Medicare Financial Management Manual (Pub. 100-06), Ch. 6 § 40.4
Report Form
40.4 - Report Form
(Rev. 6, 08-30-02)
A3-3895.4
MONTHLY PRO ADJUSTMENT BILL REPORT
INTERMEDIARY ID:
PRO ID:
STATE:
MONTH/YEA
R:
TOTAL
(A)
INPATIENT
(B)
OUTPATIENT
(C)
1.Opening Pending
2.Revisions to Opening Pending
3.Revises Opening Pending
4.Elec. Adj. Req. Rec. Received
5.Elec. Adj. Rec. Rec. Rejected
6.Elec. Adj. Rec. Received
7.Hard-Copy Adj. Req. Rec. Accepted
8.Addtl. Bills to be Proc. Due to Interim Bills
9.Total Adj. Bills to be Proc.
Report Form (Cont.)
MONTHLY PRO ADJUSTMENT BILL REPORT
INTERMEDIARY ID:
PRO ID:
STATE:
MONTH/YEA
R:
TOTAL
(A)
INPATIENT
(B)
OUTPATIENT
(C)
10.Nonprocessable Adjustment Bills-Failed
Batch/System Edits
11.Total Adj. Bills Processed
12.No. Compl. in 60 Days or Less
13.No. Compl. in 61-90 Days
14.No. Compl. in 91-120 Days
15.No. Compl. Over 120 Days
16.Closing Pending