Exhibit II: Medicare Credit Balance Report Detail Page

20.9 - Exhibit II: Medicare Credit Balance Report Detail Page (Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. Department of Health & Human Services Form Approved Centers for Medicare & Medicaid Services OMB No. 0938-0600 Medicare Credit Balance Report Detail Page Provider Name: Page of Provider Number: Contact Person: Quarter Ending: Phone Number ( ) - Medicare Part: (Indicate “A” or “B”) (1) Beneficiary Name (2) Medicare beneficiary identifier (3) ICN Number (4) Type of Bill (5) Admission Date (MM/DD/YY) (6) Discharge Date (MM/DD/YY) (7) Paid Date (MM/DD/YY) (8) Cost Report (Open/Closed) (9) Amount of Medicare Credit Balance (10) Amount of Medicare Credit Balance Repaid (11) Method of Payment (12) Amount of Medicare Credit Balance Outstanding (13) Reason for Medicare Credit Balance (14) Value Code (15) Primary Payer (Name & Billing Address) Form CMS-838 (10/03) INSTRUCTIONS FOR COMPLETING THIS PAGE ARE IN MEDICARE CREDIT BALANCE REPORT – PROVIDER INSTRUCTIONS, FORM CMS-8