US · guidance
CMS Pub. 100-06, ch. 6, § 200
Exhibits
Exhibit 1 - Medicare Program Carrier Performance Report- Page 1
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1
Carrier Number
Report Period
( Month/Yr)
Working
Days
Number and Type of Claim
Reporting Item Total
(1)
Assigned
(2)
Unassigned
(3)
A. Monthly Workload Operations
OPENING PENDING
1. Claims Pndg End of Last Mo.
2. Adjustments (Show + or -)
3. Adjusted Opening Pending
RECEIPTS
4. Tot. Clms. Rcvd. During Mo.
5. Transferred to Other Carrier
6. Net Number of Claims Received
7. Electronic Media Claims Recvd.
CLAIMS PROCESSED
8. Total CWF Claims
9. Claims Paid
10. Claims Applied To Deductible
11. Claims Denied
12. Total Non-CWF Claims
13. Claims Approved
14. Claims Denied
15. Total Claims Processed
16. Replicate Claims Processed
Exhibit 1 (Cont.)
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 (cont)
Carrier Number
Report Period
( Month/Yr)
Working
Days
Number and Type of Claim
Reporting Item
Total
(1)
Assigned
(2)
Unassigned
(3)
CLOSING PENDING
17. Claims Pending at End of Month
DISTRIBUTION OF DAYS ELAPSED SINCE RECEIPT
18. 1 - 15 Days
19. 16 - 30 Days
20. 31 - 60 Days
21. 61 - 90 Days
22. Over 90 Days
CLAIMS INVESTIGATIONS
23. No. of Clms. Invest. During Mo.
B. INQUIRIES TOTAL BENEFICIARY PROVIDER
24. Tot. No. Processed During Mo.
25. Telephone
26. Walk-In Contact
27. Written
C. MISCELLANEOUS CLAIMS
DATA
MEDICAID CROSSOVER CLAIMS
28. No. Transferred to St. Agencies
29. No. Transferred Electronically
Exhibit 1 (Cont.)
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 (cont)
Carrier Number
Report Period
( Month/Yr)
Working
Days
Number and Type of Claim
Reporting Item
Total
(1)
Assigned
(2)
Unassigned
(3)
OPTICAL CHARACTER RECOGNITION
CLMS.
30. Total Claims
MEDICARE SUMMARY NOTICES
31. Total MSNs Mailed
Form CMS-1565
Exhibit 2 - Medicare Program Carrier Performance Report - Form CMS-1565, Pages 2-9
MEDICARE PROGRAM CARRIER PERFORMANCE REPORT -
FORM CMS-1565, Pages 2-9
CARRIER WORKLOAD REPORT - PAGE __*__
PART - D (1) CLAIMS PROCESSING TIMELINESS - ALL CLAIMS
CARRIER ID________ TYPE OF CLAIM______*_____ REPORT MO.___
PAID NOT PAID
LINE NO./DAYS TOTAL
(1)
CLEAN
(2)
OTHER
(3)
CLEAN
(4)
OTHER
(5)
EMC
(6)
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
Exhibit 2 (Cont.)
PAID NOT PAID
LINE NO./DAYS TOTAL
(1)
CLEAN
(2)
OTHER
(3)
CLEAN
(4)
OTHER
(5)
EMC
(6)
30 30
31 31
32 32
33 33
34 34-45
35 46-60
36 61-90
37 91+
38 Tot 1-37
39 Mean Pt
CMS-1565 Page _*_
* PAGE NUMBER AND TYPE OF CLAIM ARE TO BE REPORTED AS FOLLOWS:
Page 2-Assigned Physician
Page 3-Assigned DME
Page 4-Assigned Lab
Page 5-Assigned Ambulance
Page 6-Assigned Other
Page 7-Unassigned
Page 8-Participating Physician
Page 9-All Claim
Exhibit 3 - Adjustments for CPEP CPT
EMC PAID
EMC NOT
PAID
ADJUSTMENTS FOR CPEP CPT
LINE NO./DAYS CLEAN
(1)
OTHER
(2)
CLEAN
(3)
CALCULATIONS:
1 1 CWF
Claims which were
beyond carrier control due
to CWF.
2 2
3 3
4 4
5 5 A. EMC clean claims
Processed beyond EMC 6 6
7 7
8 8 B. Paper clean claims
Processed beyond Paper
ceiling
9 9
10 10
11 11 C. All claims processed
Beyond 60 days ____ 12 12
13 13 WAIVER
Claims paid under the
floor For which the carrier
had a waiver from CMS.
14 14
15 15
16 16
17 17 D. EMC clean claims
Paid under EMC floor
_________
18 18
19 19
20 20 E. Paper clean claims
Paid under paper floor
________
21 21
22 22
23 23 F. All EMC claims paid
under EMC floor and all
paper claims paid under
paper floor __________
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
Exhibit 3 (Cont.)
EMC PAID EMC
NOT PAID
LINE NO./DAYS CLEAN
(1)
OTHER
(2)
CLEAN
(3)
CALCULATIONS:
34 34-45
35 46-60
36 61-90
37 91+
38 Tot 1-37
39 Mean Pt
CMS-1565 Page _*_
* PAGE NUMBER AND TYPE OF CLAIM ARE TO BE REPORTED AS FOLLOWS:
Page 10-Participating Physician (PAR)
Page 11-Total (TOT)
Exhibit 4 - Carrier Workload Report - Part-E - Interest Payment Data
CARRIER WORKLOAD REPORT - PAGE __*__
PART-E - INTEREST PAYMENT DATA
CARRIER ID
REPORT MONTH
LINE NO
CLAIM/PAYMENT
LATE DAYS
TOTAL
(1)
ASTD
PHYS
(2)
ASTD
DME
(3)
ASTD
LAB
(4)
ASTD
AMB
(5)
ASTD
OTHER
(6)
UNASTD
(7)
PARTIC.
PHYS
(8)
1. No. of Claims
2. 1 Day late
3. 2 Days Late
4. 3 Days Late
5. 4 Days Late
6. 5 Days Late
7. 6-15 A Late
8. 16-30 A Late
9. 31-60 A Late
10. 61+ A Late
11. Amount paid
12. 1 Day late
13. 2 Days Late
14. 3 Days Late
15. 4 Days Late
16. 5 Days Late
17. 6-15 A Late
18. 16-30 A Late
19. 31-60 A Late
20. 61+ A Late
CMS-1565 Page 12
Exhibit 5 - Carrier Workload Report - Part F - All Trunks Busy (ATB)
CARRIER WORKLOAD REPORT
PART F - ALL TRUNKS BUSY (ATB)
ALL TRUNKS BUSY
CARRIER ID___________ REPORT MONTH________
LOCAL
CALLS
(1)
TOLL FREE
CALLS
(2)
1. PERCENT OF ATB
2. NUMBER OF BENEFICIARY CALLS ANSWERED IN
120 SECONDS
3. TOTAL NUMBER OF
BENEFICIARY CALLS RECEIVED
4. % OF BENEFICIARY CALLS ANSWERED IN 120
SECONDS
EXPLANATION FOR FAILURES:
CMS-1565 Page 13
History
(Rev. 126; Issued: 07-13-07; Effective: 01-01-08; Implementation: 01-07-08)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
3f7c9b92011acf09380fd46c46d91aa1140f22322830046fd6439354a7fa3107
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.