US · guidance
CMS Pub. 100-06, ch. 5, § 510.5
Proof of Net Disbursements and Total Issues per Detailed Claims Data File/Report
This attachment is an illustration of the electronic spreadsheet (Exhibit 1) that will be used to input selected financial information from the detailed
claims data file and MCS reports.
Section 510.5: Proof of Net Disbursements and Total Issues per Detailed Claims Data File/Report
Col. A Col. B Col. C Col. D Col. E Col. F Col. G Col. H Col. I
Net Disbursements Total System
/ System Issues Issues per MCS
CLAIMS ADJUSTMENTS REISSUES SPECIAL ISSUES RECOUPMENTS per Report Title## MANUAL ISSUES Report Title ##
LINE DATE per Report Title## per Report Title## per Report Title## per Report Title## per Report Title## (B + C + D + E - F) (G + H)
71 12/1/2002 10,912.00
0.00 0.00 0.00 0.00
72 12/2/2002 0.00 0.00 0.00 0.00
73 12/3/2002 0.00 0.00 0.00
74 12/4/2002 0.00 0.00 0.00
75 12/5/2002 13,000,000.00 0.00 0.00
76 12/6/2002 0.00 0.00 0.00
77 12/7/2002 0.00 0.00 0.00
78 12/8/2002 0.00 0.00 0.00
79 12/9/2002 0.00 0.00 0.00
80 12/10/2002 0.00 0.00 0.00
81 12/11/2002 0.00 0.00 0.00
82 12/12/2002 0.00 0.00 0.00
83 12/13/2002 0.00 0.00 0.00
84 12/14/2002 2,000,000.00 0.00 0.00
85 12/15/2002 0.00 0.00 0.00
86 12/16/2002 0.00 0.00 0.00
87 12/17/2002 750,000.00 0.00 0.00
88 12/18/2002 0.00 0.00 0.00
89 12/19/2002 50,000.00 0.00 0.00
90 12/20/2002 0.00 0.00 0.00
91 12/21/2002 0.00 0.00 0.00
92 12/22/2002 0.00 0.00 0.00
93 12/23/2002 0.00 0.00 0.00
94 12/24/2002 0.00 0.00 0.00
95 12/25/2002 0.00 0.00 0.00
96 12/26/2002 0.00 0.00 0.00
97 12/27/2002 0.00 0.00 0.00
98 12/28/2002 0.00 215,103.80 0.00 0.00
99 12/29/2002 0.00 0.00 0.00
100 12/30/2002 0.00 0.00 0.00
101 12/31/2002 0.00 0.00 0.00
102
103 Totals 15,810,912.00 215,103.80 0.00 0.00 0.00 0.00
History
(Rev. 21, 08-01-03)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
de6e8ca87f010261f8485ca694cbbbfececce8cabcaa032b80f05ddffcd8f76f
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