Exhibits

200 - Exhibits (Rev. 126; Issued: 07-13-07; Effective: 01-01-08; Implementation: 01-07-08) Exhibit 1 - Medicare Program Carrier Performance Report- Page 1 MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 Carrier Number Report Period ( Month/Yr) Working Days Number and Type of Claim Reporting Item Total (1) Assigned (2) Unassigned (3) A. Monthly Workload Operations OPENING PENDING 1. Claims Pndg End of Last Mo. 2. Adjustments (Show + or -) 3. Adjusted Opening Pending RECEIPTS 4. Tot. Clms. Rcvd. During Mo. 5. Transferred to Other Carrier 6. Net Number of Claims Received 7. Electronic Media Claims Recvd. CLAIMS PROCESSED 8. Total CWF Claims 9. Claims Paid 10. Claims Applied To Deductible 11. Claims Denied 12. Total Non-CWF Claims 13. Claims Approved 14. Claims Denied 15. Total Claims Processed 16. Replicate Claims Processed Exhibit 1 (Cont.) MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 (cont) Carrier Number Report Period ( Month/Yr) Working Days Number and Type of Claim Reporting Item Total (1) Assigned (2) Unassigned (3) CLOSING PENDING 17. Claims Pending at End of Month DISTRIBUTION OF DAYS ELAPSED SINCE RECEIPT 18. 1 - 15 Days 19. 16 - 30 Days 20. 31 - 60 Days 21. 61 - 90 Days 22. Over 90 Days CLAIMS INVESTIGATIONS 23. No. of Clms. Invest. During Mo. B. INQUIRIES TOTAL BENEFICIARY PROVIDER 24. Tot. No. Processed During Mo. 25. Telephone 26. Walk-In Contact 27. Written C. MISCELLANEOUS CLAIMS DATA MEDICAID CROSSOVER CLAIMS 28. No. Transferred to St. Agencies 29. No. Transferred Electronically Exhibit 1 (Cont.) MEDICARE PROGRAM CARRIER PERFORMANCE REPORT- Page 1 (cont) Carrier Number Report Period ( Month/Yr) Working Days Number and Type of Claim Reporting Item Total (1) Assigned (2) Unassigned (3) OPTICAL CHARACTER RECOGNITION CLMS. 30. Total Claims MEDICARE SUMMARY NOTICES 31. Total MSNs Mailed Form CMS-1565 Exhibit 2 - Medicare Program Carrier Performance Report - Form CMS-1565, Pages 2-9 MEDICARE PROGRAM CARRIER PERFORMANCE REPORT - FORM CMS-1565, Pages 2-9 CARRIER WORKLOAD REPORT - PAGE __*__ PART - D (1) CLAIMS PROCESSING TIMELINESS - ALL CLAIMS CARRIER ID________ TYPE OF CLAIM______*_____ REPORT MO.___ PAID NOT PAID LINE NO./DAYS TOTAL (1) CLEAN (2) OTHER (3) CLEAN (4) OTHER (5) EMC (6) 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 22 23 23 24 24 25 25 26 26 27 27 28 28 29 29 Exhibit 2 (Cont.) PAID NOT PAID LINE NO./DAYS TOTAL (1) CLEAN (2) OTHER (3) CLEAN (4) OTHER (5) EMC (6) 30 30 31 31 32 32 33 33 34 34-45 35 46-60 36 61-90 37 91+ 38 Tot 1-37 39 Mean Pt CMS-1565 Page _*_ * PAGE NUMBER AND TYPE OF CLAIM ARE TO BE REPORTED AS FOLLOWS: Page 2-Assigned Physician Page 3-Assigned DME Page 4-Assigned Lab Page 5-Assigned Ambulance Page 6-Assigned Other Page 7-Unassigned Page 8-Participating Physician Page 9-All Claim Exhibit 3 - Adjustments for CPEP CPT EMC PAID EMC NOT PAID ADJUSTMENTS FOR CPEP CPT LINE NO./DAYS CLEAN (1) OTHER (2) CLEAN (3) CALCULATIONS: 1 1 CWF Claims which were beyond carrier control due to CWF. 2 2 3 3 4 4 5 5 A. EMC clean claims Processed beyond EMC 6 6 7 7 8 8 B. Paper clean claims Processed beyond Paper ceiling 9 9 10 10 11 11 C. All claims processed Beyond 60 days ____ 12 12 13 13 WAIVER Claims paid under the floor For which the carrier had a waiver from CMS. 14 14 15 15 16 16 17 17 D. EMC clean claims Paid under EMC floor _________ 18 18 19 19 20 20 E. Paper clean claims Paid under paper floor ________ 21 21 22 22 23 23 F. All EMC claims paid under EMC floor and all paper claims paid under paper floor __________ 24 24 25 25 26 26 27 27 28 28 29 29 30 30 31 31 32 32 33 33 Exhibit 3 (Cont.) EMC PAID EMC NOT PAID LINE NO./DAYS CLEAN (1) OTHER (2) CLEAN (3) CALCULATIONS: 34 34-45 35 46-60 36 61-90 37 91+ 38 Tot 1-37 39 Mean Pt CMS-1565 Page _*_ * PAGE NUMBER AND TYPE OF CLAIM ARE TO BE REPORTED AS FOLLOWS: Page 10-Participating Physician (PAR) Page 11-Total (TOT) Exhibit 4 - Carrier Workload Report - Part-E - Interest Payment Data CARRIER WORKLOAD REPORT - PAGE __*__ PART-E - INTEREST PAYMENT DATA CARRIER ID REPORT MONTH LINE NO CLAIM/PAYMENT LATE DAYS TOTAL (1) ASTD PHYS (2) ASTD DME (3) ASTD LAB (4) ASTD AMB (5) ASTD OTHER (6) UNASTD (7) PARTIC. PHYS (8) 1. No. of Claims 2. 1 Day late 3. 2 Days Late 4. 3 Days Late 5. 4 Days Late 6. 5 Days Late 7. 6-15 A Late 8. 16-30 A Late 9. 31-60 A Late 10. 61+ A Late 11. Amount paid 12. 1 Day late 13. 2 Days Late 14. 3 Days Late 15. 4 Days Late 16. 5 Days Late 17. 6-15 A Late 18. 16-30 A Late 19. 31-60 A Late 20. 61+ A Late CMS-1565 Page 12 Exhibit 5 - Carrier Workload Report - Part F - All Trunks Busy (ATB) CARRIER WORKLOAD REPORT PART F - ALL TRUNKS BUSY (ATB) ALL TRUNKS BUSY CARRIER ID___________ REPORT MONTH________ LOCAL CALLS (1) TOLL FREE CALLS (2) 1. PERCENT OF ATB 2. NUMBER OF BENEFICIARY CALLS ANSWERED IN 120 SECONDS 3. TOTAL NUMBER OF BENEFICIARY CALLS RECEIVED 4. % OF BENEFICIARY CALLS ANSWERED IN 120 SECONDS EXPLANATION FOR FAILURES: CMS-1565 Page 13