CMS Pub. 100-06, ch. 1, § 140.1

A1-1217.1, B1-4217.1

A. General

The contractor shall use this schedule to identify specific Non-COB Credits included in

the Non-COB Credit line of the Activity Screen as defined in §90.9 G. A separate

Schedule C is completed for each activity requiring the specific identification of Non-COB Credits.

B. Uses

The contractor shall complete this schedule only with the concurrence of CMS. It may

not be required of all contractors. If required, the schedule may be used for the BR, SBR,

IER and/or FACP.

C. Explanation of Entries on the Schedule C

1. Code - A three-digit code identifying each credit item. The contractor shall use 999 to

identify all remaining credits not requiring specific identification.

2. Description - A brief description of the discrete credit item. Types of credits to be

reported are described in §90.9 G. Those items requiring identification will depend on the

nature of the contractor's contract, materiality and other considerations.

3. Total Credits - The contractor shall report the total credit for each item. The total for

all Non-COB Credits, including those reported under 999 if applicable, must agree with

the total reported on the Non-COB Credits line of the Activity Screen.

150 - Exhibit of Schedule of Other Adjustments (Schedule D) - (Rev. 1,

08-30-02)

A1-1218, B1-4218

Click here to view exhibit of Schedule of Other Adjustments (Schedule D)