CMS Pub. 100-06, ch. 6, § 270.2

This part provides CMS with current quarterly workload data on the results of carrier activity in

processing claims for physician and non-physician services according to the participation status of

the physician/supplier. It also provides important related information on reasonable charge

determinations, the extent to which claims for such services are being denied, and the amount of

charges disallowed.

The carrier reports only data relating to initial claims (real and replicate) actions. It does not

report data on the disposition of reviews, hearings, or reopenings of initial claim actions.

It reports data for lines 1-34 for each column (participation/assignment status) as defined in the

Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 30. unless otherwise

stated. Specialty codes for physicians and non-physicians are listed in the Medicare Claims

Processing Manual, Chapter 26, Sections 10.8.2 and 10.8.3.

Line 1. Number of Claims Approved - total number of claims, processed to completion during

the quarter, which were paid or applied to the deductible. Claims paid or applied toward the

deductible are those reported in lines 9, 10, and 13 of Form B. The system will pre-fill columns 1

and 3 based on the total of these lines from the monthly reports.

Line 2. Physician Only - number of claims included in line 1 involving physician services only.

Line 3. Physician and Non-Physician - number of claims included in line 1 involving both

physician and non-physician services on the same claim. The carrier shows all claims in this

category under the "Non-Participant-Unassigned" column 3. Therefore, the numbers for columns 1

and 3 should be equal.

Line 4. Non-Physician Only - number of claims included in line 1 involving non-physician

services only.

Line 5. Number of Covered Services - total number of covered services on the claims approved

as shown on line 1. The carrier does not include services for which charges were completely

disallowed.

Line 6. Physician - number of physician services included in line 5. The carrier includes in this

count the covered services from the claims shown in line 2 plus the covered physician services

from the claims shown in line 3.

Line 7. Non-Physician - number of non-physician services included in line 5. The carrier

includes in this count the covered services from the claims shown in line 4 plus the covered non-physician services from the claims shown in line 3.

Line 8. Amount of Covered Charges - total amount (rounded to the nearest dollar) of billed

charges for the covered services shown in line 5. For those services in which any charges were

reduced as a result of reasonable charge, medical necessity, or global fee/rebundling

determinations, the carrier reports the total covered charges prior to such reductions. The system

will pre-fill columns 1 and 3 with the data reported in the respective columns on line 1 of Form A

for the same quarter.

Line 9. Physician - total amount (rounded to the nearest dollar) of billed charges for the covered

physician services shown in line 6. For those services in which any charges were reduced as a

result of reasonable charge, medical necessity, or global fee/rebundling determinations, the carrier

reports the total covered charges prior to such reductions.

Line 10. Non-Physician - total amount (rounded to the nearest dollar) of billed charges for the

covered non-physician services shown in line 7. For those services in which any charges were

reduced as a result of reasonable charge, medical necessity, or global fee/rebundling

determinations, the carrier reports the total covered charges prior to such reductions.

Line 11. Number of Claims Where Billed Charges Were Reduced - number of claims (real and

replicate) reported on line 1 as approved in which any charges were reduced as a result of

reasonable charge/fee schedule, medical necessity, or global fee/rebundling determinations. The

carrier counts a claim only once, regardless of the number of services reduced or the different

categories of reductions that apply. Some examples of such reductions are:

a. Charges over allowed rental limits

b. Tests included in a battery of tests,

c. Fee covered in basic allowance or surgical allowance,

d. Service included in office charge or surgery fee.

Line 12. Physician Only - number of claims included in line 11 involving physician services

only.

Line 13. Physician and Non-Physician - number of claims included in line 11 involving both

physician and non-physician services on the same claim. The carrier shows all claims in this

category under the "Non-Participant-Unassigned" column 3. Therefore, the numbers for columns

1 and 3 should be equal.

Line 14. Non-Physician Only - number of claims included in line 11 involving non-physician

services only.

Line 15. Number of Covered Services Where Charges Were Reduced - From the claims

shown in line 11, the carrier reports the number of covered services in which any charges were

reduced as a result of reasonable charge determinations, medical necessity reductions, or global

fee/rebundling reductions. It includes services where a fee is deemed to have been included in a

global fee, such as postsurgical care. (See examples given for line 11.)

Line 16. Physician - number of covered physician services included in line 15. This count

includes those services where charges were reduced on the claims shown in line 12, plus the

physician services where charges were reduced on the claims shown in line 13.

Line 17. Non-Physician - number of covered non-physician services included in line 15. This

count includes those services where charges were reduced on the claims shown in line 14, plus the

non-physician services where charges were reduced on the claims shown in line 13.

Line 18. Total Amount of Reduction - total amount (rounded to the nearest dollar) by which the

services reported in line 15 were reduced as a result of reasonable charge, medical necessity, or

global fee/rebundling determinations. The system will pre-fill columns 1 and 3 with the sum of

the data reported in the respective columns on lines 3, 5, and 7 of Form A for the same quarter.

Line 19. Physician - total amount (rounded to the nearest dollar) by which charges for physician

services reported in line 16 were reduced as a result of reasonable charge, medical necessity, or

global fee/rebundling determinations.

Line 20. Non-Physician - total amount (rounded to the nearest dollar) by which charges for non-physician services reported in line 17 were reduced as a result of reasonable charges, medical

necessity, or global fee/rebundling determinations.

Line 21. Number of Claims Denied in Full - total number of claims, processed to completion

during the quarter, in which charges for all services were completely disallowed. This number

must equal the sum of the numbers reported in lines 11 and 14 of Form B for the three months of

the quarter. The system will pre-fill columns 1 and 3 based on the total of these lines from the

monthly reports.

Line 22. Physician Only - number of claims included in line 21 involving physician services

only.

Line 23. Physician and Non-Physician - number of claims included in line 21 involving both

physician and non-physician services on the same claim. The carrier shows all claims in this

category under the "Non-Participant- Unassigned" column 3. Therefore, the numbers for columns

1 and 3 should be equal.

Line 24. Non-Physician Only - number of claims included in line 21 involving non-physician

services only.

Line 25. Number of Claims Denied in Full or in Part - sum of (1) those claims (real and

replicate) reported as denied in full in line 21, plus (2) those claims (real and replicate) reported as

approved on line 1 in which some services, but not all, were denied. The system will pre-fill

columns 1 and 3 with the data reported in the respective columns on line 8 of Form A for the same

quarter.

Line 26. Physician Only - number of claims included in line 25 involving physician services

only.

Line 27. Physician and Non-Physician - number of claims included in line 25 involving both

physician and non-physician services on the same claim. The carrier shows all claims in this

category under the "Non-Participant-Unassigned" column 3. Therefore, the numbers for columns

1 and 3 should be equal.

Line 28. Non-Physician Only - number of claims included in line 25 involving non-physician

services only.

Line 29. Number of Denied Services - number of services for which charges were fully or

partially denied on the claims shown in line 25.

Line 30. Physician - number of denied physician services included in line 29. The carrier

includes in this count the denied services from the claims shown in line 26 plus the denied

physician services from the claims shown in line 27.

Line 31. Non-Physician - number of denied non-physician services included in line 29. The

carrier includes in this count the denied services from the claims shown in line 28, plus the denied

non-physician services from the claims shown in line 27.

Line 32. Amount Disallowed - total amount (rounded to the nearest dollar) of charges disallowed

on the services shown in line 29. The system will pre-fill columns 1 and 3 with the data reported in

the respective columns on line 9 of Form A for the same quarter.

Line 33. Physician - total amount (rounded to the nearest dollar) included in line 32 as disallowed

which represented physician services as reported in line 30.

Line 34. Non-Physician - total amount (rounded to the nearest dollar) included in line 32 as

disallowed which represented non-physician services as reported in line 31.