Instructions for Completion of Form CMS-1522 - (Rev. 5, 08-30-

80.1 - Instructions for Completion of Form CMS-1522 - (Rev. 5, 08-30- 02) - (Rev. 5, 08-30-02) A1-1412.1, B1-4412.1 • Screen 1 - Section A - Purpose for Which Funds are Drawn: o Contractor shall reflect the current or prior year administrative costs drawn via Smartlink. It shall report on page 3 any special project(s) amount(s) drawn via Smartlink. o Funds Drawn this Month - Contractor enters the total amount of Federal funds drawn via payment vouchers during the calendar month for use as HI benefits, line 1-B, or SMI benefits, line 2-B. Each entry must equal the sum of the amounts shown in this category on the Form CMS-1521 dated during the calendar month. o Total Funds Expended This Month - Contractor enters total funds expended for HI benefits, line 1-D, and SMI benefits, line 2-D during the calendar month. Totals should equal the sum of all checks drawn and electronic funds transfer payments against the special bank account during the calendar month. (It shall include all checks issued and electronic funds transferred, i.e. dated during the calendar month.) Any refunds received from beneficiaries or their assignees during the calendar month because of prior overpayments deposited in the special bank account should serve to reduce total funds expended. o Funds Drawn for Fiscal Year - This is a calculated field. o Funds on Hand End of Month - This is a calculated field. o Line 3, Drugs and Line 4, Regular Administrative Costs - Contractor shall not use at this time. o Bills Paid - Lines 7 and 8 - Completed by Part A intermediaries. Part B carriers complete only line 8. o Retro-Adjustment - Part A contractors enter credit adjustments on appropriate lines. Part B contractors do not use lines 9 or 10. • Benefits Bank Account o From Bank Statement - The contractor shall take information for lines 15 through 19 from the statement of the special bank account issued by the bank at the end of the calendar month. o Line 15 - Balance Beginning of Month Per Bank - Contractor enters the balance in the special bank account as of the beginning of the calendar month as shown on the bank statement. o Line 16a - Payment Vouchers Drawn During Month - Contractor enters the total amount of funds drawn on payment vouchers (FMS-5401) during the calendar month and credited to the benefits account as shown on the bank statement. Since all checks drawn for deposit in the Time Account are cleared through the benefits account, a payment voucher is drawn for this transaction and is included in line 16a. The amount shown on this line must agree with the totals from the Form CMS-1521 corresponding to the calendar month and also with Section A, Line 5, column (b). The only exception is for vouchers in transit (line 20). o Line 16b - Other Deposits - Contractor enters all other deposits credited during the month to the special bank account as shown on the bank statement. It shall reduce the next payment voucher by the amount of the deposited refunds in the account in order to minimize idle funds in the account. It shall Include any credits or adjustments made to the bank account during the calendar month in this line. o Line 16c - Contractor shall include funds withdrawn from the Time Account and deposited in the Benefits Account. o Line 16d - Miscellaneous Credit Memo - Contractor enters any miscellaneous adjustments to the benefits bank account during the calendar month. o Line 17 - This is a calculated field. o Line 18A - Contractor shall subtract: Checks and EFT Payments Honored by Bank During Month - It enters from the bank statement the total funds charged to the special bank account as a result of checks honored and electronic funds transferred by the bank during the month. This total must include all checks that were drawn for deposit in the time account and honored by the bank during the month. o Lines 18B and C - Miscellaneous Bank Charges - Contractor enters any miscellaneous charges made to the special bank account that are part of the bank statement. o Line 19 - This is a calculated field. o Line 20 - Add: Deposits in Transit. - Enter payment vouchers drawn and other deposits made during the calendar month that the bank has not yet credited to the special bank account according to the statement. o Line 21. - This is a calculated field. o Line 22 - Subtract: Outstanding Checks. - Enter the total of all checks issued during the current month or any previous month that the bank has not yet paid as of the end of the calendar month. If during the calendar month payment is stopped on any check previously issued, or any previously issued check is otherwise voided, subtract the amount of funds represented by that check from this total before making an entry on this line. o Line 23 - This is a calculated field. o Line 24 - Highest Balance During Month Per Bank. Contractor enters the highest balance in the special bank account during the calendar month as reflected on the bank statement. • Time Account o Line 15 - Balance Beginning of Month - Contractor enters the balance in the time account as of the beginning of the calendar month as shown on the bank statement. o Line 16a - Other Deposits - Contractor enters the amount of funds drawn from the benefits account for deposit in the time account. o Line 17 - Total. - This is a calculated field. o Line 18a - Contractor enters only amount of funds withdrawn from the time account and deposited in the benefits account during the month. o Line 18b - Contractor enters any miscellaneous items. o Line 19 - Balance EOM Per Bank - This is a calculated field. • Screen 4 - Completed by Part A Contractors Only o Periodic Interim Payments - Contractor enters amounts paid during the month by category. o Accelerated Payments - Contractor enters the amount of accelerated payments paid out and received during the month. o Suspended Payments - Contractor enters the amount of payments suspended and released during the month. • Screen 5 - Bills Paid - Contractor enters the amount of money actually paid during the calendar month as follows: o Amount paid for disabled or disability (identified by Codes 1 and 3 as contained in S trailer of query reply). o Amount paid for chronic renal disease (identified by Code 2 as contained in S trailer of query reply). o Amount paid for premium paying enrollees (identified by Codes 8 and 9 as contained in S trailer of query reply). o Amount paid for aged. Contractor shall complete entries for disabled, chronic renal disease, and premium paying enrollees prior to completing the entry. It shall then subtract the sum of these entries from the calculated Total and enter that amount. o Total - (Bills paid for the month). This is a calculated field. NOTE: For those Part A intermediaries that transmit bills to CMS from more than one point, each processing point should submit to the home office at the end of the calendar month all of the data requested in screen 1. (It shall consolidate data related to amounts paid in screen 1.) • Only Part A Intermediaries complete retroactive adjustments. • Only Part A Intermediaries complete adjustments between trust funds. • Interest: o Interest Received From Providers On Overpayments - Separate Check for Interest Collected - When a check is received for interest on an overpayment, the contractor shall deposit the check immediately in the Medicare bank account. It shall report this check as an "Other Deposit" (line 16b). Also, it shall report the check as "Interest Received" on screen 5 and use as a reduction to expenditures on screen 1, funds expended column. o Check Includes Both Interest Collected and Overpayment Recoupment - Contractor shall deposit the check immediately into the Medicare bank account. It shall report the entire amount of the check as an "Other Deposit" (line 16b) on screen 2. It shall report the interest portion as "Interest Recovered" on screen 5. Both the interest recovered and the overpayment recoupment are used as a reduction to expenditures on screen 1, funds expended column. o Interest Paid to Providers on Underpayments - Separate Check for Interest Paid - When a check is issued for interest due to a provider on an underpayment, the contractor shall report it as a "Check Honored" (line 18a) on screen 2. Also, it shall report this amount as "Interest Paid" on screen 5 and as an increase to expenditures on screen 1, funds expended column. • Screen 6 - No entries are required at this time. Public reporting burden for this collection of information is estimated to average 16 hours per response. This includes time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Contractors may send comments regarding this estimated burden or any other suggestions for reducing the burden to: Centers for Medicare & Medicaid Service Office of Financial Management Baltimore, Maryland, 21244-1850; and to: Office of Management and Budget Paperwork Reduction Project (0938-0361) Washington, D.C. 20503.