US · guidance
CMS Pub. 100-06, ch. 6, § 70.14
Quarterly Supplement to the Intermediary Workload Report - CMS-1566A, Pages 1,2,3
A3-3898.14
QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT
HFCA-1566A, PAGES 1 & 2 (CROWD FORM C)
INTERMEDIARY NUMBER_______ REPORT PERIOD_______
SECTION A:
BILLS PROCESSED BY
STATE OF PROVIDER
TOTAL
1
INP HOSP
2
OUTPATIENT
3
SNF
4
HHA
5
OTHER
6
1 . TOTAL - ALL
STATE CODE XXXXXXXXXXX XXXXXXXXX XXXXXXXXXXXX XXXX XXXXX XXXXXX
Quarterly Supplement To Intermediary Workload Report (Cont.)
QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT
HFCA-1566A, PAGE 3 (CROWD FORM I)
INTERMEDIARY NUMBER_______
REPORT PERIOD_______
TOTAL
1
INPATIENT
2
OUTPATIENT
3
SNF
4
HHA
5
OTHER
6
SECTION B: BILL DENIAL DATA
XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX
1. BILLS DENIED - TOTAL
1A. MEDICAL - SUBJECT
TO WAIVER
XXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX XXXXXX XXXXXX
1B. MEDICAL - NOT SUBJECT
TO WAIVER
XXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX XXXXXX XXXXXX
1C. NONMEDICAL TOTAL
XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX XXXXXX XXXXXX
1D. NONMEDICAL MSP
XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX XXXXXX XXXXXX
2. BILLS PAID UNDER WAIVER
TOTAL
2A. INITIAL BILLS PAID
UNDER WAIVER
Quarterly Supplement To Intermediary Workload Report (Cont.)
QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT
HFCA-1566A, PAGE 3 (CROWD FORM I)
INTERMEDIARY NUMBER_______
REPORT PERIOD_______
TOTAL
1
INPATIENT
2
OUTPATIENT
3
SNF
4
HHA
5
OTHER
6
3. AMOUNT REIMBURSED UNDER
WAIVER
3A. AMOUNT ON INITIAL BILLS
SECTION C: DAY/VISIT DATA
XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX
4. DAYS/VISITS PROCESSED
XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX
5. DAYS/VISITS DENIED TOTAL
NO-PAY BILLS
XXXXXXX
XXXXXXXXXX
XXXXXXXXXXX
XXXXX
5A. MEDICAL - SUBJECT TO
WAIVER
XXXXXXX
XXXXXXXXXX
XXXXXXXXXXX
XXXXX
5B. MEDICAL - NOT SUBJECT
TO WAIVER
XXXXXXX
XXXXXXXXXX
XXXXXXXXXXX
XXXXX
5C. NONMEDICALS
XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX
Quarterly Supplement To Intermediary Workload Report (Cont.)
QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT
HFCA-1566A, PAGE 3 (CROWD FORM I)
INTERMEDIARY NUMBER_______
REPORT PERIOD_______
TOTAL
1
INPATIENT
2
OUTPATIENT
3
SNF
4
HHA
5
OTHER
6
6. DAYS/VISITS PAID UNDER
WAIVER - TOTAL
XXXXXXX
XXXXXXXXXX
XXXXXXXXXXX
XXXXX
6A. DAYS/VISITS ON
INITIAL BILLS
XXXXXXX
XXXXXXXXXX
XXXXXXXXXXX
XXXXX
Quarterly Supplement To Intermediary Workload Report (Cont.)
QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT
HFCA-1566A, PAGE 3 (CROWD FORM I)
INTERMEDIARY NUMBER_______ REPORT PERIOD_______
TOTAL
1
INPATIENT
2
OUTPATIENT
3
SNF
4
HHA
5
OTHER
6 SECTION D: DEMAND
BILL DATA
XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX
7. TOTAL DEMAND BILLS
7A. FULL/PARTIAL
REVERSALS
7B. DAYS/VISITS ON
REVERSALS
XXXXXXX
XXXXXXXXXX
XXXXXXXXXXX
XXXXX
SECTION E: NO-PAY
BILLS
XXXXXXX
XXXXXXXXXX
XXXXXXXXXXX
XXXX
XXXX
XXXXX
8. TOTAL NO-PAY BILLS
8A. DAYS/VISITS ON
NO-PAY BILLS
XXXXXXX
XXXXXXXXXX
XXXXXXXXXXX
XXXXX
8B. MSP NO-PAY BILLS
History
(Rev. 12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
85e032ab044deaa57c0e3d6b21ac5660c5d3b40cf63c805cf2c10495f45ea2fb
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