Form CMS-456 - Schedule R - (Rev. 5, 08-30-02)

90.7 - Form CMS-456 - Schedule R - (Rev. 5, 08-30-02) A1-1414.7 (Page 3 of 3 of the Monthly Intermediary Benefit Payment Report) Reconciliation Between IBPR and CMS-1522. A. Purpose and Scope The contractor shall use the Schedule R to account for any variances between line 36(g), Total on the IBPR, and the HI and SMI Benefits reported on lines 1(d) and 2(d) of the CMS-1522 Report. Schedule R is an integral part of the IBPR and must be completed each month whether or not a variance exists between the IBPR and the CMS-1522 Report. If there is no variance, the contractor shall complete line 36(g) of the IBPR and HI and SMI Benefits for lines 1(d) and 2(d) of the Form CMS-1522. If there is a variance, it shall reconcile the two reports by completing the appropriate lines. It must have the capability to substantiate all amounts reflected on Schedule R. Schedule R includes line items that will facilitate the contractor's reconciliation process. It shall input the Schedule R, along with pages 1 and 2 of the IBPR, into the Contractor Administrative Budget and Financial Management System (CAFM) for each report month. B. Instructions for Completion of Schedule R: Heading - The contractor enters the report month and year. (See §160.6A) for intermediary name and number.) Also, it enters its current letter-of-credit number. Line Item Definitions - Schedule R: CMS-456 (IBPR) Column: Line 36(g) Total - Contractor enters the amount obtained from page 2 of 3 on line 36(g) of the IBPR. Medicare Secondary Payer (Non-Providers Cash Recoveries) - Contractor enters the cash receipts and offsets applied to claims payments or other refunds that are received from attorneys, beneficiaries, insurance companies or other non-providers. These amounts should be negative numbers since they represent cash receipts. Other Recoveries Identify - Contractor enters recovered or offset amounts not included in any other line item (lines 1 through 36 or lines 1 and 3 of Schedule R). These amounts should be negative numbers since they represent cash receipts. Other Items Identify (Lines 3A through 3E) - Contractor enters any other benefit payments or refunds not included elsewhere on the CMS-456 or on lines 1 and 2. The items shown here may be unique to its operation and should be identified accordingly. It shall itemize each major category on lines 3A. through 3E. These amounts could be positive or negative numbers. Total - Contractor enters the sum of all line items in this column. It must take care to subtract negative amount(s) included on the above lines. The total amount must equal the amount in the total adjacent CMS-1522 column. 1. Remarks - Contractor enters an explanation to clarify any item or amount. • Line Item Definitions - Schedule R: CMS-1522 1. HI Benefits, Line 1 (d) - Contractor enters the HI benefits amount from form CMS-1522 in line 1(d). 2. SMI Benefits, Line 2(d) - Contractor enters the SMI benefits amount from form CMS-1522 in line 2(d). 3. Subtotal - Contractor enters the total HI and SMI benefit amounts. 4. Other Items Identify - Contractor enters any other benefit payments or refunds that may be unique to your operation that are not included on lines 1(d) or 2(d) of form CMS-1522. It shall itemize each major category and identify on line 1 through 6. These amounts could be positive or negative numbers. 5. Total - Contractor enters the sum of all line items in this column. It must take care to subtract negative amounts included in items 1 through 6. The total amount must equal the amount in the total adjacent CMS-456 column. Public reporting burden for this collection of information is estimated to average 30 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. Send comments regarding this estimated burden or any other aspect of this collection of information, including suggestions for reducing the burden, to: Centers for Medicare & Medicaid Services Office of Financial Management 7500 Security Boulevard Baltimore MD 21244-1850 and to: Office of Management and Budget Paperwork Reduction Project (0938-0361) Washington DC 20503