Exhibit 1 - Statement of Financial Position and Statement of

400.1 - Exhibit 1 - Statement of Financial Position and Statement of Operations - HI/SMI - (Rev. 5, 08-30-02) A1-1960 Exhibit 1, B1-4960.1 The FI submits the HI report (Form CMS-H750A). Both FI and carrier submit the SMI report (Form CMS-H750B). • The HI report, in applicable line item descriptions, refers to "provider" and the SMI report refers to "physicians, provider or supplier". • For the SMI report (Form CMS-H750B), the FI completes the items dealing with cost reports, PIP, and credit balances; but the carrier omits them. Also, the intermediary inserts data relating to the Provider Overpayment Report (POR), while the carrier inserts data relating to the Physician Supplier Overpayment Report (PSOR). Exhibit 1 (Cont.) Contractor Financial Reports Statement of Financial Position Hospital Insurance (HI) As of __________________ Contractor Name ID Number _______________________ __________ Assets Balance Cash Benefits Account _______________ Time Account _______________ Undeposited Collections _______________ Total Cash _______________ Accounts Receivable Non-Medicare Secondary Payments (Non-MSP) Overpayments Provider (Carriers Omit) _______________ Cost Report Settlements (Carriers Omit) _______________ Claims Accounts Receivable (Carriers Omit) _______________ PIP Accrual (Carriers Omit) _______________ Credit Balances (Carriers Omit) _______________ Other (Carriers Omit) _______________ Physician/Supplier Overpayments (Intermediaries Omit) _______________ Beneficiaries _______________ Total Non-MSP _______________ Medicare Secondary Payer (MSP) Group Health Plan Data Match _______________ Non-Data Match _______________ MSP Provider/Physician/Supplier/Beneficiary Liability (including WC, Auto, No Fault, MSP beneficiary and other MSP) MSP Beneficiary _______________ _______________ Other MSP _______________ Total MSP _______________ CMS-H750A/B Exhibit 1 (Cont.) Contractor Financial Reports Statement of Operations Hospital Insurance (HI) As of _______________ Contractor Name ID Number _______________________ __________ Other (footnote) _______________ Total Accounts Receivable _______________ Advances to Others Advance Payments _______________ Accelerated Payments (Not applicable to carriers) _______________ Total Advances _______________ Interest Receivable _______________ Other Assets (footnote) _______________ Liabilities Balance Accounts Payable Unprocessed Claims Benefits Payable _________________ Provider PIP Providers A Cost Report Settlements (Carriers Omit) _________________ PIP Providers A Estimated Payable Accrual (Carriers Omit) _________________ Non-PIP Providers A Underpayments (Interim Reviews) (Carriers Omit) _________________ Non-PIP Providers A Underpayments (Cost Settlements) (Carriers Omit) _________________ Claims Withheld for Non-receipt of Cost Reports (Carriers Omit) _________________ Physicians/Suppliers (Intermediaries Omit) _________________ Beneficiaries _________________ Claims on the Payment Floor _________________ CMS-H750A/B Exhibit 1 (Cont.) Contractor Financial Reports Statement of Operations Hospital Insurance (HI) As of _______________ Contractor Name ID Number _______________________ __________ Suspended Payments Claims ________________ Common Working File (CWF) _________________ MR/UR Prepayment Review _________________ Medicare Secondary Payer (MSP) _________________ Total Accounts Payable _______________ Accrued Interest Payable _______________ Other Liabilities Unapplied Receipts _______________ Excess Recoupments _______________ Due Medicaid _______________ Other (footnote) _______________ Total Other Liabilities _______________ TOTAL LIABILITIES _______________ Fund Account Balance Cumulative Results of Operations _______________ TOTAL LIABILITIES AND FUND ACCOUNT BALANCE _______________ Revenue Amount Interest Revenue Line 3 Adjustments (Interest) Line 5a Waivers (Interest) Line 5h Write-offs (Bad Debts)(Interest) Line 6a Transfers in from other Medicare Contractors Line 5b Transfers out to other Medicare Contractors Line 5c Transfers in from CNC (Interest) Line 6b Transfers out to CNC (Interest) Line 6c Transfers in from other CMS Locations (POR/PSOR (as applicable)) (Interest) Line 5d CMS-H750A/B Exhibit 1 (Cont.) Contractor Financial Reports Statement of Operations Hospital Insurance (HI) As of _______________ Contractor Name ID Number _______________________ __________ Transfers out to other CMS Locations (POR/PSOR (as applicable)) (Interest) Line 5e Transfers in from other CMS Locations (Not POR/PSOR (as applicable)) (Interest) Line 5f Transfers out to other CMS Locations (Not POR/PSOR (as applicable)) (Interest) Line 5g Draws on Letter of Credit ________________ Other Revenue (footnote) ________________ TOTAL REVENUE ________________ Expense Operating/Program Expense Line 2 + Benefit Expense Adjustments (Principal) Line 5a (CR or DR) Transfers In from other Medicare Contractors (Contra Account) Line 5b Transfers Out to other Medicare Contractors (Principal) Line 5c Transfers In from CNC (Contra Account) Line 6b Transfers Out to CNC (Principal) Line 6c Transfers In from other CMS Locations (POR and Not POR) (Contra Account) Line 5d&5f Transfers Out to other CMS Locations (POR and Not POR) (Principal) Line 5e&5g Less: Waivers (Principal) Line 5h Less: Write-offs (Bad debts) (Principal) Line 6a CMS-H750A/B Exhibit 1 (Cont.) Contractor Financial Reports Statement of Operations Hospital Insurance (HI) As of _______________ Contractor Name ID Number _______________________ __________ Total Program Expense ________________ Interest Expense CPT Interest ________________ Other Interest ________________ Other Expense (footnote) ________________ Prior Period Adjustments (footnote) TOTAL EXPENSE ________________ NET RESULTS OF OPERATIONS ________________ OTHER DATA (Intermediaries) Value of 1st PIP Payment Cycle in ensuing quarter ________________ CMS-H750A/B