Medicare Contractor Monthly Cash Collections Worksheet

80.2 - Medicare Contractor Monthly Cash Collections Worksheet (Rev. 80, Issued: 10-21-05, Effective: 07-01-05, Implementation: 11-21-05) The Medicare Contractor Monthly Cash Collections Worksheet is to identify cash collections deposited in the Medicare Trust Funds related to Provider Overpayments. The Medicare contractors are to follow the line by line instructions for completing the collections worksheet. The instructions are to provide uniformity throughout all contractors for the calculations of the data used to populate each line item. Medicare contractors are required to maintain supporting documentation for the amounts reported on the Medicare Contractor Monthly Cash Collections Worksheet. Medicare contractors are required to submit the worksheet via email to cashcollection@cms.hhs.gov on the 15th day of the following month end. For year-end, Medicare contractors may be required to submit the Monthly Cash Collections Worksheet in an accelerated time frame. A. Total Monthly Principal Deposit (Using Forms CMS-1522, Forms CMS-751) Line 1 - Enter the total ‘Other Deposits’ (Line 16b, Form CMS-1522) for the reporting period (e.g., June 30, etc.). Line 2 - Enter ‘Deposits-In-Transit’ (Line 20, Form CMS-1522) for the month prior to the reporting period (e.g., May 31, etc.). Line 3 - Enter ‘Deposits-In-Transit’ (Line 20, Form CMS-1522) for the reporting period (e.g., June 30, etc.). Line 4 – Enter the sum of Line 1 minus (-) Line 2 plus (+) Line 3 equal (=) ‘Total Monthly Deposits. Monthly Interest (Cash) Collections Line 5 – Enter the total ‘Received-Provider Overpayment’ (Line 1, page 4, Form CMS-1522) for reporting period (e.g., June 30, etc.). Line 6 – Enter the total ‘Interest Offset’ for the reporting period. Total ‘Interest Offset’ must equal the amount of the offset collections included in the amount reported on Line 1, page 4/4, Form CMS-1522 and included in the amount of the offset reported on Line 4b, Form CMS 751 for the quarter ending June 30, 2005. Line 7 – The sum of Line 5 minus (-) Line 6 equal (=) Monthly Interest Cash Collections. Line 8 – Monthly Interest Cash Collections = Line 7. Line 9 – The sum of Line 4 (Total Monthly Deposits) minus (-) Line 8 Monthly Interest Cash Collections) = Total Monthly Principal Cash Deposits. B. Calculate HI/SMI Percentage Split (FI Only) – 12 month rolling average Line 10 – Enter the sum of Line 4a (principal), Form CMS-751A (quarter ending June 30, 2005). For example, Line 4a (principal) for the period ending June 2005 plus (+) [Line 4a (principal), Form CMS-751A (period ending September 2004) minus (-) Line 4a (principal), Form CMS- 751A (period ending June 2004)]. The sum of Line 4a (period ending September 2004) minus Line 4a (period ending June 2004) must equal Cash Collections for the period July 2004 – September 2004. (NOTE: 12 months of most recent HI principal Cash Collections (e.g., July 2004 - June 2005)) Line 11 - Enter the sum of Line 4a (principal), Form CMS-751BA (quarter ending June 30, 2005). For example, Line 4a (principal) for the period ending June 2005 plus (+) [Line 4a (principal), Form CMS-751BA (period ending September 2004) minus (-) Line 4a (principal), Form CMS- 751BA (period ending June 2004)]. The sum of Line 4a (period ending September 2004) minus Line 4a (period ending June 2004) must equal Cash Collections for the period July 2004 – September 2004. (NOTE: 12 months of most recent SMI principal Cash Collections (e.g., July 2004 - June 2005)) Line 12 – Enter the sum of Line 10 plus (+) Line 11 = Total HI/SMI collections. Line 13 – Enter the HI percentage split. The result of Line 10 divided by Line 12. Line 14 – Enter the SMI percentage split. 1.00 minus the HI percentage split (Line 13). (NOTE: Line 14 must equal Line 11 divided by Line 12) C. HI Monthly Cash Deposit = HI percentage split (Line 13) multiplied by Total Monthly Principal Cash Deposit (Line 9). D. SMI Monthly Cash Deposit = HI percentage split (Line 13) multiplied by Total Monthly Principal Cash Deposit (Line 9). E. The Chief Financial Officer (CFO) is required to certify/sign the Medicare contractor Cash Collection Worksheet Attachment I (electronic signature is acceptable if the email is sent by the CFO), as an indication of the correctness/completeness of the data in accordance with applicable instructions. (NOTE: The sum of C and D must equal Total Monthly Principal Cash Deposits (Line 9))