CMS Pub. 100-06, ch. 5, § 400.23

CMS is required to prepare fiscal year financial statements in accordance the Office of

Management and Budget’s (OMB’s) accelerated mandated schedule. In order to meet the

accelerated timeframes, CMS requests specific contractor financial data for the

preparation and audit of CMS’ annual financial statements.

For inclusion in the year-end CMS financial statements, the Office of the Actuary

(OACT) prepares the Medicare Incurred But Not Reported (IBNR) estimate which is

based on actuarial estimates. Due to the complexity of the actuarial estimate and the

availability of data, OACT prepares this estimate for yearend statements only. The

Medicare IBNR estimate represents the amount of CMS claims incurred but not yet paid

at the end of the fiscal year (FY) and is a summation of five different components:

(1) the incurred to approval of payment amount – represents Medicare Services

provided, for which, a corresponding claim has not been approved for payment

and also is referred to as the incurred to approved amount;

(2) the retroactive settlements on cost reports amount – represents the estimated net

liability for cost reports awaiting final settlement and is also referred to as the cost

settlement amount;

(3) the approval to actual payment amount – represents the aggregate claims

approved for payment, for which, the corresponding reimbursement has not been

issued and is also referred to as the approved to paid amount;

(4) the paid to cleared amount – represents the aggregate claims for which checks

have been issued, but have not cleared the Medicare contractor’s financial

institution and is also referred to as the outstanding checks amount; and

(5) the advance payments under Periodic Interim Payment (PIP) amount – represents

the bi-weekly payments for estimated benefit payments for plans under such a

payment plan and is also referred to as the PIP amount.

The data required for items (3) through (5) is obtained directly from the Medicare

contractors and is submitted via the Benefits Payable survey (Attachment I, II, and/or III).

Typically, the survey is sent to the Medicare contractors in May or June of the current

FY.

Due to the on-going transition to the Healthcare Integrated General Ledger Accounting

System (HIGLAS) by the Medicare contractors, the data elements on the survey which

are required for submission have been revised. Instructions for each data element on the

attachments are discussed below.

1) PIP – value of the first periodic interim payment (PIP) cycle paid in the ensuing

month for the end of the month being reviewed. (Fiscal intermediaries

ONLY)

CAFM contractors should continue to utilize their shared system to obtain this

amount. If the payment cycle has not been run, please provide an estimate of

this amount. Do not include pass through costs.

HIGLAS contractors should obtain this amount from their 810 interface report.

If the payment cycle has not been run, please provide an estimate of this

amount. Do not include pass through costs.

2) Claims on the payment floor – Adjudicated claims not yet paid for both Health

Insurance (HI) and Supplemental Medical Insurance (SMI), if applicable.

CAFM contractors should continue to utilize their shared system to obtain this

amount. The amount reported on the survey must agree to the amount reported

on the year-end Form CMS-750A and/or 750B, Statement of Financial Position.

HIGLAS contractors should obtain this amount from their Summary 2 Trial

Balance, GL account 216002, Entitlement Benefit Due/Payable – Adjudicated

Claims.

3) Claims on Hold –This amount would include claims held resulting from Do Not

Forward, providers being investigated for fraud, claims payments due to

bankrupt providers. This amount does not include the amount for claims

withheld for non-receipt of cost reports. Amounts must be provided for both HI

and SMI, if applicable. (CAFM Contractors only).

CAFM contractors should obtain this amount from their shared system. The

amount reported on this survey must agree to the applicable portion reported on

the Other Liabilities (footnote) line of the year end Form CMS-750, Statement

of Financial Position. The amount should include claims held in accordance

with CR 5047, Hold on Medicare Payments.

4) Outstanding Checks – The amount of checks and EFT payments that have been

issued, but have not cleared the Medicare contractor’s banking institution.

Amounts must be provided for both HI and SMI, if applicable.

CAFM contractors should obtain this amount from their banking institution or

internally generated documentation. The amount reported on the survey must

agree to outstanding check amount reported on the September 1522, Monthly

Contractor Financial Report.

HIGLAS contractors should obtain this amount from their Summary 2 Trial

Balance, GL account 212001 - Accounts Payable Disbursements in Transit.

5) Health Professional Shortage Area payments (HPSA) – the bonus amount paid

to physicians for eligible services rendered in zip code areas that fall fully

within a designated HPSA area or are dominant to the area based on a

determination by the U.S. Postal Service and/or;

Physician Scarcity Area (PSA) – the bonus amount paid to the primary care and

specialty physicians providing eligible services in the counties with the lowest

20% ratio of primary care or specialty physicians to Medicare beneficiaries

and/or;

Transitional Outpatient Payments (TOPs) - the amount paid to rural hospitals

having 100 or fewer beds that are not classified as a sole community hospital.

(Fiscal intermediaries ONLY)

If PSA/HPSA and/or TOPs payments were disbursed on or before the last day

of the quarter/month, enter amount as zero. If PSA/HPSA and/or TOPs

payments are disbursed on or after the first day of the quarter/month, provide

the amount of the payments. Contractors must provide these amounts for both

HI and SMI, if applicable.

CAFM contractors should obtain this information from their shared system, if

applicable.

HIGLAS contractors should obtain these amounts from their 810H and 810

files, if applicable. HIGLAS contractors should also provide a footnote to

disclose whether the amounts indicated for these payments are included in GL

account 216002, Entitlement Benefit Due/Payable – Adjudicated Claims.

Time Account Balances (Attachment IV)

The CMS reports the aggregate total Part A and total Part B Time Account balances as

Medicare trust fund “Cash and Other Monetary Assets” on the balance sheet in its annual

CMS Financial Report. Previously, these account balances were obtained from the Form

CMS-750 reports; however, the year-end 750 due date is typically extended until after

annual financial statements must be completed. Therefore, time account balances as of

September 30, FY end, must be submitted as part of the attached Benefits Payable Survey

– Attachment IV. Fiscal intermediaries should prorate their time account balances

between HI and SMI.

Due Dates

The annual Joint Signature Memorandum outlining the accelerated financial reporting

timeframes for FY end Medicare contractor financial reports will provide the due date for

the Benefits Payable Survey (Attachments I, II and/or III) as well as the Time Account

Balance information (Attachment IV).

Attachment 1

Contractor No. ______ HI BENEFITS PAYABLE SURVEY

INTERMEDIARY For Period Ending: September 30, 20xx

1. PIP Providers

Value of the First PIP Cycle Paid in the ensuing month ___________

for the end of the month being reviewed. (If the payment cycle has not been run,

please provide an estimate of this amount.

Do not include Pass Through Costs.)

NOTE: HIGLAS contractors should obtain this amount from their

810 interface file.

2. Claims on the Payment Floor (in dollars) ___________

(CAFM Contractors – Amount must agree to amount reported on the

September Form CMS-750)

NOTE: HIGLAS contractors should obtain this amount from their

Summary 2 Trial Balance GL account 216002, Entitlement

Benefit Due/Payable – Adjudicated Claims.

3. Claims on Hold (in dollars) – CAFM contractors ONLY ___________

(Amount should be obtained from the Other Liabilities line on the

Form CMS-751)

4. Outstanding Checks (in dollars) ___________

(Amount must include outstanding EFTs and agree to the

outstanding check amount on the September Form CMS-1522)

NOTE: HIGLAS contractors should obtain this amount from their

Summary 2 Trial Balance GL account 212001, Accounts Payable

Disbursements in Transit.

5. PSA/HPSA/TOPS payments (in dollars) ___________

(If payments were disbursed on or before the last day of the

quarter/month, enter amount as zero. If payments are disbursed

after the 1st day of the quarter/month, provide the amount of the payments)

NOTE: HIGLAS contractors should obtain these amounts from their

810H and 810 files, if applicable. HIGLAS contractors should also provide a

footnote to disclose whether the amounts indicated for these payments are

included in GL account 216002, Entitlement Benefit Due/Payable – Adjudicated

Claims

Attachment 2

Contractor No. ______ SMI BENEFITS PAYABLE SURVEY

INTERMEDIARY For Period Ending: September 30, 20xx

1. Claims on the Payment Floor (in dollars) ___________

(CAFM Contractors – Amount must agree to amount reported on the

September Form CMS-750)

NOTE: HIGLAS contractors should obtain this amount from their

Summary 2 Trial Balance GL account 216002, Entitlement

Benefit Due/Payable – Adjudicated Claims.

2. Claims on Hold (in dollars) – CAFM contractors ONLY ___________

(Amount should be obtained from the Other Liabilities line on the

Form CMS-751)

3. Outstanding Checks (in dollars) ___________

(Amount must include outstanding EFTs and agree to the

outstanding check amount on the September Form CMS-1522)

NOTE: HIGLAS contractors should obtain this amount from their

Summary 2 Trial Balance GL account 212001, Accounts Payable

Disbursements in Transit.

4. PSA/HPSA/TOPS payments (in dollars) ___________

(If payments were disbursed on or before the last day of the

quarter/month, enter amount as zero. If payments are disbursed

after the 1st day of the quarter/month, provide the amount of the payments)

NOTE: HIGLAS contractors should obtain these amounts from their

810H and 810 files, if applicable. HIGLAS contractors should also provide a

footnote to disclose whether the amounts indicated for these payments are

included in GL account 216002, Entitlement Benefit Due/Payable – Adjudicated

Claims

Attachment 3

Contractor No. ______ BENEFITS PAYABLE SURVEY

CARRIER For Period Ending: September 30, 20xx

1. Claims on the Payment Floor (in dollars) ___________

(CAFM Contractors – Amount must agree to amount reported on the

September Form CMS-750)

NOTE: HIGLAS contractors should obtain this amount from their

Summary 2 Trial Balance GL account 216002, Entitlement

Benefit Due/Payable – Adjudicated Claims.

2. Claims on Hold (in dollars) – CAFM contractors ONLY ___________

(Amount should be obtained from the Other Liabilities line on the

Form CMS-751)

3. Outstanding Checks (in dollars) ___________

(Amount must include outstanding EFTs and agree to the

outstanding check amount on the September Form CMS-1522)

NOTE: HIGLAS contractors should obtain this amount from their

Summary 2 Trial Balance GL account 212001, Accounts Payable

Disbursements in Transit.

4. PSA/HPSA payments (in dollars) ___________

(If payments were disbursed on or before the last day of the quarter,

enter amount as zero. If payments are disbursed after the 1st day of the

quarter, provide the amount of the payments)

NOTE: HIGLAS contractors should obtain these amounts from their 810H and

810 files, if applicable. HIGLAS contractors should also provide a footnote to

disclose whether the amounts indicated for these payments are included in GL

account 216002, Entitlement Benefit Due/Payable – Adjudicated Claims

Attachment 4

FEDERAL HEALTH INSURANCE TIME ACCOUNT

Contractor No. ______

INTERMEDIARY For Period Ending: September 30, 20xx

Part A Balance (in dollars) ____________

Part B Balance (in dollars): ____________

FEDERAL SUPPLEMENTARY MEDICAL INSURANCE

TIME ACCOUNT

Contractor No. ______

CARRIER For Period Ending: September 30, 20xx

Part B Balance (in dollars) ____________