CMS Pub. 100-06, ch. 6, § 270.3

B3-13325.3

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

consistency. It uses the following checklist to assure accuracy and consistency:

1. For all lines, column 1 must equal the sum of columns 2 through 4,

2. Line 1 should equal the sum of lines 2 through 4 for all columns,

3. Line 5 should be greater than or equal to line 1 for all columns,

4. Line 5 should equal the sum of lines 6 and 7 for all columns,

5. Line 8 should be greater than or equal to line 5 for all columns,

6. Line 8 should equal the sum of lines 9 and 10 for all columns,

7. Line 9 should be greater than or equal to line 6 for all columns,

8. Line 10 should be greater than or equal to line 7 for all columns.

9. Line 11 should be less than or equal to line 1 for all columns,

10. Line 11 should equal the sum of lines 12-14 for all columns,

11. Line 12 should be less than or equal to line 2 for all columns,

12. Line 13 should be less than or equal to line 3 for all columns,

13. Line 14 should be less than or equal to line 4 for all columns,

14. Line 15 should be greater than or equal to line 11 for all columns,

15. Line 15 should equal the sum of lines 16 and 17 for all columns,

16. Line 15 should be less than or equal to line 5 for all columns,

17. Line 16 should be less than or equal to line 6 for all columns,

18. Line 17 should be less than or equal to line 7 for all columns,

19. Line 18 should be less than or equal to line 8 for all columns,

20. Line 18 should equal the sum of lines 19 and 20 for all columns,

21. Line 19 should be less than or equal to line 9 for all columns,

22. Line 20 should be less than or equal to line 10 for all columns,

23. Line 21 should equal the sum of lines 22-24 for all columns,

24. Line 25 should be greater than or equal to line 21 for all columns,

25. Line 25 should be equal to the sum of lines 26-28 for all columns,

26. Line 26 should be greater than or equal to line 22 for all columns,

27. Line 27 should be greater than or equal to line 23 for all columns,

28. Line 28 should be greater than or equal to line 24 for all columns,

29. Line 29 should be greater than or equal to line 25 for all columns,

30. Line 29 should equal the sum of lines 30 and 31 for all columns,

31. Line 32 should equal the sum of lines 33 and 34 for all columns;

32. Column 1 should equal column 3 for lines 3, 13, 23 and 27.

33. The following comparisons should be made between Form G and two other related forms,

the CMS-1565 (Form B) and the CMS-1565A (Form A):

a. Line 1, column 1, of Form G must equal the sum of lines 9, 10, + 13, column 1 of

Form B for the reporting months.

b. Line 1, sum of columns 2 + 4 of Form G must equal the sum of lines 9, 10, + 13,

column 2 of Form B for the reporting months.

c. Line 1, column 3 of Form G must equal sum of lines 9, 10, + 13, column 3 of Form B

for the reporting months.

d. Line 21, column 1 of Form G must equal sum of lines 11 + 14, column 1 of the CMS-

1565 for the reporting months.

e. Line 21 sum of columns 2 + 4 of Form G must equal sum of lines 11 + 14, column 2

of Form B for the reporting months.

f. Line 21, column 3 of Form G must equal sum of lines 11 + 14, column 3 of the Form

B for the reporting months.

g. Line 8, column 1 of Form G must equal line 1 column 1 of Form A for the same

quarter.

h. Line 8, sum of columns 2 + 4 of Form G must equal line 1 column 2 of the Form A for

the same quarter.

i. Line 8, column 3 of Form G must equal line 1 column 3 of Form A for the same

quarter.

j Line 11, column 1 of Form G must be less than or equal to the sum of lines 2, 4 + 6,

column 1 of Form A for the same quarter.

k. Line 11, sum of columns 2 + 4 of Form G must be less than or equal to the sum of

lines 2, 4 + 6, column 2 of the Form A for the same quarter.

l Line 11, column 3 of Form G must be less than or equal to the sum of lines 2, 4 + 6

column 3 of Form A for the same quarter.

m. Line 18, column 1 of Form G must equal sum of lines 3, 5 + 7, column 1 of Form A

for the same quarter.

n. Line 18, sum of columns 2 + 4 of Form G must equal sum of lines 3, 5 + 7, column 2

of Form A for the same quarter.

o. Line 18, column 3 of Form G must equal sum of lines 3, 5 + 7, column 3 of Form A

for the same quarter.

p. Line 25, column 1 of Form G must equal line 8 column 1 of Form A for the same

quarter.

q. Line 25, sum of columns 2 + 4 of Form G must equal line 8 column 2 of Form A for

the same quarter.

r. Line 25, column 3 of Form G must equal line 8, column 3 of Form A for the same

quarter.

s. Line 32, column 1 of Form G must equal line 9, column 1 of Form A for the same

quarter.

t. Line 32 sum of columns 2 + 4 of Form G must equal line 9 column 2 of Form A for

the same quarter.

u. Line 32, column 3 of Form G must equal line 9, column 3 of Form A for the same

quarter.