Exhibit 5 - Status of Non-MSP Debt - CNC - HI

400.5 - Exhibit 5 - Status of Non-MSP Debt - CNC - HI (Rev. 111; Issued: 10-27-06; Effective: 04-01-07; Implementation: 04-02-07) The screen formats in exhibits 5 and 6 are identical except 5 is for HI non-MSP and 6 is for SMI non-MSP. MSP debt is reported in exhibits 9 and 10. Exhibit 5 (Cont.) One of: Status of Non-MSP Debt - CNC; or Status of MSP Debt - CNC will be shown. One of: Hospital Insurance (HI); or Supplementary Medical Insurance (SMI) will be shown As of ___________________ Contractor Name ID Number _______________________ __________ Section A: CNC Debt Principal Principal Interest Interest Number Dollars Dollars Number 1. Beginning FY Balance ______ __________ ___________ _______ 2. New CNC Debt ______ __________ ___________ _______ 3. Interest Earned Since CNC Approval ___________ 4. Reclassified CNC Debt a. Re-established as Active A/R due to collection of cash ______ __________ ___________ ____ b. Re-established as Active A/R due to collection by offset ______ __________ ___________ ____ c. Re-established as Active A/R due to bankruptcy, fraud & abuse, litigation and appeal ______ __________ ___________ ____ d. Written-off Closed ______ __________ ___________ ____ e. Other ______ __________ ___________ ____ 5. Amounts Transferred a. Transfers In from Medicare Contractors ______ __________ ___________ ____ b. Transfers Out to Medicare Contractors ______ __________ ___________ ____ c. Transfers In from CMS RO ______ __________ ___________ ____ d. Transfers Out to CMS RO ______ __________ ___________ ____ e. Transfers In from CMS CO ______ __________ ___________ ____ f. Transfers Out to CMS CO ______ __________ ___________ ____ 6. Ending Balance ______ __________ ___________ _______ CMS-C751A Exhibit 5 (Cont.) Status of Non-MSP Debt - CNC Hospital Insurance (HI) As of _________________ Contractor Name ID Number _______________________ __________ Section B: Aging of CNC Debt (from the determination date) 1. Total CNC Debt ______ __________ ___________ _______ (a) 181 - 1 year __________ ___________ (b) 1 - 2 years __________ ___________ (c) 2 - 6 years __________ ___________ (d) 6 - 10 years * __________ ___________ (e) Over 10 years * __________ ___________ * Provide an explanation why debts in these categories were not recommended for write-off closed Section C: Collection Information Collections on CNC Debt ______ __________ ___________ _______ Section D: Status CNC Debt over 181 Days Total Delinquent 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 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. __________ _________ CMS-C751A