CMS Pub. 100-06, ch. 6, § 280.4

B3-13326.4

The carrier reports all dollar amounts to two decimal places on lines 8-13. It reports the sum of the

net figures for all of the cycles in the reporting period. It calculates and includes changes because

of adjustments to claims in a cycle, or from a previous cycle, so that these figures accurately

reflect the relationship between allowed dollars and excess dollars. Adjustments which leave

overcharges of less than $1.00 may affect the total dollar value reported on line 13, thus it may not

always equal the amount reported on line 9.

Line 8 - Total Dollars Allowed - The carrier reports the total dollars allowed from the sum of the

cycle reports for the period.

Line 9 - Dollars in Excess of Limiting Charge - The carrier reports the total dollars in excess of

the limiting charge from the sum of the cycle reports for the period.

Lines 10-13 - Procedures with Related Excess Charges - The carrier reports on lines 10-13 the

total number of procedures (column 1), and related total dollar value of excess charges (column 2)

that fall within each of the dollar ranges of excess charges on the respective lines: Line 10 is $1.00

- 4.99, line 11 is $5.00 -499.99, and line 12 is $500.00 + . The carrier need not complete line 11,

as the system will calculate it by subtracting lines 10 and 12 from line 13 (Total).