Exhibit 5

110.5 – Exhibit 5 (Rev. 45, 05-28-04) Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 5 INTERMEDIARY APPEALS REPORT INTERMEDIARY ID REPORT PERIOD PART A C. PART A AND B ALJ HEARINGS Total (1) SNF (2) HHA/Hospice (3) Other (4) PART B (5) DISPOSITIONS 68. NUMBER OF DISPOSITIONS 69. AFFIRMATIONS 70. DISMISSALS/WITHDRAWALS 71. REVERSALS (FULL OR PART) EFFECTUATIONS 72. TOTAL EFFECTUATIONS 73. NO. 1-7 DAYS 74. NO. 8-15 DAYS 75. NO. 16-30 DAYS 76. NO. OVER 30 DAYS LIMITATION OF LIABILITY 77. WAIVED - BEN & PROV. 78. AMOUNT AWARDED D. LIMITATION OF LIABILITY (CLAIM COUNTS) PART A RECONSIDERATIONS PART B Total (1) SNF (2) HHA/ Hospice (3) Other (4) Reviews (5) Hearings (6) 79. TOTAL NUMBER CONSIDERED 80. CONSIDERED - NOT WAIVED 81. WAIVED - BEN. ONLY 82. WAIVED - BEN. & PROV. 83. AMOUNT AWARDED Form CMS-2591 Screen 5