CMS Pub. 100-06, ch. 5, § 400.5

The screen formats in exhibits 5 and 6 are identical except 5 is for HI non-MSP and 6 is

for SMI non-MSP.

MSP debt is reported in exhibits 9 and 10.

Exhibit 5 (Cont.)

One of: Status of Non-MSP Debt - CNC; or Status of MSP Debt - CNC will be shown.

One of: Hospital Insurance (HI); or Supplementary Medical Insurance (SMI) will be shown

As of ___________________

Contractor Name ID Number

_______________________ __________

Section A: CNC Debt

Principal Principal Interest Interest

Number Dollars Dollars Number

1. Beginning FY Balance ______ __________ ___________ _______

2. New CNC Debt ______ __________ ___________ _______

3. Interest Earned Since CNC Approval ___________

4. Reclassified CNC Debt

a. Re-established as Active A/R due to collection of cash ______ __________ ___________ ____

b. Re-established as Active A/R due to collection by offset ______ __________ ___________ ____

c. Re-established as Active A/R due to bankruptcy, fraud &

abuse, litigation and appeal

______ __________ ___________ ____

d. Written-off Closed ______ __________ ___________ ____

e. Other ______ __________ ___________ ____

5. Amounts Transferred

a. Transfers In from Medicare Contractors ______ __________ ___________ ____

b. Transfers Out to Medicare Contractors ______ __________ ___________ ____

c. Transfers In from CMS RO ______ __________ ___________ ____

d. Transfers Out to CMS RO ______ __________ ___________ ____

e. Transfers In from CMS CO ______ __________ ___________ ____

f. Transfers Out to CMS CO ______ __________ ___________ ____

6. Ending Balance ______ __________ ___________ _______

CMS-C751A

Exhibit 5 (Cont.)

Status of Non-MSP Debt - CNC

Hospital Insurance (HI)

As of _________________

Contractor Name ID Number

_______________________ __________

Section B: Aging of CNC Debt (from the determination date)

1. Total CNC Debt ______ __________ ___________ _______

(a) 181 - 1 year __________ ___________

(b) 1 - 2 years __________ ___________

(c) 2 - 6 years __________ ___________

(d) 6 - 10 years * __________ ___________

(e) Over 10 years * __________ ___________

* Provide an explanation why debts in these categories were not recommended for write-off closed

Section C: Collection Information

Collections on CNC Debt ______ __________ ___________ _______

Section D: Status CNC Debt over 181 Days

Total Delinquent

A) Referred for Cross Servicing __________ _________

B)

1)

Not Eligible for Referral

In Bankruptcy __________ _________

2) In Appeal __________ _________

3) At Department of Justice __________ _________

4) Fraud and Abuse Investigation __________ _________

5) Deceased Debtor and Estate Closed __________ _________

6) Debts Less than $25 __________ _________

7) Federal Entity Debts, MSP only, where the only entity which

received the last demand letter is the employer and the

employer is a Federal agency; __________ _________

8) Beneficiary Debts, Non-MSP only; __________ _________

9) Pending Request for Waiver or Compromise __________ _________

10) CMS Identified Exclusions, MSP only, debts where CMS

has identified a specific debt or group of debtors as excluded

from DCIA referral. __________ _________

11) Other Exclusions, must footnote. __________ _________

12) In the Process of Internal Offset (Previously Under MMA,

Section 935 Appeal) __________ _________

C) Eligible for Referral; debts that are eligible for referral to the

Department of the Treasury for cross-servicing but not yet

referred. __________ _________

CMS-C751A

400.6 - Exhibit 6 - Status of Non-MSP Debt - CNC - SMI - (Rev. 5, 08-30-02)

See Section 400.5, Exhibit 5 – Status of Non-MSP Debt – CNC – HI

The formats in exhibits 5 and 6 are identical except 5 is for HI non-MSP and 6 is for SMI. non-MSP.

MSP debt is reported in exhibits 9 and 10.

400.7 - Exhibit 7 - Status of MSP Accounts Receivable - HI – (Rev. 5, 08-30-02)

This is an exact duplicate of Exhibit 3, except that the data is limited to data involving Medicare as

secondary payer.

This exhibit, and Exhibit 8, Status of MSP Accounts Receivable - SMI, are identical with the following

exceptions:

• Section B, items 5d through 5g and Section D, items 5d and 5e refer to the POR for HI reports and

refer to the POR/PSOR for the SMI report.

• Only carriers enter the PSOR data on the SMI report.

• The CMS Form Number for this report (HI) is CMS-M751A.

• The CMS Form Number for the SMI report is CMS-M751B.