US · guidance

CMS Pub. 100-06, ch. 6, § 430.9

Exhibits

activein force · 2026-08-25 – presentas-observed

B3-13430.9

Exhibit 1 - Screens 1 and 2 of Carrier Provider Enrollment Quarterly Workload Report

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Total Physician Group Cert Nurse M-W Cert RNA

1 2 3 4 5

Workload Operations

1. Pending End of Last Quarter

2. Adjustments

3. Adjusted Opening Pending

4. New Applications Received

5. Returned Apps Resubmitted

6. Total Applications Received

7. Applications Approved

8. Applications Denied

9. Applications Returned

10. Total Applications Processed

11. Pending End of Quarter

SCREEN 1

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Nurse Prac Ambulance Audiologist Ind Phys Ther Ind Occ Ther

6 7 8 9 10

Workload Operations

1. Pending End of Last Quarter

2. Adjustments

3. Adjusted Opening Pending

4. New Applications Received

5. Returned Apps Resubmitted

6. Total Applications Received

7. Applications Approved

8. Applications Denied

9. Applications Returned

10. Total Applications Processed

11. Pending End of Quarter

SCREEN 2

Exhibit 2 - Screens 3 and 4 of Carrier Provider Enrollment Quarterly Workload Report

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Ind Clin Psych Lic Clin SW Cert Nurse Sp Ind Phys Lab Phys Asst

11 12 13 14 15

Workload Operations

1. Pending End of Last Quarter

2. Adjustments

3. Adjusted Opening Pending

4. New Applications Received

5. Returned Apps Resubmitted

6. Total Applications Received

7. Applications Approved

8. Applications Denied

9. Applications Returned

10. Total Applications Processed

11. Pending End of Quarter

SCREEN 3

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

MSC ASC PH/W Agency VH/C Agency Ind Psych

16 17 18 19 20

Workload Operations

1. Pending End of Last Quarter

2. Adjustments

3. Adjusted Opening Pending

4. New Applications Received

5. Returned Apps Resubmitted

6. Total Applications Received

7. Applications Approved

8. Applications Denied

9. Applications Returned

10. Total Applications Processed

11. Pending End of Quarter

SCREEN 4

Exhibit 3 - Screens 5 and 6 of Carrier Provider Enrollment Quarterly Workload Report

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Port X-Ray Ind Clin Lab Unk Supp/Prov Flu Imm Biller

21 22 23 24

Workload Operations

1. Pending End of Last Quarter

2. Adjustments

3. Adjusted Opening Pending

4. New Applications Received

5. Returned Apps Resubmitted

6. Total Applications Received

7. Applications Approved

8. Applications Denied

9. Applications Returned

10. Total Applications Processed

11. Pending End of Quarter

SCREEN 5

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Total Physician Group Cert Nurse M-W Cert RNA

1 2 3 4 5

Reasons for Denial

12. Sanctioned from Medicare

13. Debarred/Excluded by Other Fed

14. Not Professionally Licensed

15. Business Address Invalid

16. Business Location Not Licensed

17. HCFA Requirements Not Met

Reason for Return

18. Incomplete

19. Unverifiable Information

20. Not Signed

21. Invalid Billing Agreement

22. Other

SCREEN 6

Exhibit 4 - Screens 7 and 8 of Carrier Provider Enrollment Quarterly Workload Report

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Nurse Prac Ambulance Audiologist Ind Phys Ther Ind Occ Ther

6 7 8 9 10

Reasons for Denial

12. Sanctioned from Medicare

13. Debarred/Excluded by Other Fed

14. Not Professionally Licensed

15. Business Address Invalid

16. Business Location Not Licensed

17. HCFA Requirements Not Met

Reason for Return

18. Incomplete

19. Unverifiable Information

20. Not Signed

21. Invalid Billing Agreement

22. Other

SCREEN 7

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Ind Clin Psych Lic Clin SW Cert Nurse Sp Ind Phys Lab Phys Asst

11 12 13 14 15

Reasons for Denial

12. Sanctioned from Medicare

13. Debarred/Excluded by Other Fed

14. Not Professionally Licensed

15. Business Address Invalid

16. Business Location Not Licensed

17. HCFA Requirements Not Met

Reason for Return

18. Incomplete

19. Unverifiable Information

20. Not Signed

21. Invalid Billing Agreement

22. Other

SCREEN 8

Exhibit 5 - Screens 9 and 10 of Carrier Provider Enrollment Quarterly Workload Report

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

MSC ASC PH/W Agency VH/C Agency Ind Psych

16 17 18 19 20

Reasons for Denial

12. Sanctioned from Medicare

13. Debarred/Excluded by Other Fed

14. Not Professionally Licensed

15. Business Address Invalid

16. Business Location Not Licensed

17. HCFA Requirements Not Met

Reason for Return

18. Incomplete

19. Unverifiable Information

20. Not Signed

21. Invalid Billing Agreement

22. Other

SCREEN 9

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Port X-Ray Ind Clin Lab Unk Supp/Prov Flu Imm Biller

21 22 23 24

Reasons for Denial

12. Sanctioned from Medicare

13. Debarred/Excluded by Other Fed

14. Not Professionally Licensed

15. Business Address Invalid

16. Business Location Not Licensed

17. HCFA Requirements Not Met

Reason for Return

18. Incomplete

19. Unverifiable Information

20. Not Signed

21. Invalid Billing Agreement

22. Other

SCREEN 10

Exhibit 6 - Screens 11 and 12 of Carrier Provider Enrollment Quarterly Workload Report

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Total Physician Group Cert Nurse M-W Cert RNA

1 2 3 4 5

Application Processing Times

23. # under 21 Days

24. # in 21-30 Days

25. # in 31-40 Days

26. # over 40 Days

Denials Appealed

27. Pending End of Last Quarter

28. Adjustments

29. Adjusted Opening Pending

30. Appeals Received

31. Denials Sustained

32. Denials Overturned

33. Total Appeals Processed

34. Pending End of Quarter

SCREEN 11

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Nurse Prac Ambulance Audiologist Ind Phys Ther Ind Occ Ther

6 7 8 9 10

Application Processing Times

23. # under 21 Days

24. # in 21-30 Days

25. # in 31-40 Days

26. # over 40 Days

Denials Appealed

27. Pending End of Last Quarter

28. Adjustments

29. Adjusted Opening Pending

30. Appeals Received

31. Denials Sustained

32. Denials Overturned

33. Total Appeals Processed

34. Pending End of Quarter

SCREEN 12

Exhibit 7 - Screen 13 and 14 of Carrier Provider Enrollment Quarterly Workload Report

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Ind Clin Psych Lic Clin SW Cert Nurse Sp Ind Phys Lab Phys Asst

11 12 13 14 15

Application Processing Times

23. # under 21 Days

24. # in 21-30 Days

25. # in 31-40 Days

26. # over 40 Days

Denials Appealed

27. Pending End of Last Quarter

28. Adjustments

29. Adjusted Opening Pending

30. Appeals Received

31. Denials Sustained

32. Denials Overturned

33. Total Appeals Processed

34. Pending End of Quarter

SCREEN 13

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

MSC ASC PH/W Agency VH/C Agency Ind Psych

16 17 18 19 20

Application Processing Times

23. # under 21 Days

24. # in 21-30 Days

25. # in 31-40 Days

26. # over 40 Days

Denials Appealed

27. Pending End of Last Quarter

28. Adjustments

29. Adjusted Opening Pending

30. Appeals Received

31. Denials Sustained

32. Denials Overturned

33. Total Appeals Processed

34. Pending End of Quarter

SCREEN 14

Exhibit 8 - Screen 15 of Carrier Provider Enrollment Quarterly Workload Report

CARRIER NAME: CONTRACTOR NUMBER:

REPORT PERIOD: CROWD FORM 4

Port X-Ray Ind Clin Lab Unk Supp/Prov Flu Imm Biller

21 22 23 24

Application Processing Times

23. # under 21 Days

24. # in 21-30 Days

25. # in 31-40 Days

26. # over 40 Days

Denials Appealed

27. Pending End of Last Quarter

28. Adjustments

29. Adjusted Opening Pending

30. Appeals Received

31. Denials Sustained

32. Denials Overturned

33. Total Appeals Processed

34. Pending End of Quarter

SCREEN 15

Monthly Statistical Report on Medicare Secondary Payer Savings

History

(Rev. 6, 08-30-02)

Provenance

Source: cms.gov
Retrieved: 2026-08-25
Edition: iom-2026-08-25
Content hash: a1c37d6a78fcbd1f6590568bacf4df6d144b3ea99aa147c3f3388e82c470f29a

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