CMS Pub. 100-06, ch. 6, § 240.3

B3-13322.3

Prior to submitting Form A to CMS, the carrier checks for completeness, accuracy, and internal

consistency.

It uses the following checklist to assure accuracy and consistency:

• For lines 1 through 9 and 20 and 21, column 1 must equal the sum of columns 2 and 3;

• Each of lines 2, 4, and 6 must be less than or equal to the total sum of lines 9, 10 and 13 on

the Form B submitted for the three months in the quarter;

• The sum of lines 3, 5, and 7 must be less than or equal to line 1 for each column;

• Line 8 should be at least equal to, but in most cases greater than, the accumulated total for

lines 11 and 14 on the Form B submitted for the three months in the quarter;

• Lines 10 + 11 + 12 + 13 + 14 + 15 + 16 + 17 + 18 = line 19 for all columns;

• The total number of items denied as reported on line 19, column 1 should be at least equal

to, but in most cases greater than, the total number of claims denied in full or in part as

reported on line 8 column 1;

• The dollar amount disallowed reported in the first column of line 9 and the second column

of line 19 must be equal; and

• The total number of claims denied reported on line 19, column 3 must be at least equal to,

but in most cases greater than the total number of claims denied in full or in part as

reported on line 8, column 1.