Quarterly Supplement to the Intermediary Workload Report - CMS-1566A, Pages 1,2,3

70.14 - Quarterly Supplement to the Intermediary Workload Report - CMS-1566A, Pages 1,2,3 (Rev. 12894; 10-17-24; Effective:11-01-24; Implementation:11-01-24) A3-3898.14 QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT HFCA-1566A, PAGES 1 & 2 (CROWD FORM C) INTERMEDIARY NUMBER_______ REPORT PERIOD_______ SECTION A: BILLS PROCESSED BY STATE OF PROVIDER TOTAL 1 INP HOSP 2 OUTPATIENT 3 SNF 4 HHA 5 OTHER 6 1 . TOTAL - ALL STATE CODE XXXXXXXXXXX XXXXXXXXX XXXXXXXXXXXX XXXX XXXXX XXXXXX Quarterly Supplement To Intermediary Workload Report (Cont.) QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT HFCA-1566A, PAGE 3 (CROWD FORM I) INTERMEDIARY NUMBER_______ REPORT PERIOD_______ TOTAL 1 INPATIENT 2 OUTPATIENT 3 SNF 4 HHA 5 OTHER 6 SECTION B: BILL DENIAL DATA XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX 1. BILLS DENIED - TOTAL 1A. MEDICAL - SUBJECT TO WAIVER XXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX XXXXXX XXXXXX 1B. MEDICAL - NOT SUBJECT TO WAIVER XXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX XXXXXX XXXXXX 1C. NONMEDICAL TOTAL XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX XXXXXX XXXXXX 1D. NONMEDICAL MSP XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXXX XXXXXX XXXXXX 2. BILLS PAID UNDER WAIVER TOTAL 2A. INITIAL BILLS PAID UNDER WAIVER Quarterly Supplement To Intermediary Workload Report (Cont.) QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT HFCA-1566A, PAGE 3 (CROWD FORM I) INTERMEDIARY NUMBER_______ REPORT PERIOD_______ TOTAL 1 INPATIENT 2 OUTPATIENT 3 SNF 4 HHA 5 OTHER 6 3. AMOUNT REIMBURSED UNDER WAIVER 3A. AMOUNT ON INITIAL BILLS SECTION C: DAY/VISIT DATA XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX 4. DAYS/VISITS PROCESSED XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX 5. DAYS/VISITS DENIED TOTAL NO-PAY BILLS XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX 5A. MEDICAL - SUBJECT TO WAIVER XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX 5B. MEDICAL - NOT SUBJECT TO WAIVER XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX 5C. NONMEDICALS XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX Quarterly Supplement To Intermediary Workload Report (Cont.) QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT HFCA-1566A, PAGE 3 (CROWD FORM I) INTERMEDIARY NUMBER_______ REPORT PERIOD_______ TOTAL 1 INPATIENT 2 OUTPATIENT 3 SNF 4 HHA 5 OTHER 6 6. DAYS/VISITS PAID UNDER WAIVER - TOTAL XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX 6A. DAYS/VISITS ON INITIAL BILLS XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX Quarterly Supplement To Intermediary Workload Report (Cont.) QUARTERLY SUPPLEMENT TO INTERMEDIARY WORKLOAD REPORT HFCA-1566A, PAGE 3 (CROWD FORM I) INTERMEDIARY NUMBER_______ REPORT PERIOD_______ TOTAL 1 INPATIENT 2 OUTPATIENT 3 SNF 4 HHA 5 OTHER 6 SECTION D: DEMAND BILL DATA XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX 7. TOTAL DEMAND BILLS 7A. FULL/PARTIAL REVERSALS 7B. DAYS/VISITS ON REVERSALS XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX SECTION E: NO-PAY BILLS XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXX XXXX XXXXX 8. TOTAL NO-PAY BILLS 8A. DAYS/VISITS ON NO-PAY BILLS XXXXXXX XXXXXXXXXX XXXXXXXXXXX XXXXX 8B. MSP NO-PAY BILLS