Old
30. Number 31-40 Days Old
31. Number Over 40 Days Old
SCREEN 8

Exhibit 9 - Screen 9 of Intermediary Provider Enrollment Quarterly Workload Report.
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
Application Workloads RHC
(11)
FQHC
(12)
CMHC
(13)
IHS
(14)
Outpatient Speech
Pathology/
Physical Therapy
(15)
Other
(16)
Application Processing Times
23. Number Under 21 Days
24. Number in 21-30 Days
25. Number in 31-40 Days
26. Number Over 40 Days
Age of Applications Pending
27. Number Under 11 Days Old
28. Number 11-20 Days Old
29. Number 21-30 Days Old
30. Number 31-40 Days Old
31. Number Over 40 Days Old
SCREEN 9

Exhibit 10 - Screens 10 and 11 of Intermediary Provider Enrollment Quarterly Workload Report.
SCREEN 10
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
CHOW Workloads Total
(1)
Accrued
Hospital
(2)
Non-
Accrued
Hospital
(3)
Religious
Nonmedical
Health Care
Hospital
(4)
Rural
Prime Care
Hospital
(5)
32. Pending End of Last Quarter
33. Adjustments to Pending
34. Adjusted Opening Pending
35. CHOWs Received
36. CHOWs Processed
37. Pending End of Quarter

Exhibit 10 (Cont.)
Exhibit 10 - Screens 10 and 11 of Intermediary Provider Enrollment Quarterly Workload Report.
SCREEN 11
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
CHOW Workloads SNF
(6)
HHA
(7)
Hospice
(8)
ESRD
(9)
CORF
(10)
32. Pending End of Last Quarter
33. Adjustments to Pending
34. Adjusted Opening Pending
35. CHOWs Received
36. CHOWs Processed
37. Pending End of Quarter

Exhibit 11 - Screen 12 of Intermediary Provider Enrollment Quarterly Workload Report.
INTERMEDIARY NAME:
REPORT PERIOD: INTERMEDIARY NUMBER:
CROWD FORM 3
CHOW Workloads RHC
(11)
FQHC
(12)
CMHC
(13)
IHS
(14)
Outpatient Speech
Pathology/Physica
l Therapy
(15)
Other
(16)
32. Pending End of Last Quarter
33. Adjustments to Pending
34. Adjusted Opening Pending
35. CHOWs Received
36. CHOWs Processed
37. Pending End of Quarter
SCREEN 12

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 intermediary’s files, on the query reply, or on the claim itself. In addition,
any information it obtains from a non-Medicare source and uses as the basis for claiming cost
avoidance savings must meet the criteria in §80.6B.
Information considered adequate for claiming cost avoidance savings includes statements on the
claim noting "automobile accident," "collision", or the name of the automobile insurer. Another
example would be previous information obtained showing EGHP coverage exits. The
intermediary does not count claims it develops as "possible" MSP situations based on routine edits
as cost avoidance savings unless it has previous information that another payer has primary
responsibility. For example, "trauma code" edits are not, by themselves, considered strong
evidence that Medicare is the secondary payer.
Line 1 - Number - The intermediary reports the total number of cost avoided claims from which it
is recording savings on the report.
Line 2 - Dollar Value - The intermediary reports the total dollar value of the potential Medicare
payments calculated for the claims on Line 1 that will be saved if the primary payer makes a
payment which relieves Medicare of all payment liability.
It shows as the amount cost avoided what Medicare would have paid. It does not count total
charges as cost avoided savings. The cost avoided amount is the "Medicare payment rate" or the
"current Medicare interim reimbursement amount" less any co-insurance amount applicable. It
reduces Part B services subject to coinsurance for the coinsurance amount or it may use a
"coinsurance reduction factor" of 19 percent to calculate coinsurance charges for all Part B
services. It does not have to query for deductible status, but may assume that the deductible has
been met.
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
Avoidance
Partial
Recoveries
Full
Recoveries
I. Partial Recovery Adjustment
o
MSP situation indicated. Medicare payment
calculated to be $1200 if Medicare was
primary payer. Claim is returned to provider.
$ 1,200
o
Provider resubmits the claim showing $900
paid by the other insurer. Medicare
secondary payment of $300 is made.
$ (1,200) * $ 900
II. "Other Payer Denial" Adjustment
• MSP situation indicated - Medicare
"primary" payment, $2,000. Claim is
returned to provider.
$ 2,000
• Other payer denies claim. Medicare
found to be primary and Medicare
payment of $2,000 is made.
$ (2,000) *
III. Full Recovery Adjustment
• MSP situation indicated - Medicare
"primary" payment, $900. Claim is
returned to provider.
$ 900
• Provider submits a "no-payment" bill
showing full payment by the other
payer.
$ (900) * $ 900
*Amounts "backed out" of cost avoidance savings figures.
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 – Monthly Intermediary Part A and Part B Appeals Report (Form
CMS-2591)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
At the end of each month, prepare and transmit to CMS a report summarizing activity on Part A
reconsiderations, Part A Administrative Law Judge (ALJ) hearings, Part B reviews, and Part B
hearings during the month. Complete a separate report for each office assigned a separate
intermediary number.
Form CMS-2591 is subject to the Paperwork Reduction Act and requires approval by the Office of
Management and Budget (OMB). OMB approval has been requested.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
Transmit the CMS-2591 to CO via PC or terminal. Use instructions in the CROWD User Guide
available via the CMS Enterprise Portal.
The report is due as soon as possible after the end of the reporting month but no later than the 15th
of the month following the end of the reporting month.
100 – Completion of Items on Form CMS-2591
(Rev. 45, 05-28-04)
100.1 – Heading
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
This report is referenced as Form J for CROWD. It submits the appropriate information for the
reporting period for each office assigned a separate contractor number and BSI.
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 appellant withdraws the
request.
The date you were notified of the
withdrawal.
• You dismiss the request or
affirm the original
determination. The date of the notice.
• You process the request to a
reversal.
The date when you submit the claim to
CWF if payment can be made without
further development, or when you
initiate development; e.g., when you
must ascertain whether or not the
provider has refunded payment to the
beneficiary.
Computing Time to Process Part B Hearings for Lines 35-39
For lines 35-39, use the matrix below to determine the number of days from receipt to completion
of Part B hearings. The date of receipt, in all cases, is the day you receive the appeal request in its
corporate mailroom. In out-of-area cases, it is the date that the second intermediary receives the
request.

Situation Date Completed
An OTR decision is made and the appellant accepts
the decision or decided to go directly to an ALJ
hearing.
The date of the OTR decision.
An OTR decision is made and the appellant
chooses in a timely fashion to proceed with the in-
person or telephone hearing.
The date of the second
decision. If the appellant
appears, and you dismiss the
hearing, use the date of notice
of dismissal.
An in-person or telephone hearing is held without
an OTR decision. The date of the decision.
The appellant withdraws the hearing request. The date you are notified of
the withdrawal.
The HO dismisses the hearing request. The date of the dismissal
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
RECONSIDERATIONS
PART B
A. INTERMEDIARY APPEAL
REQUESTS
TOT
AL
(1)
SNF
(2)
HHA/
HOSPIC
E
(3)
OTHE
R
(4)
REVIE
WS (5)
HEARIN
GS
(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
A. INTERMEDIARY APPEAL
REQUESTS
PART A RECONSIDERATIONS
TOTAL SNF HHA/HOSPI
CE
OTHER
(1) (2) (3) (4)
PROCESSING TIMES
13. AVERAGE
14. NO. COMPLETED 1-45 DAYS
15. NO. COMPLETED 46-60 DAYS
16. NO. COMPLETED 61-90 DAYS
17. NO. COMPLETED 91-120
DAYS
18. NO. COMPLETED OVER 120
DAYS
PENDING TIMES
19. CLOSING PENDING
20. NO. PENDING 1-45 DAYS
21. NO. PENDING 46-60 DAYS
22. NO. PENDING 61-90 DAYS
23. NO. PENDING 91-120 DAYS

24. NO. PENDING OVER 120
DAYS
Form CMS-2591 Screen 2
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
A. INTERMEDIARY APPEAL
REQUESTS REVIEWS
PART B APPEALS
Reviews Hearings
(1) HEARINGS (2)
PROCESSING TIMES PROCESSING TIMES
25. AVERAGE 35. AVERAGE
26. NO. 1-30 DAYS 36. NO. 1-60 DAYS
27. NO. 31-45 DAYS 37. NO. 61-90 DAYS
28. NO. 46-60 DAYS 38. NO. 91-120 DAYS
29. NO. OVER 60 DAYS 39. NO. OVER 120 DAYS
PENDING TIMES PENDING TIMES
30. CLOSING PENDING 40. AVERAGE
31. NO. 1-30 DAYS 41. NO. 1-60 DAYS
32. NO. 31-45 DAYS 42. NO. 61-90 DAYS
33. NO. 46-60 DAYS 43. NO. 91-120 DAYS
34. NO. OVER 60 DAYS 44. NO. OVER 120 DAYS
B. PART B OTR All All

HEARING RESULTS With No
Subsequent
(1)
Telephone
Hearings
(2)
In-Person
Hearings
(3)
Number
In
120 Days
(4)
45. REVERSALS
46. AFFIRMATIONS
47. TOTAL DECISIONS
48. NBR IN 120 DAYS
49. NO PREV. OTR HELD
50. PREV. OTR COUNTED
51. PREV. OTR NOT CNTD
Form CMS-2591 Screen 3
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
HEARINGS
PART A
Total
(1)
SNF
(2)
HHA/Hospice
(3)
Other
(4)
Part B
(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
C. PART A AND B ALJ
HEARINGS
Total
(1)
SNF
(2)
HHA/Hospice
(3)
Other
(4)
PART B
(5)

DISPOSITIONS
68. NUMBER OF DISPOSITIONS
69. AFFIRMATIONS
70.
DISMISSALS/WITHDRAWALS
71. REVERSALS (FULL OR
PART)
EFFECTUATIONS
72. TOTAL EFFECTUATIONS
73. NO. 1-7 DAYS
74. NO. 8-15 DAYS
75. NO. 16-30 DAYS
76. NO. OVER 30 DAYS
LIMITATION OF LIABILITY
77. WAIVED - BEN & PROV.
78. AMOUNT AWARDED
D. LIMITATION OF LIABILITY
(CLAIM COUNTS)
PART A RECONSIDERATIONS PART B
Total
(1)
SNF
(2)
HHA/
Hospice
(3)
Other
(4)
Reviews
(5)
Hearings
(6)
79. TOTAL NUMBER
CONSIDERED
80. CONSIDERED - NOT
WAIVED
81. WAIVED - BEN. ONLY
82. WAIVED - BEN. & PROV.

83. AMOUNT AWARDED
Form CMS-2591 Screen 5
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)
PART A TOTAL
(1)
PRE-
Recon
(2)
Post-
Recon
(3)
Post-ALJ
Hearing
(4)
84. TOTAL
85. UNFAVORABLE TO
CLAIMANT
86. NO CHANGE
87. FAVORABLE TO
CLAIMANT
88. AMOUNT AWARDED
PART B TOTAL
Pre-
Review
Post-
Review
Post-
Hearing
89. TOTAL
90. UNFAVORABLE TO
CLAIMANT
91. NO CHANGE
92. FAVORABLE TO
CLAIMANT
93. AMOUNT AWARDED

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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13302.1
This report is referenced as Form B for CROWD. The carrier submits the appropriate information
for the reporting period for each office assigned a separate contractor number and BSI. It reports
the number of working days scheduled for the reporting period, less any days where no claims
were processed as a result of a strike, snowstorm, etc. It does not count Saturdays, Sundays, or
holidays.
130.2 - Part A - Monthly Workload Operations
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
This part of the report presents data on carrier claims processing activity during the reporting
period. Counts of claims (real and replicate) processed, total claims (real and replicate) pending,
or pending from prior months must reflect the actual status of claims (real or replicate) workloads
as of the last day of the reporting calendar month. Data shown must be based on reliable counts of
all claims (real or replicate) processing activity and the entire "in-house" pending workload. This
data may not be derived from estimates.
If a single claim is split into two or more real claims, or into one real claim and one or more
replicate claims, the carrier considers each split (real and replicate) as a separate, distinct claim for
purposes of counting claims. The original real claim is a receipt for the month in which it was
received. It counts a claim split from the original, or identified as a replicate, as a receipt for the
month in which it is actually created or in which its system recognizes it as a separate claim. To
determine the age of pending claims, the carrier considers the receipt date as the date the original
claim was received and not the date it was split from another claim.
It reports, in Part A, only data relating to initial claims (real and replicate) actions. It does not
report data on requests for, or dispositions of, reviews, hearings, or reopenings of initial claim
actions.
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 reports 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 reports all real claims
received during the month and all split and replicate claims generated
(recognized) during the month. (See the Medicare Claims Processing
Manual for a discussion of what constitutes a claim.) Claims received
include all claims received in its mailroom during the reporting month even
though some of them were placed under computer control in the following
month. (See §120.1 for counting receipts.)
The carrier counts claims submitted electronically after they have passed its
consistency edits. Prior to that time, it may return these bills or the entire
tape (where magnetic tape is the medium of submission), as necessary,
without counting them as received. However, once the claims or tapes
have passed consistency edits and are counted as received, it uses the actual
receipt date, not the date the edits are passed, in calculating pending and
processing times.
Line 5. Transferred to Other Carriers - The carrier reports the number of claims
received, but transferred to other carriers or Part A intermediaries, during
the month because the claimant submitted the claim to the wrong
contractor. It includes claims transferred in their entirety or split off from
other claims because they contained services from physicians/suppliers
outside of their carrier jurisdiction.
Line 6. Net Number of Claims Received - The carrier shows the net number of
claims (real and replicate) received after subtracting those transferred.
Line 7. Electronic Media Claims Received - The carrier reports the net number of
claims included in line 6 which were received in paperless form via
electronic media from providers or their billing agencies and read directly
into its claims processing system. It does not count on this line claims that
it received in hardcopy and entered using an Optical Character Recognition
(OCR) device. It does not count any claims received in hardcopy and
transformed into electronic media by any entity working for it directly or
under subcontract.
It counts claims which are split automatically by computer, without manual
intervention, as electronic media claims. This includes "required" splits

only. (See the Medicare Claims Processing Manual. It excludes replicate
claims).
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 reports the number of
CWF claims (real or replicate) for which no payment was made because the
deductible had not been met. It includes claims for which all charges were
applied toward the deductible, as well as those for which some charges
were denied.
Line 11 Claims Denied - The carrier reports the number of CWF claims (real or
replicate) for which all services were denied because, for example, the
beneficiary was not eligible for Part B benefits, the filing limitation was
exceeded, or services were not covered.
Line 12. Total Non-CWF Claims - The carrier reports the number of initial claims
(real or replicate) processed outside CWF. Non-CWF claims are those
either rejected by or not submitted to CWF which it finally adjudicates
outside of CWF and are, therefore, not posted to its history in the reporting
month. It reports these claims as non-CWF, even if it plans to submit an
informational record in the future. Also, it reports these claims in the month
in which it made the determination as to their final disposition.
Line 13. Claims Approved - Of those claims reported on line 12 as not processed
through CWF, the carrier reports the number approved for payment or with
all charges applied toward the deductible.
Line 14. Claims Denied - Of those claims reported on line 12, the carrier reports the
number on which all services were denied.
Line 15. Total Claims Processed - The carrier reports the sum of lines 8 and 12.
Line 16. Replicate Claims Processed - The carrier reports the number of replicate
claims included under Total Claims Processed, line 15, column (1).

Replicate claims are those claims split off from original (real) claim.
Replicate claims are generally created because of computer line item
limitations, the carrier is making partial payments, or it is carving out
individual specialty types of services. (See the Medicare Claims
Processing Manual, Publication 100-04, Chapter 1, Section 70.2.).
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 reports the number of claims, by type, included in
line 17 which are 1-15 days old.
Line 19. 16-30 Days - The carrier reports the number of claims, by type, included in
line 17 which are 16-30 days old.
Line 20. 31-60 Days - The carrier reports the number of claims, by type, included in
line 17 which are 31-60 days old.
Line 21. 61-90 Days - The carrier reports the number of claims, by type, included in
line 17 which are 61-90 days old.
Line 22. Over 90 Days - The carrier reports the number of claims, by type, included
in line 17 which are over 90 days old.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
Medicaid Crossover Claims - This part of the report represents data on the volume of Medicaid
crossover claims.
Line 28 Number Transferred to State Agencies - The carrier reports the total number of
Medicaid crossover claims transferred to State agencies or their fiscal agents in the
reporting month.
Line 29 Number Transferred Electronically - The carrier reports the total number of Medicaid
crossover claims reported in line 28 which were transferred in the reporting month to
State agencies, or their fiscal agents, via electronic media.
Optical Character Recognition Claims
Line 30 Total Claims - The carrier reports the number of claims received in hardcopy and
entered using an OCR device. It does not count these claims as EMC claims on line 7,
page 1, or in column 6, pages 2-9.
Medicare Summary Notices (MSNs)
Line 31 Total MSNs Mailed - The carrier reports 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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13305.1
These pages are referenced as Form T (pages 2-9) and Form E (pages 10-11) for CROWD. It
submits the appropriate information for the reporting period for each office assigned a separate
contractor number and BSI.
150 - Part D (1) - Claims Processing Timeliness - All Claims
(Rev. 12456; Issued:01-11-24; Effective: 07-01-24; Implementation:07-01-24)
Pages 2-9 of the CMS-1565 include data on its activity in processing all claims to completion
during the reporting period. A claim is counted as processed to completion on the scheduled
payment date, which is the date the check is mailed, deposited in the provider’s account, or
transferred electronically. For non-paid claims, the date of completion is the date the MSN or
other notice of final action on the claim is mailed. Data shown must be based on reliable counts of
all claims (real and replicate) processing activity. The A/B MAC (B) does not estimate claim

counts. It reports only data relating to initial claims (real and replicate) actions. It does not report
data on requests for, or dispositions of, reviews, hearings, or reopenings of initial claim actions.
"Clean" claims are defined as those that do not require investigation or development external to the
A/B MAC (B)’s operation on a prepayment basis. Claims which do not meet the definition of
"clean" are "other" claims. Claims paid are those for which some payment was made (i.e.,
payment greater than zero). Claims not paid are those for which no payment was made (i.e., claim
charges applied completely toward deductible or fully denied).
On pages 2-9, the A/B MAC (B) reports:
• 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
Receipt
Paid Counter by
Days
Counter by
Claims
A 87103 87133 30 1
B 87105 87206 101 2
C 87115 87177 62 3
D 87120 87213 93 4
E 87122 87215 93 5
F 87130 87223 93 6
Total Days = 30 + 101 + 62 + 93 + 93 + 93 = 472
Mean = 472/6 = 78.6666 = 78.7
The A/B MAC (B) completes the report for each of the following claim types:
Page 2. Assigned Physician - It shows the number of assigned claims included on page 9
which involved services billed by physicians. Physicians are identified by specialty
codes 01-14, 16-30, 33-41, 44, 46, 48, 66, 70, 72, 76-79, 81-86, 90-94, 98, 99, C0, or
C3, C5, C6, C7, C8, C9, D3 D4, D7, D8, E1, E2, E3, E4, E5, E6, E7, E9, F1, F2, F3,
F4, F5, F6.
Page 3. Assigned DME - It shows the number of assigned claims included on page 9 which
involved services billed by DME suppliers.
Page 4. Assigned Lab - It shows the number of assigned claims included on page 9 which
involved services billed by an independent laboratory. Independent laboratories are
identified by specialty code 69.
Page 5. Assigned Ambulance - It shows the number of assigned claims included on page 9
which involved services billed by ambulance service suppliers. Ambulance service
suppliers are identified by specialty code 59.
Page 6. Assigned Other - It shows the number of assigned non-physician claims included on
page 9 but not represented on pages 3, 4, or 5.
Page 7. Unassigned - It shows the number of unassigned claims (real and replicate) included
on page 9.
Page 8. Participating Physician - It shows the number of claims included on page 9 involving
services rendered by physicians enrolled in the Medicare Physician/Supplier
Participation Program.
Page 9. All Claims - It shows the total number of claims (real and replicate) processed during
the month.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13308.2
This page is referenced as Form V for CROWD. The carrier submits the appropriate information
for the reporting period for each office assigned a separate contractor number and BSI.

170.3 - Part E - Interest Payment Data
(Rev. 12456; Issued:01-11-24; Effective: 07-01-24; Implementation:07-01-24)
The A/B MAC (B) reports on Page 12 of the CMS-1565 data on the claims on which it paid
interest because it paid the claims after the required payment date per §9311 of the Omnibus
Reconciliation Act of 1986 (OBRA 1986). It bases data shown on reliable counts of all claims
processing activity, not on estimates. It reports data on initial claims only. It includes in the report
all claims requiring interest payments in the month. It reports claims in the month the date of
payment falls. (For a discussion of interest payments refer to the Medicare Claims Processing
Manual, Publication 100-04, chapter 1, sections 80.2.2 and 80.2.2.1).
The A/B MAC (B) completes the report for each column as follows:
Column 1. Total - Data for all claims (real and replicate) for which interest payments were
made during the month.
Column 2. Assigned Physician - Data for the assigned claims included in column 1 which
involved services billed by physicians. Physicians are identified by specialty
codes 01-14, 16-30, 33-41, 44, 46, 48, 66, 70, 72, 76-79, 81-86, 90-94, 98, 99, C0,
C3, C5, C6, C7, C8, C9, D3, D4, D7, D8, E1, E2, E3, E4, E5, E6, E7, E9, F1, F2,
F3, F4, F5, F6.
Column 3. Assigned DME - Data for the assigned claims included in column 1 that involved
services billed by DME suppliers.
Column 4. Assigned Lab - Data for the assigned claims included in column 1 that involved
services billed by an independent laboratory. Independent laboratories are
identified by specialty code 69.
Column 5. Assigned Ambulance - Data for the assigned claims included in column 1 that
involved services billed by ambulance service suppliers. Ambulance service
suppliers are identified by specialty code 59.
Column 6. Assigned Other - Data for the assigned non-physician claims included in column 1
but not represented in columns 3, 4, or 5.
Column 7. Unassigned - Data for the unassigned claims included in column 1.
Column 8. Participating Physician - Data for claims involving services rendered by physicians
enrolled in the Medicare Physician/Supplier Participation Program.
On line 1, the A/B MAC (B) shows the number of claims on which it paid interest in the reporting
month. It reports on line 2 the number of claims included in line 1 for which it made payment 1
day after the required payment date (e.g., the required payment date is 17 days after receipt for
participating physician claims received in FY 1992.) (See §9311 of OBRA 1986.) Data for lines
3-10 are similar to those for line 2.
The A/B MAC (B) calculates the number of days late by subtracting the Julian date of the required
payment date from the Julian date of payment.
On line 11, it shows the amount paid in interest for claims reported in line 1. On lines 12-20, it
shows the amount paid in interest for claims reported in lines 2-10, respectively. It shows dollar
amounts on lines 11-20 to the nearest penny, and includes the decimal point.

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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13310
Prior to transmitting performance reports to CMS the carrier checks for the following:
• 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) (Inactive)
(Line 2 divided by line 3) times 100 = line 4 for all columns.
200 - Exhibits
(Rev. 126; Issued: 07-13-07; Effective: 01-01-08; Implementation: 01-07-08)
Exhibit 1 - Medicare Program Carrier Performance Report- Page 1
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1
Carrier Number
Report Period
( Month/Yr)
Working
Days
Number and Type of Claim
Reporting Item Total
(1)
Assigned
(2)
Unassigned
(3)
A. Monthly Workload Operations
OPENING PENDING
1. Claims Pndg End of Last Mo.
2. Adjustments (Show + or -)
3. Adjusted Opening Pending
RECEIPTS
4. Tot. Clms. Rcvd. During Mo.
5. Transferred to Other Carrier
6. Net Number of Claims Received
7. Electronic Media Claims Recvd.
CLAIMS PROCESSED

8. Total CWF Claims
9. Claims Paid
10. Claims Applied To Deductible
11. Claims Denied
12. Total Non-CWF Claims
13. Claims Approved
14. Claims Denied
15. Total Claims Processed
16. Replicate Claims Processed
Exhibit 1 (Cont.)
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 (cont)
Carrier Number
Report Period
( Month/Yr)
Working
Days
Number and Type of Claim
Reporting Item Total
(1)
Assigned
(2)
Unassigned
(3)
CLOSING PENDING
17. Claims Pending at End of Month
DISTRIBUTION OF DAYS ELAPSED SINCE RECEIPT
18. 1 - 15 Days
19. 16 - 30 Days
20. 31 - 60 Days
21. 61 - 90 Days
22. Over 90 Days
CLAIMS INVESTIGATIONS
23. No. of Clms. Invest. During Mo.
B. INQUIRIES TOTAL BENEFICIARY PROVIDER

24. Tot. No. Processed During Mo.
25. Telephone
26. Walk-In Contact
27. Written
C. MISCELLANEOUS CLAIMS
DATA
MEDICAID CROSSOVER CLAIMS
28. No. Transferred to St. Agencies
29. No. Transferred Electronically
Exhibit 1 (Cont.)
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 (cont)
Carrier Number
Report Period
( Month/Yr)
Working
Days
Number and Type of Claim
Reporting Item Total
(1)
Assigned
(2)
Unassigned
(3)
OPTICAL CHARACTER RECOGNITION
CLMS.
30. Total Claims
MEDICARE SUMMARY NOTICES
31. Total MSNs Mailed
Form CMS-1565

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
(1)
CLEAN
(2)
OTHER
(3)
CLEAN
(4)
OTHER
(5)
EMC
(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
(1)
CLEAN
(2)
OTHER
(3)
CLEAN
(4)
OTHER
(5)
EMC
(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 PAID
EMC NOT
PAID
ADJUSTMENTS FOR CPEP CPT
LINE NO./DAYS CLEAN
(1)
OTHER
(2)
CLEAN
(3)
CALCULATIONS:
1 1 CWF
Claims which were
beyond carrier control due
to CWF.
2 2
3 3
4 4
5 5 A. EMC clean claims
Processed beyond EMC	6 6
7 7
8 8 B. Paper clean claims
Processed beyond Paper
ceiling
9 9
10 10
11 11 C. All claims processed
Beyond 60 days ____	12 12
13 13 WAIVER
Claims paid under the
floor For which the carrier
had a waiver from CMS.
14 14
15 15
16 16
17 17 D. EMC clean claims
Paid under EMC floor
_________
18 18
19 19
20 20 E. Paper clean claims
Paid under paper floor
________
21 21
22 22
23 23 F. All EMC claims paid
under EMC floor and all
paper claims paid under
paper floor __________
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33

Exhibit 3 (Cont.)
EMC PAID EMC
NOT PAID
LINE NO./DAYS CLEAN
(1)
OTHER
(2)
CLEAN
(3)
CALCULATIONS:
34 34-45
35 46-60
36 61-90
37 91+
38 Tot 1-37
39 Mean Pt
CMS-1565 Page _*_
* PAGE NUMBER AND TYPE OF CLAIM ARE TO BE REPORTED AS FOLLOWS:
Page 10-Participating Physician (PAR)
Page 11-Total (TOT)

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
CLAIM/PAYMENT
LATE DAYS
TOTAL
(1)
ASTD
PHYS
(2)
ASTD
DME
(3)
ASTD
LAB
(4)
ASTD
AMB
(5)
ASTD
OTHER
(6)
UNASTD
(7)
PARTIC.
PHYS
(8)
1. No. of Claims
2. 1 Day late
3. 2 Days Late
4. 3 Days Late
5. 4 Days Late
6. 5 Days Late
7. 6-15 A Late
8. 16-30 A Late
9. 31-60 A Late
10. 61+ A Late
11. Amount paid
12. 1 Day late
13. 2 Days Late
14. 3 Days Late
15. 4 Days Late
16. 5 Days Late
17. 6-15 A Late
18. 16-30 A Late
19. 31-60 A Late
20. 61+ A Late
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
CALLS
(1)
TOLL FREE
CALLS
(2)
1. PERCENT OF ATB
2. NUMBER OF BENEFICIARY CALLS ANSWERED IN
120 SECONDS
3. TOTAL NUMBER OF
BENEFICIARY CALLS RECEIVED
4. % OF BENEFICIARY CALLS ANSWERED IN 120
SECONDS
EXPLANATION FOR FAILURES:
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
7 OTH (other than the previous types
above) An example would be regional-wide code
8 TOT (total DMEPOS claims)
If a claim contains more than one category type, the carrier reports the claim under each type
identified. For example, it reports a claim including services for oxygen (OXY), non-oxygen
equipment (NOE), and dialysis supplies (DIA) under page 2 (OXY), under page 3 (NOE), and
under page 4 (DIA). As a result, this claim will end up being counted as 3 claims under page 8
(TOT).
For each of these types (pages 1 through 8), it enters data for lines and columns as follows:
Lines - data reflecting the total of all States and territories in its jurisdiction (region). On
subsequent lines (2 and greater), enter data for each State and territory in its region.
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
State
Code
(1)
Number
(2)
In
1-60
Days
(3)
In
61-90
Days
(4)
Mean
Proc.
Time
(5)
EMC
(6)
Number
(7)
In
1-30 Days
(8)
1-Tot.
All
States
02 CT
03 DE
04 MA
05 ME
06 NH
07 NJ
08 NY
09 PA
10 RI
11 VT
12
13
14
15
16
17
18
19
20
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
for Type Indicated
Clean Claims Processed
for Type Indicated
State
Code
(1)
Number
(2)
In
1-60
Days
(3)
In
61-90
Days
(4)
Mean
Proc.
Time
(5)
EMC
(6)
Number
(7)
In
1-30 Days
(8)
1-Tot. All
States
02 DC
03 IL
04 IN
05 MD
06 MI
07 MN
08 OH
09 VA
10 WI
11 WV
12
13
14
15
16
17
18
19
20
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
for Type Indicated
Clean Claims Processed
for Type Indicated
State
Code
(1)
Number
(2)
In
1-60
Days
(3)
In
61-90
Days
(4)
Mean
Proc.
Time
(5)
EMC
(6)
Number
(7)
In
1-30 Days
(8)
1-Tot.
All
States
02 AL
03 AR
04 CO
05 FL
06 GA
07 KY
08 LA
09 MS
10 NC
11 NM
12 OK2
13 PR2
14 SC2
15 TN2
16 TX2
17 VI2
18
19
20

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
State
Code
(1)
Number
(2)
In
1-60
Days
(3)
In
61-90
Days
(4)
Mean
Proc.
Time
(5)
EMC
(6)
Number
(7)
In
1-30 Days
(8)
1-Tot.
All States
02 AK
03 AZ
04 CA
05 CM
06 GU
07 HI
08 IA
09 ID
10 KS
11 MO
12 MT
13 ND
14 NE
15 NV
16 OR
17 SD
18 UT
19 WA
20 WY
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 carrier’s Medicare Fraud and Abuse unit;
• Monitoring activity related to the carrier’s Comprehensive Limiting Charge Compliance
Program; and
• Monitoring activities dealing with the carrier’s 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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13320.2
The carrier transmits Forms CMS-1565A, CMS-1565B, CMS-1565C, and CMS-1565D to CO via
PC or terminal as soon as possible after the end of the reporting quarter, but no later than the 15th
of the following month, using instructions in the CROWD User Guide available via the CMS
Enterprise Portal. With the exception of the due date, it applies these same instructions to Form
CMS-1565E. The due date for the CMS-1565E is 75 days following the reporting quarter.
The carrier does not submit hardcopies of the reports.
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
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13322.1
This report is referenced as Form A for CROWD. The carrier submits the appropriate information
for the reporting period for each office assigned a separate contractor number and BSI.
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 (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13323
The carrier prepares and submits to CMS each quarter a report on the number of fraud workload
items handled by its Medicare fraud unit. This information is required by CMS to budget for fraud
and abuse activities, as well as to monitor the flow of work through the fraud units. It submits this
form via CROWD no later than the fifteenth day following the close of the reporting quarter.
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. 12456; Issued:01-11-24; Effective: 07-01-24; Implementation:07-01-24)
The A/B MAC (B) reports on Page 12 of the CMS-1565 data on the claims on which it paid
interest because it paid the claims after the required payment date per §9311 of the Omnibus
Reconciliation Act of 1986 (OBRA 1986). It bases data shown on reliable counts of all claims
processing activity, not on estimates. It reports data on initial claims only. It includes in the report
all claims requiring interest payments in the month. It reports claims in the month the date of
payment falls. (For a discussion of interest payments refer to the Medicare Claims Processing
Manual, Publication 100-04, chapter 1, sections 80.2.2 and 80.2.2.1).
The A/B MAC (B) completes the report for each column as follows:
Column 1. Total - Data for all claims (real and replicate) for which interest payments were
made during the month.

Column 2. Assigned Physician - Data for the assigned claims included in column 1 which
involved services billed by physicians. Physicians are identified by specialty
codes 01-14, 16-30, 33-41, 44, 46, 48, 66, 70, 72, 76-79, 81-86, 90-94, 98, 99, C0,
C3, C5, C6, C7, C8, C9, D3, D4, D7, D8, E1, E2, E3, E4, E5, E6, E7, E9, F1, F2,
F3, F4, F5, F6.
Column 3. Assigned DME - Data for the assigned claims included in column 1 that involved
services billed by DME suppliers.
Column 4. Assigned Lab - Data for the assigned claims included in column 1 that involved
services billed by an independent laboratory. Independent laboratories are
identified by specialty code 69.
Column 5. Assigned Ambulance - Data for the assigned claims included in column 1 that
involved services billed by ambulance service suppliers. Ambulance service
suppliers are identified by specialty code 59.
Column 6. Assigned Other - Data for the assigned non-physician claims included in column 1
but not represented in columns 3, 4, or 5.
Column 7. Unassigned - Data for the unassigned claims included in column 1.
Column 8. Participating Physician - Data for claims involving services rendered by physicians
enrolled in the Medicare Physician/Supplier Participation Program.
On line 1, the A/B MAC (B) shows the number of claims on which it paid interest in the reporting
month. It reports on line 2 the number of claims included in line 1 for which it made payment 1
day after the required payment date (e.g., the required payment date is 17 days after receipt for
participating physician claims received in FY 1992.) (See §9311 of OBRA 1986.) Data for lines
3-10 are similar to those for line 2.
The A/B MAC (B) calculates the number of days late by subtracting the Julian date of the required
payment date from the Julian date of payment.
On line 11, it shows the amount paid in interest for claims reported in line 1. On lines 12-20, it
shows the amount paid in interest for claims reported in lines 2-10, respectively. It shows dollar
amounts on lines 11-20 to the nearest penny, and includes the decimal point.
270 - Completion of Items on Form CMS-1565C
(Rev. 6, 08-30-02)
B3-13325
270.1 - Heading
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13325.1
This report is referenced as Form G for CROWD. The carrier submits the appropriate information
for the reporting period for each office assigned a separate contractor number and BSI. It must
submit Form A for the reporting quarter before the system will allow it to submit Form G for the
same quarter.
270.2 - Part D - Selected Claim Data by Participation Status
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)

This part provides CMS with current quarterly workload data on the results of carrier activity in
processing claims for physician and non-physician services according to the participation status of
the physician/supplier. It also provides important related information on reasonable charge
determinations, the extent to which claims for such services are being denied, and the amount of
charges disallowed.
The carrier reports only data relating to initial claims (real and replicate) actions. It does not
report data on the disposition of reviews, hearings, or reopenings of initial claim actions.
It reports data for lines 1-34 for each column (participation/assignment status) as defined in the
Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 30. unless otherwise
stated. Specialty codes for physicians and non-physicians are listed in the Medicare Claims
Processing Manual, Chapter 26, Sections 10.8.2 and 10.8.3.
Line 1. Number of Claims Approved - total number of claims, processed to completion during
the quarter, which were paid or applied to the deductible. Claims paid or applied toward the
deductible are those reported in lines 9, 10, and 13 of Form B. The system will pre-fill columns 1
and 3 based on the total of these lines from the monthly reports.
Line 2. Physician Only - number of claims included in line 1 involving physician services only.
Line 3. Physician and Non-Physician - number of claims included in line 1 involving both
physician and non-physician services on the same claim. The carrier shows all claims in this
category under the "Non-Participant-Unassigned" column 3. Therefore, the numbers for columns 1
and 3 should be equal.
Line 4. Non-Physician Only - number of claims included in line 1 involving non-physician
services only.
Line 5. Number of Covered Services - total number of covered services on the claims approved
as shown on line 1. The carrier does not include services for which charges were completely
disallowed.
Line 6. Physician - number of physician services included in line 5. The carrier includes in this
count the covered services from the claims shown in line 2 plus the covered physician services
from the claims shown in line 3.
Line 7. Non-Physician - number of non-physician services included in line 5. The carrier
includes in this count the covered services from the claims shown in line 4 plus the covered non-
physician services from the claims shown in line 3.
Line 8. Amount of Covered Charges - total amount (rounded to the nearest dollar) of billed
charges for the covered services shown in line 5. For those services in which any charges were
reduced as a result of reasonable charge, medical necessity, or global fee/rebundling
determinations, the carrier reports the total covered charges prior to such reductions. The system
will pre-fill columns 1 and 3 with the data reported in the respective columns on line 1 of Form A
for the same quarter.

Line 9. Physician - total amount (rounded to the nearest dollar) of billed charges for the covered
physician services shown in line 6. For those services in which any charges were reduced as a
result of reasonable charge, medical necessity, or global fee/rebundling determinations, the carrier
reports the total covered charges prior to such reductions.
Line 10. Non-Physician - total amount (rounded to the nearest dollar) of billed charges for the
covered non-physician services shown in line 7. For those services in which any charges were
reduced as a result of reasonable charge, medical necessity, or global fee/rebundling
determinations, the carrier reports the total covered charges prior to such reductions.
Line 11. Number of Claims Where Billed Charges Were Reduced - number of claims (real and
replicate) reported on line 1 as approved in which any charges were reduced as a result of
reasonable charge/fee schedule, medical necessity, or global fee/rebundling determinations. The
carrier counts a claim only once, regardless of the number of services reduced or the different
categories of reductions that apply. Some examples of such reductions are:
a. Charges over allowed rental limits
b. Tests included in a battery of tests,
c. Fee covered in basic allowance or surgical allowance,
d. Service included in office charge or surgery fee.
Line 12. Physician Only - number of claims included in line 11 involving physician services
only.
Line 13. Physician and Non-Physician - number of claims included in line 11 involving both
physician and non-physician services on the same claim. The carrier shows all claims in this
category under the "Non-Participant-Unassigned" column 3. Therefore, the numbers for columns
1 and 3 should be equal.
Line 14. Non-Physician Only - number of claims included in line 11 involving non-physician
services only.
Line 15. Number of Covered Services Where Charges Were Reduced - From the claims
shown in line 11, the carrier reports the number of covered services in which any charges were
reduced as a result of reasonable charge determinations, medical necessity reductions, or global
fee/rebundling reductions. It includes services where a fee is deemed to have been included in a
global fee, such as postsurgical care. (See examples given for line 11.)
Line 16. Physician - number of covered physician services included in line 15. This count
includes those services where charges were reduced on the claims shown in line 12, plus the
physician services where charges were reduced on the claims shown in line 13.
Line 17. Non-Physician - number of covered non-physician services included in line 15. This
count includes those services where charges were reduced on the claims shown in line 14, plus the
non-physician services where charges were reduced on the claims shown in line 13.
Line 18. Total Amount of Reduction - total amount (rounded to the nearest dollar) by which the
services reported in line 15 were reduced as a result of reasonable charge, medical necessity, or

global fee/rebundling determinations. The system will pre-fill columns 1 and 3 with the sum of
the data reported in the respective columns on lines 3, 5, and 7 of Form A for the same quarter.
Line 19. Physician - total amount (rounded to the nearest dollar) by which charges for physician
services reported in line 16 were reduced as a result of reasonable charge, medical necessity, or
global fee/rebundling determinations.
Line 20. Non-Physician - total amount (rounded to the nearest dollar) by which charges for non-
physician services reported in line 17 were reduced as a result of reasonable charges, medical
necessity, or global fee/rebundling determinations.
Line 21. Number of Claims Denied in Full - total number of claims, processed to completion
during the quarter, in which charges for all services were completely disallowed. This number
must equal the sum of the numbers reported in lines 11 and 14 of Form B for the three months of
the quarter. The system will pre-fill columns 1 and 3 based on the total of these lines from the
monthly reports.
Line 22. Physician Only - number of claims included in line 21 involving physician services
only.
Line 23. Physician and Non-Physician - number of claims included in line 21 involving both
physician and non-physician services on the same claim. The carrier shows all claims in this
category under the "Non-Participant- Unassigned" column 3. Therefore, the numbers for columns
1 and 3 should be equal.
Line 24. Non-Physician Only - number of claims included in line 21 involving non-physician
services only.
Line 25. Number of Claims Denied in Full or in Part - sum of (1) those claims (real and
replicate) reported as denied in full in line 21, plus (2) those claims (real and replicate) reported as
approved on line 1 in which some services, but not all, were denied. The system will pre-fill
columns 1 and 3 with the data reported in the respective columns on line 8 of Form A for the same
quarter.
Line 26. Physician Only - number of claims included in line 25 involving physician services
only.
Line 27. Physician and Non-Physician - number of claims included in line 25 involving both
physician and non-physician services on the same claim. The carrier shows all claims in this
category under the "Non-Participant-Unassigned" column 3. Therefore, the numbers for columns
1 and 3 should be equal.
Line 28. Non-Physician Only - number of claims included in line 25 involving non-physician
services only.
Line 29. Number of Denied Services - number of services for which charges were fully or
partially denied on the claims shown in line 25.

Line 30. Physician - number of denied physician services included in line 29. The carrier
includes in this count the denied services from the claims shown in line 26 plus the denied
physician services from the claims shown in line 27.
Line 31. Non-Physician - number of denied non-physician services included in line 29. The
carrier includes in this count the denied services from the claims shown in line 28, plus the denied
non-physician services from the claims shown in line 27.
Line 32. Amount Disallowed - total amount (rounded to the nearest dollar) of charges disallowed
on the services shown in line 29. The system will pre-fill columns 1 and 3 with the data reported in
the respective columns on line 9 of Form A for the same quarter.
Line 33. Physician - total amount (rounded to the nearest dollar) included in line 32 as disallowed
which represented physician services as reported in line 30.
Line 34. Non-Physician - total amount (rounded to the nearest dollar) included in line 32 as
disallowed which represented non-physician services as reported in line 31.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13326.1

This report is referenced as Form N for CROWD. The carrier submits the appropriate information
for the reporting period for each office assigned a separate contractor number and BSI.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The carriers/Part B MACs prepare and submit to CMS each quarter a report on information
regarding incentive payments made to physicians who render covered Medicare services in HPSAs
(see Pub. 100-04, Chapter 12, §§90.4 – 90.4.7) on the results of its review of sample claims for
HPSA incentive payments processed during the reporting quarter. It submits this report via
CROWD no later than the 75th day following the close of the reporting quarter.
290.1 - Heading
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
This report is referenced as Form S for CROWD. The carrier/Part B MAC submits the appropriate
information for the reporting period for each office assigned a separate contractor number and
BSI.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13329
Exhibit 1 - Medicare Program Quarterly Supplement To The Carrier Performance Report CMS-
1565a (Crowd Form A)
MEDICARE PROGRAM QUARTERLY SUPPLEMENT TO THE CARRIER PERFORMANCE
REPORT CMS-1565A (CROWD FORM A)
CARRIER REPORTING PERIOD
(QUARTER AND YEAR)
NUMBER AND TYPE OF CLAIM
REPORTING ITEM TOTAL - 1 ASSIGNED - 2 UNASSIGNED - 3

A. CLAIMS REDUCED OR DENIED
COVERED CHARGES
1. Tot. Cvrd. Charges For All Claims
REAS. CHG./FEE SCHED.
REDUCTIONS
2. No. of Clms w/Reas Chg/Fee Sched
Red
3. Amount of Reduction (in $)
MEDICAL NECESSITY
REDUCTIONS
4. Number of Claims w/ Med. Nec. Red.
5. Amount of Reduction (in $)
GLOBAL FEE/REBUNDLING
REDUCTIONS
6. No. of Claims w/ Glo. Fee/Rebun
Red.
7. Amount of Reduction (in $)
DENIALS
8. Claims Denied in Full or in Part
9. Amount Disallowed (in $)
REASONS FOR DENIAL NUMBER OF
ITEMS DENIED
(1)
AMOUNT
DISALLOWED
(2)
NUMBER OF
CLMS DENIED
(3)
10. Claimant Ineligible
11. Filing Limitation Exceeded
12. Duplicate Claim
13. Services Not Covered
14. Services Not Medically Necessary
15. MSP
16. Missing Information
17. Global Fee/Rebundling
18. Other
19. Total
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_______________________________
FRAUD WORKLOAD ITEM
TOTAL
1
BENEFICIARY
COMPLAINT
2
OIG
HOTLINE
3
REFERRAL
& OTHERS
4
1. OPENING PENDING
2. ADJUSTMENTS
3. ADJUSTED PENDING
4. WORKLOAD RECEIVED
5. TOTAL CLEARED
6. BY CONTRACTOR
7. BY REFERRAL
8. CLOSING PENDING
FORM-CMS 1565B

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
REPORTING ITEM
TOTAL
1
NON-PAR
ASSIGNED
2
NON-PAR
UNASSGNED
3
PARTICI-
PANTS
4
1. CLAIMS APPROVED: TOTAL
2. PHYS ONLY
3. PHYS AND NONPHYS
4. NONPHYS ONLY
5. COVRD SERVICES: NUMBER
6. PHYS
7. NONPHYS
8. AMT COVRD CHRGS: TOTAL
9. PHYS
10. NONPHYS
11. CLAIMS REDUCED: TOTAL
12. PHYS ONLY
13. PHYS AND NONPHYS
14. NONPHYS ONLY
15. COVRD SRVCS RED: NUM
16. PHYS
17. NONPHYS
18. AMOUNT REDUCED: TOTAL
19. PHYS
20. NONPHYS
21. FULL DENIALS: NUMBER
22. PHYS ONLY
23. PHYS AND NONPHYS
24. NONPHYS ONLY
25. FULL/PART DENIALS: NUM
26. PHYS ONLY
27. PHYS AND NONPHYS
28. NONPHYS ONLY
29. DENIED SERVICES: NUM
30. PHYS
31. NONPHYS
32. AMT DISALLOWED: TOTAL

33. PHYS
34. NONPHYS
FORM-CMS 1565C

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
12. $500+
13. TOTAL
# OF
PROCEDURES TOTAL $ VALUE
14. VERIFICATIONS POSTED TO LCEF
15. NOT REQUESTED ON LCER
16. UNACCEPTABLE VERIFICATIONS
17. LCMRs SENT TO IND PHYSICIANS
18. LCMRs SENT TO GROUP PRACTICES
19. LCMRs SENT TO ALL OTHER PROVIDERS
20. TOTAL LCMRs SENT FOR PERIOD
21. SRLs SENT TO IND PHYSICIANS
22. SRLs SENT TO GROUP PRACTICES
23. SRLs SENT TO ALL OTHER PROVIDERS
24. TOTAL SRLs SENT FOR PERIOD
FORM-CMS 1565D

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 _______________
ERROR DESCRIPTIONS
# OF CLAIMS
CURRENT
QUARTER
# OF CLAIMS
PRIOR
QUARTER
19. OFFICE IN, SERVICE OUTSIDE HPSA
20. OFFICE OUTSIDE, SERV. OUTSIDE HPSA
21. MULTI-OFFICE, SERVICE NON-HPSA OFF.
22. BENE. IN HPSA, SERVICE OUTSIDE HPSA
23. PROV. CODE PRIOR TO EFF. DATE HPSA
24. SERVICE AREA NO LONGER HPSA
25. NON-PHYSICIAN PRACTITIONER
26. NON-PHYSICIAN SERVICE
27. CARRIER PROVIDED INCORRECT INFO.
28. CARRIER PUBLISHED INCORRECT
NOTICE
29. CARRIER KEYING/PROCESSING ERROR
30. OTHER

310 - Carrier Beneficiary Overpayment Activity Report (Form CMS-2174) -
(Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13350
At the end of each calendar quarter (i.e., December, March, June, September) the carrier prepares
and submits to CMS a report summarizing beneficiary overpayment activity completed during the
reporting quarter. It completes a separate report for each carrier office that has been assigned a
separate carrier number.
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 (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
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 (Inactive)
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13360
330.1 - Heading
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13360.1
This report is referenced as Form O for CROWD. The carrier enters its ID number in the number
box. In the space labeled "Reporting Period" it enters the fiscal quarter and year (e.g., 0190 for
October-December 1989) for which the report is prepared.
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
OF
CLAIMS
AMOUNT
OF
MONEY
A.BENEFICIARY OVERPAYMENTS
1. PENDING START OF QUARTER
2. ADJUSTMENTS TO OPENING PENDING
3. ADJUSTED OPENING PENDING
4. DISCOVERED DURING REPORTING QUARTER
5. DISPOSITIONS
6. COLLECTED
7. RECOUPED BY OFFSET
8. RECOUPED BY REFUND
9. UNCOLLECTIBLES
10. REFERRED TO REGIONAL OFFICE
11. WAIVED BY CONTRACTOR
12. ABANDONED IN ACCORD WITH MAN. INSTR.
13. PENDING END OF QUARTER
B. CAUSE OF OVERPAYMENTS
14. BENEFICIARY NOT ENTITLED
15. SERVICES NOT COVERED
16. CHARGE EXCEEDED REASONABLE CHARGE
17. PAYMENT MADE TO WRONG PAYEE
18. DUPLICATE PAYMENT
19. MEDICALLY UNNECESSARY SERVICES
20. SERVICES NOT RENDERED

NUMBER
OF
CLAIMS
AMOUNT
OF
MONEY
21. MEDICARE SECONDARY PAYER
22. DOCUMENTATION/CODING/DATA ENTRY
23. OTHER
C. HOW OVERPAYMENTS WERE DISCOVERED
24. REPORTED BY BENEFICIARY OR SUPPLIER
25. CMS's CARRIER QUALITY CONTROL
PROGRAM
26. CARRIER INTERNAL AUDIT OR REVIEW
27. GOVERNMENT AGENCY
28. OTHER METHODS OF DISCOVERY

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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13400.2
The carrier transmits form CMS-2590 to CO via PC or terminal. It uses instructions in the
CROWD User Guide available via the CMS Enterprise Portal.
The report is due as soon as possible after the end of the reporting month but no later than the 15th
of the month following the end of the reporting month.
360 - Completion of Items on Form CMS-2590
(Rev. 6, 08-30-02)
B3-13410

360.1 - Heading
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13410.1
This report is referenced as Form H for CROWD. The carrier submits the appropriate information
for the reporting period for each office assigned a separate contractor number and BSI.
360.2 - Section A - Carrier Appeal Requests
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13410.2
Section A: Carrier Appeal Requests - This part concerns data from the Part B appeals process.
The number of appeals requested (received), completed, and pending reflects the status of the
workload as of the last day of the reporting month. The carrier bases data on actual counts of each
activity and not on sampling or other estimating techniques.
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 reports, under the appropriate columns, the numbers of reviews on
line 18 and hearings reported on line 28 as the closing pending on the previous month's report.
Line 2. Adjustments to Pending - If it is necessary to revise the pending figure for the close of
the previous month because of inventories or reporting errors, the carrier reports the adjustment. It
reports requests received near the end of the reporting month and placed under control sometime
after the reporting month as received in the reporting month, not as requests received in the
subsequent month. If some cases were not counted in the proper month's receipts, it counts them
as adjustments to the opening pending in the subsequent month.
If line 3 of the current month differs from the closing pending of the previous month, there must be
an entry in line 2 for the current month. The carrier precedes the entry by a "+" or "-," as
appropriate.
Line 3. Adjusted Pending - It reports the result of line 1 + line 2 (taking into account the "-" sign,
if any).
Line 4. Requests Received - It reports, under the appropriate columns, the number of review and
hearing requests received during the reporting month. (See definitions for columns 1 and 3 for a
discussion of what constitutes a request for a review and hearing.) It includes requests transferred
to it by other contractors if it incurs the administrative costs for processing the appeals, and reports
the costs on the Interim Expenditure Report (Form CMS-1524).
If one physician submits one request involving several assigned claims (and several beneficiaries),
the carrier counts this as one request. If one beneficiary submits a request involving several
unassigned bills (from several different physicians), it counts this as one request. If an appellant
submits more than one request (for different claims) at different times, the carrier counts each
request.
NOTE: See definition of column (3) for instructions on hearings requested subsequent to OTR
decisions.
Line 4A. Medical Necessity Documentation Denials - The carrier reports the number of requests
included in line 4 that involved initial claim denials for lack of medical documentation.
Line 5. Transferred - The carrier reports, under column 1, the number of review requests it
transferred to other carriers because it did not process the original claim(s). It reports, under
column 3, the number of hearing requests transferred to other carriers because the claimant is not
within the original carrier's geographical area, or the claim was transferred to ROs because the
issues are outside the HO's responsibility. (See The Medicare Claims Processing Manual, Chapter
30, Beneficiary Correspondence and Appeals) For columns 1 and 3, if it reported a review or
hearing as transferred, it does not report any information regarding it on lines 6-39. The transfer is
the final action.
Line 6. Requests Cleared - The carrier reports, under the appropriate columns, the total number
of all reviews, telephone reviews, and hearings completed during the month. It reports all
completed reviews and hearings, regardless of the final outcome, i.e., affirmation, reversal,
withdrawal, or dismissal. It considers a review cleared when the final determination (EOMB or
other notice - including dismissal) is printed or typed, or upon notification of withdrawal by the

appellant. In the case of a reversal, it considers the case cleared when it initiates the adjustment
action.
A hearing is cleared when the decision is signed, or one of the following conditions is present:
• The 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 reports the total number of claims (as defined in
§§3000-3000.2) involved in the appeals reported as cleared during the month on line 6. For
example, if it processes decisions for two hearings in the month, one of which involved three
claims, and the other involved seven claims, it reports 10 claims under column 3.
Line 8. Amount in Controversy - For the hearings reported as affirmed (line 9) or reversed (line
11), during the month, the carrier shows the total dollar amount in controversy on the initial
hearing request. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary
Correspondence and Appeals on how to determine the amount in controversy.) It shows results
rounded to the nearest dollar.
Line 9. Affirmations - Under the appropriate columns, the carrier shows the number of all
reviews, telephone reviews, and hearings completed during the month in which the previous
determination was completely upheld, e.g., no change was made. All parts of all claims in a case
must be upheld in order to be counted as an affirmation. An OTR hearing decision does not count
as a previous decision if the appellant subsequently requests an in-person or telephone hearing. If
the in-person/telephone hearing is dismissed because the appellant did not appear, or the request
was withdrawn, the carrier uses the OTR decision to determine if the case is counted here.
See line 11 for partial affirmations. (They are not included here.)

If the carrier upholds its original determination, but pays under limitation of liability, it counts the
review or hearing determination as an affirmation. It reports the appropriate information in
Section D.
Line 10. Dism./Withdr - The carrier reports, under the appropriate columns, the number of all
reviews, telephone reviews, and hearings that were withdrawn by the appellant or dismissed
(before determination) by the carrier or the HO. It reports here and in lines 4 and 6 an appeal that
is requested and withdrawn or dismissed within the same month. If the appellant requests an in-
person or telephone hearing after receiving an OTR decision and the carrier dismisses the hearing
because the appellant failed to appear, the OTR decision is the final decision, not the dismissal.
Similarly, for a withdrawal, the OTR decision is used.
A dismissal at the review level is done when written correspondence or a telephone conversation
has been identified as a review request, but the claimant does not have the right to an appeal.
Misrouted correspondence is not a dismissal. If the carrier has incorrectly counted such
correspondence as a review on a previous report, it uses line 2 (adjustments to pending) to correct
the count. It does not count a duplicate request for review on the report. Likewise, it does not
count on the report a request for review received before an initial claim determination has been
rendered. (It considers the request an inquiry.)
Line 11. Reversals (Full or Part) - Under the appropriate columns, the carrier shows the number
of all reviews, telephone reviews, and hearings completed during the month in which at least part
of the prior determination was reversed (e.g., a change was made and some or all of the new
determination was in favor of the appellant). For example, if a review or hearing involves several
claims, and the initial determinations for some of the claims are affirmed and some are reversed,
the review or hearing decision is a reversal. An OTR hearing decision does not count as a
previous decision if the appellant subsequently requests an in-person or telephone hearing. If the
in-person/telephone hearing is dismissed because the appellant did not appear, or the request was
withdrawn, the carrier uses the OTR decision to determine if the case is counted here.
Line 12. Amount Awarded - For cases included in line 11 where the issue on the appeal was not a
reasonable charge determination, the carrier shows the amount of allowed charges for services
where the determination was reversed. It shows charges after reasonable charge reductions, but
prior to application of deductible and coinsurance amounts. If the issue was a reasonable charge
reduction, it shows the additional amount allowed. It rounds results to the nearest dollar.
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 original determination
The date of the notice

Carrier processes the request to
reversal
The date the carrier initiates the adjustment
request
Line 13. Review Processing Time - Average - The average number of days from receipt of the
review request to the date of completion for all review requests (both written and telephone).
To compute the average number of days from request to completion, the carrier divides the total
days elapsed for all requests cleared in the month by the number of requests cleared. It rounds
results to the nearest day. It calculates the days elapsed for an individual request by subtracting the
Julian date of receipt of the request from the Julian date of completion.
If the request is cleared in the year following the year of receipt, the carrier adds 365 or 366 to the
result, as appropriate. (Otherwise, it will get a negative number.) If a case is cleared the same day
it is received, it considers the case to require one day.
NOTE: The carrier includes all cases cleared regardless of whether they were affirmed, reversed,
dismissed, or withdrawn.
Line 14. Reviews Completed in 1-30 Days - The number of reviews that required 1-30 days to
complete. If a case is cleared the same day it is received, the carrier considers it to require 1 day.
Line 15. Reviews Completed in 31-45 Days - The number of reviews that required 31-45 days to
complete.
Line 16. Reviews Completed in 46-60 Days - The number of reviews that required 46-60 days to
complete.
Line 17. Reviews Completed Over 60 Days - The number of reviews that required more than 60
days to complete.
Line 18. Closing Pending-Reviews - The total number of reviews that have not been completed
by the end of the reporting month.
Line 19. Reviews Pending 1-30 Days - The number of reviews included in line 18 that have been
pending 1-30 days, inclusive, at the end of the reporting month.
Line 20. Reviews Pending 31-45 Days - The number of reviews included in line 18 that have
been pending 31-45 days, inclusive, at the end of the reporting month.
Line 21. Reviews Pending 46-60 Days - The number of reviews included in line 18 that have
been pending 46-60 days, inclusive, at the end of the reporting month.
Line 22. Reviews Pending Over 60 Days - The number of reviews included in line 18 that have
been pending more than 60 days at the end of the reporting month.
Computing Time to Process Carrier Hearings for Lines 23-27
For lines 23-27, the carrier uses the matrix below to determine the number of days from receipt to
completion of hearings. The date of receipt in all cases is the day the carrier who is processing the

case received it in its corporate mailroom. In out-of-area cases the receipt date is the date that the
second carrier received the request.
Situation Date Completed
An OTR decision is made and the appellant
accepts the decision or decides to go directly
to an ALJ hearing.
The date of the OTR decision.
An OTR decision is made, and the appellant
chooses in a timely fashion, to proceed with
the in-person or telephone hearing.
The date of the second decision. If the appellant
does not appear, and the carrier dismisses the
hearing, it uses the date of the dismissal notice.
An in-person or telephone hearing is held
without an OTR decision.
The date of the decision.
The appellant withdraws the hearing
request.
The date the carrier was notified of the withdrawal.
The HO dismisses the hearing request. The date of the dismissal notice.
Line 23. Hearing Processing Time - Average - The carrier reports the average number of days
from the receipt of the hearing request to the date of completion. See methodology under line 13.
Line 24. Hearings Completed in 1-60 Days - The number of hearings that required 1-60 days to
complete. If a case is cleared the same day it is received, the carrier considers it to require 1 day.
Line 25. Hearings Completed in 61-90 Days - The number of hearings that required 61-90 days
to complete.
Line 26. Hearings Completed in 91-120 Days - The number of hearings that required 91-120
days to complete.
Line 27. Number Completed Over 120 Days - The number of cases that required 121 days or
more to complete.
Line 28. Closing Pending-Hearings - The total number of hearings that have not been completed
by the end of the reporting month.
Line 29. Hearings Pending 1-60 Days - The number of hearings included in line 28 that were
pending 1-60 days, inclusive, at the end of the reporting month.
Line 30. Hearings Pending 61-90 Days - The number of hearings included in line 28 that were
pending 61-90 days, inclusive, at the end of the reporting month.
Line 31. Hearings Pending 91-120 Days - The number of hearings included in line 28 that were
pending 91-120 days, inclusive, at the end of the reporting month.
Line 32. Hearings Pending Over 120 Days - The number of hearings included in line 28 that
were pending more than 120 days at the end of the reporting month.
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 reports the total number of hearing decisions completed
during the month that resulted in a reversal or affirmation (exclude dismissals and withdrawals).
This includes those hearings shown in lines 9 and 11.
Line 36. Number in 120 Days - For cases included in line 35, the carrier shows the number that
were completed within 120 days of receipt. It uses the methodology shown in column (4) to
determine the completion date.

Line 37. No Previous OTR Held - For cases included in line 35, columns (2) and (3), the carrier
reports the number where it held the telephone or in-person hearing without first making an OTR
decision (i.e., the OTR hearing was bypassed.) In column (4), it reports the number of cases
included in either column (2) or (3) that were completed within 120 days.
Line 38. Previous OTR Counted - For cases included in line 35, columns (2) and (3), the carrier
reports the number where it included the OTR count on a previous report. In column (4), it
reports the number of cases included in either column (2) or (3) that were completed within 120
days. Cases reported in line 38 are those where an OTR decision was made, and the appellant
either accepted the OTR decision, did not respond timely in accordance with The Medicare Claims
Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals, or decided to go
directly from the OTR decision to an ALJ hearing. Then, subsequent to this OTR decision
"acceptance," the appellant decided that they wanted a telephone or in-person hearing. The
carrier does not include these cases in line 6.
Line 39. Previous OTR Not Counted - For cases included in line 35, columns (2) and (3), the
carrier reports the number where it did not include the OTR count on a previous report. These are
cases where it made the OTR decision first and the appellant indicated in a timely fashion that they
wanted a telephone or in-person hearing. In column (4), it reports the number of cases included in
either column (2) or (3) that were completed within 120 days.
360.3 - Section B - ALJ Hearings
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13410.3
Section B is intended for all requests for ALJ hearings including those expected to be dismissed
for failure to meet the $500 amount in controversy requirement or for any other reason (such as a
lack of a fair hearing).
The carrier counts ALJ Hearings in Columns 1 and 2 using the following two methodologies:
Column (1) Total - The total of all ALJ hearing requests as originally filed.
Column (2) Dispositions - For lines 49 and 51-53 only, the carrier reports the number of
dispositions rendered by the ALJ(s) in cases reported as cleared for the month in Line 49. There
will usually be more ALJ dispositions than cases counted in line 49. A case is not counted in line
49 until the ALJ has cleared all of the claims included in the request for hearing.
EXAMPLE: The carrier forwards one request to an ALJ involving 20 claims. The ALJ
dismisses 10 claims at once. A month later, the ALJ decides to affirm the original
decision on 5 others as one group. The other 5 receive separate determinations.
This is counted as 7 dispositions.
Line 40. Opening Pending - The number of ALJ hearings reported on line 57 as closing pending
on the previous month's report.

Line 41. Adjustments to Pending - If line 42 of the current month differs from data in line 57 of
the previous month, there must be an entry in line 41 for the current month. The carrier precedes
the entry by a "+" or "-", as appropriate. See definition for line 2.
Line 42. Adjusted Opening Pending - The result of line 40 + line 41 (taking into account the "-"
sign, if any).
Line 43. Requests Received - The number of ALJ hearings requested during the month. (See The
Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals.)
Line 44. Requests Forwarded to ALJ - The number of ALJ hearing requests forwarded to ALJs
during the month. The carrier considers the case forwarded when all necessary material has been
mailed to the ALJ.
Line 45. No. of Claims Involved - The number of claims involved in the ALJ hearing requests
forwarded to ALJs as reported on line 44. (See MCM-3, §§3000-3000.2 for definition of claim.)
Line 46. No. Forwarded in 1-7 Days - The number of ALJ hearing requests forwarded to ALJs
within 7 calendar days from receipt of the request to mailing of the necessary information. The
carrier shows data for all cases mailed during the month. The number must be less than, or equal
to, the number shown in line 44.
Line 47. No. Forwarded in 1-14 Days - The number of ALJ hearing requests forwarded to ALJs
within 14 days from receipt of the request to mailing of the necessary information. The carrier
shows data for all cases mailed during the month. The number must be less than, or equal to, the
number shown in line 44.
Line 48. Average Time to Forward - The average number of calendar days from receipt of the
ALJ request to the mailing date of the necessary information. The carrier the same methodology
for counting as discussed in §360.2 for line 13.
Line 49. ALJ Hearings Completed - The number of ALJ hearing requests completed during the
month. The carrier considers a case completed when it receives the completed decision from the
ALJ for all parts of the case.
Line 50. Amount in Controversy - For ALJ hearings reported as affirmed (line 51) or reversed
(line 53), during the month, the carrier shows the total dollar amount remaining in controversy
according to the initial ALJ hearing request. This should be the amount remaining after previous
appeal decisions. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary
Correspondence and Appeals on how to determine the amount in controversy.) It rounds results
to the nearest dollar.
Line 51. Affirmations - The carrier reports number of completed ALJ hearings in which the
previous determination was completely upheld i.e., no change was made. All parts of all claims in
a case must be upheld in order for the case to be counted as an affirmation. See line 53 for partial
affirmations. (The carrier does not include partial affirmations on this line.)

If the prior determination is upheld, but payment is made under limitation of liability, the carrier
counts the ALJ hearing determination as an affirmation. It reports the appropriate information in
lines 55 and 56.
Line 52. Dismissals/Withdrawals - The e number of completed ALJ hearings that were
withdrawn by the appellant or dismissed (before determination) by the ALJ. The carrier reports an
appeal that was requested and withdrawn or dismissed within the same month here and in lines 43,
44, and 49.
Line 53. Reversals (Full or Part) - The total number of completed ALJ hearings in which at least
part of the prior determination was reversed i.e., a change was made and some or all of the new
determination was in favor of the appellant. For example, if an ALJ hearing involves several
claims, and the initial determinations for some of the claims are affirmed and some are reversed,
the carrier considers the decision a reversal.
Line 54. Amount Awarded - For cases included in line 53, the carrier shows the amount of
allowed charges for services where the determination was reversed. It shows charges after
reasonable charge reductions, but prior to application of deductible and coinsurance amounts. (If
the appeal involved a reasonable charge reduction, it shows the additional amount allowed.) It
rounds results to the nearest dollar.
Line 55. Waived - Ben. and Prov - The number of claims involved in requests for ALJ hearings
where limitation of liability was granted to both the beneficiary and provider in an assigned claim
(see The Medicare Claims Processing Manual, Chapter X, Limitation on Liability), or where the
provider's liability was limited in an unassigned claim(see 3 The Medicare Claims Processing
Manual, Chapter X, Limitation on Liability).
Line 56. Amount Awarded - For cases included in line 55, the carrier shows the amount of
allowed charges for services (including the noncovered services) where the liability of the
beneficiary and provider were limited. It shows charges after reasonable charge reductions, but
prior to application of deductible and coinsurance amounts, rounding results to the nearest dollar.
Line 57. Closing Pending - The total number of ALJ hearing requests that were not completed by
the end of the reporting month. The carrier considers a case transferred to an ALJ as pending until
it has received the complete decision from the ALJ for all parts of the case.
Line 58. Effectuation of ALJ Decisions - The number of ALJ hearing decisions for which it
initiated effectuation during the month. The carrier considers effectuation of a decision to be
initiated when it completes the following:
• 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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
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 reports, under the appropriate columns, the
number of assigned claims meeting the conditions above for which limitation of liability was
considered during the month.
Line 69. Considered - Not Waived - The carrier reports under the appropriate columns the
number of assigned claims meeting the conditions above on which limitation of liability was
considered but was not granted to the beneficiary.
Line 70. Waived - Bene. Only - The carrier shows, under the appropriate columns, the number of
assigned claims meeting the conditions above on which it granted limitation of liability to only the
beneficiary.
Line 71. Waived - Bene. and Prov. - The carrier reports, under the appropriate columns, the
numbers of assigned claims where it granted limitation of liability during the reporting month to
both the beneficiary and provider.
Line 72. Amount Awarded - For cases included in line 71, the carrier shows the amount of
allowed charges for services (including noncovered services) where limitation of liability is

granted to the beneficiary and provider. It shows charges after reasonable charge reductions, but
prior to application of deductible and coinsurance amounts, rounding results to the nearest dollar.
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 reports, under the appropriate columns, the
number of unassigned claims that meet the conditions of §7330 for which limitation of liability
was considered during the month.
Line 74. Phys. Refund Waived - The carrier reports, under the appropriate columns, the number
of unassigned claims that meet the requirements of §7330 on which it waived the liability of the
provider to refund to the beneficiary the amount disallowed as not reasonable and necessary.
Line 75. Phys. Refund Upheld - The carrier reports, under the appropriate columns, the number
of unassigned claims that meet the requirements of The Medicare Claims Processing Manual,
Chapter X, Limitation on Liability chapter, on which it required the physician to refund the
amount disallowed.
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 _____________________
A. CARRIER APPEAL REQUESTS
TOTAL
REVIEWS
(1)
TELEPHONE
REVIEWS
(2)
HEARINGS
(3)
1. OPENING PENDING
2. ADJSTMTS TO PNDNG
3. ADJUSTED PENDING
4. REQUESTS RECEIVED
4A. MED. DOC. DENIALS
5. REQUESTS TRANSFERRED
6. REQUESTS CLEARED
7. NO. OF CLAIMS
8. AMT IN CONTROVERSY
9. AFFIRMATIONS
10. DISMISSED/WITHDRAWN
11. REVERSALS
12. AMOUNT AWARDED
FORM CMS-2590 SCREEN 1

Exhibit 2 - Medicare Program - Carrier Appeals Report - Form CMS-2590
MEDICARE PROGRAM - CARRIER APPEALS REPORT - FORM CMS-2590
CARRIER ID __________________ REPORT PERIOD _____________________
REVIEW
REQUESTS
REVIEWS
(1)
HEARING
REQUESTS
HEARINGS
(2)
PROCESSING TIMES PROCESSING TIMES
13. REVIEWS- AVERAGE 23. HEARINGS- AVERAGE
14. NBR COMP 1-30 DYS 24. NBR COMP 1-60 DYS
15. NBR COMP 31-45
DYS
25. NBR COMP 61-90 DYS
16. NBR COMP 46-60
DYS
26. NBR COMP 91-120
DYS
17. NBR COMP 60 DYS+ 27. NBR COMP 120 DYS+
PENDING TIMES PENDING TIMES
18. CLOSING PENDING 28. CLOSING PENDING
19. NBR COMP 1-30 DYS 29. NBR COMP 1-60 DYS
20. NBR COMP 31-45
DYS
30. NBR COMP 61-90 DYS
21. NBR COMP 46-60
DYS
31. NBR COMP 91-120
DYS
22. NBR COMP 60 DYS+ 32. NBR COMP 120 DYS+
HEARING RESULTS
OTR
WITH NO
SUBSEQUENT
HEARING
(1)
TELEPHONE
(2)
IN-
PERSON
(3)
NBR IN
120 DYS
(4)
33. REVERSALS
34. AFFIRMATIONS
35. TOTAL DECISIONS
36. NBR IN 120 DYS
37. NO PREV OTR HELD
38. PREV OTR COUNTED
39. PREV OTR NOT
COUNTED
FORM CMS-2590 SCREEN 2

Exhibit 3 - Medicare Program - Carrier Appeals Report - Form CMS 2590
MEDICARE PROGRAM - CARRIER APPEALS REPORT - FORM CMS 2590
CARRIER ID ___________________ REPORT PERIOD _____________________
B. PART B ALJ HEARINGS
TOTAL
(1)
DISPOSITIONS
(2)
B. PART B ALJ
HEARINGS
TOTAL
(1)
40 OPENING PENDING 55. WAIVED -
BEN & PROV
41 ADJUSTMENTS TO
PENDING
56. AMOUNT
AWARDED
42. ADJUSTED OPENING
PENDING
57. CLOSING
PENDING
43. REQUESTS RECEIVED 58. EFFECT.
OF ALJ DEC
44. REQ. FORWARDED TO
ALJ
59. NO. 1-7
DAYS
45. NO. OF CLAIMS
INVOLVED
60. NO. 8-15
DAYS
46. NO. IN 1-7 CALNDR
DAYS
61. NO. 16-30
DAYS
47. NO. IN 1-14 CLNDR
DAYS
62. NO. OVER
30 DAYS
48. AVG TIME TO
FORWARD
49. COMPLETED
50. AMOUNT IN
CONTROVERSY
51. AFFIRMATIONS
52.
DISMISSALS/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 ____________________
C. REOPENINGS (CLAIM COUNTS
TOTAL
(1)
PRE-REVIEW
(2)
POST-
REVIEW
(3)
POST-
HEARING
(4)
63. TOTAL
64. UNFAVORABLE TO
CLAIMANT
65. NO CHANGE
66. FAVORABLE TO CLAIMANT
67. AMOUNT AWARDED
D. LIMITATION OF LIABILITY
(CLAIM COUNTS)
INITIAL
CLAIM
(1)
REVIEW
(2)
HEARING
(3)
ASSIGNED CASES
68. TOTAL NUMBER
CONSIDERED
69. CONSIDERED - NOT
WAIVED
70. WAIVED-BEN. ONLY
71. WAIVED-BEN.& PROV
72. AMT AWARDED
UNASSIGNED CASES
73. TOTAL NUMBER
CONSIDERED
74. PHYS REFUND WAIVED
75. PHYS REFUND UPHELD
FORM CMS-2590 SCREEN 4

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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The carrier/A/B MAC transmits data about the Participating Physician/Supplier Program to CO via
PC or terminal. It uses instructions in the CROWD User Guide available via the CMS Enterprise
Portal.
The report is due 45 days after the end of the enrollment period. It includes updated data as of the
end of the most recent enrollment period.
The carrier/A/B MAC does not submit hard copies of the report.
400 - Completion of Items on Participating Physician/Supplier Report
(Rev. 6, 08-30-02)
B3-13422
400.1 - Heading
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
B3-13422.1
This report is referenced as Form F for CROWD. The carrier submits the appropriate information
for the reporting period for each office assigned a separate contractor number and BSI.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The following list of codes and narrative describe the kind of medicine physicians practice.
Code Physician/Limited License Physician (LLP) Specialty Codes
01 General Practice
02 General Surgery
03 Allergy/Immunology
04 Otolaryngology
05 Anesthesiology
06 Cardiology
07 Dermatology
08 Family Practice
09 Interventional Pain Management
10 Gastroenterology
11 Internal Medicine
12 Osteopathic Manipulative Medicine
13 Neurology
14 Neurosurgery
16 Obstetrics/Gynecology
17 Hospice and Palliative Care
18 Ophthalmology
19 Oral Surgery (Dentists only) (LLP)
20 Orthopedic Surgery
21 Cardiac Electrophysiology
22 Pathology
23 Sports Medicine
24 Plastic and Reconstructive Surgery
25 Physical Medicine and Rehabilitation
26 Psychiatry
27 Geriatric Psychiatry
28 Colorectal Surgery (formerly Proctology)
29 Pulmonary Disease
30 Diagnostic Radiology
33 Thoracic Surgery
34 Urology
35 Chiropractic (LLP)
36 Nuclear Medicine
37 Pediatric Medicine
38 Geriatric Medicine
39 Nephrology
40 Hand Surgery
41 Optometry (LLP)
44 Infectious Disease
46 Endocrinology

Code Physician/Limited License Physician (LLP) Specialty Codes
48 Podiatry (LLP)
66 Rheumatology
70 Single or Multispecialty Clinic or Group Practice
72 Pain Management
76 Peripheral Vascular Disease
77 Vascular Surgery
78 Cardiac Surgery
79 Addiction Medicine
81 Critical Care (Intensivist)
82 Hematology
83 Hematology/Oncology
84 Preventive Medicine
85 Maxillofacial Surgery (LLP)
86 Neuropsychiatry
90 Medical Oncology
91 Surgical Oncology
92 Radiation Oncology
93 Emergency Medicine
94 Interventional Radiology
98 Gynecological Oncology
99 Unknown Physician Specialty
C0 Sleep Medicine
C3 Interventional Cardiology
C5 Dentist
C6 Hospitalist
C7 Advanced Heart Failure and Transplant Cardiology
C8 Medical Toxicology
C9 Hematopoietic Cell Transplantation and Cellular Therapy
D3 Medical Genetics and Genomics
D4 Undersea and Hyperbaric Medicine
D7 Micrographic Dermatologic Surgery
D8 Adult Congenital Heart Disease
E1 Marriage and Family Therapist
E2 Mental Health Counselors
E3 Dental Anesthesiology
E4 Dental Public Health
E5 Endodontics
E6 Oral and Maxillofacial Pathology
E7 Oral and Maxillofacial Radiology
E9 Oral Medicine
F1 Orofacial Pain
F2 Orthodontics and Dentofacial Orthopedics
F3 Pediatric Dentistry
F4 Periodontics
F5 Prosthodontics
F6 Epileptologists

NOTE: Specialty Code Use for Service in an Independent Laboratory. For services performed in
an independent laboratory, show the specialty code of the physician ordering the x-rays and
requesting payment. If the independent laboratory requests payment, use supplier code "69".
400.5 - Non-Physician Practitioner/Supplier Specialty Codes
(Rev.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The following list of codes and narrative describe the kind of medicine non-
physician practitioners or other healthcare providers/suppliers practice.
Code Non-Physician Practitioner/Supplier Specialty Codes
15 Speech Language Pathologist in Private Practice
31 Intensive Cardiac Rehabilitation (ICR)
32 Anesthesiologist Assistant
42 Certified Nurse Midwife (effective July 1, 1988)
43 Certified Registered Nurse Anesthetist (CRNA)
45 Mammography Screening Center
47 Independent Diagnostic Testing Facility (IDTF)
49 Ambulatory Surgical Center
50 Nurse Practitioner
59 Ambulance Service Supplier, e.g., private ambulance companies, funeral homes
60 Public Health or Welfare Agencies (Federal, State, and local)
61 Voluntary Health or Charitable Agencies (e.g., National Cancer Society,
National Heart Association, Catholic Charities)
62 Psychologist (Billing Independently)
63 Portable X-Ray Supplier (Billing Independently)
64 Audiologist (Billing Independently)
65 Physical Therapist in Private Practice
67 Occupational Therapist in Private Practice
68 Clinical Psychologist
69 Clinical Laboratory (Billing Independently)
71 Registered Dietitian/Nutrition Professional
73 Mass Immunization Roster Biller (Mass Immunizers have to roster bill
assigned claims and can only bill for immunizations)
74 Radiation Therapy Centers
75 Slide Preparation Facilities
80 Licensed Clinical Social Worker
88 Unknown Provider
89 Certified Clinical Nurse Specialist
95 Unknown Supplier
97 Physician Assistant
A5 Pharmacy

C1 Centralized Flu
C2 Indirect Payment Procedure
C4 Restricted Use
D1 Medicare Diabetes Prevention Program
D2 Restricted Use
D5 Opioid Treatment Program
D6 Home Infusion Therapy Services
Note: Specialty Code Use for Service in an Independent Laboratory. For services performed
in an independent laboratory, show the specialty code of the physician ordering the x-rays
and requesting payment. If the independent laboratory requests payment, use supplier code
“69”.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
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
Participants Non-Participants
Par
Drop-Out
Current
(6)
Non-Par
Sign-Up
Current
(7)
Par
Disenrolls
(8)
SPECIALTY
CODE/GROUP
Prior
(1)
Current
(2)
Contin.
(3)
Prior
(4)
Current
(5)
01-PHY
02-PHY
03-PHY
04-PHY
05-PHY
06-PHY
07-PHY
08-PHY
09-PHY
10-PHY
11-PHY

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
SPECIALTY
CODE/GROUP
Participants Non-Participants
Par
Drop-Out
Current
(6)
Non-Par
Sign-Up
Current
(7)
Par
Disenrolls
(8)
Prior
(1)
Current
(2)
Contin.
(3)
Prior
(4)
Current
(5)
12-PHY
13-PHY
14-PHY
15-NPP
16-PHY
17-PHY
18-PHY
19-LLP
20-PHY
21-PHY
22-PHY
23-PHY
24-PHY

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
SPECIALTY
CODE/GROUP
Participants Non-Participants
Par
Drop-Out
Current
(6)
Non-Par
Sign-Up
Current
(7)
Par
Disenrolls
(8)
Prior
(1)
Current
(2)
Contin.
(3)
Prior
(4)
Current
(5)
25-PHY
26-PHY
27-PHY
28-PHY
29-PHY
30-PHY
31-SUP
32-NPP
33-PHY
34-PHY
35-LLP
36-PHY
37-PHY

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 (IDTF)
48 Podiatry
49 Ambulatory Surgical Center
50 Nurse Practitioner
SPECIALTY
CODE/GROUP
Participants Non-Participants
Par
Drop-Out
Current
(6)
Non-Par
Sign-Up
Current
(7)
Par
Disenrolls
(8)
Prior
(1)
Current
(2)
Contin.
(3)
Prior
(4)
Current
(5)
38-PHY
39-PHY
40-PHY
41-LLP
42-NPP
43-NPP
44-PHY
45-SUP
46-PHY
47-SUP
48-LLP
49-SUP
50-NPP

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
SPECIALTY
CODE/GROUP
Participants Non-Participants
Par
Drop-Out
Current
(6)
Non-Par
Sign-Up
Current
(7)
Par
Disenrolls
(8)
Prior
(1)
Current
(2)
Contin.
(3)
Prior
(4)
Current
(5)
59-SUP
60-SUP
61-SUP
62-NPP
63-SUP
64-NPP
65-NPP
66-PHY
67-NPP
68-NPP
69-SUP
70-PHY
71-NPP

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
SPECIALTY
CODE/GROUP
Participants Non-Participants
Par
Drop-Out
Current
(6)
Non-Par
Sign-Up
Current
(7)
Par
Disenrolls
(8)
Prior
(1)
Current
(2)
Contin.
(3)
Prior
(4)
Current
(5)
72-PHY
73-SUP
74-SUP
75-SUP
76-PHY
77-PHY
78-PHY
79-PHY
80-NPP
81-PHY
82-PHY
83-PHY
84-PHY

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
SPECIALTY
CODE/GROUP
Participants Non-Participants
Par
Drop-Out
Current
(6)
Non-Par
Sign-Up
Current
(7)
Par
Disenrolls
(8)
Prior
(1)
Current
(2)
Contin.
(3)
Prior
(4)
Current
(5)
85-LLP
86-PHY
88-NPP
89-NPP
90-PHY
91-PHY
92-PHY
93-PHY
94-PHY
95-SUP
97-NPP
98-PHY
99-PHY

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
E1 Marriage and Family Therapist
E2 Mental Health Counselors
E3 Dental Anesthesiology
E4 Dental Public Health
E5 Endodontics
E6 Oral and Maxillofacial Pathology
E7 Oral and Maxillofacial Radiology
E9 Oral Medicine
F1 Orofacial Pain
F2 Orthodontics and Dentofacial Orthopedics
F3 Pediatric Dentistry
F4 Periodontics
F5 Prosthodontics
F6 Epileptologists
SPECIALTY
CODE/GROUP
Participants Non-Participants
Par
Drop-Out
Current
(6)
Non-Par
Sign-Up
Current
(7)
Par
Disenrolls
(8)
Prior
(1)
Current
(2)
Contin.
(3)
Prior
(4)
Current
(5)
A5-SUP
C0-PHY
C1-NPP

C2-NPP
C3-PHY
C4-RES
C5-PHY
C6-PHY
C7-PHY
C8-PHY
C9-PHY
D1-SUP
D2-RES
D3-PHY
D4-PHY
D5-SUP
D6-SUP
D7-PHY
D8-PHY
E1-PHY
E2-PHY
E3-PHY
E4-PHY
E5-PHY
E6-PHY
E7-PHY
E9-PHY
F1-PHY
F2-PHY
F3-PHY
F4-PHY
F5-PHY
F6-PHY

Exhibit 1 - Participating Physician/Supplier Report - Screen 9
PARTICIPATING PHYSICIAN/SUPPLIER REPORT
SPECIALTY CODES
Total Physicians - The contractor reports in the appropriate column the total of all specialty codes
applicable to physicians.
Total LLPs - The contractor reports in the appropriate column the total of all specialty codes
applicable to limited license physicians.
Total NPPs - The contractor reports in the appropriate column the total of all specialty codes
applicable to non-physician practitioners.
Total Physicians/LLPs/NPPs - The contractor reports in the appropriate column the sum of all
physicians, LLPs and NPPs.
Total Suppliers - The contractor reports in the appropriate column the total of all specialty codes
applicable to suppliers.
SPECIALTY
CODE/GROUP
Participants Non-Participants
Par
Drop-Out
Current
(6)
Non-Par
Sign-Up
Current
(7)
Par
Disenrolls
(8)
Prior
(1)
Current
(2)
Contin.
(3)
Prior
(4)
Current
(5)
TOTALs
PHYs*
LLPs*
NPPs*
PHYs/LLPS/NPPs*
SUPs*
* These lines do not represent specific specialty codes. They are the totals of the specialty sub-
groups.
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
applicant’s business location was not properly licensed.
Line 17 - CMS Requirements Not Met - The number of applications denied because the
applicant did not meet all CMS requirements.
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 ReportCARRIER NAME: 	CONTRACTOR NUMBER:
REPORT PERIOD: 	CROW D FORM 4
Total Physician Group Cert Nurse M-W Cert RNA
1 	2 	3 	4 	5
W orkload 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: 	CROW D FORM 4
Nurse Prac Ambulance Audiologist Ind Phys Ther Ind Occ Ther
6 	7 	8 	9 	10
W orkload 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: 	CROW D FORM 4
Ind Clin Psych Lic Clin SW Cert Nurse Sp Ind Phys Lab Phys Asst
11 	12 	13 	14 	15
W orkload 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: 	CROW D FORM 4
MSC 	ASC PH/W Agency VH/C Agency Ind Psych
16 	17 	18 	19 	20
W orkload 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: 	CROW D FORM 4
Port X-Ray Ind Clin Lab Unk Supp/Prov Flu Imm Biller
21 	22 	23 	24
W orkload 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: 	CROW D 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: 	CROW D 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: 	CROW D 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: 	CROW D 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: 	CROW D 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: 	CROW D 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: 	CROW D 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: 	CROW D 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: 	CROW D 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: 	CROW D 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
Avoidance
Partial
Recoveries
Full
Recoveries
I. Partial Recovery Adjustment
MSP situation indicated.
Medicare's payment calculated
to be $50 if Medicare was
primary payer. Claim is
returned to submitter.
$ 50
Claim is resubmitted
showing $30 paid by the other
insurer. a Medicare
secondary payment of $20 is
made.
$(50) * $ 30
II. "Other" Payer Denial Adjustment
MSP situation indicated -
Medicare's "primary" payment
calculated to be $75. Claim
is returned to submitter.
$ 75
Other payer denies claim.
Medicare found to be primary
and Medicare payment of $75
is made.
$ (75)*
III. Full Recovery Adjustment
MSP situation indicated -
Medicare's "primary" payment
calculated to be $80. Claim
is returned to submitter
.$ 80
Provider or other source
informs carrier that full
payment was made by the
other payer.
$ (80)* $ 80
*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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
At the end of each month, the contractor prepares and transmits to CMS a report summarizing
monthly activity on redeterminations processed by A/B and DME MACs, as well as those actions
associated with reconsiderations, and Administrative Law Judge (ALJ) hearings and Part A and
Part B Medicare Appeals Council effectuations that are processed by A/B and DME MACs.
Contractors shall complete separate reports for each office where a separate A/B or DME MAC
Jurisdictional identification number has been assigned.
NOTE: The report is NOT designed to be completed by the Qualified Independent Contractor
(QIC) or the Administrative Qualified Independent Contractor (AdQIC). All data shall be entered
by the contractor except for those lines that are indicated as “Not Applicable” (e.g., Medicare
Approved Amount). The data in the “Not Applicable” lines are not required. Contractors shall
continue to use the CMS-2591 and CMS-2590 reports to capture data on appeal workloads
received prior to the implementation date of the CMS-2592 report. The CMS-2591 and 2590
reports will be used to record appeals related data received prior to the implementation of the
CMS-2592 report until all pending appeals workloads have been completed. If a case was received
prior to the implementation of the CMS-2592, and as such is captured on the CMS-2591 or CMS-
2590, tracking for the case remains on the CMS-2591 or CMS-2590 until all levels of appeal for
the case have been completed.
Note: The CMS-2591 and 2590 reports will continue to be used to capture reopenings data that is
not clerical in nature, and as such, is not captured on the CMS-2592 report.
Form CMS-2592 is subject to the Paperwork Reduction Act and requires approval by the Office of
Management and Budget (OMB). OMB approval has been requested.
Purpose and Scope--The CMS-2592 enables CMS to tabulate data for administrative purposes on
the following information.
• 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 CROWD
User Guide available via the CMS Enterprise Portal.
The report is due as soon as possible after the end of the reporting month but no later than the 15th
of the month following the end of the reporting month.
COMPLETION OF ITEMS ON FORM CMS-2592
Heading – This report is referenced as Form 7 for CROWD. It submits the appropriate
information for the reporting period for each office assigned a separate contractor number and
BSI.
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.12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's
Medicare identification number. For purposes of this manual, Medicare beneficiary identifier
references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary
Identifier (MBI) during the new Medicare card transition period and after for certain business areas
that will continue to use the HICN as part of their processes.
This section concerns data from Part A and Part B of A appeals processed by A/B MACs (A) as
well as Part B appeals processed by A/B MACs (B) and DME MACs.
Redeterminations. The number of redeterminations requested (received), completed, and
pending reflects the status of the workload as of the last day of the reporting month. Base data on
actual counts of each activity and not on sampling or other estimating techniques.
A redetermination is the first level of appeal following an initial determination of a Part A claim or
Part B claim. It is a re-evaluation of the facts and findings of a claim to determine whether the
initial decision was correct. (See the Medicare Claims Processing Manual, Publication 100-04,
Chapter 29, Section 310.)

Do not count duplicate redetermination requests or redetermination requests received before you
have made an initial determination on a claim. Do not count inquiries. Count one redetermination
per request received. With the exception of those lines for which claims counts are specifically
requested in the report, count only cases. Do not count a duplicate request for appeal as a
processed appeal. Duplicate requests can be reflected in Line 2 (Adjustment to Pending) of the
CMS-2592 Report for the subsequent month.
Redeterminations fall into the following categories:
Column (1) Part A Cases- Use Column 1 to report information on Part A services processed by
the A/B MAC (A).
Column (2) Part B of A Cases- Use Column 2 to report information on Part B services processed
by the A/B MAC (A).
Column (3) Part B Cases- Use Column 3 to report information on Part B services processed by the
A/B MAC (B) or DME MAC.
Line 1. Opening Pending - Show under columns 1-3, the number of redetermination cases
reported on Line 21 as the closing pending redetermination cases on the previous month's report.
Line 2. Adjustments to Pending - CMS understands that it is often necessary to revise the
categorization of data from the original categorization given when a case was initially received at
the contractor. Likewise, it is often necessary to move data from one line to another in order to
maintain accuracy. Prior to the submission of the monthly 2592 report to CMS, contractors are
permitted to make changes to data during the reporting month to ensure that appeal workloads are
accurately reflected.
Once the monthly 2592 report has been submitted to CMS, any changes to the closing pending
figure of the report must be reflected in the Adjustments to Pending line of the subsequent month’s
report. If it is necessary to revise the pending figure for the close of the previous month’s report
because of inventories or reporting errors, enter the adjustment. If some cases were not counted in
the proper month's receipts, count them as adjustments to the opening pending count in the
subsequent month. Examples include any instances where something originally categorized as an
appeal was determined not to be an appeal, or vice-versa. Duplicate requests for redetermination
are also reflected here. If the contractor receives a request for appeal near the end of the reporting
month but the case arrives too late to be reflected as a receipt in the CMS-2592 report for that
month, count the case in the Adjustment to Pending line of the subsequent month’s report. The
purpose of the Adjustments to Pending line is to allow the contractor to modify Opening Pending
counts, thereby correcting errors resulting from inventory or reporting problems that were
identified after the submission of the CMS-2592 previous month’s report to CMS.
Do not make adjustments to the Pending line or other lines of the 2592 report once the report has
been submitted to CMS. If there is an entry for Line 2, it should be preceded by a "+" or "-", as
appropriate.
Line 3. Adjusted Pending - Enter the result of Line 1 + Line 2 (taking into account the "-" sign,
if any).

Line 4. Requests Received - Show, under the appropriate columns, the number of requests for
redeterminations received during the reporting month. Include requests transferred to you by other
A/B or DME MACs or remanded by the Qualified Independent Contractor (QIC).
NOTE: See the “Note” under Line 6 (Requests Cleared) regarding the handling of Medicare
Secondary Payer (MSP) cases.
Line 4.a. Adjusted Requests Received - As a result of actions taken by the A/B and DME MACs
to process appeals during the reporting month, show on this line the number of receipts that have
actually been validated by the MAC to be a redetermination. This line should include both RAC
and non-RAC redeterminations.
NOTE: See the “Note” under Line 6 (Requests Cleared) regarding the handling of Medicare
Secondary Payer (MSP) cases.
Line 4.1. Number of Claims Received – Show the total number of redetermination claims
involved in Line 4.a.
Line 4.2. Recovery Audit Contractor (RAC) Requests Received - Of the redetermination
requests reported in Line 4.a, show the number that are Recovery Audit related. Line 4.2 is a
subset of Line 4.a and should contain only RAC redeterminations.
Line 4.2.1. Number of RAC Claims Received – Show the number of redetermination claims
involved in Line 4.2.
Line 5. Misrouted Requests Forwarded to Another Contractor - Show under columns 1
through 3 the number of redetermination requests the contractor forwarded to other contractors,
because they were misrouted to you and you did not process the original claim(s). For columns 1-
3, if you have reported a redetermination as forwarded, do not report any information regarding it
on Lines 6-29. The forwarding of the misrouted request is the final action.
NOTE: This line is not intended for QIC reconsideration requests that were misrouted.
Line 6. Requests Cleared - Show, under the appropriate columns, the total number of
redeterminations completed during the month. Report all completed redeterminations, regardless if
the final outcome was an affirmation, reversal, withdrawal, or dismissal. Do not count cases that
were transferred to another contractor because they were misrouted.
NOTE: A/B MACs (A) should count received and completed MSP redetermination cases in
Columns 1 of Lines 4 and 6, as appropriate, regardless of whether claims involved are Part A, Part
B or a combination. Do not count or report claims involved in MSP cases. MSP cases should be
counted in Lines 4, 6, 7, 8, 9, 10 and 11. Do not count MSP claims on Lines 4.1, 6.1, 7.1, 8.1, 9.1,
10.1 and 11.1.
A/B MACs (B) that handle MSP cases should count them in Column 3.
Line 6.1. Number of Claims Cleared – Show the total number of claims involved in Line 6.

NOTE: For Lines 6.1 through 11.1 (letters a through i), enter the number and type of claim
processed. If no claims from a certain claim type are processed, report zero (0). Refer to
instructions for the CMS-1565 and 1566, as well as appropriate sections of the Claims Processing
Manual for guidance on determining the categories and types of claims processed by A/B MACs
and DME MACs.
Line 6.1a – Report the number of SNF claims included in Line 6.1. Line 6.1b – Report the number
of Home Health claims included in Line 6.1. Line 6.1c – Report the number of Inpatient Hospital
claims included in Line 6.1. Line 6.1d – Report the number of Outpatient claims included in Line
6.1. Line 6.1e – Report the number of Lab claims included in Line 6.1. Line 6.1f – Report the
number of Ambulance claims included in Line 6.1. Line 6.1g – Report the number of DME claims
included in Line 6.1. Line 6.1h – Report the number of Physician claims reported in Line 6.1.
Line 6.1i – Report the number of Other claims or claims where the provider type cannot be
determined based on the information on the claim included in Line 6.1.
Consider a redetermination cleared when:
• 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/
Withdrawal
= Report As

X Full
X Partial
X Affirmation
X Dismissal/ Withdrawal
X X Partial
X X Partial
X X Full
X X X Partial
X X X X Partial
X X Partial
X X Partial
X X Affirmation
X X X Partial
Line 8. Affirmations - Under the appropriate columns, show the number of completed
redeterminations from Line 6 in which the previous determinations were completely upheld; i.e.,
no change was made. All claims in a case must be upheld in order for the case to be counted as an
affirmation. In instances where claims some are affirmed, but all others are dismissed or
withdrawn, count the case as an affirmation. (Do not include partial reversals in this line. See Line
9 for partial reversals). Include those instances where the decision was affirmed, but a change in
liability was noted.
Line 8a. Waiver of Liability Amount Paid (Not Applicable) - Show the amount paid under
waiver of liability, on the basis that the party did not know that the service wasn’t payable under
Medicare.
Line 8.1. Number of Claims Affirmed – Show the number of claims involved in Line 6.1 for
which the decision was affirmed.
NOTE -- The following example is counted as an affirmation: A claim is denied at the initial
determination level and a redetermination is requested. At the redetermination level, the denial is
upheld but the denial is for a reason other than was determined to be applicable at the initial
determination level. Count the claim as an affirmation.
Line 8.1a – Report the number of SNF claims included in Line 8.1. Line 8.1b – Report the number
of Home Health claims included in Line 8.1. Line 8.1c – Report the number of Inpatient Hospital
claims included in Line 8.1. Line 8.1d – Report the number of Outpatient claims included in Line
8.1. Line 8.1e – Report the number of Lab claims included in Line 8.1. Line 8.1f – Report the
number of Ambulance claims included in Line 8.1. Line 8.1g – Report the number of DME claims
included in Line 8.1. Line 8.1h – Report the number of Physician claims reported in Line 8.1.
Line 8.1i – Report the number of Other claims or claims where the provider type cannot be
determined based on the information on the claim included in Line 8.1.
Line 8.2. RAC Redeterminations Affirmed- Of the affirmation cases reported in Line 8, how
many are RAC related?

Line 8.2.1. Number of RAC Claims Involved – Show the number of claims involved in Line
8.2.
Line 9. Partial Reversals - Under the appropriate columns, show the number of completed
redeterminations, from Line 6 in which part of the prior determination decision of the appealed
lines was reversed. That is, a change was made and some part of the new determination was in
favor of the appellant. NOTE: Consider a case reversed when the initial determination is changed
upon appeal, irrespective of a change in payment.
Line 9.1. Number of Claims Partially Reversed – Show the number of claims involved in Line
6.1 for which the decision is partially reversed. Note: It is possible to have zero claims in Line
9.1, even when cases are recorded in Line 9.
Line 9.1a – Report the number of SNF claims included in Line 9.1. Line 9.1b – Report the number
of Home Health claims included in Line 9.1. Line 9.1c – Report the number of Inpatient Hospital
claims included in Line 9.1. Line 9.1d – Report the number of Outpatient claims included in Line
9.1. Line 9.1e – Report the number of Lab claims included in Line 9.1. Line 9.1f – Report the
number of Ambulance claims included in Line 9.1. Line 9.1g – Report the number of DME claims
included in Line 9.1. Line 9.1h – Report the number of Physician claims reported in Line 9.1.
Line 9.1i – Report the number of Other claims or claims where the provider type cannot be
determined based on the information on the claim included in Line 9.1.
Line 9.2. RAC Redeterminations Partially Reversed– Of the partially reversed cases reported
in Line 9, how many are RAC related?
Line 9.2.1 Number of RAC Claims Involved – Show the number of claims involved in Line
9.2.
Line 10. Full Reversals - Under the appropriate columns, show the total number of completed
redeterminations from Line 6 in which the previous determination decision of the appealed lines
was completely reversed. NOTE: Consider a case reversed when the initial determination is
changed upon appeal, irrespective of a change in payment.
Line 10.1. Number of Claims Fully Reversed – Show the number of claims involved in Line 6.1
for which the decision is fully reversed.
Line 10.1a – Report the number of SNF claims included in Line 10.1. Line 10.1b – Report the
number of Home Health claims included in Line 10.1. Line 10.1c – Report the number of
Inpatient Hospital claims included in Line 10.1. Line 10.1d – Report the number of Outpatient
claims included in Line 10.1. Line 10.1e – Report the number of Lab claims included in Line
10.1. Line 10.1f – Report the number of Ambulance claims included in Line 10.1. Line 10.1g –
Report the number of DME claims included in Line 10.1. Line 10.1h – Report the number of
Physician claims reported in Line 10.1. Line 10.1i – Report the number of Other claims or claims
where the provider type cannot be determined based on the information on the claim included in
Line 10.1.
Line 10.2 RAC Redeterminations Fully Reversed – Of the fully reversed cases reported in Line
10, how many are RAC related?

Line 10.2.1 Number of RAC Claims Involved – Show the number of claims involved in Line
10.2.
Line 11. Dismissals/Withdrawals - Report, under the appropriate column, the number of cases
from Line 6 that were withdrawn by the appellant or dismissed (before determination) by you. In
order for a case to be recorded in Line 11, all claims in the case must be dismissed or withdrawn.
NOTE: Do not count cases that were dismissed because they were determined to be incomplete
in Line 11. Cases that were dismissed because they were determined to be incomplete should only
be counted in Line 12.
Line 11.1. Number of Claims Dismissed or Withdrawn – Show the number of claims involved
in Line 6.1 which were dismissed or withdrawn.
Line 11.1a – Report the number of SNF claims included in Line 11.1. Line 11.1b – Report the
number of Home Health claims included in Line 11.1. Line 11.1c – Report the number of
Inpatient Hospital claims included in Line 11.1. Line 11.1d – Report the number of Outpatient
claims included in Line 11.1. Line 11.1e – Report the number of Lab claims included in Line
11.1. Line 11.1f – Report the number of Ambulance claims included in Line 11.1. Line 11.1g –
Report the number of DME claims included in Line 11.1. Line 11.1h – Report the number of
Physician claims reported in Line 11.1. Line 11.1i – Report the number of Other claims or claims
where the provider type cannot be determined based on the information on the claim included in
Line 11.1.
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
determination.
For both full and partial reversals,
when the contractor completes the
action that sets in motion correct

o
The contractor affirms the initial
determination
payment of the claim and the
contractor mails the decision letter
to the party.
The date the decision letter is
mailed to the party.
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 QIC’s decision is favorable to the appellant and gives a specific amount to be paid,
effectuation must occur within 30 calendar days of the date of the QIC’s decision. If the decision
is favorable but the amount to be paid must be computed, effectuation must occur within 30 days

after the amount is computed. The amount must be computed as soon as possible, but no later than
30 calendar days of the date of receipt of the QIC’s decision.
Line 42a. Number of Claims Involved – Show the number of claims involved in Line 42.
NOTE: Information captured in Lines 43, 44 and 45 reflects time to compute the amount to be
paid as well as the effectuation timeframes. Information provided in Lines 43-45 also assumes that
contractors must calculate the amounts to be paid. Even though all appropriate timeframes are not
reflected here, contractors are still required to follow applicable manual requirements and
timeframes with regard to receipt, calculation and effectuation of decisions. CMS anticipates that
effectuation of most decisions for which the amount is provided should fall into Line 43.
Line 43. Number Effectuated in 1-30 Days - Show the number of claims from Line 42a where
you effectuated the decision within 30 calendar days. Effectuation days include the day of receipt
of the reconsideration effectuation notice in your corporate mailroom or electronic transmission,
such as fax or secure e-mail through the day the payment is issued.
43a. Contractor Computed Amount – Of the number reflected on Line 43, show the number
where the contractor was required to compute the amount to be paid. An entry of zero indicates
that the contractor was not required to compute the amount for any claim.
Line 44. Number Effectuated in 31-60 Days - Show the number of claims from Line 42a where
you effectuated the decision within 31-60 calendar days. Effectuation days include the day of
receipt of the reconsideration effectuation notice in your corporate mailroom or electronic
transmission, such as fax or secure e-mail through the day the payment is issued.
44a. Contractor Computed Amount – Of the number reflected on Line 44, show the number
where the contractor was required to compute the amount to be paid. An entry of zero indicates
that the contractor was not required to compute the amount for any claim.
Line 45. Number Effectuated in Over 60 Days - Show the number of claims from Line 42a
where you effectuated the decision in more than 60 calendar days. Effectuation days include the
day of receipt of the reconsideration effectuation notice in your corporate mailroom or electronic
transmission, such as fax or secure e-mail through the day the payment is issued.
45a. Contractor Computed Amount – Of the number reflected on Line 45, show the number
where the contractor was required to compute the amount to be paid. An entry of zero indicates
that the contractor was not required to compute the amount for any claim.
Line 46. Medicare Approved Amount (Not Applicable) - For decisions included in Line 42
show the Medicare approved amount for services at the QIC level where the determination was
reversed, either fully or partially. Show the charges prior to application of the deductible and
coinsurance. Round results to the nearest dollar.
It is preferable to report the Medicare Approved Amount at the time that cases are reported on line
42. However, CMS will consider it acceptable for contractors to report the Medicare Approved
Amount when adjustment claims tied to cases that are reporting or will report to line 42 finalize.

Line 46a. Waiver of Liability Amount Paid (Not Applicable) – Of the amount recorded on
Line 46, show the amount applicable to a waiver of liability payment on the basis that the party did
not know that the service wasn’t payable under Medicare.
Line 47. Closing Pending Reconsiderations - Show the total number of reconsideration requests
that were not effectuated by the end of the reporting month. Consider a case pending from the date
of receipt of the request at the contractor, or the date of the request for the case file from the QIC,
until you have received the completed decision from the QIC for all parts of the case. This number
shall also reflect those case files not yet forwarded to the QIC by the contractor as well as those
decisions that have been received by the contractor from the QIC that still require effectuation on
the part of the contractor. For example, if you receive a case from the QIC, and have initiated the
adjustment into the system, but have not issued the payment, the case is reported in Line 47 as
pending.
Do not include instances where a misrouted file has been sent to the proper QIC in another
jurisdiction. Misrouted files that belong to a QIC in another jurisdiction should be considered
closed once they have been forwarded to the appropriate QIC. Files that are forwarded to the QIC
servicing the same jurisdiction as the contractor should remain open until the effectuation is
complete.
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 wasn’t payable under Medicare.
Line 57. Closing Pending ALJ Decisions - Show the total number of ALJ decisions that were
received from the AdQIC, but were not completed by the contractor at the end of the reporting
month, and as such, are still pending effectuation. All claims associated with the decision must be
received from the AdQIC in order for the decision to be considered complete.
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 contractor’s mailroom.
Line 11. Clerical Error Reopenings Processed in 31-60 Days - Show the number of clerical
error reopenings from Line 2 processed in 31-60 calendar days. The processing time frame starts
from the date of receipt of the request in the contractor’s mailroom.
Line 11a. Clerical Error Reopenings Processed in More than 60 Days – Show the number of
clerical error reopenings from Line 2 processed in 61 days or more. The processing time frame
starts from the date of receipt of the request in the contractor’s mailroom.
Line 12. Total Number of Clerical Error Reopening Requests Pending –Show the number of
clerical error reopenings pending at the close of the reporting month.
Line 13. Total Number of Higher Level Reopenings Requiring Adjustment by the
Contractor – Show the number of claims that were reopened by the QIC, ALJ or Medicare
Appeals Council that require an adjustment by the contractor. These are claims for which the
contractor must effectuate the claim as a result of the reopening decision at the higher level.
Line 14. Amount Awarded (Not Applicable) – Show the amount approved for services from
Line 13 where the determination was reversed, either fully or partially. Show amounts that are
sent to the provider. Round results to the nearest dollar.
It is preferable to report the Medicare Approved Amount at the time that cases are reported on line
13. However, CMS will consider it acceptable for contractors to report the Medicare Approved
Amount when adjustment claims tied to cases that are reporting or will report to line 13 finalize.
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 month’s 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 month’s 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 month’s 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
MAC (A)
Processed by
A/B MAC (A)
Processed by
A/B MAC (B) or
Durable Medical
Equipment (DME)
MAC
Section I:
Redeterminations
1: Opening Pending
2: Adjustments to Pending
3: Adjusted Pending
4: Requests Received
4.a Adjusted Requests
Received
4.1 Number of Claims
Received

4.2. Recovery Audit
Contractor (RAC) Requests
Received
4.2.1 Number of RAC
Claims Received
5: Misrouted Requests
Forwarded to Another
Contractor
6: Requests Cleared
6.1 Number of Claims
Cleared
a. SNF
b. Home Health
c Inpatient Hospital
d. Outpatient
e. Lab
f. Ambulance
g. DME
h. Physician
i. Other
6.2. Recovery Audit
Contractor (RAC)
Redeterminations Cleared
6.2.1 Number of RAC
Claims Involved
7: Cleared -- Evidence
Submitted after Request
7.1: Number of Claims
Involved
a. SNF (Not Applicable)
b. Home Health (Not
Applicable)
c. Inpatient Hospital (Not
Applicable)
d. Outpatient (Not
Applicable)
e. Lab (Not Applicable)
f. Ambulance (Not
Applicable)
g. DME (Not Applicable)
h. Physician (Not
Applicable)
i. Other (Not Applicable)
7.2: RAC Redeterminations
Cleared With Additional
Documentation
7.2.1: Number of RAC
Claims Involved
8: Affirmations

8a. Waiver of Liability
Amount Paid (Not
Applicable)
8.1: Number of Claims
Affirmed
a. SNF
b. Home Health
c. Inpatient Hospital
d. Outpatient
e. Lab
f. Ambulance
g. DME
h. Physician
i. Other
8.2 RAC Redeterminations
Affirmed
8.2.1: Number of RAC
Claims Involved
9: Partial Reversals
9.1: Number of Claims
Partially Reversed
a. SNF
b. Home Health
c. Inpatient Hospital
d. Outpatient
e. Lab
f. Ambulance
g. DME
h. Physician
i. Other
9.2: RAC Redeterminations
Partially Reversed
9.2.1: Number of RAC
Claims Involved
10: Full Reversals
10.1 Number of Claims
Fully Reversed
a. SNF
b. Home Health
c. Inpatient Hospital
d. Outpatient
e. Lab
f. Ambulance
g. DME
h. Physician
i. Other
10.2: RAC
Redeterminations Fully
Reversed

10.2.1: Number of RAC
Claims Involved
11: Dismissals/Withdrawals
11.1 Number of Claims
Dismissed or Withdrawn
a. SNF
b. Home Health
c Inpatient Hospital
d. Outpatient
e. Lab
f. Ambulance
g. DME
h. Physician
i. Other
11.2: RAC
Redeterminations
Dismissed or Withdrawn
11.2.1: Number of RAC
Claims Involved
12: Number of Incomplete
Redeterminations Requests
Dismissed
13:Medicare Approved
Amount (Not Applicable)
14: Redeterminations
Processing Time –Average
15: Redeterminations
Completed in 1-60 days
15a. RAC Redeterminations
Completed in 1-60 days
16: Redeterminations
Completed in Over 60 days
16 a. RAC
Redeterminations
Completed in Over 60 days
17: Redeterminations
Processing Time- Average
(Documentation Submitted
Later)
18: Redeterminations
Completed in 1-60 days
(Documentation Submitted
Later)
18a. RAC Redeterminations
Completed in 1-60 days
(Documentation Submitted
Later)
19: Redeterminations
Completed in 61-74 days
(Documentation Submitted
Later)

19a. RAC Redeterminations
Completed in 61-74 days
(Documentation Submitted
Later)
20: Redeterminations
Completed in over 74 days
(Documentation Submitted
Later)
20a. RAC Redeterminations
Completed in over 74 days
(Documentation Submitted
Later)
21: Closing Pending
Redeterminations
22 Redeterminations
Pending 1-30 days
23: Redeterminations
Pending 31-60 days
24: Redeterminations
Pending 61-74 Days
25: Redeterminations
Pending Over 74 days
26: Total Effectuations
26a: Number of Claims
Involved
27: Number Effectuated 1-
30 Days
28: Number Effectuated 31-
60 Days
29: Number Effectuated
over 60 Days
Section II: QIC
Reconsiderations
30: Opening Pending
31: Adjustments to Pending
32: Adjusted Opening
Pending
33: Requests For QIC
Reconsideration Received
by the Contractor
33a. Misrouted Requests
Forwarded to QIC
33b. Misrouted Requests
Forwarded Timely
33c. Misrouted Requests
Forwarded Untimely
34. Requests from QIC for
Case Files
35: Number of Case Files
Forwarded to QIC
36: Number Forwarded in
1-5 days

36a: Number Forwarded in
6 Days
37: Number Forwarded in
7-8 Days
37a: Number Forwarded in
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. 12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
This report, referenced as Form Y for CROWD, is used only when program requirements compel
CMS to collect data on an interim basis before the data elements can be incorporated into one of
the regular forms. The Medicare contractor submits the appropriate information for the reporting
period for each office assigned a separate contractor number and BSI no later than the 10th day of
the following month using instructions in the CROWD User Guide available via the CMS
Enterprise Portal.
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#
R12894FM 10/17/2024 Migration of the Contractor Reporting of Operational
and Workload Data (CROWD) to the Centers for
Medicare & Medicaid Services (CMS) Enterprise Portal
– Internet-Only Manual (IOM) Updates
11/01/2024 12743
R12456FM 01/11/2024 New Physician Specialty Code for Epileptologists 07/01/2024 13425
R10521FM 12/16/2020 New Medicare National Uniform Billing Committee
(NUBC) Type of Bill (TOB), Condition Code and
implementing Billing Codes for Opioid Treatment
Programs
01/04/2021 11856
R10374FM 09/25/2020 New Physician Specialty Code for Micrographic
Dermatologic Surgery (MDS) and Adult Congenital
Heart Disease (ACHD) and a New Supplier Specialty
Code for Home Infusion Therapy Services
10/05/2020 11750
R10319FM 08/28/2020 Removal of Contractor Requirement to Submit
Electronic Data Interchange (EDI) Data into the
Contractor Reporting of Operational and Workload
Data (CROWD) System (Form 5)
09/29/2020 11909
08/06/2020 New Medicare National Uniform Billing Committee
(NUBC) Type of Bill (TOB), Condition Code and
implementing Billing Codes for Opioid Treatment
Programs- Rescinded and replaced by transmittal 10521
SENSITIVE/CONTROVERSIAL
01/04/2021 11856
R10124FM 05/08/2020 New Physician Specialty Code for Micrographic
Dermatologic Surgery (MDS) and Adult Congenital
Heart Disease (ACHD) and a New Supplier Specialty
Code for Home Infusion Therapy Services- Rescinded
and replaced by transmittal 10374
10/05/2020 11750
12/05/2019 New Medicare Provider Specialty Code (D5) and
Billing Codes for Opioid Treatment Programs and New
Place of Service Code 58
01/06/2020 11353
10/29/2019 New Medicare Provider Specialty Code (D5) and
Billing Codes for Opioid Treatment Programs and New
Place of Service Code 58
SENSITIVE/CONTROVERSIAL
01/06/2020 11353
09/23/2019 New Medicare Provider Specialty Code (D5) and
Billing Codes for Opioid Treatment Programs and New
Place of Service Code 58- Rescinded and replaced by
Transmittal 329
SENSITIVE/CONTROVERSIAL
01/06/2020 11353

08/01/2019 New Medicare Provider Specialty Code (D5) and
Billing Codes for Opioid Treatment Programs and New
Place of Service Code 58-Rescinded and replaced by
Transmittal 324
SENSITIVE/CONTROVERSIAL
01/06/2020 11353
R315FM 05/17/2019 Update to Publication (Pub.) 100-06 to Provide
Language-Only Changes for the New Medicare Card
Project
06/18/2019 11211
R309FM 12/20/2018 New Physician Specialty Code for Undersea and
Hyperbaric Medicine
01/07/2019 10666
R304FM 04/27/2018 New Physician Specialty Code for Medical Genetics
and Genomics
10/01/2018 10457
R302FM 03/30/2018 Removal of Contractor Reporting Requirements for the
Physician Scarcity Area (PSA), the Health Professional
Shortage Area Surgical Incentive Payment Program
(HSIP) and the Primary Care Payment Incentive
Program (PCIP) Quarterly Reports
07/02/2018 10406
R298FM 02/02/2018 Removal of Contractor Reporting Requirements for the
Physician Scarcity Area (PSA), the Health Professional
Shortage Area Surgical Incentive Payment Program
(HSIP) and the Primary Care Payment Incentive
Program (PCIP) Quarterly Reports Rescinded and
replaced by Transmittal 302
07/02/2018 10406
R290FM 07/14/2017 New Specialty Code for Pharmacy 01/02/2018 9821
R283FM 04/28/2017 New Physician Specialty Code for Advanced Heart
Failure and Transplant Cardiology, Medical
Toxicology, and Hematopoietic Cell Transplantation
and Cellular Therapy
10/02/2017 9957
R276FM 11/25/2016 New Physician Specialty Code for Hospitalist 04/03/2017 9716
R274FM 10/28/2016 New Physician Specialty Code for Hospitalist –
Rescinded and replaced by Transmittal 276
04/03/2017 9716
R269FM 06/22/2016 New Physician Specialty Code for Dentist 07/05/2016 9355
R268FM 06/15/2016 New Physician Specialty Code for Dentist – Rescinded
and replaced by Transmittal 269
07/05/2016 9355
R265FM 03/16/2016 Contractor Reporting of Operational and Workload
Data (CROWD) Form 5 Update with Revisions to Pub.
100-06 Medicare Financial Management Manual,
Chapter 6
07/05/2016 8998

R263FM 02/05/2016 Contractor Reporting of Operational and Workload
Data (CROWD) Form 5 Update with Revisions to Pub.
100-06 Medicare Financial Management Manual,
Chapter 6 – Rescinded and replaced by Transmittal 265
07/05/2016 8998
R262FM 01/29/2016 New Physician Specialty Code for Dentist – Rescinded
and replaced by Transmittal 268
07/05/2016 9355
R253FM 08/06/2015 Update the Contractor Reporting of Operational and
Workload Data (CROWD) CMS-2592 Report to
Indicate Requests Received in Claims and Requests
Received That Are Recovery Audit Related
01/04/2015 9157
R248FM 12/19/2014 Revision of Pub. 100-06 - Medicare Financial
Management Manual, Chapter 6 - Intermediary and
Carrier Financial Reports, and Pub. 100-09 - Medicare
Contractor Beneficiary and Provider Communications,
Chapter 6 - Provider Customer Service Program
01/23/2015 8906
R238FM 08/22/2014 New Physician Specialty Code for Interventional
Cardiology
01/05/2015 8812
R221FM 06/12/2013 New Non-Physician Code for Complimentary Insurer 10/07/2013 8282
R219FM 05/03/2013 New Non-Physician Code for Complimentary Insurer –
Rescinded and replaced by Transmittal 221
10/07/2013 8282
R216FM 12/14/2012 Modification/Addition of Group Codes/Specialty Codes 01/15/2013 8090
R212FM 08/10/2012 New Non-Physician Specialty Code for Centralized Flu 01/07/2012 7884
R209FM 04/27/2012 New Physician Specialty Code for Sleep Medicine and
Sports Medicine
10/01/2012 7600
R195FM 09/30/2011 To Create Form 9 Within the Contractor Reporting of
Operational and Workload Data (CROWD) System for
the Reporting of Primary Care Incentive Payments
(PCIP) and HPSA Surgical Incentive Payments (HSIP)
07/05/2011 7285
R191FM 07/13/2011 Add Physician Specialty Codes for Cardiac
Electrophysiology (21) and Sports Medicine (23) to
CROWD Forms “F” (ParDoc) and “8” (OptOut) –
Rescinded and replaced by Transmittal 191
07/05/2011 7233
R188FM 04/22/2011 Modify CROWD Form K to Allow the Submission of
Additional Medicare Summary Payer (MSP) Savings
Information
07/05/2011
and
10/03/2011
7291
R183FM 02/04/2011 To Create Form 9 Within the Contractor Reporting of
Operational and Workload Data (CROWD) System for
the Reporting of Primary Care Incentive Payments
(PCIP) and HPSA Surgical Incentive Payments (HSIP)
– Rescinded and replaced by Transmittal 195
07/05/2011 7285
R181FM 01/04/2011 Add Physician Specialty Codes for Cardiac
Electrophysiology (21) and Sports Medicine (23) to
CROWD Forms “F” (ParDoc) and “8” (OptOut) –
Rescinded and replaced by Transmittal 191
07/05/2011 7233

R178FM 12/03/2010 Add Physician Specialty Codes for Cardiac
Electrophysiology (21) and Sports Medicine (23) to
CROWD Forms “F” (ParDoc) and “8” (OptOut) -
Rescinded and replaced by Transmittal 181
07/05/2011 7233
R177FM 12/03/2010 Add Supplier Specialty Code 95 (Advanced Diagnostic
Imaging (ADI) Accreditation) to CROWD Form F
(Participating Physician/Supplier Report) – Rescinded
and not replaced.
07/05/2011 7226
R176FM 11/12/2010 Clarification for Data Entry on Health Professional
Shortage Area Reports
12/13/2010 7223
R175FM 10/28/2010 Change the Name of Physician Specialty Code 12 from
Osteopathic Manipulative Therapy to Osteopathic
Manipulative Medicine
04/04/2011 7093
R173FM 10/15/2010 Update to the Quarterly Opt Out Reporting Form (Form
8) in the Contractor Reporting of Operational Workload
Data (CROWD)
11/16/2010 7165
R171FM 05/28/2010 Expansion of Form 5 of the Contractor Reporting of
Operational and Workload Data (CROWD)
10/04/2010 6969
R170FM 05/21/2010 Cardiac Rehabilitation and Intensive Cardiac
Rehabilitation
10/04/2010 6850
R163FM 12/04/2009 Add Physician Specialty Code 27 (Geriatric Psychiatry)
to CROWD Form F (Participating Physicians/Supplier
Report)
04/05/2010 6613
R159FM 10/09/2009 Add Physician Specialty Code 27 (Geriatric Psychiatry)
to CROWD Form F (Participating Physicians/Supplier
Report) – Rescinded and replaced by Transmittal 163
04/05/2010 6613
R157FM 08/21/2009 Add Specialty Codes to CROWD Form F (Participating
Physicians Data)
01/04/2010 6580
R155FM 07/31/2009 New Reporting Requirements for the Quarterly Opt Out
Report in Contractor Reporting of Operational
Workload Data (CROWD)
01/04/2010 6562
R144FM 11/28/2008 Revisions to the Monthly Statistical Report on
Intermediary and Carrier Part A and Part B Appeals
Activity Form (CMS-2592) to Capture Data on
Recovery Audit Contractor (RAC) Redeterminations
04/06/2009 6251
R131FM 09/21/2007 Participating Physicians Report – Deletion of
Requirement to Forward a Memorandum to CMS
Detailing Adjustments for Form F Column 1 (PAR
Prior) (from previous enrollment period)
01/07/2008 5697
R130FM 08/31/2007 “Revisions” of the CROWD Report 01/07/2008 5555
R126FM 07/13/2007 Manual Revision Re: MSN Workload Reporting 01/07/2008 5642
R123FM 06/08/2007 Contractor CROWD Form 5 Completion Changes 10/01/2007 4274
R121FM 05/02/2007 Contractor CROWD Form 5 Completion Changes –
Replaced by Transmittal 123
10/01/2007 4274

R119FM 04/20/2007 Contractor CROWD Form 5 Completion Changes -
Replaced by Transmittal 121
10/01/2007 4274
R98FM 06/16/2006 Correction of CROWD Form 5 Reporting for Internet
Pilot Carriers
07/17/2006 5120
R96FM 05/26/2006 Development of New Report to Capture BIPA and
MMA Appeals Data
07/03/2006 5056
R88FM 01/06/2006 Clarification to IOM 100-06, Sections 290.7 and 290.8 02/06/2006 4198
R86FM 12/02/2005 Development of New Report to Capture BIPA and
MMA Appeals Data – Replaced by Transmittal 96, CR
5056
07/03/2006 4148
R85FM 11/17/2005 Expansion of Form 5 of the Contractor Reporting of
Operational and Workload Data (CROWD) – Replaced
by Transmittal 85
04/03/2006 3864
R82FM 10/31/2005 Expansion of Form 5 of the Contractor Reporting of
Operational and Workload Data (CROWD) – Replaced
by Transmittal 85
04/03/2006 3864
R76FM 08/12/2005 Development of New Report to Capture BIPA and
MMA Appeals Data – Replaced by Transmittal 86, CR
4148
04/03/2006 3837
R65FM 02/25/2005 Revised Reporting Requirements for Contractor
Reporting of Operational and Workload Data
(CROWD) Physician Scarcity Area (PSA) Quarterly
Report (CMS Form-1565F, CROWD Form 6)
07/05/2005 3673
R57FM 10/22/2004 Revised Reporting Requirements for Contractor
Reporting of Operational and Workload Data
(CROWD) Health Professional Shortage Area (HPSA)
Quarterly Report (CMS Form-1565E, CROWD Form
S)
04/04/2005 3472
R56FM 10/22/2004 Revision to Balancing Requirements on Form 5, Line
10 of the Contractor Reporting of Operational and
Workload Data (CROWD)
11/22/2004 3486
R45FM 05/28/2004 Workload Reporting N/A 3246
R40FM 04/30/2004 Medicare Contractor Transaction Report 10/04/2004 3257
R36FM 03/12/2004 Medicare Contractor Transaction Report (FormCMS-5) N/A 2249
&
2547
R06FM 08/30/2002 Initial Publication of Chapter N/A N/A
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