Exhibit 11 - Medicare Contractor Account Definitions - Data Element

400.11 - Exhibit 11 - Medicare Contractor Account Definitions - Data Element Definitions - (Rev. 5, 08-30-02) Medicare Contractor Account Definitions Data Element Definitions Account Number Title 1000 Assets 1100 Cash 1100.01 Part A and Part B 1100.01.01 Benefit Account 1100.01.02 Time Account 1110 Undeposited Collections Medicare Contractor Account Definitions Data Element Definitions Account Number Title 1110.01 Part A and Part B 1110.01.01 Undeposited Collections 1310 Accounts Receivable 1310.01 Part A and Part B 1310.01.01 Non-MSP Overpayments 1310.01.01.01 Provider 1310.01.01.01.01 Cost Report Settlements (FI) 1310.01.01.01.02 Claims Accounts Receivable (FI) 1310.01.01.01.03 PIP Accrual (FI) 1310.01.01.01.04 Credit Balance (FI) 1310.01.01.01.05 Other (FI) 1310.01.01.02 Beneficiaries 1310.01.01.03 Physicians/Suppliers 1310.01.04 Medicare Secondary Payer (MSP) 1310.01.04.01 Group Health Plan 1310.01.04.01.01 Data Match 1310.01.04.01.02 Non-Data Match 1310.01.04.02 Liability MSP 1310.01.04.02.01 MSP Beneficiary 1310.01.04.02.02 MSP Provider/Physician Supplier 1310.01.04.03 Other MSP 1310.01.99 Other 1311 Advances to Others 1311.01 Part A and Part B 1311.01.01 Advance Payments 1311.01.02 Accelerated Payments 1330 Interest Receivable 1330.01 Part A and Part B 1990 Other Assets 1990.01 Part A and Part B 2000 Liabilities 2110 Accounts Payable 2110.01 Part A and Part B 2110.01.01 Unprocessed Claims 2110.01.02 Benefits Payable 2110.01.02.01 Provider 2110.01.02.01.01 -PIP Provider Cost Report Settlements 2110.01.02.01.02 -PIP Provider Estimated Payable Accrual Medicare Contractor Account Definitions Data Element Definitions Account Number Title 2110.01.02.01.03 -Non-PIP Provider Underpayments Interim Rate 2110.01.02.01.04 -Non-PIP Provider Underpayments (Cost Report Settlement) 2110.01.02.01.05 Claims Withheld for Non-receipt of Cost Reports 2110.01.02.02 Beneficiaries 2110.01.02.03 Physicians/Suppliers 2110.01.02.04 Claims on the Payment Floor 2110.01.03 Suspended Payments 2110.01.03.01 Claims 2110.01.03.02 Common Working File (CWF) 2110.01.03.03 MR/UR Prepayment Review 2110.01.03.0 Medicare Secondary Payer (MSP) 2140 Accrued Interest Payable 2140.01 Part A and Part B 2990 Other Liabilities 2990.01 Part A and Part B 2990.01.01 Unapplied Receipts 2990.01.02 Excess Recoupments 2990.01.03 Due Medicaid 2990.01.04 Other 3010 Fund Account Balance 3310 Cumulative Results of Operations 3310.01 Part A and Part B 5000 Revenue 5303 Interest Revenue 5303.01 Part A and Part B 5303.01.01 Adjustments/Waivers (Contra Account) 5303.01.02 Write-off Closed/Transfers 5303.01.02.01 Bad Debt (Contra Account) 5303.01.02.02 Transfers Out to Other CMS Locations (Contra Account) 5303.01.02.02.01 Transfers In from Other CMS Locations 5303.01.02.03 Transfers Out to CNC (Contra Account) 5303.01.02.03.01 Transfers In from CNC 5303.01.02.04 Transfers Out to Other Medicare Contractors (Contra Account) 5303.01.02.04.01 Transfers In from Other Medicare Contractors 5700 Appropriated Capital Used 5700.01 Part A and Part B, Draws on Letter of Credit 5900 Other Revenue Medicare Contractor Account Definitions Data Element Definitions Account Number Title 5900.01 Part A and Part B 5900.01.01 Other 6000 Expense 6100 Operating/Program Expense 6100.01 Part A and Part B 6101 Waivers 6101.01 Part A and Part B 6101.01.02 Transfers Out to Other CMS Locations (Contra Account) 6101.01.02.01 Transfers In from Other CMS Locations 6101.01.03 Transfers Out to CNC (Contra Account) 6101.01.03.01 Transfers In from CNC 6101.01.04 Transfers Out to Other Medicare Contractors (Contra Account) 6101.01.04.01 Transfers In from Other Medicare Contractors 6106 Write Offs/Transfers 6106.01 Part A and Part B 6106.01.01 Bad Debts 6330 Interest Expense 6330.01 Part A and Part B 6330.01.01 CPT Interest 6330.01.02 Other Interest 6909 Other Expense 6909.01 Part A and Part B 7400 Prior Period Adjustments 7400.01 Part A and Part B Medicare Contractor Account Definitions Data Element Definitions The account numbers used in this chart are for reference purposes only. They are not mandated for use by Medicare contractors. Account Number Title 1000 Assets The contractor reports amounts of physical items or rights to ownership 1100 Cash The contractor reports monetary resources on hand or on deposit with banks or other financial institutions. Balances are the end of quarter amounts per the contractor's books. Account Number Title 1100.01 Part A and Part B The contractor reports cash allocable for Hospital Insurance (HI) and Supplementary Medical Insurance (SMI) activities. HI data must reconcile to Column E, Line 1, on Form CMS-1522, Monthly Contractor Financial Report. SMI data must reconcile to Column E, Line 2. Prorate the Time Account by the number of checks and electronic funds transfers (EFTs) issued for HI or SMI services. (See Exhibit 15 Protocol for Prorating Intermediary Time Account Balances between HI and SMI.) 1100.01.01 Benefits Account The contractor reports the Federal Health Insurance Benefits Account by HI and SMI 1100.01.02 Time Account The contractor reports the balance as of the end of the quarter in the Federal Health Insurance Time Account by HI and SMI. 1110 Undeposited Collections 1110.01 Part A and Part B The contractor reports undeposited collections for HI and SMI activities 1110.01.03 Undeposited Collections The contractor reports collections on hand not deposited within the accounting period. Undeposited collections include those items received by the last day of the quarter that will be deposited during the subsequent quarter. The contractor prorates undeposited collections on the basis of Column D, Funds Expended, on Form CMS-1522, Monthly Contractor Financial Report for Part A (HI) and Part B (SMI). Report deposits in transit as part of the book balance for either 1100.01.01, Benefits Account, or 1100.01.02, Time Account. It reports amounts due from others. A receivable is the identification of an overpayment for services rendered. CMS will only recognize receivables related to Fraud and Abuse once they are litigated by the Department of Justice (DOJ) 1310.01.01 Overpayments The contractor accounts receivable for overpayments. It includes amounts that exceed adjudicated claims processed, cost reports settled, or other authorized payments. This includes, but is not limited to, overpayments resulting from adjustment bills. It reclassifies any overpayment when Medicare is deemed as secondary payer to 1310.01.04, MSP 1310.01.01.01 Provider The intermediary reports overpayments for institutional providers. This includes, but is not limited to, those items listed on the Provider Overpayment Report (POR) and the Credit Balance Summary Report. Include periodic interim payments (PIP) in excess of PIP bills. Include overpayments resulting from the receipt of cost reports, tentative settlements or cost settlements when the Notices of Provider Reimbursement (NPR) are prepared. It includes overpayments from PRRB settlements when the Notices of Correction (NOC) are prepared. This is not a carrier function. 1310.01.01.01.01 Cost Report Settlements Account Number Title The intermediary reports the accounts receivable as a result of cost report settlements, interim rate reviews and overpayments as a result of accelerated payments 1310.01.01.01.02 Claims Accounts Receivable The intermediary reports the accounts receivable as a result of claims accounts receivable. This is not a carrier function. 1310.01.01.01.03 PIP Accrual The intermediary reports the amount accrued for the (estimated) accounts receivable PIP. (See Exhibit 13 Protocol for Estimating Payables and Receivables for PIP). This is not a carrier function. 1310.01.01.01.04 Credit Balances The intermediary reports the accounts receivable as a result of credit balance reports This is not a carrier function. 1310.01.01.02 Beneficiaries The contractor reports overpayments for beneficiaries. This includes, but is not limited to, those items listed on the CMS-2174, Carrier Beneficiary Overpayment Activity Report. 1310.01.01.03 Physicians/Suppliers The carrier reports overpayments for physicians and suppliers. This includes, but is not limited to, those items listed on the Physician/Supplier Overpayment Report (PSOR) This is not an intermediary function. 1310.01.04 Medicare Secondary Payer The contractor reports accounts receivable for amounts due as a result of MSP activity, and based on documented debts due Medicare for all debtors. Debtors are employers, insurers, providers, beneficiaries or other persons to whom a demand letter has been issued 1310.01.04.01 Group Health Plan (GHP) 1310.01.04.01.01 Data Match (FI) The contractor includes the amounts identified (CMS supplied receivables via tapes with an identified report ID on MPaRTS) as a result of MSP activity for which a demand letter has been issued for IRS/SSA Data Match cases. Outstanding receivables are the amount of debt that has been demanded and payment has not yet been received 1310.01.04.01.02 Non-Data Match (FI) The contractor includes the amounts identified (debt specific to GHP debt, working aged, disability, End-Stage Renal Disease (ESRD) as a result of MSP activity for which a demand letter has been issued. Outstanding receivables are the amount of debt that has been demanded and payment has not yet been received 1310.01.04.02 Liability MSP The contractor includes the amounts (inclusive of all workman's compensation, automobile/no fault and liability debt, this includes CMS identified cases) due to Account Number Title MSP activity for which a settlement has been reached related to liability cases. Outstanding receivables are the amount of debts that have been demanded, subsequent to settlement and/or other action, and payment has not yet been received. 1310.01.04.02.01 MSP Beneficiaries 1310.01.04.02.02 MSP Providers/Physicians/Suppliers Outstanding receivables are the amount of MSP initiated debts that have been demanded and payment has not yet been received. 1310.01.04.03 Other MSP The contractor includes the amounts due as a result of other MSP activity for which a valid MSP debt has been recognized. 1310.01.99 Other The contractor reports actual or estimated other accounts receivable. It includes those receivables not otherwise classified in the categories presented above. It provides an identifying footnote on CAFM of the nature of this receivable 1311 Advances to Others The contractor reports payments made to providers, physicians, or suppliers in anticipation of claims being processed. Advances are not to be considered as accounts receivable. It does not include them on Form CMS-751A/B, Status of Account Receivable report 1311.01 Part A and Part B The contractor reports advance payments and accelerated payments attributable to HI and SMI activities 1311.01.01 Advance Payments The contractor the outstanding balance for payments authorized by CMS instructions for advanced payments based on actual provider claims data. If not recovered according to CMS instructions, it reclassifies and reports as overpayments 1311.01.02 Accelerated Payments (FI) The intermediary reports the outstanding balance for payments authorized by CMS instructions for accelerated payments based on actual provider claims data. If not recovered according to CMS instructions, it reclassifies and reports as overpayments This is not a carrier function. 1330 Interest Receivable The contractor reports interest receivable on accounts receivable. It accrues interest through the last day of the reporting period. 1330.01 Part A and Part B The contractor reports HI and SMI interest receivable on accounts receivable, including extended repayment plans 1990 Other Assets Account Number Title The contractor reports assets that are not otherwise classified. It provides an identifying footnote in the remarks section of Form CMS-750A/B report. 1990.01 Part A and Part B The contractor reports HI and SMI unclassified assets. 2000 Liabilities The contractor reports amounts owed after processing Medicare claims and related activities 2110 Accounts Payable Report amounts owed after processing Medicare claims or other authorized expenditures. This includes, but is not limited to, underpayments resulting from adjustment bills 2110.01 Part A and Part B The contractor reports accounts payable attributable to HI and SMI activities 2110.01.01 Unprocessed Claims The contractor reports the value of the accounts payable for unprocessed claims received in-house that have not yet started processing. The actual value may be developed after the reporting period but before the required date for reporting. It uses the 30 day rolling average for the number of claims received and not processed to determine the number of average unprocessed claims. 2110.01.02 Benefits Payable The contractor reports accounts payable for those claims that have completed processing checks, but have not yet been issued nor offsets applied. This includes, but is not limited to, underpayments resulting from adjustment bills. It includes claims approved by the Common Working File (CWF) and claims not approved by the CWF, but approved by the RO for payment outside the CWF. 2110.01.02.01 Provider The intermediary reports benefits payable to institutional providers of Medicare services. This includes, but is not limited to the following: accounts receivable accrual where the periodic interim payment (PIP) bills is in excess of periodic interim payments (PIP); underpayments from receipt of accepted cost reports, tentative settlements and final cost settlements, when Notices of Provider Reimbursement (NPR) are prepared; and underpayments for PRRB settlements, when Notices of Correction (NOC) are prepared, etc This is not a carrier function. 2110.01.02.01.01 PIP Providers - Cost Report Settlements The intermediary reports benefits payable to PIP providers as a result of Cost Report Settlements This is not a carrier function. 2110.01.02.01.02 PIP Providers - Estimated Payable Accrued The intermediary reports the amount accrued for the (estimated) accounts payable PIP. (See Exhibit 13 Protocol for Estimating Payables and Receivables for PIP). This is not a carrier function. 2110.01.02.01.03 Non-PIP Providers - Underpayments (Interim Rate) The intermediary reports benefits payable to Non-PIP providers as a result of Interim Rate Reviews This is not a carrier function Account Number Title 2110.01.02.01.04 Non-PIP Providers - Underpayments (Cost Report Settlement) The intermediary reports benefits payable to Non-PIP providers as a result of Cost Report Settlements This is not a carrier function. 2110.01.02.01.05 Claims Payments Withheld for Non-receipt of Cost Reports The intermediary reports benefits payable for claims withheld for payment for non-receipt of provider cost reports This is not a carrier function. 2110.01.02.02 Beneficiaries The contractor reports benefits payable to beneficiaries for reimbursement for Medicare services. 2110.01.02.03 Physicians/Suppliers The carrier reports benefits payable to physicians or suppliers of Medicare services. This includes, but is not limited to, underpayments of quarterly Health Professional Shortage Area (HPSA) bonus amounts for which a check has not been issued. Not an intermediary function. 2110.01.02.04 Claims on the Payment Floor Adjudicated claims not yet paid 2110.01.03 Suspended Payments The contractor reports actual or estimated benefits payable for claims that were suspended from payment to allow for additional processing. 2110.01.03.01 Claims The contractor reports estimated benefits payable for claims needing additional information or further development, including CWF rejects and adjustments 210.01.03.02 Common Working File (CWF) The contractor reports benefits payable for claims that are pending submission or were submitted to the CWF for approval. 2110.01.03.03 MR/UR Prepayment Review The contractor reports estimated benefits payable, based on a developed rate, suspended for MR/UR before payment. The payables after MR/UR are in 2110.01.02, Benefits Payable 2110.01.03.04 Medicare as Secondary Payer (MSP) The contractor reports benefits payable that are suspended for investigation of third party liability for MSP prior to payment 2140 Accrued Interest Payable The contractor reports actual or estimated interest payable on Medicare liabilities through the end of the reporting period including, but not limited to, pending claims, court settlements, claims payment timeliness (CPT), etc. 2140.01 Part A and Part B The contractor reports HI and SMI interest payable on Medicare liabilities Account Number Title 2990 Other Liabilities The contractor reports liabilities not otherwise classified. It provides an identifying footnote in the remarks section of Form CMS-750A/B report. 2990.01 Part A and Part B The contractor reports other liabilities attributable to HI and SMI activities. 2990.01.01 Unapplied Receipts The contractor reports amounts deposited and not yet applied to an accounts receivable. 2990.01.02 Excess Recoupments The contractor reports amounts recovered from overpayments or from other sources in excess of receivables established and which are eligible for refund. It includes those payables identified as due to third party liability payers, e.g., excess recoupment of MSP recoveries being returned to the third party. 2990.01.03 Due Medicaid The contractor reports Medicare claims reimbursements withheld based on RO instructions for payment to Medicaid. 2990.01.99 Other The contractor reports actual or estimated amounts payable not otherwise classified. These include, but are not limited to, claims payments withheld to satisfy Internal Revenue Service liens, court liens, unidentified receipts that have not been applied to an account receivable. It provides an identifying footnote in CAFM. 3010 Fund Balance Fund balance reflects the cumulative results of program operations and extraordinary items. It equals the difference between assets and liabilities. 3310 Cumulative Results of Operations These accounts track the net difference between income and expense activity as reported on the Statement of Operations. This account is updated with the current year-to-date net results of operations 3310.01 Part A and Part B The contractor reports HI and SMI interest revenue from accounts receivable. It includes current fiscal period earned interest, and any adjustments. It also includes accrued interest in account 1330, Interest Receivable 5000 Revenue and Other Financing Sources The contractor reports the amount of income from Medicare activities. Typical sources are draws on letter of credit, interest and recoveries of amounts expended in prior periods. 5303 Interest Revenue The contractor reports interest earned from accounts receivable. 5303.01 Part A and Part B Account Number Title The contractor reports HI and SMI interest revenue from accounts receivable. Include current fiscal period earned interest, and any adjustments. This will also include accrued interest in account 1330, Interest Receivable. 5303.01.01 Adjustments/Waivers (Interest) The contractor reports the reduction of the amounts of interest receivable based on Collections on Delinquent Debt in accordance with §§1862(b) and 1870(c) of the Social Security Act. It reconciles this with Form CMS-751A/B, Status of Accounts Receivable, Line 5h, Waivers (Interest). 5303.01.02 Write-offs Closed/Transfers (Interest) The contractor reports interest receivable for which collection efforts have been abandoned or that have been transferred to another Medicare contractor or other CMS location. These accounts must be reconciled with the receiving Medicare contractor or other CMS location. 5303.01.02.01 Amounts Written-Off Closed (Bad Debts) (Interest) The contractor reports interest receivables for which collection is no longer being pursued according to CMS regulations. It reconciles this with Form CMS- 751A/B, Status of Accounts Receivable, Line 6a, Amounts Written-off Closed (Bad Debts). 5303.01.02.02 Transfers Out to other CMS Locations (POR/PSOR & Not POR/PSOR) (Interest). POR not applicable to carriers. The contractor reports interest receivable transferred to other CMS locations. Reconcile with Form CMS-751A/B, Status of Accounts Receivable, Line 5e, Transfers Out to Other CMS Locations, POR/PSOR, (interest) and Line 5g, Transfers Out to Other CMS Locations, Not POR/PSOR, (interest). POR not applicable to carriers. 5303.01.02.02.01 Transfers In from other CMS Locations (POR/PSOR & Not POR/PSOR) (Interest). POR not applicable to carriers. The contractor reports interest receivable that has been transferred to your location from other CMS locations in the current period. It reconciles this with Form CMS-751 A/B, Status of Accounts Receivable, Line 5d, Transfers In from Other CMS Locations, POR, (interest), and Line 5f, Transfers In from Other CMS Locations, Not POR, (interest). POR not applicable to carriers. 5303.01.02.03 Transfers Out to CNC (Interest) The contractor reports interest receivable transferred to CNC in accordance with CMS regulations. It transfers the full amount of interest due on the debt. It reconciles this with Form CMS-C751, Status of Non-MSP Debt - CNC, Line 2, New CNC A/R (interest) and Line 6c, Transfers Out to CNC 5303.01.02.03.01 Transfers In from CNC (Interest) The contractor reports interest receivable that has been transferred in to its location from CNC. 5303.01.02.04 Transfers Out to other Medicare Contractors (Interest) The contractor reports interest receivable transferred to other Medicare contractors. Reconcile with Form CMS-751A/B, Status of Accounts Receivable, Line 5c, Transfers Out to Other Medicare Contractors. Account Number Title 5303.01.02.04.01 Transfers in from other Medicare Contractors (Interest) The contractor reports interest receivable transferred to your location from other Medicare contractors. It reconciles this with Form CMS-751A/B Status of Accounts Receivable, Line 5b, Transfers In from Other Medicare Contractors (Interest) 5700 Appropriated Capital Used The contractor reports the amount of Medicare funds drawn to be matched against current period expense. This amount must be consistent with amounts reported on Form CMS-1521, Contractor Draws on Letter of Credit, and on Form CMS-1522, Monthly Contractor Financial Report. The contractor does not include administrative draws through the Payment Management System (PMS), (Smartlink) 5700.01 Part A and Part B, Draws on Letter-of-Credit 5900 Other Revenue The contractor reports revenue not otherwise classified. It provides identifying footnote(s) in the remarks section of Form CMS-750 A/R report 5900.01 Part A and Part B The contractor reports HI and SMI other revenue 5900.01.01 Other The contractor reports revenue not otherwise classified 6000 Expense The contractor reports the outflow of assets or incurrence of liabilities during a period resulting from rendering Medicare services. 6100 Operating/Program Expense The contractor reports net benefits costs incurred throughout the FY. The expense is the adjusted benefits outlay in cash or its equivalent and accrued liabilities incurred in carrying out the Medicare program. This includes, but is not limited to, adjustments for MSP recoveries, reconsiderations, and pending litigation. 6100.01 Part A and Part B The contractor reports HI and SMI benefit program expense. 6101 Waivers (Principal) The contractor reports HI and SMI waiver expense. 6101.01 Part A and Part B The contractor reports the reduction of the amounts receivable based on application of §§1862(b) and 1870(c) of the Social Security Act. It reconciles this with Form CMS-751A/B, Status of Accounts Receivable, Line 5h, Waivers. 6101.01.02 Transfers Out to other CMS Locations (Principal) The contractor reports accounts receivable transferred to other CMS locations. It reconciles this with Form CMS-751A/B, Status of Accounts Receivable, Line 5e, Account Number Title Transfers Out to Other CMS Locations, POR/PSOR and Line 5g, Transfers to Other CMS Locations, Not POR/PSOR. POR not applicable to carriers. 6101.01.02.01 Transfers In from other CMS Locations (Principal) The contractor reports accounts receivable amounts that have been transferred to its location from other CMS locations in the current period. It reconciles this with Form CMS-751 A/B, Status of Accounts Receivable, Line 5d, Transfers In from Other CMS Locations, POR/PSOR (principal), and Line 5f, Transfers In from Other CMS Locations, Not POR/PSOR (principal). POR not applicable to carriers. 6101.01.03 Transfers Out to CNC (Principal) The contractor reports accounts receivable amounts that have been transferred to CNC in accordance with CMS regulations. . It reconciles this with Form CMS- C751A/B, Status of Non- MSP Debt - CNC, Line 2, New CNC A/R, and Line 6c Transfers Out to CNC of Form CMS-751A/B, Status of Accounts Receivable report. It transfers the full amount of principal due. 6101.01.03.01 Transfers In from CNC (Principal) The contractor reports accounts receivable amounts that have been re-established as an active accounts receivable. It reconciles this with Form CMS-751A/B, Status of Accounts Receivable, Line 6b, Transfers In from CNC 6101.01.04 Transfers Out to other Medicare Contractors (Principal) The contractor reports HI and SMI accounts receivable transferred out to a Medicare contractor for collection. It reconciles this with Form CMS-751A/B, Status of Accounts Receivable, Line 5c, Transfers to Other Medicare Contractors. 6101.01.04.01 Transfers In from other Medicare Contractors (Principal) The contractor reports HI and SMI accounts receivable transferred to your location from other Medicare contractors. It reconciles this with Form CMS-751 A/B, Status of Accounts Receivable, Line 5b, Transfers In from Other Medicare Contractors. 6106 Write-offs Closed/Transfers (Principal) The contractor reports accounts receivable for which collection efforts have been abandoned, or that have been transferred to another Medicare contractor or other CMS location. These accounts must be reconciled with the receiving Medicare contractor or other CMS location. 6106.01 Part A and Part B The contractor reports HI and SMI accounts receivable written off or transferred. 6106.01.01 Amounts Written-Off Closed (Bad Debts) (Principal) The contractor reports receivables for which collection is no longer being pursued according to CMS rules. It reconciles this with Form CMS-751A/B, Status of Accounts Receivable, Line 6a, Amounts Written-off Closed (Bad Debts). 6330 Interest Expense The contractor reports interest expense incurred for claims for Medicare benefits or accounts payable. Account Number Title 6330.01 Part A and Part B The contractor reports HI and SMI interest expense. 6330.01.01 Claims Payment Timeliness (CPT) Interest The contractor reports interest paid for claims that failed the claims payment timeliness (CPT) requirement. It reconciles this with Form CMS-1522, interest paid, claims timeliness. 6330.01.02 Other Interest The contractor reports interest for other late payments. It reconciles this with Form CMS-1522, interest paid, provider underpayments. 6909 Other Expense The contractor reports benefit expenses not reported in named categories or otherwise classified. It provides an identifying footnote in the remarks section of Form CMS-750A/B report. 6909.01 Part A and Part B The contractor reports HI and SMI unclassified benefit expenses. 7400 Prior Period Adjustments The contractor reports adjustments for prior period activity to restate assets, liabilities, etc. It provides an identifying footnote in the remarks section of Form CMS-750 report. 7400.01 Part A and Part B The contractor reports HI and SMI prior period adjustments.