Exhibit 3: MEDICARE CREDIT BALANCE SUMMARY REPORT

10.11 - Exhibit 3: MEDICARE CREDIT BALANCE SUMMARY REPORT (Rev. 99, Issued: 06-30-06; Effective/Implementation Dates: 10-02-06) Fiscal Intermediary: (Name and Number) Quarter Ended: Credit Balance Activities by Type of Provider for This Quarter Number of Amount of Identified Identified No. of Providers No. of Providers Medicare Credit Medicare Credit Required to Submit That Submitted Balances on Balances on Type of CMS Form 838 CMS Form 838 CMS Form 838 CMS Form 838 Provider For This Quarter For This Quarter For This Quarter For This Quarter Hospital $ SNF HHA ESRD Other TOTAL $ NOTE: See the next page for a sample of a completed summary report. Prepared by: ___________________ Date Prepared: ___________________ Approved by: ___________________ Date Approved: ___________________ Exhibit 3 (Continued) SAMPLE REPORT MEDICARE CREDIT BALANCE SUMMARY REPORT Fiscal Intermediary: Blue Cross Blue Shield of Xxxxxxx 00xxx Quarter Ended: 9/30/2004 Credit Balance Activities by Type of Provider for this Quarter: Number of Amount of Identified Identified No. of Providers No. of Providers Medicare Credit Medicare Credit Required to Submit That Submitted a Balances on Balances on Type of CMS Form 838 CMS Form 838 CMS Form 838 CMS Form 838 Provider For This Quarter For This Quarter For This Quarter For This Quarter Hospital 300 257 1,348 $643,278 SNF 278 215 288 86,441 HHA 0 0 0 0 ESRD 21 21 0 0 Other 34 33 15 3,065 TOTAL 633 526 1,651 $732,784 Prepared by: ___________________ Date Prepared: ___________________ Approved by: ___________________ Date Approved: ___________________