Exhibit 17 - Instructions for the Transfer of Debt Between

400.17 - Exhibit 17 - Instructions for the Transfer of Debt Between Reporting Entities - (Rev. 5, 08-30-02) A1-1960.17, B1-4960.10 Instructions for the Transfer of Debt Between Reporting Entities CMS continues to receive criticism from the OIG and its financial statement auditors for being inconsistent in methods of transferring accounts receivable cases to and from Medicare contractors, and other CMS locations. This criticism is a direct result of the lack of a formalized process and specific instructions for transferring accounts receivable cases between reporting entities. For financial reporting purposes, the term "referred" is used when a case is not physically sent to the receiving entity for collection purposes. In a "referral" situation, the receiving entity merely "advises and/or assists" the referring entity on what actions to take next with respect to the debt. The responsibility to collect and report the accounts receivable remains with the referring entity and must be reported as part of the ending accounts receivable balance on their Form CMS-H751A/B, Status of Accounts Receivable report. A "transfer" results when a copy of the up-to-date overpayment case file is physically "transferred" to another reporting entity, i.e., the RO, CO or another Medicare contractor. Along with the case file, the transferring entity must attach a "Transfer Request and Notification of Acceptance" form (see Exhibit 17, Attachment I for intermediaries (parts A and B transfers and Attachment II for carriers). This form will serve as both: 1) the transferring entity's request to transfer the case(s), and 2) the receiving entity's notification of acceptance of the transfer. The transferring entity must complete the form and sign Line 1. The form summarizes the case(s) requiring transfer approval. No entry will be made on Form CMS-751A/B at this time. Upon receipt of the form, the entity receiving the request will sign Line 2 of the form and forward a copy of the form back to the transferring entity. This will notify the transferring entity of the receipt of the request. The receiving entity will process the request within 30 days of receipt of the transfer, and will return a copy of the Transfer Request and Notification of Acceptance form indicating the case(s) approved for transfer by signing Line 3 of the form. Only upon receipt of the form signed by the receiving entity, will the transferring entity update its internal systems to reflect the transfer of the accounts receivable to the receiving entity. The transferring entity will reflect the dollar amount of the case(s) approved for transfer on the appropriate transfers out line of Form CMS-H751A/B (Line 5c, Transfers Out to Other Medicare Contractors; Line 5e, Transfers Out to Other CMS Locations, POR/PSOR; Line 5g, Transfers Out to Other CMS Locations, Not on POR/PSOR). Also upon receipt of the form, the transferring entity must sign Line 4 and forward a copy to the receiving entity to acknowledge receipt of the formal approval for transfer. The receiving entity will update all internal systems, as well as the POR/PSOR to reflect the transfer. The location or Medicare contractor number must also be updated in the POR/PSOR system to reflect the transfer. In addition, the receiving entity will reflect the dollar amount of the case(s) approved for transfer on the appropriate transfers in line of Form CMS-H751A/B (Line 5b, Transfers In from Other Medicare Contractors; Line 5d, Transfers In From Other CMS Locations, POR/PSOR; Line 5f, Transfers In from Other CMS Locations, Not POR/PSOR). Prior to submission of the quarterly Form CMS-H750/751A/B, reporting entities must reconcile the transfers in and transfers out lines to ensure approved transfers are only being reported. In addition to the requirement to maintain detailed transaction level documentation to support these lines, reporting entities must also retain copies of the signed Transfer Request and Notification of Acceptance forms. Exhibit 17, Attachment I TRANSFER REQUEST AND NOTIFICATION OF ACCEPTANCE FORM INTERMEDIARY PART A OR PART B - ACCOUNTS RECEIVABLE (Indicate whether HI or SMI) Provider Name Provider Number Cost Report Period Overpayment Determination Date Original Amount Outstanding Principal Balance Outstanding Interest Balance Acceptance Of Transfer Yes/No Reason for Rejection Line 1:Requesting/Transferring Entity Official: (Signature required) Total Dollar Amount Requested for Transfer: $ Title: Telephone: Date Requested: Line 2: Acknowledgement of Receipt of (Signature required) (Date received) Request Form Line 3: Approving/Receiving Entity Official: (Signature required) Total Dollar Amount Approved for Transfer: $ Title: Telephone: Date Approved: Line 4: Acknowledgement of Receipt of (Signature required) (Date received) Approved Form Exhibit 17 - Attachment II TRANSFER REQUEST & NOTIFICATION OF ACCEPTANCE FORM CARRIER ACCOUNTS RECEIVABLE Provider Name Provider Number Claim Number Claim Paid Date Overpayment Determination Date Original Amount Outstanding Principal Balance Outstanding Interest Balance Acceptance Of Transfer Yes/No Reason for Rejection Line 1:Requesting/Transferring Entity Official: (Signature required) Total Dollar Amount Requested for Transfer: $ Title: Telephone: Date Requested: Line 2: Acknowledgement of Receipt of (Signature required) (Date received) Request Form Line 3: Approving/Receiving Entity Official: (Signature required) Total Dollar Amount Approved for Transfer: $ Title: Telephone: Date Approved: Line 4: Acknowledgement of Receipt of (Signature required) (Date received) Approved Form