Medicare Financial Management Manual (Pub. 100-06), Ch. 6 § 210.3
Exhibits
Length: 463 wordsOfficial source
210.3 - Exhibits
B3-13312.3
Exhibit 1 - DMEPOS State Report - REGION A
DMEPOS State Report - REGION A
Carrier No._______ Report Period_______ Type_______
Total Claims Processed for Type Indicated
Clean Claims Processed for Type
Indicated
State
Code
(1)
Number
(2)
In
1-60
Days
(3)
In
61-90
Days
(4)
Mean
Proc.
Time
(5)
EMC
(6)
Number
(7)
In
1-30 Days
(8)
1-Tot.
All
States
02 CT
03 DE
04 MA
05 ME
06 NH
07 NJ
08 NY
09 PA
10 RI
11 VT
12
13
14
15
16
17
18
19
20
TYPE
Page 1-PEN
Page 2-Oxygen
Page 3-Non-Oxygen Equipment
Page 4-Dialysis Supplies
Page 5-Non-Dialysis Supplies
Page 6-Prosthetics and Orthotics
Page 7-Other
Page 8-Total
Exhibit 2 - DMEPOS State Report - REGION B
DMEPOS State Report - REGION B
Carrier No._______ Report Period_______ Type_______
Total Claims Processed
for Type Indicated
Clean Claims Processed
for Type Indicated
State
Code
(1)
Number
(2)
In
1-60
Days
(3)
In
61-90
Days
(4)
Mean
Proc.
Time
(5)
EMC
(6)
Number
(7)
In
1-30 Days
(8)
1-Tot. All
States
02 DC
03 IL
04 IN
05 MD
06 MI
07 MN
08 OH
09 VA
10 WI
11 WV
12
13
14
15
16
17
18
19
20
TYPE
Page 1-PEN
Page 2-Oxygen
Page 3-Non-Oxygen Equipment
Page 4-Dialysis Supplies
Page 5-Non-Dialysis Supplies
Page 6-Prosthetics and Orthotics
Page 7-Other
Page 8-Total
Exhibit 3 - DMEPOS State Report - REGION C
DMEPOS State Report - REGION C
Carrier No._______ Report Period_______ Type_______
Total Claims Processed
for Type Indicated
Clean Claims Processed
for Type Indicated
State
Code
(1)
Number
(2)
In
1-60
Days
(3)
In
61-90
Days
(4)
Mean
Proc.
Time
(5)
EMC
(6)
Number
(7)
In
1-30 Days
(8)
1-Tot.
All
States
02 AL
03 AR
04 CO
05 FL
06 GA
07 KY
08 LA
09 MS
10 NC
11 NM
12 OK2
13 PR2
14 SC2
15 TN2
16 TX2
17 VI2
18
19
20
TYPE
Page 1-PEN
Page 2-Oxygen
Page 3-Non-Oxygen Equipment
Page 4-Dialysis Supplies
Page 5-Non-Dialysis Supplies
Page 6-Prosthetics and Orthotics
Page 7-Other
Page 8-Total
Exhibit 4 - DMEPOS State Report - REGION D
DMEPOS State Report - REGION D
Carrier No._______ Report Period_______ Type_______
Total Claims Processed for Type Indicated
Clean Claims Processed
for Type Indicated
State
Code
(1)
Number
(2)
In
1-60
Days
(3)
In
61-90
Days
(4)
Mean
Proc.
Time
(5)
EMC
(6)
Number
(7)
In
1-30 Days
(8)
1-Tot.
All States
02 AK
03 AZ
04 CA
05 CM
06 GU
07 HI
08 IA
09 ID
10 KS
11 MO
12 MT
13 ND
14 NE
15 NV
16 OR
17 SD
18 UT
19 WA
20 WY
TYPE
Page 1-PEN
Page 2-Oxygen
Page 3-Non-Oxygen Equipment
Page 4-Dialysis Supplies
Page 5-Non-Dialysis Supplies
Page 6-Prosthetics and Orthotics
Page 7-Other
Page 8-Total