CMS Pub. 100-06, ch. 6, § 160

for CPEP CPT Calculations

(Rev. 6, 08-30-02)

B3-13307

Pages 10-11 of the CMS-1565 include data bills paid or denied during the month that were

received via electronic media. The basic instructions and definitions that apply to pages 2-9 (see

§150) also apply to pages 10-11. The carrier reports the following information for Participating

Physician EMC claims (page 10) and all EMC claims (page 11):

• Column 1 - the number of EMC claims that were included in column 2 (paid clean) for the

corresponding claim type on page 8 or 9, as appropriate.

• Column 2 - the number of EMC claims that were included in column 3 (paid other) for the

corresponding claim type on page 8 or 9, as appropriate.

• Column 3 - the number of EMC claims that were included in column 4 (not paid clean) for

the corresponding claim type on page 8 or 9, as appropriate.

For each claim type (PAR and TOT), the carrier reports the following adjustments for CPEP CPT

calculations:

CWF - Claims which were beyond carrier control due to CWF.

A. The number of EMC clean claims processed beyond the EMC ceiling.

B. The number of paper clean claims processed beyond the paper ceiling.

C. The number of all claims processed beyond 60 days.

WAIVER - Claims paid under the floor for which the carrier had a waiver from CMS.

D. The number of EMC clean claims paid under the EMC floor.

E. The number of paper clean claims paid under the paper floor.

F. The number of all EMC claims paid under the EMC floor plus the number of all paper

claims paid under the paper floor.