Exhibit 18 - Collection Reconciliation/Acknowledgement Form - (Rev. 5, 08-30-

400.18 - Exhibit 18 - Collection Reconciliation/Acknowledgement Form - (Rev. 5, 08-30- 02) A1-1960.18, B1-4960.11 Collection Reconciliation/Acknowledgement Form There are instances where one reporting entity has received and deposited cash/check/offset/electronic funds transfers (EFTs) for a receivable that is being reported by another entity. In this situation, accounts receivable cases will not be transferred to the location where the deposit of the money is made. To ensure proper matching and application of the collection of monies to the outstanding receivable, the "Collection Reconciliation/Acknowledgement" form must be completed. This form must be completed by the entity (Medicare contractor, CMS RO or CO) receiving a collection for an accounts receivable that is currently being reported on the financial reports (Forms CMS-H751A/B-CMS-R751A/B) of another entity. Medicare contractors are required to ensure that internal controls are in place over the cash/check receipts process to ensure adequate accounting, recording and custody of Medicare assets. Treatment of Collections Made by a Medicare Contractor for an Account Receivable at Another Medicare Contractor Location (applies to Non-Medicare Secondary Payer (MSP) accounts receivables and MSP accounts receivables) If a Medicare contractor collects a debt on behalf of another Medicare contractor, whether the receipt was solicited or unsolicited, then the collection must be forwarded to the Medicare contractor that has the accounts receivable. In these instances, the Medicare contractor receiving the collection would deposit the collection and re-issue that amount to the Medicare contractor that is reporting the accounts receivable. The Medicare contractor reissuing the check should ensure that proper segregation of duties exist over the check re-issuance (e.g., that the preparer is different from the check authorizer). The re-issued check must be made payable to "Medicare." In addition, the check must be accompanied by a completed Collection Reconciliation/Acknowledgement Form (see MIM §1960.18 and MCM §4960.11), any correspondence received, and a copy of the original check including the postmark date. The CFO for Medicare Operations for the Medicare contractor reporting the accounts receivable should be contacted and informed of the pending check. A listing of CFO contacts has been issued to each Medicare contractor CFO. The deposit and re-issuance of the collection will only affect the CMS-H750A/B of the Medicare contractor that received the collection. The Collection Reconciliation/Acknowledgement Form will allow for tracking of the payment. Upon receipt of the check and Collection Reconciliation/Acknowledgement Form, the Medicare contractor reporting the receivable will apply its normal cash receipt procedures. However, a signed copy of the Collection Reconciliation/Acknowledgement Form must be returned to the Medicare contractor that sent the collection. MSP additional information: Medicare contractors should follow the deposit and re-issue process whenever another Medicare contractor has the account receivable or another Medicare contractor is or should be the lead Medicare contractor. If there is no account receivable established but Medicare contractor X is the lead and Medicare contractor Y receives payment, Medicare contractor Y should follow the deposit/re-issue process. If there is no lead established and Medicare contractor Y receives payment, Medicare contractor Y should do an electronic referral via the Electronic Correspondence Referral System (ECRS) and follow the deposit/re-issue process if another Medicare contractor is assigned lead. This rule should be followed even if the non-lead Medicare contractor has an interest and/or has paid some of the claims at issue. Treatment of Collections Made by a Medicare Contractor for an Account Receivable at a CMS Regional Office Location (applies to Non-MSP accounts receivables and MSP accounts receivables.) If a Medicare contractor collects a debt on behalf of a CMS RO location, whether the receipt was solicited or unsolicited, then the account receivable balance must be transferred to the Medicare contractor that received the collection. In these instances, the Medicare contractor receiving the collection would initiate the process by completing the Collection Reconciliation/Acknowledgement Form and sending it to the CMS RO who is reporting the receivable to notify them of the collection. The Medicare contractor that received the collection would deposit any cash or checks received into unapplied receipts, which would be reported as a liability until the transfer is complete. In turn, the CMS RO reporting the receivable will complete the Transfer Request and Notification of Acceptance Form (TRNA) described in §1960.17 of the MIM and §4960.10 of the MCM. (The use of the TRNA is also discussed in question number 68.) Once both parties sign the TRNA, the transfer is considered complete and the collection would then be applied to the account receivable. The CMS RO transferring the receivable would record the account receivable on Line 5c, Transfer Out to other Medicare Contractors. The Medicare contractor receiving the account receivable would record it on Line 5d/5f, Transfers In from other CMS Locations POR/PSOR or Not on POR/PSOR and the applicable collection on either Line 4a, Cash/Check Collections or Line 4b, Offset Collections. Only in the instance where a collection is made by offset for an account receivable at a CMS RO location can notification of the offset be e-mailed. The e-mail must be retained for audit trail purposes. The e-mail notification must be followed-up with the actual Collection Reconciliation/Acknowledgement Form and the Transfer Request and Notification of Acceptance form with all the appropriate signatures. Furthermore, since offsets may only be identified after being applied, the offset transaction must be moved manually on the Forms CMS-751A/B (i.e., the full amount of the accounts receivable prior to the offset must be shown as a transfer in and the amount of the offset must be captured on Line 4b, Offset Collection.) To assist in accounting for these offset transactions ONLY, Medicare contractors can prepare the Collection Reconciliation/Acknowledgement Form(s) on a monthly basis. Treatment of Collections Made by A Medicare Contractor for an Account Receivable at CO Non-MSP: If Medicare contractors receive collections on debt that is at the Debt Collection Center (DCC), and that debt is being reported by CO, the Medicare contractor must notify the CO by submitting the Collection Reconciliation/Acknowledgement form (refer to §1960.18 of the MIM and §4960.11 of the MCM). In addition, the receipt should be deposited into unapplied receipts until the actual account receivable is transferred back to the Medicare contractor. Once CO receives the Collection Reconciliation/Acknowledgement form, it will perform the necessary steps to update the collection information in the Debt Collection System (DCS) and the Provider Overpayment Reporting (POR) system or the Physician/Supplier Overpayment Reporting (PSOR) system. CO will change the accounts receivable location code in DCS from "H," which means CO is reporting the account receivable to "C," which means the Medicare contractor is reporting the account receivable. CO will also update the POR/PSOR with the appropriate location code of "IDC," which means the fiscal intermediary at debt collection or "CDC," which means the carrier at debt collection (i.e., the debt has been forwarded to debt collection but the debt is still on the books of the fiscal intermediary or carrier). If a balance is remaining after posting the collection, the debt will remain at DCC for cross servicing/TOP. To allow the Medicare contractors to properly apply the collection in their internal systems, CO will then transfer the receivable back to the Medicare contractor using the TRNA (refer to §1960.17 of the MIM and §4960.10 of the MCM). Upon CO receiving the signed TRNA from the Medicare contractor, CO will cease to report the receivable on its Form CMS-R751A/B. Once the TRNA has been signed and the receivable has been transferred, the Medicare contractor will record the transfer in of the receivable on Line 5d, Transfers In from other CMS Locations, POR/PSOR, or Line 5f, Transfers In from other CMS Locations, Not POR/PSOR. The receipt would then be applied to the account receivable and the collection would be recorded on Line 4a, Cash/Check Collections or Line 4b, Offset Collection on the appropriate Form CMS- H751A/B. MSP: If Medicare contractor X has an account receivable other than a debt which has been referred to the Department of Health and Human Services (DHHS) Program Support Center (PSC) under the DCIA and the CO/RO receives payment, the Medicare contractor should use Line 4c, Collections Deposited at Another Location and footnote in the comments section of the Form CMS-M751A/B that the CO/RO received the payment. An example of this type of receipt would be coordination of benefits contractor misrouted checks. Usage of the Collection Reconciliation/Acknowledgement Form In the instance where a Medicare contractor, RO or CO receives a collection (whether cash, checks, offset or EFT) the entity receiving the collection must complete lines 1 through 10 of the form and attach all documentation showing the collection and the re-issued check, if applicable. In the instance where a RO receives cash/checks and does not maintain a Medicare bank account to deposit the funds received, the RO must complete lines 1 through 10 of the form and attach the cash/check. This form should be forwarded to the reporting entity no later than (15) fifteen days before the end of the quarter. The entity receiving the form and the check must sign the form on line 11 and forward a copy of the form to the official who signed line 10, no later than (15) fifteen days after receipt of the form. This will acknowledge the receipt of the form and the check. Collection Reconciliation/Acknowledgement Form 1. Location of A/R_________________________(i.e., Medicare contractor, RO, or CO) 2. Location of the Collection _________________(i.e., Medicare contractor, RO, or CO. If RO Collection, indicate such even though actual deposit is made at Central Office) 3. Region_________ Medicare contractor Name and Number_________________________ 4. Non-MSP Accounts Receivable Provider/Physician/Supplier) Number_______________ Provider/Physician/Supplier Name__________________________________ Provider/Physician/Supplier Name__________________________________ Overpayment Determination Date__________________ Claim Number_________________ Cost Report Year ___________________ MSP Accounts Receivable Debtor Name ______________________________________ HIC # / Report ID___________________________________ Determination Date__________________ Beneficiary Name ___________________________________ 5. Was debt in CNC status prior to this collection:__________________(Yes/No) 6. Date of Collection (Postmark or Government Collection date)______________ 7. Type of Collection ____________________ (i.e., cash/check or offset) Check Number or Government Collection Number _____________________________ Amount of Collection $__________________ Amount Applied to Principal $__________________ Amount Applied to Interest $__________________ 8. Collection Reported in quarter ending__________________ 9. A/R Reported in quarter ending_______________________ _____________________________ _____________________________ 10. Signature of Official at Location Where Collection is Reported 11. Signature of Official at Location Where Reduction of A/R is Recorded Phone #________________________ Fax #__________________________ Phone #________________________ Fax #__________________________