CMS Pub. 100-06, ch. 3, § 200.8

02/01/2015 $7,319.18 $ - Loan-voluntary 54 -

02/01/2015 $ $52,680.82 Loan-voluntary 54 -

03/01/2015 $7,380.93 $ - Loan-voluntary 53 -

03/01/2015 $ $52,619.07 Loan-voluntary 53 -

04/01/2015 $47,443.21 $ - Loan-voluntary 52 -

04/01/2015 $ $52,556.79 Loan-voluntary 52 -

05/01/2015 $47,843.51 $ - Loan-voluntary 51 -

05/01/2015 $ $52,156.49 Loan-voluntary 51 -

06/01/2015 $48,247.19 $ - Loan-voluntary 50 -

06/01/2015 $ $51,752.81 Loan-voluntary 50 -

07/01/2015 $48,654.28 $ - Loan-voluntary 49 -

07/01/2015 $ $51,345.72 Loan-voluntary 49 -

08/01/2015 $49,064.80 $ - Loan-voluntary 48 -

08/01/2015 $ $50,935.20 Loan-voluntary 48 -

09/01/2015 $ $50,521.22 Loan-voluntary 47 -

09/01/2015 $49,478.78 $ - Loan-voluntary 47 -

10/01/2015 $ $50,103.74 Loan-voluntary 46 -

10/01/2015 $49,896.26 $ - Loan-voluntary 46 -

11/01/2015 $ $49,682.74 Loan-voluntary 45 -

11/01/2015 $50,317.26 $ - Loan-voluntary 45 -

12/01/2015 $ $49,258.19 Loan-voluntary 44 -

12/01/2015 $50,741.81 $ - Loan-voluntary 44 -

01/01/2016 $ $48,830.05 Loan-voluntary 43 -

01/01/2016 $51,169.95 $ - Loan-voluntary 43 -

02/01/2016 $ $48,398.31 Loan-voluntary 42 -

02/01/2016 $51,601.69 $ - Loan-voluntary 42 -

03/01/2016 $ $47,962.92 Loan-voluntary 41 -

03/01/2016 $52,037.08 $ - Loan-voluntary 41 -

04/01/2016 $ $47,523.86 Loan-voluntary 40 -

04/01/2016 $50,448.03 $ - Loan-voluntary 40 -

05/09/2016 $ $4,504.19 No 39 -

05/10/2016 $ $768.93 No 39 -

05/17/2016 $ $147.33 No 38 -

05/18/2016 $ $895.34 No 38 -

05/25/2016 $ $1,119.57 No 38 -

06/16/2016 $ $1,270.85 No 37 -

06/23/2016 $ $1,805.01 No 37 -

06/28/2016 $ $1,580.27 No 37 -

06/29/2016 $ $3,551.93 No 37 -

07/01/2016 $ $3,542.16 No 37 -

07/08/2016 $ $2,886.24 No 37 -

07/11/2016 $ $6,785.34 No 36 -

07/13/2016 $ $890.36 No 36 -

07/26/2016 $ $1,438.45 No 36 -

08/05/2016 $ $497.48 No 36 -

08/10/2016 $ $2,486.16 No 35 -

08/11/2016 $ $602.27 No 35 -

08/16/2016 $ $765.90 No 35 -

08/18/2016 $ $854.74 No 35 -

08/23/2016 $ $686.88 No 35 -

09/14/2016 $ $413.57 No 34 -

09/26/2016 $ $2,638.57 No 34 -

10/05/2016 $ $3,605.91 No 34 -

10/11/2016 $ $1,916.53 No 33 -

10/18/2016 $ $872.56 No 33 -

10/19/2016 $ $1,541.62 No 33 -

12/12/2016 $ $558.72 No 31 -

12/15/2016 $ $3,285.16 No 31 -

12/21/2016 $ $602.27 No 31 -

01/09/2017 $ $775.35 No 30 -

01/11/2017 $ $4,505.74 No 30 -

01/12/2017 $ $2,330.08 No 30 -

01/17/2017 $ $686.88 No 30 -

02/08/2017 $ $628.47 No 29 -

02/14/2017 $ $2,249.28 No 29 -

02/23/2017 $ $1,276.13 No 29 -

04/21/2017 $ $22.01 No 27 -

10/01/2018 $ $506.20 No 9 -

02/04/2019 $ $129.63 No 5 -

05/13/2019 $ $1,273.09 No 2 -

Contractors shall report 935 interest paid each calendar quarter based on an ALJ or

subsequent level decision for fully and partially favorable decisions that were reversed

from the previous decision.

• Report 935 Interest payment amounts on all provider types.

• When a provider has more than one decision, those amounts shall be aggregated.

Report shall be sent electronically to:

Medicareoverpayments@cms.hhs.gov.

The contractor shall have 30 calendar days from the end of the calendar quarter to submit

the report to CMS.

Exhibit 1: 935 Interest Payment Tracking Report

1st Quarter: October, November and December

2nd Quarter: January, February and March

3rd Quarter: April, May and June

4th Quarter: July, August and September

Include the following on the report:

1. Provider Name

2. Appeal Case #

3. Decision Date

4. Decision

5. 935 Interest Amount

Example:

Provider Name Appeal

case #

Decision Date Decision 935 Interest-

Amount

ABC DME Home XXXXXXXXX 01/03/2019 Fully

Favorable

135000

Georgia Homecare XXXXXXXXX 01/05/2019 Fully Favora 25000

Total Care XXXXXXXXX 01/18/2019 Partially

Favorable

29

Maximum Health group XXXXXXXXX 01/29/2019 Partially

Favorable

156000

Total $316029