Credit Balance Report - Details Page Completion

Within 30 days of each quarter, Providers must complete two pages of the Credit Balance Report, the Certification Page and a Detail Page for each provider or subunit.

Move your cursor over any of the fields or check boxes below to view a pop-up explaining how to complete each area of the Details Page of the Credit Balance Report.

Medicare Credit Balance Report Detail Page

Enter the provider's name. Enter the provider's six-digit provider number. Enter the quarter (and year) that this Detail Page is for. Indicate what part of Medicare this Detail Page is for. Indicate how many pages you're sending, and what page this is. Indicate a person we can contact if we have questions about the form. Enter your contact person's phone number. Enter a '1' if the credit balance resulted from duplicate Medicare payments, a '2' for a primary payment by another insurer, or a '3' for 'other reasons.' In column 15, provide an explanation for each credit balance with a '3.' Enter the amount of the outstanding Medicare credit balance (column 9 minus column 10). Enter a zero if you've made full payment with the CMS-838 or a previously submitted claim adjustment. Enter 'C' if you are submitting a check with the CMS-838 to repay the credit balance amount in column 9, an 'A' if you are submitting a hard copy claim adjustment (e.g., adjustment bill in UB-92 format) with the CMS-838, or an 'X' if you've already submitted an adjustment bill. Enter the amount of the Medicare credit balance your facility is sending/repaying with the submission of this report. Enter the amount of the Medicare credit balance. Enter an 'O' if the claim is for an open Medicare cost reporting period, or a 'C' if the claim pertains to a closed cost reporting period. (An open cost report is one where an NPR has not yet been issued. Do not consider a cost report open if it was reopened for a specific issue such as graduate medical education or malpractice insurance.) Enter the month, day and year (e.g., 01/01/07) the claim was paid. If a duplicate Medicare payment caused the credit balance, ensure the paid date and ICN number correspond to the most recent payment. Enter the date the patient left your facility (or ended treatment for outpatient services). Enter the date the patient was admitted at your facility (or began outpatient services). Enter the 3-digit number explaining the type of bill; for example, 111 for inpatient or 131 for outpatient. Enter the 14-digit ICN for the claim. Enter the beneficiary's Medicare ID number. Enter the beneficiary's name. Complete this column only if the credit balance was caused by a payment when Medicare was not the primary payer. If more than one code applies, enter the code applicable to the payer with the largest liability. Complete this column only if Medicare wasn't the primary payer. Enter the primary payer's name and billing address.

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