CMS Pub. 100-06, ch. 6, § 130.3

The carrier reports the number of responses it processed as a result of inquiries from, or on behalf

of, Medicare beneficiaries or providers during the reporting month. It reports only inquiries

processed related to the Medicare program. It excludes inquiries addressing its private line of

business. It bases the data on actual counts, not on estimates or samples.

The carrier counts inquiries as follows:

Beneficiary - It counts one inquiry per contact (telephone, written, walk-in), regardless of how

many claims the beneficiary inquires about. For example, if a beneficiary writes it about the status

of two claims, it counts the response as one beneficiary written inquiry. It counts responses to re-

contacts made by that beneficiary as an additional inquiry. It counts any inquiry made by a

beneficiary, or by anyone on behalf of the beneficiary, except a provider.

Provider - It counts one inquiry per contact. For example, if a provider calls or writes it regarding

the status of 10 claims, it counts the response as one provider-written or phone inquiry. It counts

any inquiry made by a provider, or anyone on behalf of the provider, except a beneficiary. It

counts inquiries regardless of whether they relate to assigned or unassigned claims.

• It counts beneficiary and provider inquiries as follows:

• It counts Medicare inquiries directed to it for a response if they are requests for information

from beneficiaries or providers (physicians/suppliers) or their representatives.

• It does not count, as inquiries, professional relations activities and contacts (i.e., its training

programs for providers on new requirements).

• It counts voice inquiries captured electronically as telephone inquiries, and electronic mail

inquiries as written inquiries. It does not count electronic inquiries if the provider can

access the carrier system to determine claim status without its involvement.

• It does not count inquiries related specifically to the physician fee freeze or MSP. (This is

to achieve comparability with the CMS-1524 budget form, where all costs related to the fee

freeze and MSP are reported on separate lines.)

• It counts congressional inquiries in the appropriate category (i.e., as a beneficiary inquiry if

made on behalf of a beneficiary, and as a provider inquiry if made on behalf of a provider).

• It counts inquiries made by the RO or the SSA DO in the appropriate category if the

inquiries are on behalf of a beneficiary or a provider and relate to a specific claim. It does

not count the inquiries if they are of a general nature (i.e., ongoing liaison necessary during

monitoring of day-to-day operations).

• It does not count Part A inquiries if it handles all Part A inquiries for an intermediary on a

routine basis. In this case, it charges the related costs to the intermediary. It does not

include the volume of work on the CMS-1565.

• It counts misdirected telephone inquiries (i.e., those that must be referred to another source

for response) as processed telephone inquiries. It does not count misdirected written

inquiries.

• It does not count requests for reviews or hearings as inquiries. (See The Medicare Claims

Processing, Beneficiary Correspondence and Administrative Appeals, for definitions of

reviews and hearings.) It reports reviews and hearings on the CMS-2590, not on the CMS-

1565.