US · guidance

CMS Pub. 100-06, ch. 6, § 70.27

Exhibits

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

A3-3898.27

Exhibit 1 - Screen 1 of Intermediary Provider Enrollment Quarterly Workload Report.

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

Application Workloads

Total

(1)

Accrued

Hospital

(2)

Non-

Accrued

Hospital

(3)

Religious Nonmedical

Health Care Hospital

(4)

Rural

Prim Care

Hospital

(5)

1. Pending End of Last Quarter

2. Adjustments to Pending

3. Adjusted Opening Pending

4. New Applications Received

5. Returned Appls Resubmitted

6. Total Applications Received

7. Applications Approval Recmd

8. Applications Denial Recmd

9. Applications Returned

10. Total Applications Processed

11. Pending End of Quarter

SCREEN 1

Exhibit 2 - Screen 2 of Intermediary Provider Enrollment Quarterly Workload Report.

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

Application Workloads

SNF

(6)

HHA

(7)

Hospice

(8)

ESRD

(9)

CORF

(10)

1. Pending End of Last Quarter

2. Adjustments to Pending

3. Adjusted Opening Pending

4. New Applications Received

5. Returned Appls Resubmitted

6. Total Applications Received

7. Applications Approval Recmd

8. Applications Denial Recmd

9. Applications Returned

10. Total Applications Processed

11. Pending End of Quarter

SCREEN 2

Exhibit 3 - Screen 3 of Intermediary Provider Enrollment Quarterly Workload Report.

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

Application Workloads

RHC

(11)

FQH

(12)

CMHC

(13)

IHS

(14)

Outpatient Speech

Pathology

PhysicalTherapy

(15)

Other

(16)

1. Pending End of Last Quarter

2. Adjustments to Pending

3. Adjusted Opening Pending

4. New Applications Received

5. Returned Appls Resubmitted

6. Total Applications Received

7. Applications Approval Recmd

8. Applications Denial Recmd

9. Applications Returned

10. Total Applications Processed

11. Pending End of Quarter

SCREEN 3

Exhibit 4 - Screen 4 of Intermediary Provider Enrollment Quarterly Workload Report.

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

Application Workloads

Total

(1)

Accrued

Hospital

(2)

Non-

Accrued

Hospital

(3)

Religious

Nonmedical

Health Care

Hospital

(4)

Rural

Prime Care

Hospital

(5)

Reason for Denial Recommendation

12. Sanctioned from Medicare

13. Debarred/Excluded by Other Fed

14. Not Professionally Licensed

15. Business Address Invalid

16. Business Location Not Licensed

17. CMS Requirements Not Met

Reason for Return

18. Incomplete

19. Unverifiable Information

20. Not Signed

21. Invalid Billing Agreement

22. Other

SCREEN 4

Exhibit 5 - Screen 5 of Intermediary Provider Enrollment Quarterly Workload Report.

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

Application

SNF

(6)

HHA

(7)

Hospice

(8)

ESRD

(9)

CORF

(10)

Reason for Denial Recommendation

12. Sanctioned from Medicare

13. Debarred/Excluded by Other Fed

14. Not Professionally Licensed

15. Business Address Invalid

16. Business Location Not Licensed

17. CMS Requirements Not Met

Reason for Return

18. Incomplete

19. Unverifiable Information

20. Not Signed

21. Invalid Billing Agreement

22. Other

SCREEN 5

Exhibit 6 - Screen 6 of Intermediary Provider Enrollment Quarterly Workload Report.

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

Application Workloads

RHC

(11)

FQHC

(12)

CMHC

(13)

IHS

(14)

Outpatient Speech

Pathology/

Physical Therapy

(15)

Other

(16)

Reasons for Denial Recommendation

12. Sanctioned from Medicare

13. Debarred/Excld by Other Fed

14. Not Professionally Licensed

15. Business Address Invalid

16. Business Location Not Licens

17. CMS Requirements Not Met

Reason for Return

18. Incomplete

19. Unverifiable Information

20. Not Signed

21. Invalid Billing Agreement

22. Other

SCREEN 6

Exhibit 7 - Screen 7 of Intermediary Provider Enrollment Quarterly Workload Report.

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

Application Workloads

Total

(1)

Accrued

Hospital

(2)

Non-

Accrued

Hospital

(3)

Religious

Nonmedical

Health Care

Hospital

(4)

Rural

Prime Care

Hospital

(5)

Application Processing Times

23. Number Under 21 Days

24. Number in 21-30 Days

25. Number in 31-40 Days

26. Number Over 40 Days

Age of Applications Pending

27. Number Under 11 Days Old

28. Number 11-20 Days Old

29. Number 21-30 Days Old

30. Number 31-40 Days Old

31. Number Over 40 Days Old

SCREEN 7

Exhibit 8 - Screen 8 of Intermediary Provider Enrollment Quarterly Workload Report.

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

Application Workloads

SNF

(6)

HHA

(7)

Hospice

(8)

ESRD

(9)

CORF

(10)

Application Processing Times

23. Number Under 21 Days

24. Number in 21-30 Days

25. Number in 31-40 Days

26. Number Over 40 Days

Age of Applications Pending

27. Number Under 11 Days Old

28. Number 11-20 Days Old

29. Number 21-30 Days Old

30. Number 31-40 Days Old

31. Number Over 40 Days Old

SCREEN 8

Exhibit 9 - Screen 9 of Intermediary Provider Enrollment Quarterly Workload Report.

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

Application Workloads

RHC

(11)

FQHC

(12)

CMHC

(13)

IHS

(14)

Outpatient Speech

Pathology/

Physical Therapy

(15)

Other

(16)

Application Processing Times

23. Number Under 21 Days

24. Number in 21-30 Days

25. Number in 31-40 Days

26. Number Over 40 Days

Age of Applications Pending

27. Number Under 11 Days Old

28. Number 11-20 Days Old

29. Number 21-30 Days Old

30. Number 31-40 Days Old

31. Number Over 40 Days Old

SCREEN 9

Exhibit 10 - Screens 10 and 11 of Intermediary Provider Enrollment Quarterly Workload Report.

SCREEN 10

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

CHOW Workloads

Total

(1)

Accrued

Hospital

(2)

Non-

Accrued

Hospital

(3)

Religious

Nonmedical

Health Care

Hospital

(4)

Rural

Prime Care

Hospital

(5)

32. Pending End of Last Quarter

33. Adjustments to Pending

34. Adjusted Opening Pending

35. CHOWs Received

36. CHOWs Processed

37. Pending End of Quarter

Exhibit 10 (Cont.)

Exhibit 10 - Screens 10 and 11 of Intermediary Provider Enrollment Quarterly Workload Report.

SCREEN 11

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

CHOW Workloads

SNF

(6)

HHA

(7)

Hospice

(8)

ESRD

(9)

CORF

(10)

32. Pending End of Last Quarter

33. Adjustments to Pending

34. Adjusted Opening Pending

35. CHOWs Received

36. CHOWs Processed

37. Pending End of Quarter

Exhibit 11 - Screen 12 of Intermediary Provider Enrollment Quarterly Workload Report.

INTERMEDIARY NAME:

REPORT PERIOD:

INTERMEDIARY NUMBER:

CROWD FORM 3

CHOW Workloads

RHC

(11)

FQHC

(12)

CMHC

(13)

IHS

(14)

Outpatient Speech

Pathology/Physica

l Therapy

(15)

Other

(16)

32. Pending End of Last Quarter

33. Adjustments to Pending

34. Adjusted Opening Pending

35. CHOWs Received

36. CHOWs Processed

37. Pending End of Quarter

SCREEN 12

History

(Rev. 6, 08-30-02)

Provenance

Source: cms.gov
Retrieved: 2026-08-25
Edition: iom-2026-08-25
Content hash: c92f07c56dcb6d1bd5164abd48e95fc4c5c9b40c89883edc3e680371135b7853

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