NHIC EDI

The Credit Balance Report for quarter ending June 30, 2010 is due July 30,2010.
Your CMS-838 Certification Page and Detail Page can be faxed along with a fax cover sheet to 414-459-5700; make sure all sheets are completed legibly. Reports failing to meet the criteria will be rejected and not considered timely.

The Medicare Credit Balance Report is due within 30 days after the end of the calendar quarter.

The credit balance report consists of two parts:
1. A Certification page that must be completed by all providers
2. A Detail Page (also know as the CMS-838 form)

20% of all Credit Balance Reports received are invalid.
Incomplete credit balance reports will be rejected!

Avoid the top ten reasons for incomplete Credit Balance Reports

Completion Reminders

414-459-5700

Note: Please enter the date of submission following the method/code.

• Checks are not encouraged; Electronic claim adjustments are preferred. If a check is submitted, an adjustment will be initiated and the appropriate overpayment recovered. A refund of your check amount will then be made.

For more detailed information on Medicare Credit Balance Reports, refer to http://www.medicarenhic.com/PA/PartA_MedCreditBalanceReporting.shtml

General Information

The CMS-838 is specifically used to monitor the identification and recovery of "credit balances" due the Medicare program. A credit balance is defined as an improper or excess payment made to a provider as the result of patient billing or claims processing errors. Examples of Medicare credit balances include instances where a provider is:

paid twice for the same service
paid for services planned but not performed or for noncovered services; or
overpaid because of errors made in calculating beneficiary deductible and/or coinsurance amounts.

Another credit balance situation occurs where a hospital bills and is paid for outpatient services that are also included on a beneficiary’s inpatient claim.

Credit balances would not include proper payments made by Medicare in excess of a provider’s charges such as diagnosis-related group (DRG) payments made to hospitals under the Medicare prospective payment system (PPS).

For the purpose of completing the CMS-838 form (create hyperlink to www.cms.hhs.gov/cmsforms/downloads/CMS838.pdf ), a Medicare credit balance is an amount determined to be refundable to the Medicare program. Generally, when a provider receives an improper or excess payment for a claim it is reflected in their accounting records (patient accounts receivable) as a “credit.” However, Medicare credit balances include money due the program regardless of its classification in a provider's accounting records. For example, if a provider maintains credit balance accounts for a stipulated period, e.g., 90 days, and then transfers the accounts or writes them off to a holding account, this does not relieve the provider of its liability to the program. In these instances, the provider is responsible for identifying and repaying all monies due to Medicare.

Due Dates

Medicare credit balance reports are due within 30 days after the end of the calendar quarter:

	For the Quarter Ending:	Medicare Credit Balance Report is Due By:
	06/30/XX	07/30/XX
	09/30/XX	10/30/XX
	12/31/XX	01/30/XX
	03/31/XX	04/30/XX

Medicare credit balance reports submitted to NHIC must be faxed or postmarked by the due date to be considered “received timely.” Submissions postmarked prior to the end of the reporting quarter will be rejected.

Late Reports (Mailed or Faxed)

Credits are considered to have occurred effective the date of the Medicare remittance advice —not the date that the remittance advice is reviewed for accuracy.

Do not include credits on the report that occur after the reporting date, but before the report is submitted.

If your credit balance report is not received by the due date, you will be placed on 100 percent suspension of claims payments until the report has been accepted.

Providers Who Terminate From Medicare or Change Intermediaries

Providers who terminate from the Medicare program are expected to file reports covering the quarter during which the change occurred and the following two quarters. For example, if a provider terminates in May, they are expected to file the report covering that quarter (June 30) and then file reports after the close of the September and December quarters.

Providers, who remain in the Medicare program but change fiscal intermediaries, are also expected to file reports according to these instructions.

The termination of the provider number or change in fiscal intermediary is considered official only after the Centers for Medicare & Medicaid Services (CMS) notifies NHIC; changes cannot be recognized until such official notification is received.

Completing the Medicare Credit Balance Report

The credit balance report consists of two parts:

A Certification Page that must be completed by all providers. And,
A Detail Page (also known as the CMS-838 form)

You are only required to complete the Detail Page if you have actual credits to report. All submissions must have a printed name, a title, and a signed Certification Page.

Who Can Sign the Certification Page?
An officer, director, president, controller, manager, supervisor, or administrator of the facility may sign the report. will reject a report that is not signed by an appropriate party.

Completing the Certification Page
All providers must complete the Certification Page. will reject a Credit Balance Report that is not completed accurately. The Certification Page allows for providers to check the box that states that they have no credits to report for that quarter.

Complete all spaces.
Print or type all data.
Indicate the Medicare provider number. Your provider number should be written as follows: XX - XXXX. Medicare provider numbers consist of six digits. The first two digits are the state code and the next four is the provider type. Note that the state code and provider type information will be separated by a dash.
Prepare separate Certification Pages for each individual provider number for which the report is being submitted.
Do not submit separate Certification Pages for Part "A" (inpatient) and Part "B" (outpatient) services.
Indicate the full name and telephone number of the person who can answer questions about the report.
If you have zero credits to report, do not attach the Detail Page to your report. Just mark the appropriate box that indicates that “There are no Medicare credit balances to report for this quarter”. Please do not attach information to your report to document that you have zero credit balances for the period. Keep this documentation with your credit balance records should your record keeping capabilities be reviewed in the future.

Completing the CMS-838 Detail Page

Only complete and attach the CMS-838 form if there are credit balances to report.

You are responsible for reviewing all Medicare remittance advice issued by during the reporting quarter to determine if a credit balance situation has occurred. The beneficiary dates of service will have no bearing on when the credit should be reported—only the remittance advice date determines when the credit should be reported if you have credits to report.

Part A credit balances and Part B credit balances must be reported on separate CMS-838 reports.
Complete information in each column according to the following specific instructions.
Only the net amount due to the Medicare program is to be reported as a credit balance.
Do not include on the report any credits that occur after the last day of the reporting quarter, but before the report are submitted.
Number the Detail Pages; please add all credit balances at the bottom of the Detail Page.
Once a credit balance has been reported, do not repeat the credit balance on a subsequent report. If you are concerned about any delay in the processing of a claim correction, please contact the Customer Service Representative for your state.
Providers may create their own version of the Detail Page provided the format remains the same and the same column headings from the preprinted form are used. Please do not reduce the size of this form.

Completing the CMS-838 Detail Page Columns

Complete the following data fields for each Medicare credit balance by providing the following information.

Column	Explanation and/or Special Instructions
Column 1	The last name and first initial of the Medicare beneficiary.
Column 2	The Health Insurance Claim Number (HICN) of the Medicare beneficiary.
Column 3	The 14-digit Document Control Number (DCN) that appears on the Medicare remittance advice.
Column 4	The three-digit number delineating the type of bill
Columns 5 and 6	The month, day and year the beneficiary was admitted and discharged.
Column 7	The month, day and year the claim was paid. If the credit is the result of a duplicate Medicare payment, the paid date and DCN number must correspond to the most recent payment. If the credit is the result of a Medicare Secondary Payer (MSP) situation, the date in this column is the date that the primary payer made payment.
Column 8	Complete based on the actual service dates of the credit balance claim reported. Indicate "O" when the service dates fall within a cost reporting period for which a Notice of Program Reimbursement (NPR) has not yet been issued Indicate "C" when the service dates fall within a cost reporting period for which a NPR has been issued Indicate "O" when the cost report is still open Indicate "C" when the cost report is closed
Column 9	Report the "net reimbursement amount" due the Medicare program. This is the amount that was previously paid by Medicare.
Column 10	The amount reported in column 10 will be the same amount as reported in column 9. A request for an adjustment to a claim will be considered a repayment of the credit balance amount.
Column 11	C Check submitted A Hard-copy claim adjustment submitted Z Combination of check and adjustment bill X Adjustment has already been submitted electronically or by hard copy
Column 12	The amount of the credit balance that remains outstanding (column 9 minus column 10). This should be zero since column 9 and column 10 equal.
Column 13	Identifies the reason for the credit balance: Duplicate Medicare payment (You must attach the Medicare remittance advice in order to identify duplicate payments. Note: If an adjustment request was made via the Medicare Part A Direct Data Entry [MEDA DDE] system, no attachment is required. Primary payment made by another insurer Other Attach Medicare remittance advice and UB-92/04 claim forms marking all corrections in red. Note: If an adjustment request was made via the MEDA DDE system, no attachment is required.
Column 14	The value code to which the primary payment relates. Use the code that identifies who made the primary payment. Only complete if the credit balance was caused by a payment when Medicare was not the primary payer. 12 Working Aged 13 End-Stage Renal Disease 14 Auto No-Fault/Liability 15 Workers’ Compensation 16 Other Government Program 41 Black Lung 42 Veterans Administration 43 Disability 44 Conditional Payment 47 Liability
Column 15	When a credit is due on a Medicare Secondary Payer (MSP) claim, indicate the amount that the primary payer paid on the claim in the margin to the right of column 15.
Totals	Add totals at bottom of page for columns 9, 10, and 12.

Please read CMS Medicare Learning Network (MLN) Matters article for important information pertaining to credit balance instructions.

Completion Reminders

Your CMS-838 Certification Page and Detail Page can be faxed along with a fax cover sheet; make sure all sheets are completed legibly. Reports failing to meet the criteria will be rejected and not considered timely.
Submit an adjustment as soon as a credit balance is discovered during the quarter; do not wait to submit the adjustment with your credit balance report.
Once a credit balance has been reported, it should not be included on a subsequent report. If the adjustment has not been finalized, we will contact you.
Home health providers should not include Request for Anticipated Payments (RAPs) on credit balance reports. A mechanism already exists to recover a RAP payment if the final bill is not received.
The information requested in column 11 has changed. Please indicate the method of payment as follows:

C = Check submitted
A = Hard-copy claim adjustment submitted
Z = Combination of check and adjustment bill
X = Adjustment has already been submitted electronically or
by hard copy

Note: Please enter the date of submission following the method/code.
Checks are not encouraged; Electronic claim adjustments are preferred. If a check is submitted, an adjustment will be initiated and the appropriate overpayment recovered. A refund of your check amount will then be made.

Credit Balance Report Articles

Tips for Filing the Medicare Credit Balance Report Certification Page

CMS 838 Credit Balance On-line Reporting

Providers are now able to submit their CMS 838 detail reports via the Fiscal Intermediary Standard System Direct Data Entry (FISS/DDE) On-line Reports. Please refer to the On-line Reports chapter found in the FISS DDE Manual.

Reminder: Continue to fax or send in the certification page when submitting the credit balance 838 detail reports through DDE and indicate on the certification form that you have submitted the report through DDE.

Records Supporting Form CMS-838 Data Submission

Providers must develop and maintain documentation that shows that each patient with a credit balance (i.e., transfer, holding account, etc.) was reviewed to determine the amount attributable to Medicare and what to report on the CMS-838 form. At a minimum, your procedures should:

identify whether or not the patient is an eligible Medicare beneficiary;

identify other liable insurers and the primary payer; and

adhere to applicable Medicare reimbursement rules.

Penalties may be imposed for failure to submit the CMS-838 form, or for not maintaining documentation that adequately supports the credit balance data reported to the Medicare program. Intermediaries will review a provider’s documentation during their audits/reviews performed for cost report settlement purposes.

Adjustments Owed Medicare

All amounts owed Medicare, as shown in column 9 of the credit balance report, must be paid at the time that the report is due (refer to Compliance with MSP Regulations) by submitting adjustment claims prior to or with the CMS-838 form.

Compliance with Medicare as Secondary Payer Regulations

MSP-related credit balances must be reported using the date of the primary payer's payment as the date of occurrence in column 7 on the Detail Page.

MSP regulation 42 CFR 489.20 requires providers to reimburse Medicare within 60 days from the date that they receive payment from another payer (primary to Medicare) for the same services. Submission of the CMS-838 form and adherence to its instructions do not interfere with this rule; credit balances resulting from MSP payments must be repaid within the 60-day period.

Credit balances resulting from MSP payments must be reported on the CMS-838 form if they have not been repaid as of the last day of the reporting quarter. When an MSP credit balance is identified and repaid within a reporting quarter, in accordance with the 60-day requirement, it should not be included on the CMS-838 form, i.e., once payment is made a credit balance would no longer be reflected in the provider's records.

If an MSP credit balance occurs late in a reporting quarter and the CMS-838 form is due prior to the expiration of the 60-day repayment period, it would be reported on the credit balance report. However, payment of the credit balance does not have to be made at the time the CMS-838 form is submitted but must be repaid within the specified 60-day period.

Low Medicare Utilization Exemption

Low Medicare utilization providers are defined as those providers who, in their latest cost report filing, were authorized and elected to file a less than full or no Medicare business cost report. Once a provider files a full cost report, they must complete and submit a quarterly CMS-838 form thereafter, or until such time as they qualify, and elect to file a less than full cost report.

Those providers, who will not be filing a completed Detail Page because they are claiming the low Medicare utilization exemption, should check the "Qualify as a Low Utilization Provider" box on the Certification Page and submit or fax with fax cover sheet, the signed certification page to the appropriate address.

Primary Provider Responsible for Subprovider Reporting

Each hospital, skilled nursing facility or home health agency with an attached subprovider is responsible for submitting separate reports for each distinct provider number where NHIC, Corp. is the Medicare claims processing intermediary.

05/13/2010