Exhibit 3 - Status of Accounts Receivable - HI

400.3 - Exhibit 3 - Status of Accounts Receivable - HI (Rev. 111; Issued: 10-27-06; Effective: 04-01-07; Implementation: 04-02-07) This exhibit is the same as Exhibit 4, Status of Accounts Receivable – SMI, with the following exceptions: Section B, items 5d through 5g and Section D, items 5d and 5e refer to the POR for the HI report and refer to the POR/PSOR for the SMI report. Only intermediaries enter POR data on both the HI report and the SMI report. Only carriers enter the PSOR data on the SMI report. CMS-751A is the CMS Form Number for the HI (Part A) report. CMS-751B is the CMS Form Number for the SMI (Part B) report. Exhibit 3 (Cont.) Status of Accounts Receivable Hospital Insurance (HI) As of _________________ Contractor Name ID Number _______________________ __________ Section A: Outstanding Receivables Principal Principal Interest Interest Number Dollars Dollars Number 1. Beginning FY Balance _________ __________ _________ _______ 2a. New Receivables _________ __________ 2b. Accrued Receivables _________ __________ 3. Interest Earned _________ _______ 4a. Cash/Check Collections __________ _________ 4b. Offset Collections __________ _________ 4c. Collections Deposited at Another Location __________ _________ 5a. Adjusted Amounts __________ Internal Adjustments __________ _________ Auditor/Consultant Adjustments __________ _________ 5b. Transfers In from other Medicare Contractors __________ _________ 5c. Transfers Out to other Medicare Contractors __________ _________ 5d. Transfers In from other CMS Locations, POR/PSOR __________ _________ 5e. Transfers Out to other CMS Locations, POR/PSOR __________ _________ 5f. Transfers In from other CMS Locations, not POR/PSOR __________ _________ 5g. Transfers Out to other CMS Locations, not POR/PSOR __________ _________ 5h. Waivers __________ _________ 6a. Amounts Written-off (Bad Debts) __________ __________ _________ 6b. Transfers In from CNC __________ __________ _________ 6c. Transfers Out to CNC __________ __________ _________ 7. Ending Balance _________ __________ ___________ _______ a. Current __________ ___________ b. Non-current __________ 8. Allowance for Uncollectible Accounts __________ 9. Total Receivables Net of Allowance __________ ___________ 10. Cash/Offsets received for Receivables at Another Location __________ ___________ CMS-H751A Exhibit 3 (Cont.) Status of Accounts Receivable Hospital Insurance (HI) As of _________________ Contractor Name ID Number _______________________ __________ Section B: Delinquent Receivables Principal Principal Interest Interest Number Dollars Dollars Number 1. Total Not Delinquent _________ __________ ___________ _______ 2. Total Delinquent _________ __________ ___________ _______ (a) 1 - 30 days __________ ___________ (b) 31 - 60 days __________ ___________ (c) 61 - 90 days __________ ___________ (d) 91 - 180 days __________ ___________ (e) 181 - 365 days __________ ___________ (f) 1 - 2 years __________ ___________ (g) 2 - 6 years __________ ___________ (h) 6 - 10 years __________ ___________ (i) Over 10 years __________ ___________ 3. Total Delinquent 1 - 180 days _________ __________ _________ _______ (a) In Bankruptcy __________ _________ (b) In Appeal __________ _________ (c) At Department of Justice __________ _________ (d) Referred for Cross Servicing __________ _________ (e) Other Status __________ _________ (f) In the Process of Internal Offset (Previously Under MMA Section 935 Appeal) 4. Total Delinquent 181 days & over _____ __________ _________ _______ A) Referred for Cross Servicing __________ _________ B) 1) Not Eligible for Referral In Bankruptcy __________ __________ 2) In Appeal __________ __________ 3) At Department of Justice __________ __________ 4) Fraud and Abuse Investigation __________ __________ 5) Deceased Debtor and Estate Closed __________ __________ 6) Debts Less than $25 __________ __________ 7) Federal Entity Debts, MSP only, where the only entity which received the last demand letter is the employer and the employer is a Federal agency; __________ __________ 8) Beneficiary Debts, Non-MSP only; __________ __________ 9) Pending Request for Waiver or Compromise __________ __________ 10) CMS Identified Exclusions, MSP only, debts where CMS has identified a specific debt or group of debtors as excluded from DCIA referral. __________ __________ 11) Other Exclusions, must footnote. __________ __________ 12) In the Process of Internal Offset. (Previously Under Medicare Modernization Act (MMA) Section 935 Appeal) __________ __________ C) Eligible for Referral; debts that are eligible for referral to the Department of the Treasury for cross-servicing but not yet referred. __________ __________ Exhibit 3 (Cont.) Status of Accounts Receivable Hospital Insurance (HI) As of _________________ Contractor Name ID Number _______________________ __________ Section C: Other Collections 4c. Collections Deposited at another Location Principal Dollars Interest Dollars Contractor/Region ____________________ __________ _________ ____________________ __________ _________ ____________________ __________ _________ ____________________ __________ _________ ____________________ __________ _________ 10. Cash Offsets Received for Receivables at another Location Principal Dollars Interest Dollars Contractor/Region ____________________ __________ _________ ____________________ __________ _________ ____________________ __________ _________ ____________________ __________ _________ ____________________ __________ _________ Collections on Delinquent Debt _________ __________ _________ ________ Section D: Transferred Receivables 5c. Transfers Out to other Medicare Contractors Principal Dollars Interest Dollars Contractor Number ____________________ __________ _________ ____________________ __________ _________ ____________________ __________ _________ ____________________ __________ _________ ____________________ __________ _________ CMS-H751A Exhibit 3 (Cont.) Status of Accounts Receivable Hospital Insurance (HI) As of _________________ Contractor Name ID Number _______________________ __________ 5d. Transfers Out to other CMS Locations, POR 1. Boston __________ _________ 2. New York __________ _________ 3. Philadelphia __________ _________ 4. Atlanta __________ _________ 5. Chicago __________ _________ 6. Dallas __________ _________ 7. Kansas City __________ _________ 8. Denver __________ _________ 9. San Francisco __________ _________ 10. Seattle __________ _________ 11. Central Office __________ _________ 5e. Transfers Out to other CMS Locations, Not on POR 1. Boston __________ _________ 2. New York __________ _________ 3. Philadelphia __________ _________ 4. Atlanta __________ _________ 5. Chicago __________ _________ 6. Dallas __________ _________ 7. Kansas City __________ _________ 8. Denver __________ _________ 9. San Francisco __________ _________ 10. Seattle __________ _________ 11. Central Office __________ _________ CMS-H751A