CMS Pub. 100-06, ch. 6, § 330.2

B3-13360.2

The carrier reports the number of claims and the dollar amounts for which a determination was

made during the reporting quarter or a previous quarter that a beneficiary-recoverable overpayment

had been made. It does not count potential overpayment claims under investigation. It includes

individual overpayments discovered as part of CMS's Carrier Quality Control Program (QA) end-of-line review sample. It does not include projections of overpayments from QA samples. It

includes overpayments discovered where Medicare is secondary to prime insurers (Department of

Labor - BL, WC, VA, auto medical or no fault, liability, EGHP under the working aged or ESRD

provisions or LGHP under the disabled provision) that also paid the beneficiary.

Round amounts to the nearest whole dollar.

Line 1. Pending Start of Quarter - The number of claims and dollar amount of beneficiary

overpayments reported in line 13 as the closing pending on the previous quarter's report.

Line 2. Adjustments to Opening Pending - Any adjustments to the previous quarter's closing

pending amount due to errors, decisions resulting from reviews and hearings, reopenings, etc.

Show as a plus or a minus, as appropriate.

Line 3. Adjusted Opening Pending - The result of line 1 + line 2, as appropriate.

Line 4. Discovered During Reporting Quarter - The number of claims and the dollar amount

for which a determination was made during the reporting quarter that a beneficiary-recoverable

overpayment had been made. This does not include potential overpayments under investigation. It

includes claims where the payee returned or never negotiated the check(s).

Claim counts are treated differently from money amounts in lines 5-9 below. A claim is counted

in these lines only when it has been fully disposed. This line does not include partial dispositions

in the claim counts for lines 5-9. It does not include any money amounts partially disposed in

lines 5-9 as appropriate.

Line 5. Dispositions - The number of claims for which:

Recovery of a beneficiary-recoverable overpayment by offset or refund was completed during the

quarter (see NOTE 3); or

A determination was made during the quarter that the overpayment is uncollectible or is to be

abandoned in accordance with Chapter 3, §§190 ff.

This includes any amount recouped by offset or refund, or determined to be uncollectible or

abandoned in accordance with Chapter 3, §§190 ff. during the quarter, regardless of whether it was

a full or partial determination.

NOTES:

1. If part of an overpayment is recouped and the remainder is determined to be

uncollectible or abandoned, the disposition of the overpayment is considered to

be completed.

2. If the disposition of the overpayment is completed and it falls into more than one

line of lines 7, 8, 10-12, it is counted once under the "number of claims" in the

line category accounting for the greatest dollar amount. The carrier reports the

money amount in each appropriate line, however. (It does not report any money

amounts reported in previous quarters.)

3. If part of the overpayment has been recouped and part is still outstanding at the

end of the quarter, the carrier includes the amount recouped. It does not include

the claim count. It includes the portion of the overpayment which is still

outstanding in the claim count and amount for line 10.

Line 6. Collected - The carrier enters the number of overpayments recouped by offset or refund

during the reporting quarter. Under the money column, it reports any amount recovered by offset

or refund.

Line 7. Recouped by Offset - The carrier enters the number of beneficiary-recoverable

overpayment claims for which it completed disposition during the reporting quarter and for which

most or all of the dollar amounts were recouped by offsetting payment on subsequent requests for

payment. (This includes cases where a letter has been written to the payee requesting a refund, but

before the refund is received a request for payment is received which completes repayment of the

overpayment.) Under the money amount column, it reports any amount recovered by this method,

whether a full or partial recovery.

Line 8. Recouped by Refund - The carrier enters the number of beneficiary-recoverable

overpayment claims for which it completed disposition during the reporting quarter and the final

disposition was made by a refund. (It includes cases where the payees returned the checks.) Under

the money amount column, it reports any amount recovered by refund, whether a full or partial

recovery.

Line 9. Uncollectibles - The carrier reports the number of beneficiary-recoverable overpayment

claims for which it completed disposition during the reporting quarter by determining for most or

all of the dollar amount, to be uncollectible and have either referred to the RO, waived, or

abandoned them. Under the money column, it reports the amount involved.

Line 10. Referred to RO - The carrier enters the number of beneficiary-recoverable overpayment

claims for which it completed disposition during the reporting quarter and where, for most or all of

the dollar amount, it terminated recovery efforts and referred the claim to the RO. (See Chapter 3,

§§190 ff.) Under the money amount column, it reports the amount referred to RO.

Line 11. Waived by Contractor - The carrier enters the number of beneficiary-recoverable

overpayment claims for which it completed disposition during the reporting quarter and where it

waived most or all of the dollar amounts. (See Chapter 3, §§190 ff). Under the recovery amount

column, it reports any amount waived in this way during the quarter.

NOTE: A waiver is a case in which the beneficiary is liable and the criteria in Chapter 4, §100B

for waiver recovery is met; i.e., it appears from the circumstances of the overpayment that the

beneficiary was without fault and that the recovery would be against equity and good conscience

or would defeat the purpose of the Medicare Program (i.e., cause the individual financial

hardship).

Line 12. Abandoned in Accordance with Manual Instructions - The carrier enters the number

of beneficiary-recoverable overpayment claims for which it completed disposition during the

reporting quarter and which it abandoned for most or all of the dollar amount in accordance with

Chapter 4, §70. Under the money amount column, it reports any amount abandoned.

A claim is abandoned when recovery has been terminated because:

• The total overpayment is less than $50,

• The carrier has not taken action to reopen the payment decision within 4 years (48months)

after the date of the initial payment determination,

• Deceased beneficiary has no estate and there are no surviving relatives, or Beneficiary is on

public assistance

Line 13. Pending End of Quarter - The carrier enters the number of beneficiary-recoverable

overpayments claims with any amount outstanding at the end of the reporting quarter. If part of a

claim is recouped and part is outstanding, it reports only the amount outstanding. It does not

include any amounts which have been recouped, either in full or in part.