Credit Balance Report - Certification Page Completion

Providers must complete two pages of the Credit Balance Report CMS 838 form, the Certification Page and a Detail Page for each provider or subunit. Move your cursor over any of the fields or check boxes to view a pop-up explaining how to complete each area of the required Certification Page.

Medicare Credit Balance Report Certification PageFacilities must submit a credit balance report within 30 days after the end of each quarter (March 31, June 30, September 30, and December 31). Print the name and title of the Officer or Administrator of the facility. Print today's date. The Officer or Administrator of the facility must sign here. If they have their intermediary's written permission, Low Utilization Providers do not have to submit credit reports. If you're attaching a Detail Page with the Certification Page, check this box. If your facility didn't have any Medicare credit balances during the quarter, check this box. Add your contact person's information in this area. Enter the provider's name. Note: Submit a separate Certification Page for each subunit that has a Medicare provider number. Enter the provider's six-digit provider number. Note: Submit a separate Certification Page for each subunit that has a Medicare provider number.

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